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0121 TANBARK ROAD - Health
121 Tanbark Road Marstons Mills P A = 100 027002 y I I TOWN OF BARNSTABLE LOCATION Z�° l ql7�641�J� a SEWAGE# .VILLAGE�y��STor->S f�/� ASSESSOR'S MAP&PARCEL%/90"027-oo2 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY lo&p LEACHING FACILITY:(type) ,�-fD0 s4s�t7Fi'S (size) / 3 NO.OF BEDROOMS 7 OWNER PERMIT DATE: 2 -A-Ar COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY -� 14 - 2 44 G. 7p, b,,, tO. I9 '3 o e 0 4, No. Fee lobl� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes Yication for Mis oral stem Construction 3permit Application for a Permit to Construct( ) Repair(4-)—Upgrade(G)--Abandon( ) []Complete System ❑Individual Components Location Address or Lot No.121 ji4n 6,4rl< ,9q Ow er's N e, dre s d Tel.No. 1S rvlylrfrONS Wil �^ Assessor's MapTarcel /00 _ p;{7_pio- �� t 05 + I Installer's Name,Address,and Tel.No.fD g—yw-9'73g Designer's Name,A .ress,and T No.SO Fs' �Josc�Li Q� l3<�r�o �fo*iS Z A16 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil- Nature of Repairs or Alterations(Answer when applicable) �ZOi3"f#l/0EU�W,`!� %O ��iv`!S Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Healt . ti 4 Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. k, Date Issued rrk ww.3 No. a Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Yication for.30is oral stem Construction Permit 6 Application for a Permit to Constrict( ) Repair Upgrade(LrAbandon( ) ❑Complete System ❑Individual Components - Loc,ati, on Address or Lot No.121 O er's Name, dre s 4ndTel.No. Assessors Map/Parcel loQ — vg _ 02 Installer's Name,Address,and Tel.NoSJY-y .Z "r�j 73 Designer's Name,Address,and T No.50 ✓�"c/�� �� 13/� ^G'U,5 S is C 7/ f2VGllvi`.St�/�/�v�/i�� /_=• �-���G-v��.�; C�2537 Type of Building: Dwelling No.of Bedrooms Lot Size s ft. Garbage Grinder ��.... ..r g q• g ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title i Size of Septic Tank k Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable).Zv�j`1 "a Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage diiposelsystem in ' accordance with the provisions of Title 5 of the Environmental Code and not to place the system i %operation„untila,Certificate of ¢, Compliance has been issued by this Board of Healt - � c '.Date > Application Approved by Application Disapproved by Date 1 ,. for the following reasons t 1 Permit No.. J,', Date Issued r s _ �_. - ---- ---------- -- -- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(z_') Upgraded Abandoned( )by .1jj e1t;,4 r at l '2( �/5 i 7 y�l �"" f�</?� � Ir9,�S t✓< ,t�=i �/. has been cons ct dege e with the provisions of Title 5 and the for Disposal System Construction Permit No. / a Designer />/-`�L�;,� �" „Sc; ;',j 4.416 ',•,< #bedrooms Approved design flow gpd The issuance of this pe t 1#not2 a construed s a guarantee that the system will function as designed. Date /U Inspect-_ nspect --------------------- --- 4Pf fA - '----- ---- --_---------__- -- _ - = - _. -- ti �� -top. ✓ THE COMMONWEALTH OF MASSACHUSETTS Fee PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Bisposal *pstem Construction �ermlt Permission is hereby granted to Construct( ) Repair( 4-4- Upgrade( 4. Abandon( ) System located at /2-/ and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Cons do mu t 1becompleted within three years of the date of this permit.Date /.� Approved by 41 ) ZXL2 . 1 1 OCT/09/201—D/FRI ' 0:23 R FAX No. P. 001/1011 Town of Barnstable •.°°" Regulatory Services . Richard V, Scab,Interim Director � � r ]Public Health Division Thomas NfcKean,Director 200 Main Street,Hyannis,MA 02601 Ofnee: 508-862-4644 Fax: 308-790-6304 Installer&Designer Certification Form Date: Sewage Permit4 Assessor's MapTarce /00 Designer: �{�, nj Ilzc Installer: (�_S�oh De,4_R�-r25 Address: PO go< qs l Address: dl a LmmeaY t,Qha-e On— a S was issued a permit to install a da ) (installer) septic system at �� � �� based on a design drawn by (address) • -1 dated q n p� desig ) � �P�^ �� I certify that a sep d tic system re ced above was installed substantially according to ` the design, which may include minor approved changes such as lateral relocation of the distribution box an&or septic tank Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State&Local Regulations. plan revision or certified as-built by designer to follow. Strip out(if required)was inspected and the soils were found satisfactory. I certify that the systena referenced above was cons c ;d fiance with the terms of the RA approval letters(if applicable) bA REM rtaUer's � r ,f i W er's Signature) (Affix tamp He Ye) PLEASE RETLItN TO B STABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT DE ISSUED UNTIL BOTH TWS FORM AND A& $L'ILT CARD ARE RECEYVED BY THE BAYtNSTABI,E PUBLIC HEALTH DIVISION. THANK YOU. QAScpdObesianer Certification Form RJev 8-14-13.doe I Town of BAr nstable P# l � Department of Regulatory Services ' Ph r Public Health Division Date •1639• tee$ 200 Main Street,Hyannis MA 02601 Date Scheduled ` �r Time o^^ Fee Pd. Soil Suitabilit y' Assessment fog- ►dew e Dispos l ✓ r.l Performed By: Witnessed By: �` 1� i LOCATION & GENERAL INFORMATION Location Address 'pT"� � ! Owner's Name L I Address �.Frd�✓�� Assessor's Map/P4tcel: 100 C;)'5:7/0 C/ a. I Engineer's Namey -1 NEW CONS' UNION REPAIR X Telephone# Sb% 360 Land Use —� �" s/ Slopes(%) �/. Surface Stones ++gg���� Distances from Open Water Body ft Possible Wee Area "Z� ft Drinking Water Well tZ� / ft Drainage Way ft. Property Line ft Other ft SKETCH:(street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes) ! I O I I Parent material(geologic) Levd psi i Depth to Bedrock - Depth to Groundwakdr: Standing Water in Hole:' i Weeping from Pit Face Estimated Seasonal;qigh Groundwater i Dt TION FOR SEASONAL HIGH WATER TA-ME Method Used: in, Depth to 50ll M0tll9s: In. Depth Cib�serve�standing in obs.hole: I in, oroundWater Adjustment i1 Depth toiweeping from side of obs.hole: ; Adj,faetoC Adj.(7roundwaterLeVel,,o 'Index Well# Reading Date Index Well level PERCOLATION TEST' . Dille— Time Observation Time at 9", -------- Hole# ! 6 Depth of Perc Time at 6" - � Time Start Pre-soak Time.@ End Pre-soak - Rate MinJInch - ---� ' Additional Testing Needed(Y/N). Site Suitability Assessment: Site Passed Site Failed: Original:.Public 1441th Division Observation Hole Data To Be Completed on Back--- :- 1. • ou must first notify the ***If percola#on test is to be condracted within 100' of wetland,.,You US Barnstable C4.4servation Division at least one(1) week prior to beginning. DEEP OBSERVATION HOLE LOG. Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel 4-" St fl-1 't j 2. 7 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistent %Gra el 51-1 132.% DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell)_ Mottling (Structure,Stones,Boulders. Consistent %Gravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color $oil 61h r Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. ra I E Flood Insurance Rate Map: Above 500 year flood boundary NO-- Yes Within 500 year boundary No Yes„ r Within 100 year flood boundary No_ Yes .Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist.in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring per ious material? Certification ,� I certify that on (date)I have passed the soil evaluator examination approved by the Departmen f Enviro mental Protection and that the above analysis was performed by me consistent with the require tr ' in expe tise and experience described in 3,10 CUR 15 . Signature Date.01 l j Q:VSEPTICIPERCFORM.DOC N p , r O cc u7 mPostage $ O `' A Certified Fee ,� p Return Receipt Fee i WQ§tmark p (Endorsement Required) (Vero O Restricted Delivery Fee Cr� O (Endorsement Required) /y J p Total Postage&Fees $ a 3 r� o David P. Santos Jr. r%- 121 Tanbark Road Marstons Mills, MA 02648 Certified Mail Provides: o A mailing receipt o A unique identifier for your mailpiece - e A record of delivery kept by the Postal Service for two years Important Reminders: e Certified Mail may ONLY be combined with First-Class Mall®or Priority Malle. o Certified Mail is not available for any class of international mail. • NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. o For an additional fee,a Return Receipt maybe requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPSe postmark on your Certified Mail receipt is required. o For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". o If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail i receipt is not needed,detach and affix label with postage and mail. IMPORTANT.Save this receipt and present it when making an inquiry. '.{ PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 �SENDER:COMPLETEIHIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Signature item 4 if Restricted Delivery is desired. X��,�Il Agent ■ Print your name and address.on the reverse Addressee so that we can return the card to you. B. Received by(Print d Name) C. Date of Delivery ■ Attach this card to the back of the mailpiece, or on the front if space permits. 1. Article Addressed to: D. Is delivery address different from item 1? ❑Yes If YES,enter delivery address below: ❑No-, David P:.Santos Jr. - 121 Tanbark Road Marstons Mills, MA 02648 3. Service Type ❑Certified Mail ❑Express Mail ❑Registered ❑Return Receipt for Merchandise j �! ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes a 2. Article Number (Transfer from service label) 70141200 0001 0358 7 5 8 0 �\ I PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540 I I UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid I LISPS I i Permit No.G-10 I I j • Sender: Please print your name, address, and ZIP+4 in this box' j I C Town of Barnstable I Public Health Division I 200 Main Street I Hyannis, MA 02601 I i i r Barnstable Town of Barnstable Regulatory Services Department p BARNSTABL E.MAPA 9A�#` Public Health Division m 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL # 7014 1200 0001 0358 7580 August 26, 2015 David P. Santos Jr. 121 Tanbark Road Marstons Mills, MA 02648 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 121 Tanbark Road,Marstons Mills, MA was inspected on 8/15/2015, by Chad Hathaway, registered sanitarian and health agent for the Town of Barnstable Health Department. The inspection of the septic system showed that the system "Failed" under the guidelines of Chapter 1995 TITLE 5 (31( C,R15.00) due to the following: • Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or Cesspool. You are ordered to replace the septic system within one (1)year of the date you receive of this notification. Failure.to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BO RD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\121 Tanbark Rd MM Aug 2015.doc ti Town of Barnstable + BARNSlABM b 9. ,�� Regulatory Services Department ArfD�,t� Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 7/6/15 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1) YEAR DEADLINE CRITERIA XStatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any "conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑.Leaching pit or cesspool with high liquid level, <12"below inlet(per Town Code §360-9.1) OTHER Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M '< 121 Tanbark (five 1�o cL01 , J Property Address Santos Owner Owner's Name information is c• required for every Mamie �/� MA 8/5/15 page. Cilrylrown State Zip Code Date of Inspection :a Ia..7 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: o key to move your cursor-do not Chad Hathaway use the return Name of Inspector key. H.P.S. � Company Name P.O.Box 151 Company Address Forestdale Ma 02644 City/Town State Zip Code 774-274-2581 12866 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority 8/5/15 Inspectors Sign re Date The system inspector shall s it a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 <L . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 121 Tanbark Drive Property Address Santos Owner Owner's Name information is Mashpee MA 8/5/15 required for every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 121 Tanbark Drive Property Address Santos Owner Owner's Name information is Mash pee MA 8/5/15 required for every p page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 121 Tanbark Drive Property Address Santos Owner Owner's Name information is Mashpee MA 8/5/15 required for every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ® ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ® ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 �. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4 M , 121 Tanbark Drive Property Address Santos Owner Owner's Name information is Mash pee MA 8/5/15 required for every p page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 121 Tanbark Drive Property Address Santos Owner Owner's Name information is Mashpee MA 8/5/15 required for every page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ❑ ❑ Existing information. For example, a plan at the Board of Health. ❑ ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 �. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 121 Tanbark Drive Property Address Santos Owner Owner's Name information is Mash pee MA 8/5/15 required for every p page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) I Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 �. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 121 Tanbark Drive Property Address Santos Owner Owner's Name information is Mash pee MA 8/5/15 required for every p page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: every 2 years owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 121 Tanbark Drive Property Address Santos Owner Owner's Name information is Mash pee MA 8/5/15 required for every p page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1989 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2'feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line. 24 feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1'6"feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 3" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' M 121 Tanbark Drive Property Address Santos Owner Owner's Name information is Mash pee MA 8/5/15 required for every p page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 31" Scum thickness 4" Distance from top of scum to top of outlet tee or baffle 2" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? tape and sludge judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): pump every 2-3 years as maint. to protect leaching Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 121 Tanbark Drive Property Address Santos Owner Owner's Name information is Mash pee MA 8/5/15 required for every p page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 4 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 121 Tanbark Drive Property Address Santos Owner Owner's Name information is Mash pee MA 8/5/15 required for every p page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): overfull due to failed leach pit Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: existing leach pit water level is in riser 1' higher then existing leach pit !sins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 121 Tanbark Drive Property Address Santos Owner Owners Name information is Mash pee MA 815/15 required for every P page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 �. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 121 Tanbark Drive Property Address Santos Owner Owner's Name information is Mash pee MA 8/5/15 required for every p page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 . ' �• Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 121 Tanbark Drive Property Address Santos Owner Owner's Name information is Mash pee MA 8/5/15 required for every P page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately O y3 3C� � �y �3 I 'V c`'1-j Li t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ti 121 Tanbark Drive Property Address Santos Owner Owner's Name information is Mashpee MA 8/5/15 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 15 + feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: online topo maps You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts F r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 121 Tanbark Drive Property Address Santos Owner Owner's Name information is Mash pee MA 8/5/15 required for every p page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 tv Ro ! Finished Basement Un-Finished Basement � � G k j HW i �3 ., �, . - r r A... . , .,. � i a_,{ .{'e 1 n .0 -. .t . j: � .. .•t.i J•:�.. '.-A._ as 3 i `...�. ♦ r�r '.. s.). a:'. .. ,a ..c r .>) r, k x f;x n !"'1 J x ; .}'. i) Y 4� r '4t •?!A i r w; i :.t!. y Y...7 f .. �4 � �~i� ♦ ��..r..� C m9 � y tF f o LO 0 7 3 0 Q1 rt O 0 �.l101, '3 J :C:loset _ Closet _ r - F La r� O S S 6 (f. q �' > ��� # "T�+,�;' tom' ;%,'��v' x n�^ vt"�r`• +:ti'f " 4 o r .F yy .py ,eyC T i •y. � •,. .rMw�,wmaa�-am�u'vra,:..v��.ww.,_..,,y.:rrn-..w++w.-.✓am..m...� -- -_ r - gg fi yr t Bathroom 1 A Y.,, Bedroom ,' �;. k ::x• Closet Bedroom � : ., ,:tf ,5 n F. r:A.f•:. .k'i..,a R xx a .� - ,_ :: . Hallway Second iti l l Y.a•Jk 'A i'a! ♦ 'k•A: N}' QX.riN e O t p 9{= LJ ' ay 'W.:. iT 3"Yy ... ♦ . d , - -..f x..4r k 'A':I., a "AER: ..' Fr „ <.,.'E ♦ :dt Lf i Y.d a>E '.A'M A iA!A, 'Iry �a" + s ;tf + f� f • t a gad" 14 TOWN OF BARNSTABLE V LOCATION f/ ,SEWAGE # �� VILLAGE ASS MAP & LOT INSTALLER'S NAME 8i PHONE NOS_/ LbL,Z. SEPTIC TANK CAPACITY C; 'L LEACHING FACILITY':(type) C- � �_,� (size) -9; NO. OF BEDROOMS PRIM TE WEII OR P IC WAT. BUILDER OR OWNER-69p�� DATE PERMIT ISSUED: DATE COLIPLIANCE ISSUED: VARIANCE GRANTED: Yes No /�J r 4-3 --- 4 r Z� FEs..... ......... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Appliration for Uiipntia1 Mar Tongtrnrtion ermit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: n n 0-r /!� �,�,v�3sia�iL rP-®ph MAr2370NS MZCL� M�+ - -._...... - .._.. - .................................•--•:--------• -----.----•� . l�r� C >Z C(_N 73...jocation- iU es O P 5 fJ l�Ot '' ` ! N VSLL e J . it_5 Co r OwnerOwner... SQ Address Installer Address /� Type of Building Size Lot... ...f-------------------Sq. feet ddO a Dwelling—No. of Bedrooms............. ............................. Attic (Y) Garbage Grinder (�) pa Other—Type of Building ............................ .No. of persons............................ Showers ( ) — Cafeteria ( ) PaOther fixtures ---------------•-•--•---•----•-- - -- --•----•----------••-----•---•-------- W Design Flow.................`..�............•.....•..gallons per person per day. Total daily flow._........_..._..�.d_.........._.......__._gallons. P: Septic Tank—Liquid capacity t6PP__gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No. .................... Width.................... Total Length...._............... Total leaching area--------------------sq. ft. Seepage Pit No--------------------- Diameter--------------...... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) I" `" Percolation Test Results Performed b CFv �� �' w"G'"` •-• Date....d' ..3a ..� Test Pit No. 1__-_C.a___._minutes per inch Depth of Test Pit..... ----- Depth to ground water---- Ald'15---____- 4L Test Pit No. 2................minutes per inch Depth of Test Pit.................__. Depth to ground water------.................. W ...•---•-•-•----------------•---- O Description of Soil................ `"r�� �'E�R e Zs V --••-•-•-•-•-•------------------------•-----••---••-•••---••••-•------•--•••••----••-•--._...-•----.....••-•----••----•---•••--•......---•--•-•-••......----•--•------W x •-----------------------------------------------•-•-----------------------------•-••-•-------------•---•-----------•-•----••----•-•---•-----------•--------•------•••••-------•----•--••----•-•---••--- U Nature of Repairs or Alterations—Answer when applicable._________________________________________________•-_-__-__-___-___-___-•---_____----_-------__. -----------•------------------------------------------•----•------•-----•-••------••-...........-••---•-••-••---•-••-------•----•••--------•-------•---•--------....................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of' T':.:: p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b n issued y the board of health. '_ Aye lV- Signed.... ...... ..................f.................................................. -----!/ Date Application Approved By--•- ---------1-' �� `�------ Date Application Disapproved for the following reasons:-------•-----------------------•----•----------------------------- ----------•--•-• •--_------•--------- --•••----•••-----•---•----•-••--••-••-•••----•-••---••-•----••-•------•--•-•--------•----...•-•-----•---•------•-----•-••-•--•-•-•---•••---•-••-•-•---------•------•-••••-------•.....•---•----••-•-•--- ^ e� Date Permit No.............(.tij.-.I.....:..:J ......................... Issued.............................................------...__ Date No................--....... � FEB............... ..,y... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......... ......OF...... �d f -------------------------------------------------- App iratinn for Disposal Wor S Cnnnstrurtiun Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .................s.................. ...... ..... ... Location- ddre Lot IQo. ! i e �ri �C +sr � p �a , r.�E� --....... - ----------- --------------------•--------............------ .........._............................t.......................................................... g Owner Address •-------------------------- ------------•--• -----......----•---•--.. .---...---------.._........_.........-----....--------•-•----------•rr•--._._........S---'feet Installer Address q. Type of BuildingSize Lot... Eat Dwelling—No. of Bedrooms............. ..........................Expansion Attic (`" ) Garbage Grinder ( f) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) W Design Flow... they fixtures --- gallons per person per day. Total daily flow..-.......•3 !N..._.._................gallon. G: Septic Tank—Liquid capacity O ..gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—NTo..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area......_...........sq. ft. Z Other Distribution box ( ) Dosing tank ( ) a Percolation Test Results Performed by ' - --- Date.. 1.1 -`' le t -•--- 15 -Test Pit No. 1....�. ....minutes per inch Depth of Test Pit....r _!_. .... Depth to ground water .-A--✓ ---e' ----- 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..._-_-____-____-..._. P4 -----------.........................................................................................--.......-------------•-•------------......._.......----- D Description of Soil------ ............5 a re) `�=-�- - e&I '.( _.. -------------------------------------------------------------------------------------------------------------------------------------------- .......................................................... 0 Nature of Repairs or Alterations—Answer when applicable.--............................................................................................. -------•-----------------------•---•-------------•------------------•------•--•----........------•-----•---------------------------------------...----•-----•------•--------------•------------.._..... Agreement: The undersigned agrees to install the afor edescribed Individual Sewage Disposal System in accordance with the provisions of TTTt.-w of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Co pliance has ben issued y the board of health. 6 -� . t 4 Da _ Application Approved B 9 Date Application Disapproved the owing reasons:----•---------••----•------..•..---•-------------------•-------------------------------------•---•-----•-------- --••-•-••-•---•--------------••-•-----•-•- ------------------._...---------•-----------•••••-•••--•--••............-•••••......----------------•-••••----•------•------•---••...... Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH %-Cutifirat r of Toutplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed O or Repaired ( ) bY-----... -------a *,c c _ .......�t.-.....`'.0-" ---------------•--------------- �y Installer at......--• -.. .....a N +. <.... ...... . ---`-— a A ,t E,. .... has been installed in accordance with the provisions of i T / The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated----------__.._...._._.___..__--_-_-_---------. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. �'\ DATE..................••--•. --- Inspector...............-. .....................--•-----------------------••-- THE COMMONWEALTH OF MASSACHUSETTS pc, BOARD OF HEALTH No..........:..•----------- FEE.- Disposal Works Tonstrurtion jkrmit Permission is hereby granted....... 0�� t. q' ' ----------------------------------------- •-•--•....... .-•---•------- to Construct (` ) or Repair ( ) an Individual Sewage Disposal System •----•... ....--•- ......... .r---------- - --------- • ............................................................. Street as shown on the application for Disposal Works Construction Permit ...��..�.._._ Dated.......................................... ........ Board of Health DATE--------� -----� �,�------•-------- FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS i COMMONWEALTH OF MASSACHUSETTS = EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION i TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: /,;2` K Owner's Name: Owner's Address: Date of Inspection: Name of Inspector:,(please print), Company Name: /K ,�— Mailing Address: ' C _ �l Telephone Number: JS"`Ca _;'s— CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reponcd below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my rrauling and experience in the proper function and maintenance of on site sewage disposal systems. I arff.41DEP- approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: a Passes—Li Conditionally Passes — y4 Needs Further Evaluation by the Local Approving Authority Fails _. Inspector's Signature: j J�� 1�. Date: �•� � G, r,r k The system inspector shall submit a copy of this inspection report to the Approving Authority (Bard of Hcaith or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original,should be sent to the system owner and copies sent to the buyer, if applicable, and the appruyin�-, authority. Notes and Comments '***Phis repor-i only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 inspection Form 6/15/2000 page i Page 2 of 1 I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: /,2/ :2,y /',f/L 71Y. Owner: Date of Inspection: -) (r, Inspectio❑ Summary: Check A, ,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If"not determined" please explain. The septic tank is metal and over 20 years old* or,the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. 'A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed ND explain: 2 Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ;2 ha r-�� .- Owner: Date of Inspection: _� /;z /(} T C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system.is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitroger is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate "yes" or"no" to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool .Discharge or.ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or N. cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than '/, day flow _Z Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ✓ Any portion of the SAS, cesspool or privy is below high ground water elevation. _ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ ✓ Any portion of a cesspool or privy is within a Zone I of a public well. 7 Any portion of a cesspool or privy is within 50 feet of a private water supply well. j� Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as. described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes" or"no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— I WPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 111 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 42 / , Owner: Date of Inspection: 1 __ Check if the following have been done. You must indicate 'des" or"no" as to each of the following: Yes No Pumping information was provided by tha owne occupant, or Board of Health �[ Were any of the system components pumped out in the previous two weeks ? Has the system received normal flows in the previous two week period '.) Have large volumes of water been introduced to the system recently or as part of this inspection ? ✓ _ Were as built plans of the system obtained and examined? (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out ? 1z _ Were all system components, excluding the SAS, located on site? I/_ Were the septic tank, manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ? •/_ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes no _ Existing information. For example, a plan ut the Board of Health. t/_ Determined in the field (if any of the failure criteria related to Part.0 is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)) 5 Page 6 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: A; , r Owner: Date of Inspection: �— FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):( gn): Number of bedrooms (actual):� DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x # of bedrooms): Number of current residents: `Z, Does residence have a garbage grinder(yes or no): /,JO Is laundry on a separate sewage system (yes or no):&0 cif yes separate inspection required] Laundry system inspected(yes or no):AC} Seasonal use: (yes or no): Water meter readings, if available (last 2 years usage (gpd)): Sump pump(yes or no): ^-�C> Last date of occupancy:j-7' 0—�}-�.1 COMMERCIAUINDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203):—__ gpd Basis of design flow(se ats/persons/sgft,etc.): Grease trap present(yes or no): — Industrial waste holding tank present(yes or no): — Non-sanitary waste discharged to the Title 5 system (yes or no): — Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as pan of the inspection (yes or no): IU(3 If yes, volume pumped: gallons -- How was quantity pumped determined? Reason for pumping: --- -- --� __ — TYPE OF SYSTEM . Septic tank, distribution box, soil absurptiun system _Single cesspool Overflow cesspool _—Privy _Shared system(yes or no)(if yes, attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) Tight tank. —Attach a copy of the DEP approval —Other(describe): Approximate age of all comp one Its, date ' stalled (if known) and source of information: Were sewage odors detected when arriving at the site (yes or no): IJJO 6 Page 7 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1�21 � 1a rk %c . Owner: Date of Inspection: _ BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: _(locate on site plan) Depth below grade: 1 v Material of construction: cuncrete _meuil _ .fiberglass_polyethylene —other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _(attach a copy of certificate) h •4 a Dimensions: / (j k S d 1( ,2-7 Sludge depth: % i Distance from top of sludge to bottom of outlet tee or baffle: Z� Scum thickness: % Distance from top of scum to top of outlet tee or baffle: 4�1p h Distance from bottom of scum to bottom of outlet tee or tlaflle: How were dimensions determined: fsR"�.as�.�.d�i it.{.��s L.�-t A-►t'n- Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): _ GREASE TRAP: _(locate on site plan) Depth below grade: _ Material of construction: —_concrete__—metal _ fiberglass__polyethylene_other (explain): —_ Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7 Page 8 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: n/ Owner: j,S' Date of Inspection: _ TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete metal _fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: _gallons/day Alarm present (yes or no): Alarm level: Arum in working order (yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX:LL(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): / PUMP CHAMBER: (locate on site plan) Pumps in working order (yes or no): Alarms in working order(yes or no): Comments (note condition of pwnp charnbcr, condition of pumps and appurtenances, etc.): 8 Page 9 of I 1 OFFICIAL INSPECTION FORM -- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ��/ 1- ��• i Owner: i"o Date of Inspection: l SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: T✓y e leaching pits, number: _ leaching chambers, number: _ leaching galleries, number: _ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number: _ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): CESSPOOLS: (cesspool must be pumped as part of inspect ion)(locate on site plan) Number and configuration: Depth—.top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no); ._. Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 9 Page 10 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: �2� ���(-� C. �/� 1• Owner: rf Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Lo(mte where public water supply enters the building. Li i �O �. 10 Page 1 I of I I OFFICIAL INSPECTION FORM ,.. NUT P'OR VOLUNTARY ASSESSMENTS SUBSURFAC4SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 11/ ��i' _YjI C . Owner: c S Date of Inspection: ^ SITE EXAM Slope AJ c Surface water ,j U Check cellar '1brL e, Shallow wells tj o Estimated depth.to ground water y(."� feet Please indicate (check) all methods uScd to deter) mic Ille lttgll gl'Ound water elevation: Obtained from system design plates on rccurd - If chucked, date of'design plan reviewed: — Observed site(abutting property/obscrvation holo within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers- (attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: I1 FORM30 \'I�� HOBBS&WARREN'M THE COMMONWEALTH OF MASSACHUSETTS BOARD O F HEALTH CITY/TOW w _ DEPART R NT o ADDRESS ,,T gEL �E � � P �HONE 12 Address i01, ----- -- --- — Occupant 0 4- Floor Apartment lNo._ - No.of Occupa is o No.of Habitable Rooms ? No.Sleeping Rooms-- — No.dwelling or rooming units _ _ No.Sto ies.__ __ Name and address of owner_ j>pp '� ,�o— .$,Q. YO &2k l j 0 Y.(M/l Remarks Reg. Vio. YARD Out Bld s.: Fences: V'I D. . 3 Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows.-- Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall, Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusin ,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom 1 3 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.: I,20 Stacks, Flues,Vents,Safeties: - - _Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS C ECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PERJURY." r ,ems INSPECTOR a TITLE a L A.M. DATE _ ® TIME l©` P.M. A.M. THE NEXT SCHEDULED REINSPECTION P.M. EJ 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B)and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any abject, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0) shall be deemed to be a con- dition which may endanger or materially impair the health'or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. -\ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE QFFICE,OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF'ENVIRONMEN JUL 2 9 2004 TOWN OFBARNSTABLE HEALTH DEPT. TITLE 5 OVFIChAL IN PECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS is CIO SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A co CERTIFICATION U_ MAP Property Atiddress: r-. / �j yZ STu�S PARCEL: : IZ)?- O® Z N",. LOT 1 . • •,.. Owh�er's�:a°me: V.n1L`.S Owner's Address �S� w�•t Date of Inspection: 7 22, 75 e Name of Inspector: (please print) Company Name: l T' - Mailing Address: �tv ca Telephone Number: 6-0 j0<PX- 6 700 `" OD P CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information eported co below is true, accurate and complete as of the time of the,inspection. The,inspection was performed based on my r_3 rn training and experience in the.proper function and maintenance of on site sewage disposal systems. I am a D P approved system inspector pursuant to Section 15,340 of Title 5(310 CMR 15.000). The system: .Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature. i��L��� �� o /! Date: 7�Z•�S/ The system inspector shall submit a copy of this inspection repbrt to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system.is a shared system or has a design flow of 10,000 gpd or greater, the inspector$nd the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 . Page 2 of I I OFFICIAL INSPECTION FORM-NOT FOR VO LUNTARY OLUNTARY ASSESSMENTS SUBSURFACE. SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: /,2 I .J Cot —1zCl / q �e Owner: Date of Inspection: 2 1/0 I❑spection Summary: Check A B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have-not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If"not determined" please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or eViltration or tank failure is imminent'. System will pass inspection if the existing tank is replaced with a complying,septic tank as approved by the'Board of Health. 'A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available, ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health):. broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced, ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND,explain: 2 Page 3 of I 1 OFFICIAL INSPECTIONYORM'.•NOT FOR.VOLUNTARY+ASSESSMENTS ' SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A, CERTIFICATION(continued) I`. Property Address: �/ 'j ) Owner: Date of Inspection: Z, d C. Further Evaluation is Required by the Board of Health, Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment; 1. System will pass unless Board of Health determines In.accordance.with'310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect-public health,;safety and the environment: Cesspool or privy is within 50 feet:of a surface water.,,. _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health,safety and environment: '•JU , tld ., „• lli:iiiv/ Y' ;' 1r! :. _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or.tributary to a surface water.supply; — The system has a septic tank and SAS and the SAS is within a Zone.•1 of a public water supply. — The system has a septic tank and SAS and the,SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and,the SAS is less than 100 feet but 50 feet or more from a private water supply well**.Method-used to determine distance.." r **This system passes if the well water analysis,performed at a DEP certified d laboratory,• bade ' for colifo bacteria and volatile organic compounds indicates that the'we 11 is free from pollution the presence of ammonia nitrogen and nitrate nitrogeri is equal to or less than 5 utmn from that facility and failure criteria are triggered::A copy of the.analysis must.be attached to,this.forme ' provided that no other 3, Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM NOT<F,OR:VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A:'V :l CERTIFICATION(contiiiued) Property Address: Owner: . Date of Inspection: D. System Failure Criteria applicable to all systems; You must indicate "yes" or"no to each.of:the following fora 1 inspections: . Yes Nn Backup.of sewage into facility or,system component:due to overloaded or clogged SAS or cesspool _Z Discharge or ponding,of effluent to the surface of the ground,or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box"above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/, day flow _jZ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped IZ Any portion of the SAS,cesspool or privy is below high ground water elevation. ,L Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water:suPPly. - _6Z Any portion,of a cesspool or privy is:within a Zone l of a public}veil. _jZ Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool.or:privy is less than 100 feet,but greaterlhan.50 feet from a private water supply well with no acceptable water quality.analysis; (This.system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well istree from pollution from that facilityand the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to.this form.) (Yes/No).The system. ails.I.have.determined that one:or.more of the above failure criteria exist as. described in 310 CMR 15.303,therefore the system,fails:,The system owner should contact the Board of Health to determine what will be necessary to correct the failure.. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either`yes"or"no"to each of the following: The following criteria apply to large systems in addition to the criteria above) yeS no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the systetir is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator'of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM:-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL:SYSTEM,INSPECTION FORM PART B ! CHECKLIST Property Address: 2 ,J r Owner. / Date of Inspection: :7 /2-1- Check if the following have been done.You must indicate"yes"or"no"as to each of the following: t • Yes No ✓— Pumping information was provided by the caner ecupant, or Board of Health ✓ Were any of the system components pumped out in the previous two weeks ? — Has the system received normal flows in the previous two week period ? Have large volumes of water been introduced to the system recently or as part of this inspection ? _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) — Was the facility or dwelling inspected for signs of sewage back up? — Was the site inspected for signs of break out? — Were all system components, eluding the SAS, located on site 7. . — Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees,material of construction, dimensions,depth of liquid, depth of sludge and depth of scum ? Z/ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no ✓— Existing information. For example, a plan at the Board of Health.. — Determined in the field(if any of the failure criteria related to Part.0 is at issue approximation of distance is unacceptable) [310 CMR]5.302(3)(b)) w' 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOWVOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSALtSYSTEM INSPECTION FORM PART C f SYSTEM INFORMATION Property Address: r Owner: Date of Inspection: RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): Number of bedrooms(act#)::L . DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Z30 Number of current residents: 3 Does residence have a garbage grinder(yes or no): ,�>O Is laundry on a separate sewage system,(yes or no):No [if yes separate,inspection required] Laundry system inspected(yes or no): No Seasonal use: (yes orno):No.,.,:..;,: ,:,: ;,•... .::: . Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no): N O Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): >nd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no):_ �;,:, ; .;,; Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): If yes, volume pumped:b00gallons--How was quanti pumped determined? T.y /C, ` 7te-ICk Reason for pumping: /-fo •.� 'i A-+)Gee TYPE OF SYSTEM Septic tank,distribution box, soil absorption system _Single cesspool Overflow cesspool -Privy Shared system(yes or no)(if yes, attach previous inspection records, if any) _ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components, date installed if known)and source of information: b� N u6L IT R-r Were sewage odors detected when arriving at the site(yes or no):&L-0 6 Page 7 of I 1 OFFICIAL INSPECTION:FORM--NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE'DISPOSAL.SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION:(continued) Property Address: IA,-4/ ,J r 7—o. Owner: Date of Inspection: Z. BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: _(locate on site plan) Depth below grade: /Z ` Material of construction:Zoncrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes.or no):_(attach a copy of certificate) Dimensions: /Oz STD k'7 Sludge depth: ! Distance from top of sludge to bottom of outlet tee or baffle: 2. • Scum thickness:.. Distance from top,of scum to top of outlet tee or baffle: 41 Distance from bottom of scum to bottom of outlet tee or baffle: y How were dimensions determined: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural.integrity, liquid levels as related to outlet invert,evi ence of leakage9�etc.): �?l` J GREASE TRAP: _(locate on site plan) . r Depth below grade: _ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions:- Scum thickness: Distance from top of scum to top of outlet tee or baffle: P Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): 7 Page 8 of] ] OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION,FORM PART C SYSTEM.INFORMATION(continued) Property Address: Owner: Date of Inspection; TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material.of construction: concrete metal fiberglass__polyethylene other(explain): Dimensions: Capacity: gallons • Design Flow: T gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments (condition of alarm and float switches,etc.): DISTRIBUTI ON BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments (note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box, etc.): PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): • Page 9 of 11 OFFICIAL INSPECTION YORM-NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION(continued). Property Address: -7;�,J r Owner:-F t Date of Inspection: Z, O SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) 1f SAS not located explain why: Type ' ✓leaching pits, number: _ leaching chambers, number: _ leaching galleries, number: leaching trenches, number, length: leaching fields,number, dimensions: _overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): 1 1 f G N a ) .J f 4 CA t a✓i /t ull v CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: . (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 9 Page 10 of I I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /I/ z, Owner: Date of Inspection: 7a SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. z,3` i �rl` r , 4 � a _ 10 Page 1 I of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFAC4 SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . • SYSTEM INFORMATION(continued) Property Address: Owner: T Date of Inspection: SITE EXAM Slope tis o Surface water v o Check cellar Shallow wells ,..� 'e Estimated depth tpground water �D feet "Please indicate (check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: —Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: ✓ Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: P e5 a/' a(Z-r-r-, ' 11 i SHEET 7 OF 7 i i A* I MARSTONS MILLS LOT 130 ,wtw LOT 129 LOCATION MAP _ 1e1 f\0►O OT 2 4` i-� i il4 LOT 12b' r6 \� i IIJ / LOT Jt LOT 137 101 ��'\... �59 4 17 10.JN s7 sL ! fi LOT 124- ' lei ,1 d LOT 106 1 0 I `� r_ V / ► A i r ffA � ypad 1 e I � -'101V25"" ';yoo LOT 123` r I ` LOT 1 w 11 .1;i 1 b /1. '# ( lA+ X L_ 74e LOT 13 Kew b1i LOT 149 I �� once s i " / p C LOT 'li / 101 LOT 134 L�f 133 j6 1 1 �\ ��' LOT 122 ,aaa t UAU �' 1 ly '� „ 1eb, ,' r ;yo 1/ • '�LOTe s1 COT 107 Tsai 1!. ` ! WS LOT 14e 1aS�! / / 4� -COT MO ^ t fi.S > / /� �0.1 '1a °iIOT 147; o y ` �, ' -, faae�r ' 1 RD/ ` °r —�— �-�/ t LOT 11 79w , e s o > L T j' tom 1�O 1/ v •`, Imes �� >l'�'' , LOT 117 \ LOT/143�` T f ' \4] / �' Pam' •' „7►,0 `}, �~ 0 a 'LO7< d` ,oba RK ,�, M ` 11,0 .•� � 1 '' $ 5" /r1EeT 7A or"I Po1C Srnt.. vt s A►4p 1/ G LOT 115 �• \., ywtsvu llw4 -Mor. Riffoow{a. LOT 146 -LM145 ,Jh'�, o a !.taf 04rS7 7A oPOP- {.7 }� �trmNp•, LOT 10E `. ? 1/� /om SF ( 9t rot 4 7j IL, ool f .r LOT 116 ! �r \. J LOT 11� 10. a IL t m IF lei LOT w.1Pe� + LO 114 ' `} �• LOT 11� t0.m,1g �, 14 OF y ,0.eM 11• .a i Isle 06 .0,41w1N0 e4 bM0 �. ws.MlldJb r ��'' 1�1 �• b� r � 1 ,�, 3 11 29 8B FINAL BLDG. AND SEPTIC LOCATIONS PAL BUILDING LOCATION PLAN DON ll 0 1�� e.j' Sy 1 10 2 INITIAL I ELK No ° eT BUILDING LOCATION PLAN M.'RSTONS MILLS WOODLANDS LOT 110 N \ LOT 109 ,7,eee¢ 1 BARNSTABLE, MASS CHUSETTS PON WOODLANDS ASSOCIATES \ \\ SCALE: 1- w 507 JOB NO. 1339�aJ�,o o•_ b.� Jo a �,'-'"r^u t\:1• I f1 LEVY, E2=1 & ►AGNO MICU INC aLmme Loom mmn Mimi m uiaaea 889 WM HALLO STRW CNRTzffv= MA o�ssz • a .. ,3 SHEET 7A OF 7 ou ewv rr►w AR r ri o IS apa r I1AR I�rT�3A a rS OLMAR are t A I OESCN CALCULATi0f15: ® RlRmut or smtems eommm se.K an " s ra a MIX ow"Im woe R) �. tOG110M 11AP ���� Iwgi t�q R ftoL was IN m R r - K TIMWAL SIX OFC TTAAIRr XW Alorm umC TY �0�, IBM howls AKA WL L$r Ifs_C PACIT"r �:`mocnA 7 ses nu um li �1 sox mu•me 1111:"a or •ARIt•rYl• mum An �4MICIIf r0R D[NNlAQ 01110MO L v KMM 1000 QALLON STTIC TANK r r r I t �rOiwv n�T mum �K snomwr 70 a MY w W"umn um TO San armsl to•AC s [ SEPTIC SYSTEM o0�11 F 1 to 1 WMA• ALL CCte or TK tlAlerARr weld at"K CAIAt[ en w reAIL lIOTTOM OF TEST MOLE v■Rm mom It-»Lemo m Mal 1149Y AR[umm OR _ WMI 10 R.CI OWAS ON/MelRl MM R-=e 1UP011000 LEAdeNO PIT FOWL t umm A 1010011 to R.01,1111111112 CR • Ipt011TK AID 141R}CAL CmmoL.Kt mw 6AINVIINK j •1MelO MA Re1mm e,uLmq RM file-to i LOT N0. ELEVATIONSFOX W"LEOOHD: ELEV. 106 1T7108 109 110 111 112 113 114 115 116 117 118jI119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 Sim TAM Roileox� � OCAn I r.O.FOUND I Anclom MIARY U AYese rrr p A 75.5 7s.5 71.0 76.o 7bo 710 7s•e 1411 741E 1s•5 7L.0 77.• 7r.e� 00.e,;6.•+ eel •L• No ♦til,• M• - 31.o 91.e 7 rmCR�MTl01T T 7�f •%%0 74,5 7f.6 ro 74.• 7!O sm at Mom well Imlil 7'4.e 74,? 7i•e 7fe 74.0 7e,o '71r•5 •f 7s.o 74io 73.0 70.0 71.5 7H1. A B 1b.e 64.0 6" iN ii•1 M.0 Ns 71.5 7t.o 7}• 7" 7*0 76.0116; I>:5 rs W.7r•1 1b•I X.S. - 'wo 7M 1*4 f 71,i 71+1 24 xe THr�i 7!s T;.f 4 70.5 741 7;,'1 1 71.1 7yA 7i4 N4 Ks "f •4W -p,v B C 7Ie.1 s 69.7 •sH► "S i77 Kt 7ti Al 79J 71.1 74•s 7r.7 7••t 177. 17•t �. T7•� �7.b 'K.t - 77.7 i1. 7 71.t 14 '7L; 7t.i 71•s 7o.s 'k-t 11.1 7%% 7;.i 7f.3 4 7A4 1t•0 7t.1 71. 61.1 66 0!3 r3.1 10.7 C 0 70.0 H.. 6e.1 604 60•4 61.0 60.e 7te 71•9 7sf 79,5 74.0 10.9l 71.0 r.0 77.e 7b.e 7s0 77 X.o - 77.0 7714 7!•e o '71.1 4i4 'A.I 70.0 70.0 7Gf 7}o ri4 ftol 71.1 7S+ 1a./ 71A 7b. 641 HPbo yfe •H►s 7k5 �p E i41/ pe•e •t3 i;.4 K,i is3W i 7l.3n. 7.3 A! J 7. f 7 y10 Tl4 is.* 73, ; EL11.3 7 7 F 6e,1 •tt ps.t •tt 64.6 ,.• -4.1 71.1 • 7s•Ir 7f.1 7f.6.�i II;H, 76.6' 111 77,1 77.1 14 - 77.1 711 ` 7iY 1n7 7ssf 1 19.1 64.1p NqJ 71•L 7t.i 71 74.7 744 7s.1 1•i iAs 66 1r5l.i 64+ 6 •9 5..01 7A4 F G 6,1.S 69.0 1eoir.0 670 to73•S 7f.0{ 7i. 775 7. 14.6 s.0 7 .1 1• 4.s1.0 •s •0 745 74.e 7s.• ,sa71r -I*-*- 7LO 77.0 G !i H •30 iL8 eto 57.0 s1.o •Lo •s•f •Af ►so 64.9 Hte A7.5 •10 ,v1.6 I7o.f lie. 71.5 't.0 71•o a1.5 - 71.0 71.0 o1s +.T•f i./.f K.e r4s psf p!f ifo rhS H Hso 405 b4AP %o "t 64.6 14.5 ps•f 64f 9i.f I.s.o A.4o APPROVED: BOARD of HEALTH J f4s ff.s f5•0 e;0 we .4T.0 ffA 60.1% pLp it•I L;• Nf •s,o� if.5 �e.e Lie i7S •10 p7;o 649 - 1-7.e ii•5 ib5 •s.f N•f 0t.• M•f. 51.t 043 il•0 •ts •1ke p4r s4.o H.s.• ps.o Wf p.f db4 41.s 1.0 .o (e.o J K 7Rt 71b 7e•0 •4o µo 7e.0 11.0 7t•3 73• 7kf 7l.1 s.0 77.f 74.e 4,f 7}5 f•.• 0mv600 71•5 _ bqo ytLf •A� A� 4 11 3 7f.3 744 74.0 75.0 U3 7s•e 70.0 74• 78-5 77,0 7s 1s 74f 1'w3 7} I• 61•0 7b.f it.* 7K.o K I L 78•5 W.5 6e.0 60-0 hs 0•0 10.1 70.0 7;,c 04 7t.o 170.9 17.01 A.e 7Me 19•e 74f 7*91 70.3 75.e - 71•b 'H•b 71•0 7&'• 7;•s 711.E IL 794 73-01 73•f 74.7 ,0 7" 7k0 1f's '49 74.0 111.e 11.0 10.0 7t6 73.s L 1I i M n.o 71.e 479 7IRo7 •e 77.0 Y l » .r s1: 9 70 - 7. f 46-0 n,o 7;t o 'As ss.f 72,s 175.0 74 1 o s 70.4 14.4 7so 7b. A4S Ito 1f.s M r s N 79.0 77.0 J40 60.0 66.0 .79.9 7'&0 71.3. Ito 7*3 'he 716.0 7t.bl 7tyl 710 7k%o 74.4 7" Ito 7i.0 7•.0 7 71.e 43.5 7;.f 1}0 7s•t 74r 1s.0 76..5 r. -r!•3 14.3 7i•0 7;«O ARHr s H►o i4,o 1••S 7e.S N 1 12 INITIAL ISSUE MCT r `� NO. DATE DESCRIPTION BY HN PERC TEST 1 C TEST 2 PERC TEST 3 PERC TEST 4 PERC TEST 5 SEPTIC SYSTEM DESIGN LOT 116 - LOT 125 LOT 131 LOT 14e � L LOT I" 'f �:. M A RS TO NS MILLS WOODLANDS IN BANKMe onew+er eAuee.nL eeK >• ~` • �_`_ BARNSTABLE. MASSACHUSETTS swelf.e! `- r w M �ARee SIM INS 1100111MR>•A�rtrt� WOODLANDS ASSOCIATES REALTY TRUST all .e. u11M War .e.� SCALE. 1' >• 40' JOB No. 1]3e/sne a BATS v INK Tm� CAI v SK iQ1� OAT[C►RCl TQ1 Ml[v e64 MMS M . b r WI110N Or ■llmm BY A WTI==BY A A•-° ATIw�BY A.i` McTRON ry TOT MA• pote"im RATE 3.L10L/Mel POtMAIM RATE-&A-- A m /gpaAlgl Mlt SH�se1L/MOI Pm00.Allm1"it "0 -u-m'A� P010"1mR BAR SLrybl I n •`C,�f PERCOLATION SOIL TESTS LM MIDGE TAG11$R 0=43 lip• oIa® lam amteT.1 a to smte OEY nL41 JUM srxar CZ1slR = YA IIIl0.1Y - r LEGEND MARSTONS MILLS {� PROPOSED CONTOUR 98 PROPOSED SPOT GRADE OLD FALMOUTH RD. —— 98 —— EXISTING CONTOUR F + 96.52 EXISTING SPOT GRADE p. W— EXISTING WATER SERVICE of n LOCUS TEST PIT o� v S Qom' -A �pN P EXISTINGE 1,000G '. LOCUS MAP SEP. TANK LOCUS INFORMATION 120.00' --- --� 77---�—-- o TITLE REF: C7 83240 78 _ PARCEL ID: MAP 100 PAR. 027/002 - --- LET-11 9 AREA = 10,200 sf+- Q�%�^,• LAND COURT PLAN 29500"fl {° EXISTING �\� — ,Z ASSR MAP PCL27-2 SEPTIC SYSTEM � LEACH REPAIR PLAN —-{ -�- �1 �--� ' LOCATED AT: �� x �� I 121 TANBARK ROAD �, 1.-12.5'-a o MARSTONS MILLS, MA m J z \ TP-2 o PREPARED FOR /U0 N o z z +z ° o SANTON/EAGAN rrl rn I i p SEPTEMBER 27, 2015 z _ 78 10 f OF Vq PAVED DRIVEWAY b A RE M A�.�E�� \ N o. 1140 I7 120.00' 7- ----�— MEYER & SONS INC. } BENCH MARK P. O. Box 981 PLAN PAINT SPOT ON E. SANDWICH, MA 02537 BULKHEAD CORNER — 1 -PH. 508 360 331 78.68 ( ) SCALE: 1 in = 20 ft USCS DATUM ASSUMED fax (774)413-9468 i - meyerandsonstitle5@gmail.com www.meyerandsons.com SHEET 1 OF 2 J#1491 TOP OF FND. NOTE: PLACE MAGNETIC MARKING TAPE OVER ALL COVERS EL: 77.91 BRING ALL COVERS TO WITHIN 3" OF FINISH GRADE FINISHED GRADE (76.40) A�F.G.EL: 77.4 F.G.EL: 77.4 F.G. EL: 76.8 � MAINTAIN Z% MIN SLOPE OVER LEACHING AREA ° F.G.EL: 76.35 2" OF 3/8" DOUBLE WASHED / » V. STONE OR FILTER FABRIC 3/4" - 1-1 2 . DOUBLE WASHED STONE 6„ 4" SCH 40 PVC t 1011I ®®®®• O ®®®® 14 6 Co? S= 1% (MIN.) ®®®®®®®®®®® TEE'S ARE TO BE INV. ��•� ®®®®®®®®®®® :4 4" SCH 4o PVC 2 EFF. DEPTH ®®®0a0a00®® :A INV.75.05 INV. lq:10 4' 2 X 8.5' 4 EXISTING OUTLET BAFFLE ' GAS PROPOSED DB-3 :...•. ., •.:..•. . DISTRIBUTION BOX EFFECTIVE LENGTH = 25' INV. 75.30 `� . ... (1-120) INV. ELEV.= 73.2-'r EXISTING 1,000 GALLON SEPTIC TANK GAS BAFFLE TO BE INSTALLED ON P��� OF '�ss9 BREAKOUT OUTLET TEE AS MANUFACTURED BY � cyo ELEV.= 74.25 TUF-TITE, ZABEL, OR EQUAL o ARREN M. �, �, TOP CONC. ELEV.= 74.25 im NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING I 0" 11.40 INV. ELEV.= 73.25 lam 0 •00 PIPE INVERTS PRIOR TO CONSTRUCTION \ ®®®®®®® 2) D-BOX SHALL BE SET LEVEL AND TRUE TO 'pf�/$fit � ®000000 GRADE ON A.MECHANICALLY COMPACTED SIX p� ®®®®®®® X4NITAR� �L BOTTOM EL.= 71 .25 ®®®®®®® INCH CRUSHED STONE BASE, AS SPECIFIED IN 3.75' 5 FT. 3.75' 310 CMR 15.221(2) �CkZA �� 3) REPLACE EXISTING 1,000 GALLON SEPTIC TANK SEPARATION 5.85 FT. EFFECTIVE WIDTH = 12.5' WITH 1500 GALLON SEPTIC TANK IF FAILED, DAMAGED, NOT H2O LOADING, OR UNDERSIZED. SEPTIC SYSTEM PROFILE SOIL ABSORPTION SYSTEM (SECTION) 4) INSTALL INLET & OUTLET TEES W/ BOTTOM OF TESTHOLE EL: 65.40 GAS BAFFLE AS REQUIRED (500 GALLON H2O LEACH CHAMBER) GENERAL NOTES: SOIL LOGS DESIGN CRITERIA **NO PROPOSED INCREASE IN FLOW** 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL P#: 14817 NUMBER OF BEDROOMS: 2 BEDROOM DWELUNG/3 BEDROOM DESIGN BOARD OF HEALTH AND THE DESIGN ENGINEER. 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS DATE: SEPTEMBER 17, 2015 SOIL TEXTURAL CLASS: CLASS I (0.74 GPO/SF) OF THE STATE ENVIRONMENTAL CODE, TITLE V. AND ANY APPLICABLE DESIGN PERCOLATION RATE: <2 MIN/IN LOCAL RULES AND REGULATIONS. SOIL EVALUATOR: DARREN MEYER, R.S., CSE #1614 DAILY FLOW: 110 G.P.D. X 3 BR = DESIGN FLOW: 330 G.P.D. 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFlLLED PRIOR WITNESS: DAVID STANTON, BARNSTABLE B.O.H. TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE GARBAGE GRINDER: NO (not designed for garbage grinder) DESIGN ENGINEER. 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING Elev. TP-1Depth SEPTIC TANK: 330 gpd x 200� = 660 gpd, USE EXISTING 1,000 GAL. SEPTIC TANK TP-2 oe th FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN Depth � Elev. � ENGINEER BEFORE CONSTRUCTION CONTINUES. 76.50 A 0" 76.40 0" (330) = 445.94 S.F. t 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. A LEACHING AREA REQUIRED: 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF LOAMY SAND LOAMY SAND •74 O T THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF 1OYR 3/1 , HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. 76.25 B 4" 75.90 s" USE TWO (2) 500 GALLON (H20) PRECAST LEACH CHAMBERS W/ 4 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. LOAMY SAND LOAMY SAND STONE ON ENDS & 3.75' STONE ON SIDES: 25' L x 12.5' W x 2'D 8.ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED IOYR 6/6 10YR 6/6 TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. 73.32 38" 73.32 37" BOTTOM AREA: 25 x 12.5= 312.5 SF 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE C C SIDE AREA: (25 + 12.5) X 2 X 2 = 150 SF THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING MEDIUM SAND MEDIUM SAND CONSTRUCTION. PERC 0 EL. 72.25 2.5Y 7/4 TOTAL SQUARE FEET PROVIDED = 462 vs. 445.94 REQ'D 10. EXISTING LEACHING TO BE PUMPED, CRUSHED AND REMOVED PER TITLE 5. 2.SY 7/4 REMOVED ALL SPOILED SOILS AND REPLACE W/ CLEAN MED. SAND PER TITLE 5. 69.83 C2 80" t 69.40 C2 84" DESIGN FLOW PROVIDED: 0.74(462 S.F.) = 342.25 G.P.D. vs. 330 G.P.D. req'd 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION COARSE SAND COARSE SAND 2.5Y 7/3 PROPOSED SEPTIC SYSTEM UPGRADE PLAN 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY 65.50 132" 65.40 132" 121 TANBARK ROAD, 'MARSTONS MILLS, MA 13. NO PRIVATE WELLS WITHIN 150' OF PROPOSED LEACHING. 14. NO WETLANDS WITHIN 100' OF PROPOSED LEACHING. PERC RATE <2 MIN/IN. (•C" HORIZON) Prepared for: Santon Ea an 15. ALL PIPING TO BE 4" SCH 40 0 SPECIFIED UNLESS FT 1/8"/ ( ) Design and Siteplan by: SCALE NO GROUNDWATER OBSERVED DRAWN &SONS INC. DMM I, Darren M. Meyer, R.S., CS certify that t am currently approved b MAOEP pursuant to 310 CMR 15.017 MEYER N.T.S. eY E, hereby fy tIY PP Y P to conduct soil evaluations and that the above analysis has been performed by me consistent with the PO BOX 981 SHEET N0. ' requirements of 310 CMR 15.017. I further certify that I have passed the Soil Eval. Exam in October, 1999. EAST SANDWICH,MA 02537 DATE CHECKED 508-sa2922 09/27/15 DMM 2 of 2