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,rp Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
� !% 153 Tanbark Rd
u
Property Address
Domingue Donalson
Owner Owner's Name
information is required for every Marstons Mills MA 02648 06-24-2020
page. Citylrown State Zip Code Date of Inspection
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. Inspector Information -571#
on the computer,
use only the tab Michael T Bisienere
key to move your Name of Inspector
cursor-do not Cape Septic Inspections
use the return
key. Company Name
52 Rivers End Road
Co
� Company Address
Teaticket Ma. 02536
CitylTown State Zip Code
508-280-3356 S13938
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CM 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
06-24-2020
I pector's Slg ature Date
The system inspector shall submit 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 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 form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: 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.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
153 Tanbark Rd
Property Address
Domingue Donalson
Owner Owner's Name
information is required for every Marstons Mills MA 02648 06-24-2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) 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:
This 2 bedroom home has a 3 bedroom septic system. There is an H-10 1000 gallon septic tank and
an H-10 D-Box feeding two leaching chambers with stone. At the time of the inspection there was
appx. 8 inches of ponding water. And no visible failure criteria was found.
2) 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):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
153 Tanbark Rd
Property Address
Dominque Donalson
Owner Owner's Name
information is required for every Marstons Mills MA 02648 06-24-2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ 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):
3) 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.
a. 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:
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u-
153 Tanbark Rd
Property Address
Dominque Donalson
Owner Owner's Name
information is required for every Marstons Mills MA 02648 06-24-2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ 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
b. 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.
c. Other:
4) 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
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
�v Title 5 Official Inspection Form
ii Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
v 153 Tanbark Rd
Property Address
Dominque Donalson
Owner Owner's Name
information is required for every Marstons Mills MA 02648 06-24-2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® 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/z day flow
❑ ® 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 water supply
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 2000 gpd-
10,000 gpd.
❑ ® 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.
5) 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 CA.
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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
- r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
153 Tanbark Rd
Property Address
Dominque Donalson
Owner Owner's Name
information is required for every Marstons Mills MA 02648 06-24-2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
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)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
AN`�, Commonwealth of Massachusetts
,e Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
153 Tanbark Rd
Property Address
Domingue Donalson
Owner Owner's Name
information is required for every Marstons Mills MA 02648 06-24-2020
page. Cityfrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd plus
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d Town water
9 ( Y 9 (gpd)):
Detail:
In 2019-93,000 gallons were used and in 2018-100 000 gallons were used.
Sump pump? ❑ Yes ® No
Last date of occupancy: occupiedDate
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
AN
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u-
153 Tanbark Rd
Property Address
Dominque Donalson
Owner Owner's Name
information is required for every Marstons Mills MA 02648 06-24-2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
153 Tanbark Rd
Property Address
Dominque Donalson
Owner Owner's Name
information is required for every Marstons Mills MA 02648 06-24-2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
4. 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):
Approximate age of all components, date installed (if known) and source of information:
new leaching installed in 2000
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 39"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: town water
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
water was flushed and it came freely
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u-
153 Tanbark Rd
Property Address
Dominque Donalson
Owner Owner's Name
information is required for every Marstons Mills MA 02648 06-24-2020
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 30"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:
standard H-10 1000
Sludge depth:
3"
Distance from top of sludge to bottom of outlet tee or baffle
33"
Scum thickness
2"
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle 13"
How were dimensions determined? 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.):
recommend the new owner put the septic tank on a maint. plan with a local septic pumping co.
based on the future use of the home. At the time of inspection the liquid level was at working level
and the tee's were in place.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
cam, Commonwealth of Massachusetts
�v Title 5 Official Inspection Form
r- �1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
153 Tanbark Rd
Property Address
Dominque Donalson
Owner Owner's Name
information is required for every Marstons Mills MA 02648 06-24-2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. 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
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8.y 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
,rA Title 5 Official Inspection Form
+= l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
153 Tanbark Rd
Property Address
Dominque Donalson
Owner Owner's Name
information is required for every Marstons Mills MA 02648 06-24-2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
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
9. Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 01.
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.):
At the time of the inspection the liquid level was at working level and there were no visible signs of
leakage or solids carryover.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
�v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
153 Tanbark Rd
V
Property Address
Dominque Donalson
Owner Owner's Name
information is required for every Marstons Mills MA 02648 06-24-2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.).
10. 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.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 2
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
c Commonwealth of Massachusetts
,tiT Title 5 Official Inspection Form
<O Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
153 Tanbark Rd
Property Address
Dominque Donalson
Owner Owner's Name
information is required for every Marstons Mills MA 02648 06-24-2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
At the time of the inspection no visible failure criteria was found.
12. 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
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
�n ,? Title 5 Official Inspection Form
'? ii Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c !% 153 Tanbark Rd
Property Address
Domingue Donalson
Owner Owner's Name
information is required for every Marstons Mills MA 02648 06-24-2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. 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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
(P Title 5 Official Inspection Form
i; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
153 Tanbark Rd
Property Address
Dominque Donalson
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 06-24-2020
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
14. 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
**As-Built from the gpH attached on next page**
i
t5insp.doc•rev.7/26/2018
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
TOWN OF BARNSTABLE
Lt, tiON / � � �� 2Y� SEWAGE# —
VILLAGE_r1/ ^sror» 2 %%; ASSESSOR'S MAP&LOT'^,�o?s
INSTALLER'S NAME&PHONE NO. —
SEPTIC TANK CAPACITY /.i9
LEACHING FACILITY:(type) (size) 5" /NO.OF BEDROOMS__
BUILDER OR OWNER
PERMITDATE: /7— `i—00 COMPLIANCE DATE: 10
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 leachi�g facility) Feet
A
Furnished by
I
1
I
I
� S
S
Commonwealth of Massachusetts
�v ,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u—
153 Tanbark Rd
Property Address
Domingue Donalson
Owner Owner's Name
information is required for every Marstons Mills MA 02648 06-24-2020
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 15 plus feetfeet
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:
You must describe how you established the high ground water elevation:
augered a hole to 15 feet to show four plus feet of seperation.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
lip Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
153 Tanbark Rd
Property Address
Domingue Donalson
Owner Owner's Name
information is required for every Marstons Mills MA 02648 06-24-2020
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
� Commonwealth of Massachusetts /% -�zb 1901
Title 5 Official Inspection orm
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r.r�
153 Tanbark Rd. Marstons Mills !K'31
Property Address
Donalson (buyer)
Owner Owner's ame
information is
required for every Hya is Mig MA 02601 09/01/15 =''
page. Ci� State Zip Code Date of Inspection
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 fonts A. General Information
on the computer, I /1 ZZ
use only the tab 1. Inspector:
key to move your
cursor-do not Brian Reyenger
use the return Name of Inspector
key.
Ranger Construction
Company Name
46 Crowell Rd.
Company Address
a East Falmouth MA 02536
City/Town State Zip Code
508-274-9753 SI 13242
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. 1 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
09/01/15
Inspector's Signaturq Date
The system inspector shall submit 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
R ' 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.
VS
t5ins•11/10 rifle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
P r .
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
153 Tanbark Rd. Marstons Mills
Property Address
Donalson (buyer)
Owner Owner's Name
information is required for every Hyannis MA 02601 09/01/15
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:
® 1 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:
System is in working condition- 1000 gallon Septic tank , D-box , 2-500 H2O chambers
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):
t51ns-11/10 Title 5 Official Inspection Forth: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
153 Tanbark Rd. Marstons Mills
Property Address
Donalson (buyer)
Owner Owner's Name
information is required for every Hyannis MA 02601 09/01/15
page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
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•11/10 Title 5 Official Inspection form: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
153 Tanbark Rd. Marstons Mills
Property Address
Donalson (buyer)
Owner Owner's Name
information is required for every Hyannis MA 02601 09/01/15
page. Cityrrown 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/s day flow
t5ins-11110 Tito 5 Official InspectJon 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
153 Tanbark Rd. Marstons Mills
Property Address
Donalson (buyer)
Owner Owner's Name
information is required for every Hyannis MA 02601 09/01/15
page. City/Town 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 triggfored.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. 1 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•11/10 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
153 Tanbark Rd. Marstons Mills
Property Address
Donalson (buyer)
Owner Owner's Name
information is required for every Hyannis MA 02601 09/01/15
_
page. Cityrrown 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
t6lns r 11/10 Tile 5 Official Insp
ection Forth: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
153 Tanbark Rd. Marstons Mills
Property Address
Donalson (buyer)
Owner Owner's Name
information is y
required for every Hyannis MA 02601 09/01/15
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
2 x 1000 gallon cesspools
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
2013- 154k 2014-100k
Sump pump? ❑ Yes ® No
Last date of occupancy: currentlyDate
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
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•11/10 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
153 Tanbark Rd. Marstons Mills
Property Address
Donalson (buyer)
Owner owner's Name
information is Hyannis MA 02601 09/01/15
required for every y
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:
Septic tank originally installed-leaching installed in 2000
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 3.5
feet
Material of construction:
❑ cast iron ®40 PVC ❑other(explain):
Distance from private water supply well or suction line: 150
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Good Condition 4" PVC
Septic Tank(locate on site plan):
Depth below grade: 2.8
p g 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
Sludge depth: 3"
t5ins•11/10 Title 5 Offidal 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
153 Tanbark Rd. Marstons Mills
Property Address
Donalson (buyer)
Owner Owner's Name
information is required for every Hyannis MA 02601 09/01/15
page. citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: NA
Date
Other(describe below):
General Information
Pumping Records:
Source of information: NA
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/Altemative 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•11110 Title 5 Official Inspecdon 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
153 Tanbark Rd. Marstons Mills
Property Address
Donalson (buyer)
Owner Owner's Name
information is required for every Hyannis MA 02601 09/01/15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top 9 of sludge to bottom of outlet tee or baffle 36" +/
Scum thickness
0"
Distance from top of scum to top of outlet tee or baffle NA
Distance from bottom of scum to bottom of outlet tee or baffle NA
How were dimensions determined? measured
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is in good condition for age-Sanitary T's are intact, liquid level at correct height
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑ fiberglass ❑polyethylene ❑other(explain):
Dimensions:
x . 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•11/10 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
153 Tanbark Rd. Marstons Mills
Property Address
Donalson (buyer)
Owner Owner's Name
information is required for every Hyannis MA 02601 09/01/15
page. Cityrrown 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 11 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
153 Tanbark Rd. Marstons Mills
Property Address
Donalson (buyer)
Owner Owner's Name
information is y required for every Hyannis MA 02601 09/01/15
page. Cityrrown 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.):
good condition-3.5'below grade
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.):
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
t51ns-11110 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
w 153 Tanbark Rd. Marstons Mills
Property Address
Donalson (buyer)
Owner Owner's Name
information is Hyannis MA 02601 09/01/15
required for every �
page_ Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 2-500
❑ 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 kjonding, damp soil, condition of
vegetation, etc.):
Chambers were dry at time of observation,staining indicates signs of previously near capacity
Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
_ Number and configuration
Depth—top of liquid to inlet invert
,i
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-11110 Title 6 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
153 Tanbark Rd. Marstons Mills
Property Address
Donalson (buyer)
Owner Owner's Name
information is required for every Hyannis MA 02601 09/01/15
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-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
b Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
153 Tanbark Rd.Marstons Mills
Property Address
Donalson (buyer)
Owner Owner's Name
information Hyannis is MA 02601 09/01/15
required for every _
page. Cityfrown 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
3
/0o9;
- a Sao A Z_ z2.5- t37—= 3,4
?C 3 2 r 33 3s"
0 4` Sr°-
1ve A 4 r 3 � 4 -s 48
t5ins•11110 Title 5 OOidal 1 nspecdon Form:Subsurface Swage Disposal System•Page 15 0l 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
153 Tanbark Rd. Marstons Mills
Property Address
Donalson (buyer)
Owner Owner's Name
information isHyannis MA 02601 09/01/15
required Y
for every
page- Citylrown 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: 10'+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: 2000
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
site evaluation
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Design plans on file showing no ground water @ 10+ below grade
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 16 or 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
153 Tanbark Rd. Marstons Mills
Property Address
Donalson (buyer)
Owner Owner's Name
information is required for every Hyannis MA 02601 09/01/15
page- Cityrrown 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 11110 Title 5 Official Inspection Forth!Subsurface Sewage Disposal System-Page 17 of 17
COMMONWEALTH OF MASSACHUSETTS
z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
Y
M , a DEPARTMENT OF ENVIRONMENTAL PROTECTION
�, -��e►�
� o
�'aM 5J0y
/� 350 MAIN STREET MAR 2 1 2005
�r`� WEST YARMOUTH,MA
508-775-2800 `„ gqi{NSTABLE
r�,:+_TH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION P
MAP 100—PARC 025 l
Property Address: 153 TANBARK ROAD -ARC&
MARSTONS MILLS,MA 02648
Owner's Name: TERKELSON,BONNIE
Owner's Address: 153 TANBARK ROAD
MARSTONS MILLS,MA 02648
Date of Inspection MARCH 8,2005
Name of Inspector:(please print) JAMES D.SEARS
Company Name: A&B Canco
Mailing Address: 350 Main Street
West Yarmouth,MA 02673
Telephone Number: 508-775-2800
CERTIFICATION STATEMENT
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
Needs Further Evaluation by the Local Approving Authority
Fails �^o_,
Inspector's Signature: d-� ate: 3 0•S
The system inspector shall submit 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 tot he 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 bow the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 153 TANBARK ROAD
MARSTONS MILLS,MA 02648
Owner: TERKELSON,BONNIE
Date of Inspection: MARCH 8,2005
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: N/A
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 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:
Title 5 Inspection Form 6/15/2000 2
Page 3 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 153 TANBARK ROAD
MARSTONS MILLS,MA 02648
Owner: TERKELSON,BONNIE
Date of Inspection: MARCH 8,2005
C. Further Evaluation is Required by the Board of Health:N/A
Conditions exist which require fiurther 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 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 1 of 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 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:
Title 5 Inspection Form 6/15%2000 3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 153 TANBARK ROAD
MARSTONS MILLS,MA 02648
Owner: TERKELSON,BONNIE
Date of Inspection: MARCH 8,2005
D. System Failure Criteria applicable to all systems: N/A
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 pit is less than 6"below invert or available volume is less than%day flow
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
N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply
' N/A Any portion of a cesspool or privy is within a Zone 1 of a public well
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well
N/A 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 or less than S ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.)
NO (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: N/A
To be considered a large system the system must service 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—IWPA)or a
mapped Zone 11 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 is 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.
Title 5 Inspection Form 6/15/2000 4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 153 TANBARK ROAD
MARSTONS MILLS,MA 02648
Owner: TERKELSON,BONNIE
Date of Inspection: MARCH 8, 2005
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)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 C is at issue approximation of
distance is unacceptable)[310 CMR 15.302(3xb)]
�I
Title 5 Inspection Form 6/15/2000 5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 153 TANBARK ROAD
MARSTONS MILLS,MA 02648
Owner: TERKELSON,BONNIE
Date of Inspection: MARCH 8,2005
FLOW CONDITIONS
RESIDENTIAL✓
Number of Bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CUR 15.203(for example: 110 gpd x#of bedrooms: 330
Number of current residents: 2
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): YES
Seasonal use(yes or no): NO
Water meter readings,if available(last 2 years usage(gpd)): 2004—96,000 GAL./2003—47,000 GAL
Sump pump(yes or no) NO
Last date of occupancy: PRESENT
C OMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CUR 15.203):
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: N/A NOTE:TO BE PUMPED AFTER INSPECTION-MAINTENANCE.
Was system pumped as part of the inspection(yes or 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)
Tight tank I Attach copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
AROUND 1989
Were sewage odors detected when arriving at the site(yes or no): NO
Title 5 Inspection Form 6/15;'2000 6
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 153 TANBARK ROAD
MARSTONS MILLS,MA 02648
Owner: TERKELSON,BONNIE
Date of Inspection: MARCH 8,2005
BUILDING SEWER(locate on site plan): ✓
Depth below grade: 20"
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 onsite plan): ✓
Depth below grade: 33"
Material of construction: concrete 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: 1000-GALLON PRE CAST `
Sludge depth: 4"
Distance from top of sludge to the bottom of outlet tee or baffle: 26"
Scum thickness: 5"
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: 13"
How were dimensions determined: ASBUILT&TAPE
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
MAIN TANK AT WORKING LEVEL,INLET TEE—OUTLET TEE.INLET COVER AT 30".
NO SIGN OF OVER LOADING.
GREASE TRAP(located on site plan) N/A
Depth below grade:
Material of construction: i 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.):
i
Title 5 Inspection Form 6/15.2000 7
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 153 TANBARK ROAD
MARSTONS MILLS,MA 02648
Owner: TERKELSON,BONNIE
Date of Inspection: MARCH 8,2005
TIGHT or HOLDING TANK: N/A (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: Alarm in working order(yes or no):
Date of last pumping
Comments(condition of alarm and float switches,etc.):
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.,):
D-BOX IS 16"X 16"—4'/2 'BELOW GRADE,ONE LINE IN—ONE LINE OUT.BOX IS CLEAN&SOLID.
NO SIGN OF OVERLOADING OR SOLID CARRY OVER.
PUMP CHAMBER: N/A (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.):
t- w
e
Title S.Inspection Form 6/15/2000 8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 153 TANBARK ROAD
MARSTONS MILLS,MA 02648
Owner: TERKELSON,BONNIE
Date of Inspection: MARCH 8, 2005
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching chambers,number: 2
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.)
LEACHING IS TWO(2)500-GALLON DRY WELLS 25'X 13'.LEACHING IS V2`BELOW GRADE,2"WATER.
NO SIGN OF OVERLOADING OR SOLID CARRY OVER.
CESSPOOLS: N/A (cesspool must be pumped as part of inspectionXlocate 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: N/A (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.)
Title 5 Inspection Form 6/15/.2000 9
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 153 TANBARK ROAD
MARSTONS MILLS,MA 02648
Owner: TERKELSON,BONNIE
Date of Inspection: MARCH 8, 2005
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permr_nent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
1J"
i
3y.
y`
Title 5 Inspection Form 6/15;2000 10
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 153 TANBARK ROAD
MARSTONS MILLS,MA 02648
Owner: TERKELSON.BONNIE
Date of Inspection: MARCH 8, 2005
SITE EXAM . °.
Slope
Surface water,
Check cellar
Shallow wells
Estimated depth to groundwater 51' 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:
Observation site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation
__�77 Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USGS WELL DATA
WELL SDW 253 AT 51'.
7 `
y-
Title 5.Inspection Form 6/15/2000 t l l
i
A
TROY WILLIAMS
SEPTIC INSPECTIONS 4
,
Certified by MA Department of Environmental Protection 4 05) 760-1819
40 Old Bass River Road { RIC11VVE8 „a
South Dennis,MA 02660 FEB 2 1996 ..
v
COMMMeatth Of Massact Usetts '
Executive Office of Errvlon•nentd Affah
U
Department of
Environmental Protection -T
%VMm F.Wald
GOA~
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David&Str hs
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
0� CERTIFKATION
1I )
Property Address: /5 3 T—�L w,k- ut. a i s tv-s/�Address of Owner. d c
Date of Inspection: d 113 of different) C/Q
Name of Inspector�n•y (�✓ //; u..,
Company Name,Address a;d Telephone Number:
CERTIFICATION STATEMENT f� S
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 inspection..The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
_ZPasses
Conditionally Passes
Needs Further Evaluation By the local Approving Authority
_ Fails
Inspector's Signature: � Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A,B,C,or D:
Al SYSTEM PASSES:
_—' r have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
Bl SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,
passes inspection.
Indicate yes,no,or not determined(Y. N,or ND). Describe basis of determination in all Instances. If'not determined',explain why not)
_ The septic tank is metal,cracked, structurally unsound, shows substantial infiltration or exfihration,or tank failure is
imminent. The system will pass inspection N the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: S 3 Tu h 6 u rh
Owner: N d I
Date of Inspection: a //3 /y
Bl SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four 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
Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N/1
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The svclem has a septic tank ano sod absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a well water analysis 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•
DI SYSTEM FAILS: H11-?
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Backup of sewage into facility or system component due to an 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.
revised 8/15/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: / S' 3 6 ,-h
Owner:
Date of Inspection:
DI SYSTEM FAILS (continued):
Static liquid level in the distribution box above outlet invert due to an overloaded or dogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to dogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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.
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 SO feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS: /V�/g
The following criteria apply to large systems in addition to the criteria above:
The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety
and the environment because one or more of the following conditions exist:
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 Il of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 6/15/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: /,S_3
Owner:
Date of Inspection:
Check if the following have been done:
✓Pumping information was requested of the owner, occupant, and Board of Health.
(/None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
f i
i . Large volumes of water have not been introduced into the system recently or as part o this inspection.
Burin that rod
g Pe rg
_ZAs built plans have been obtained and examined. Note if they are not available with WA.
ZThe facility or dwelling was inspected for signs of sewage back-up.
ZThe system does not receive non-sanitary or industrial waste flow
_ZThe site was inspected for signs of breakout.
ZAII system components, excluding the Soil Absorption System, have been located on the site.
i tank was inspected for condition of baffles or
The septic tank manholes were uncovered, opened, and the interior of the septic pe
tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
t"The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
ZThe facility ownp- (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 6/15/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: / ,5,3 Two,
Owner:
Date of Inspection: Al "� ��` '
3
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 330 gal Ions
Number of bedrooms:
Number of current residents:
Garbage grinder (yes or no):,,6/v _
Laundry connected to system (yes or no): S
Seasonal use (yes or no): n/0
Water meter readings, if available:
f y
Last date of occupancy: kdjo
COMMERCIAUINDUSTRIAL: ,V
Type of establishment:
Design flow:_gallons/day
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:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
1 a S a- i''')ro-c-�' /\/0 V '-� C 9'/ . ;C— o.2,L V •-'-�t✓
System pumped as part of inspection: (yes or no) V 0
If yes, volume pumped Rallons
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)
Other (explain)
installed if known and source of information:
APPROXIMATE AGE of all components, date s ed ( ) �1
?0 e. - c-, S- I., I �-
Sewage odors detected when arriving at the site: (yes or no) IVO
(revised 8/15/951 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: /.S 3 I �-w�/c
Owner: /1-7 d t I
Date of Inspection:
� A3 iyb
SEPTIC TANK:_✓
(locate on site plan)
Depth below grade:
Material of construction: ✓ncrete _metal _FRP —other(explain)
Dimensions: C_ /X V6 /00
Sludge depth: y
Distance from top of sludge to bottom of outlet tee or baffle:
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:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) o d
O•� /c a la -. o✓ S�"✓ �'iJ tom... o� Nn 4,sr.ems_ �, // �+ {'� .N a-S �•1 o J r id
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP —other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum t^ hottor- of oWle! tee or battle-
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage. etc.)
revised 8/15/951 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner.
Date of Inspection:
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal_FRP—other(explain)
Dimensions:
Capacity: eal Ions
Design flow: >;allons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_✓
(locate on site plan)
Depth of liquid level above outlet invert: �' L
Comments:
mote if level and+distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) D—.7 o,r
1 1 G- S T--y � � � e r/ a�. /) i •. tnl o v /1 ` c. s o �� ��
PUMP CHAMBER://i9
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 6/15/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection: a21/3 9 6
SOIL ABSORPTION SYSTEM (SAS): 1�
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
if not determined to be present, explain:
Type: leaching pits, number:
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetatio ,etc.) -S ° a
�w,-A S.A.h .( U-, � � �t � _ /Vb 7'i �, a s d � ✓ct� c. / �r �
CESSPOOLS:
(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 (cesspool must be pumped as part of inspection)
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.)
:revised 6/15/95) 8
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: f S ,3
Owner: /`I ; t
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
tiPp
3s' �a ,
0-13a) 1000 �-L I
6 x 6,
DEPTH TO GROUNDWATER
Depth to groundwater. � feet adjusted high groundwater level
method of determination or approximation: H-Z. .l c a
(revised 6/15/95) 9
0 tTALLER'S
TO OF BARN AB E o�
�L � SEWAGE #
� . �,l l�ASSESSOR'S MAP' LO NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: 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
T.Furnished by
s ('
Ac Olt
ac ��
61
TOWN OF BARNSTABLE �' �✓
V- L N SEWAGE # d a 3 I y
,T
VI?LAGS ASSESSOR'S MAP & LOT 1190 D 2.5" POl
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY /000
LEACHING FACILITY: (type) ^S"o 0 �A>/ PIV 4�11;ll (size) <,5— X /3
NO. OF BEDROOMS .3
BUILDER OR OWNER /n 11F_0 � ur?:51- �lal�
PERMIT DATE:_/0 — 41—00 COMPLIANCE DATE: /0
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 faaccih, Feet
Furnished by
d '
,.
.� .. _
w
i
3��1�
.� Z 3 �s, w���
3y, a �
0
r.
No. &000 ' Fee
- THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ?�
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
0(ppficatiou for Mt.5poga1 *pgtem Cow5truction Permit
Application for a Permit to Construct(,�:- ffepair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. �5 j ��qh 6�rk Owner's Name,Address and Tel.No.
Assessor's Map/Parcel /01' C`/��
10,0 02C 001
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
✓&J•ook 0-G '6,0NHOS t,16,5-c/al, a-c_
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 gallons per day. Calculated daily flow gallons.
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 w n applicable) ZG' 5 Y';Wll -.5 Od 4o&/ t6z
4r2-,�2 1
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 Certifi-
cate of Compliance has been issued by this Board of Health.
Signed Date /D-�/- 00
Application Approved by Date
Application Disapproved fo Pthelowing reasons
Permit No. Date Issued
� No. Fee ' Y
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH rDIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
2pplication for Diopogal *potent Construction Permit
Application for a Permit to Construct(4-Mepair( )Upgrade( )Abandon( ) O Comp`lete System ❑Individual Components
Location Address or Lot No. S? rqH a.9,rk owner's Name,Address and Tel.No.
Assessor'sMap/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Jos tPG� U c 13,orr�5 c/6,5-r/off, Q Z5iVs--os
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank sue` Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer wh n applicable) T�4 1� - 5i7D Ge�� vQZ
(e//7,4 "7''
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 Certifi-
cate of Compliance has been issued by this Board of Health.
Signed /7 n /7 Date /0 - - 0
Application Approved by :�__Date
Application Disapproved for the following reasons
Permit No. =C' Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed(e_- Zepaired( )Upgraded( )
Abandoned( )by, ,10.5-e.04
at h p has b e constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. ated
Installer Ins z' /21 214-1-0-5 Designer
The issuance of this permit sthall�.olt�be construed as a guarantee that the syst� ww,I f!u�ntoltio f asides geed
Date i t t �"1 I C�0 Inspector �� �
— ---------------------------
No. ��'l/C/ 74 /00 90 6 Fee
/ THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Dizpooal 6pgtem Construction Permit
Permission is hereby granted to Construct( �: )-R�-pair( )Upgrade( )Abandon( )
System located at /S3 Teti
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Constructi n u t be'Completed within three years of the date of t Fp
7 4� r
J I,
Date: Approved by
f• •
1/6r99
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only. -
CERTIFICATION OF SKETCH AYD APPLICATION FORA DISPOSAL
WORKS CONSTRUCTION PERMIT CW=0UT DESlgY, D PLANSI
hereby ce-diy that the application for disposal worts
construction permit signed by me dated /d concerning the
properry located at /.53 ��� /3,g��c l/ meets all of the
following criteria: Ir
—The failed system is coanec ed to a residential dwelling only. These are no commercial or business
uses associated with the dwellnnz.
The soil is classined as CUSS I and the percolation rate is less than or equal to i minutes per inch.
l�7'nere are no wetlands within 100 feat of the oroposed septic sysem
,��7nere are no orivate wells within 150 fey;of the oroposed septic s-,,stern
There is no increase in flow and/or change in use oroposed
&- T-nere are no variances requested or neyded.
i ne bottom o2 the proposed leaching fac.,liry will not be located less than Eve feet above the
maximum adjusted�oundwater table elevation. (Adjust the zoundwater table using the Frimptor
method when applicable)
• LF the S.A.S. will be located with '-50 of any vegetated wetlands, the bactom of the oroposed
leac:dng facility will not be located less than founeen(1,) fee;above the ma.-urnum adiused
Q*oundwater table e!evation,
Please complete the Following:
A) Too of Cround Surface �ievation(using CIS inior nation) 7 q, s
B) G.W. E'.e/aaon j� -the:NL42(. ;iigh G.W. Adjustment _
D=--RE`i CE $ET�N-EEN• a,and 3
slGti�� - utiur� D a.T^a. /a- y—a
(Sketc`i proposed plan of srse n on back
q::ca ch toidcr
i
� /S3
Q
�XisT/may 6C�oo
L/?
o
O '
t
"� .? .A� � .� .a..aw.v. n V F`irlb•' ,w-�•.'"' :a "` -. s. 2?.- F �:,.t,,,>'.a.;`x { .5--,:.Ew.cati",Sk7�ta F�•y'4.�. ..`"".� .sm ."z'h,�:s '�u"'kl '
PRI i. is d�,a1"c"`` '"G'a,Y3.., .,.L.: -"" °S.SaS 'r".'-Fr"' �^ .y.`�xt� "m ,y"'�' t' �y""yu""?a�p�'^".n�':'�'' ?ti''..x�fiiS"�3.N^•L'a''�h^�"r�ti. 3 ,,. ..3 T:
4 4 ' TOWN OF BARNSTABLE
T` a
LOCATION �H �r SEWAGE # �0 39 y
VILLAGE ASSESSOR'S MAP & LOT/,9O 0 2-r aOl .
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY A200 _
LEACHING FACILITY: (type) �. , O dAl �v ui! %s (size) X /3
NO.OF BEDROOMS 3
BUILDER OR OWNER 15 ��2
PERMTTDATE: 00 COMPLIANCE DATE: /O
Separation Distance Between the: L
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet k
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet x
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leachin faci ' ) Feet
Furnished by
I }r
2 e.(
_
r
YhiF-+�..,
Qgggig-
2
i
4
s
r
D /
js, a
`.
-�
Il 1
TOWN OF BARNSTABLE
LATION )a ��.r Jti. SEWAGE # S y
VILLAGE i S _ ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO. 0, LC v
SEPTIC TANK CAPACITY ° b
LEACHING FACILITY: (type) , _ __(size) G Xb
NO.OF BEDROOMS 3 _
BUILDER OR OWNER 62►^w �.✓ //
PERMUDATE: I< �l ��`l COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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 ___
t t
1 -
{
�`� � ! / /
� ..
,36 .. _
��
..
� i . .,
„� c
,�
1
- �. � � _ _ a
4i� TOWN OF BARNSTABLE
LOCATION ( 6 `4 zA I-cwti b-1 <(, A �. SEWAGE 'T '50
VILLAGE wI�JS inS �`�l�S ASSESSOR'S MAP & LOT
INSTALLER'S NAME ra PHONE NO. 360
SEPTIC TANK CAPACITY I , e d o !2n (L A S
LEACHING FACILITY:(type)
NO. OF BEDROOMS _PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER 6tTfvj
DATE PERMIT ISSUED:
DATE COUPLIANCE ISSUED: 1 �1
VARIANCE GRANTED: Yes No
7�
.SI
?zZ
u
L6*-4 ►Z3
Q� 7 y�j
No..11.1..:' .. FE:s.......1. .........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........7..............................O F..............:..............-.........
AVVIira#ion for Ui ipaiial Works Towitrurtion Frrmit
Application is hereby made for a Permit to Construct (V ) or Repair ( ) an Individual Sewage Disposal
System at:
4oT I93 I-,-,vc3/4rZ.K IZoA1) H,49-sfo.NS J.tr<<S
...................................................................T----------....... .................................---------- ..........•--------------....----------_.
Location-Ad res or Lot No
G'Zf-F�✓�3 Cl? F':............................`3ok 5 -) (!tX ICx,iZC tL�
--------•-•---------------------• �.._ --------------------------..-...----------
Owner Address
Installer Address
UType of Building Size Lot._ �r `79___.____Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic (Y) Garbage Grinder (�/)
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
A4Other fixtures ---------------------------•---•-------------------•----•••---•--••••••--------------------••--•--•------------
W Design Flow................'�. ..... gallons per person per day. Total daily flow.......... .?10--_-----.-•----"_--_....gallons.
WSeptic Tank—Liquid capacity_t�� ._gallons Length................ Width................ Diameter---------------- Depth_._.._..........
x 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 ( )
�-+ t Ev Ze q�uJ G� uw��•vt� Date lild F
a Percolation Test Results Performed by..___.____ Y....................;---.--•-------------------•- l --------•-----
Test Pit No. 1................minutes per inch Depth of Test Pit___�`�:-s.___.._ Depth to ground water.._N°�'�....._.
rZq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water____-_...__-_"_---_____.
Ix -------- .. ..... ...........
0 Description of Soil...Mc'....v�----•-------.. -N..------ ---••- ..........tom--------------------------------•-------------------....................-••••••••••••••-•-••...•••-••••----------•-••---•••••-------------------------•••••------•---•-----•----•-••---•----•------••-•-•-••--------•-•--•----•------••••••••••••--------...--••••-----------•.
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
V 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,L_=" ,
p J of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has en issue y thoard.of 1 lth.
Signed_... �(,l c� l /a l 1
l
jJ�
Application Approved By....... :-A--!/�-�_S......�..-- _ l ���`�D� -
-------- ---•-•-••--•--.....----
Date
Application Disapproved for the following reasons:---•---------------------------•----"-------•-------------------------------------------------------------------
--•------•-•-•••-•...................•••------•-•---••-•---------........-------•-•----------••--•-----...------------••--••-----------------•--•-------------•---•-•-------------...-- .................
Date
Permit No....... Issued...... - y .........................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...-----._.J_6.(*'.At..............OF........s,�v "N v"4 c
Appliratiun for Disposal Works Tuntrurtion jJrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
4ojr, r'P3 ir>M.3'14kN rk..01)r) �-fr9g :i0a, S fq.1 < e5
---.....---••----------------------------------------•----------•-•--•-•---•--.._...._........_... ----•--•-••••••-•.....................--•---......----...._.._...._•-••-•..................._.....
o
location-Add Addrres r lu or Lot No.
-- — ................................................. .........................................-
.5� ..............................................
Owner ' Address
W ,.�
Installer Address
d Type of Building Size Lot_._ '!y-------Sq. feet
U Dwelling—No. of Bedrooms......... ................................Expansion Attic (4/) Garbage Grinder
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
al Other fixtures ............................... ..
W Design Flow............... ...................... per person per day. Total daily flow______... ...............................?6
......
9 Septic Tank—Liquid capacityl �..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 ;'
Percolation Test Results Performed by.--�. a . F a I)etf )("f J� t v r"�,,`'t: Date_ ,(I I`�4........._._._.
1.4 Test Pit No. 1................minutes per inch Depth of Test Pit _-_..._........ Depth to ground water...._________._.........
4q Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P+ ------------------•.--------- = ---•-----------------------------------------------------------------------•---------------------
D Desk ption of Soil--- =a.t e,1.._...... 5 f ... `_�!', c a:�
x ... -•-•••--------------•---•-----•-----•--------........_....---
V ---.•--•-•--------------•------------•-•--•---••---•---•••---•---•-••-••-----•-•--------•-•-•----•--•---------------•-•-------•-•--------------------•-•--••------••-----•••------•----•----••-•-•----
W /
-----------------------------------------------------
----------------------------------------•----------------------------------------•-------------------------------------------•------•••-••---
U Nature of Repairs or Alterations—Answer when applicable_____________________________•_-___--•----.----_-__•______-___-.-_-__--_-____-_-_.-._-----•___.
------------------------------------------------------------------------------------------------------•-••---------------------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
�-F^
the provisions of I'1 T i T:LE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bden issppuedl,,Iy th/6e?{board of rhealth. p
Fn `yrr+4-;J \ Jl .✓�l/'sy F.+{+ ,.� -•.......................... ......d r V f
Signed r --.---. ------
..-� �J �: �LI �{ f/1 Date
Application Approved By. . =j ...(`.... _..... - <�. -•----Z--=-fit
Date
Application Disapproved for the following reasons----------------------------•----------------•--------...---------------------------------------------••----•-•--
..•--•••-•----•--••---•-••...----••-•---------•----------••--------•---------••-•-•-••-•-------.....•••---------------•-----------------•-----------------•-•--••••••----•---------•------••---•-------
Date
Permit No------=1-1:-4=:.-----•--------------------------- Issued-......f.:;
jc
41te -------------------
.ate
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................... .............................................................
dw
Qrrtifiratr of Tomplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( t/) or Repaired ( }
Installer
has been installed in accordance with the provisions of Ti i IE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No....�c�f__-_--:TG.................... dated.......�.-.���:..�. .._....__-____---
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE YHAT YHE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.......................... -.. -�. /............................ Inspector... --•-----------------------------•-------.-----
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........... ?LM".............OF............
..........`(tvA-.N.S{/7p'.�p..C.
No... TJ _.... FEE...�~J ---------------
Uiupual Works T-Puntr ion ami#
Permission i�hereby granted.... I.'z c S. .....Q- �t��-------------•-••----..._......------------------.........------........-----•---
to Construct (o/) or Repair ( ) an Individual Sewage DisKosal System„
.......................... -r--•--••---•---........-------•-•-•----....._......•----•-•••-••••--
reet
as shown on the application for Disposal Works Construction P > NOJ�'�__.'�!&..... Da ...I:
= Board of a th
DATE---------- / -----------------------------•-----
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS ,
y
i
SHEET 7A OF 7
,A4 OLD FALMOUTH RD. 20'IM CR AS SHOWN ON PLAN w
LOCUS
I V IRN. PRECAST CONCRETE RISER AS REOIED
S/NNWM DN ftAN SEE NOTES 2 R 3
lr
CANRNETT
4(n MARSTONS MILLS T.O. ® u� ® DESIGN CALCULATIONS: -�:
It
2S I A 1 ® GARBAGE DISPOSAL UNIT N/A
J
NION TOTAL ESTIMATED FLOW
We PER FT. r SOa b PVC PIPE }, Y (110 GAL/BR./DAY%L BR.) CAL/DAY
LOCATION MAP �� M0L PITON I/r PER rt. r SIX 40 PVC PPE REQUIRED SEPTIC TANK CAPACITY aR5 GAL
I'm u4 _� MN.FITOI I/R•PEI rt. gk
r LAYER DF ACTUAL SZE OF SEPTIC TANK _CAL RMIN.
' W _ TEACHING AREA REQUIREMENTS MIN.
�. SMEWALL AREA 2_5 GAL/S.F.
BOTTOM AREA 1.0 GAL/S.F.
1'-0• LEACHING CAPACITY(BOTTOM+SDEWALL) 550 Gµ, I
LAYR € 1r(5NNs)(I.0)+21r(SxSR2.5)
s'-0 S
Umip Y RESERVE LEACHING
CAPACITY Eo--GAL.
{LIENHM !
>. m SIONE i
DISTRIBUTION NOTES: i
BOX
®- 1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.EG.E.
TITLE 5 AND THE TOWN OF BARN STABLE RULES AND
REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE
1000 GALLON SEPTIC TANK r I _ z ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO
WITHIN 12'OF FINISHED GRADE
J. ANY MASONRY UNITS USED TO BRING COVERS TO GRADE j
TO' I SMALL BE MORTARED IN PLACE
SEPTIC SYSTEM PROFILE 4. ALL COMPONENTS OF THE SANITARY SY51EM SHALL BE CAPABLE
NDT TO SCALE BOTTOM OF TEST HOLE OF WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR
WITHIN 10 FT.OF DRIVES OR PARKING AREAS M-20 LOADING i
LEACHING PIT SHALL BE USED UNDER OR WITHIN 10 FT.OF DRIVES OR
PARKING.
5. HORIZONTAL AND VERTICAL CONTROL.SEE LEVY.ELDREDGE i
t WAGNER FIELD NOTEBOOK f ME t AS PLAN 13M-10
I
\E-LEV.
ELEVATIONS LEGEND: j
FINAL SPOT ELEVATION 1
106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 1 3)1124 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 rnSsmIS'nONBO% �a
PRIMARY LEACHING PIT 0
O.FOUND.
A 7W.•5 72,5 71•0 �. O 2,0 �( RESERVE LEACHING PIT �,W
0 1b• 110 1 74.0 745 15.5 74.0 7Zo 7f,7 _ AND PERCOLATION TEST �01
go.o fe.5 �0•5 f1.0 ;slo 01.0 00. bl•o 9Lo V.s 71,v 7*5 75,5 7f,o 74.o T 9• 7f,o •7b•5 1AfA RESERVE LEA SERVHING PIT 1
14.0 1Q, 76•0 77•0 1 o Y5,5 75.0 1fv 12.0 ;N,O 71.5 73.E A AND DEEP OBSERVATION Mold
B 70•5 6q,? 66.0 64.1 Gi•I 0.0 615 7r,5 72.v 73,0 73,0 74.? 76.0 -161 71.5 775 1gs' � 19d 1 7b.5 7b,o 7f0 15R 1 5 766 71A 7l,6 1D•?
�� - 4 7oN5 79,0 13.5 3:q 75.5 74.4 13.9 1z1 71.4 74 mq•4 iiN5 is5 44.0 11.0 B
C 70.t G9y 65.7 b3•6 65•• LZ7 L4•1, 761 Al 71.7 7t1 74t 75.7 10.2- 77. 111 7b.►I77•B,!71,b 16.L - 77.7 77.7 7f,1 74.011 '71.3 124 71.3 70.L 7pa 11.1 19t 73.4 1st 74.413.4 1t.b 11•I 71• Gq•I Gi• IFft 66.7 1b.7 C
D 70.0 0-- 49.7 6341 65.6 61,5 61.0 71.0 165 796 7t,S 74.0 75.5 1h0 11•0 1710 76.o I>e.b I77,i 76.o - 77.5 77.5
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IJ I; APPROVED: BOARD OF HEALTH
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1 12 9 88 INITIAL ISSUE MCT
NO. DATE DESCRIPTION BY
PERC TEST 1 PERC TEST 2 PERC TEST 3 PERC TEST 4 PERC TEST 5 SEPTIC SYSTEM DESIGN
LOT 116 LOT 125 LOT 131 LOT 149 LOT 146 MARSTONS MILLS WOODLANDS
aEl:.�,tt ELv..n.DA EM._Ijas 0.00- on..Tze: as �,..•E� aoorw IN
AID malO W/SONE CLAn mp AND Summ TOP AND aesoR Mm RAND W/STOR PN
I.AND.'am I.AN,
slemA -
RAMD WEE Mm RAND W/1"m Nmame W/mL„ENE WED. W/SIL BMW BARNSTABLE, MASSACHUSETTS
. MD R/ffrm ERe TUNe
'"`'" """"D WOODLANDS ASSOCIATES REALTY TRUST
LL IRE RAND W/PESSIO mm SAND Mm.SAND W/STGNE a0
'I WAS.am W/STOR PkEE,/N 2"m W/STCRE - .,... .,.
Km LDD W/9L s1WNE la 'W/�•RAND%/NLW zm NE SCALE: 1. = 40' JOB NO. 1338/SEPTIC
va LLA {HIND MEL SAND FINE SAND W/F PEIKO PNE/Mm.SAND HIKIMM SAMo
ND RATES No WATER No WATm No WAIM NO WATER eO C
40 0 40 L Y
DATE OF SOIL TEST EneL= DATE OF SOIL TESTS DATE OF SOIL TESTS DATE OF SOIL TEST 19" DATE EB SOIL TEST 1��
WITNESSED BY a WITNESSED BY A 0unno WITNESSED BY A-Imme WITNESSED BY A&AWm_ WITNESSED BY 1 OLORM
PERCOLATION RATE <2 MIN./INCH PERCOLATION RATE <2 MIN./INCH PERCOLATION RATE 5_1_MIN./INCH PERCOLATION RATE 12 mIN./ONCH PERCOLATION RATE <<2 MIN./INCH
PERCOLATION SOIL TESTS LEVY, ELDREDGE do WAGNER ASSOCIAItS INC.
u►m o acm1 m PUN1®B L m=YY RS
889 WEST MAIN STREET CENTERV1112 MA 02632
SHEET 7 OF 7
� I
4T �
MARSTOMNS MILLS
LOT 130
+4tltt s
"wigs
LOT 129
LOCATION MAP 101 few
IF
to 1
O� y3/ LOT 12i I
s tan IF
y�
74, do
/ T� i
NJ._-turn
LOT 31
Lu
All ��.. IF taco s�� IsD`I f
LOT 137 ty'` �y\t .. / LOT 124 101
���.\
.IyA i
-64
/�� LOT 123\
x b �� \ LOT IF nao s /
' I 11 I 7MAN' LOT 13 1 y/ 61r
LOT 149
LOT 136
LOT 134 ♦ LOT 122
u.M LAP1
1: LOT 121
A�M3 I
(fir aio
L I `�I
OT 107 IF f
LOT 148 I /
r
ei
°BLOT 147 j 0¢ :, y ` ►a tom' � � `
, LOT 119
'LOT 141 \ '�\� \�� ,ww s r to- s p.
tOT
__--\I T.tr 11i y �`r` • '�Y' +axo s I - i 7 s �' lOT 120 '•
\ - o �"� � � �Y. '1t� �> '�� ' , !, LOT 117' � s• totes s
LOT
�� y� 4
70.10' /,• 1 '/ i11 , vllrA 'pA tOf/143 t '.�k/ 7 t o. '$ <''b• I V I
� _.,� '� � „iy,o � 7t•p � �` -�0 ti,4 RK Y �I r �� ty� �
l- I.bfi! 6~T 7A OF't Fo1L sou. v6.1 *-4b
LOT 115 .\..� 7?WK9VL4MW4 TEST. 1tC"Llrf145 .
�\ 1 toPoo s it.p•" stnq T 7A e r 7 Pv2 •Lecoomb
I�1 LOT toe vt tom' LOT�1��� ',fu»s � a t' �•p of
� �
Vw-
V S' LOT 116
Ltes4Il tF ..\`, y tom IF
\. �G �
\ - Iot
6 LOT Ili Will 4' �+LO 114
+a4a a i d to s
�''' I ..\ r \� < �tiP ( .. ` Ia 4f •• ,o,r..,.4 a.t, I!}eo E tu•1�mo.4 r.
I I 3 11 29 BB FINAL BLDG. AND SEPTIC LOCATIONS PAL
LOCATION PLAN
1 1 10 2 W INITIAL IS
� �p•o ��tY � i NO. DATE DESCRIPTi BY
1:1 tiM� `„ BUILDING LOCATION PLAN i
\" ' LOT no MARSTONS MILLS WOODLANDS
LOT 109 +t,w s BARNSTABLE, MASS CHUSETTS
\` 6• WOODLANDS ASSOCIATES US
t SCALE: 1 50 JOB NO. 1338
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