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Home My WebLink About0063 TREE TOP CIRCLE - Health 63 Tree Top Circle Marstons Mills P A = 150 064 i �1 Commonwealth of Massachusetts 670.-OUV ri 3 Title 5 Official Inspection Form i i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 Treetop Cir Property Address fvj Morgan Lavelle Owner Owner's Name information is required for every Marstons Mills MA 02648 8-24-20 page. City/Town . 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. A. Inspector Information Shawn Mcelroy Name of Inspector Wiper Cape Septic Services Company Name P.O. Box 73 Company Address East Falmouth MA 02536 City/rown State Zip Code 508-495-0905 S13971 Telephone Number License Number B. Certification I certify that:l am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000);1 have personally inspected the sewage disposal system at theproperty 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 8-24-20 I spector's Signature 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.M6/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 c Commonwealth of•Massachusetts r� 3 Title 5 Official Inspection Form lf it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 Treetop Cir Property Address Morgan Lavelle Owner Owner's Name information is required for every Marstons Mills MA 02648 8-24-20 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) Syste'm 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: System is in good working order with no sign of failure. 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 El ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 f Commonwealth of Massachusetts r� Title 5 Official Inspection Form ar Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �o! 63 Treetop Cir Property Address Morgan Lavelle Owner Owner's Name information is required for every Marstons Mills MA 02648 8-24-20 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 El ❑ ND (Explain below): ❑ obstruction is removed ❑ Y El ❑ ND (Explain below): ❑ distribution box is leveled or replaced El ❑ 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 ON ❑ 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: Lt5in sp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 c Commonwealth of Massachusetts ��. 4. 3 Title 5 Official Inspection Form � I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments !aJ 63 Treetop Cir Property Address Morgan Lavelle Owner Owner's Name information is required for every Marstons Mills MA 02648 8-24-20 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 th e he heard 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 asses system if the well water analysis, performed y p y , r 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 f r Commonwealth of Massachusetts r� f. Title 5 Official Inspection Form C�l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 Treetop Cir Property Address Morgan Lavelle Owner Owner's Name information is required for every Marstons Mills MA 02648 8-24-20 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 El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/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 3� Title 5 Official Inspection Form ICI' �► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r J ,fc7 63 Treetop Cir Property Address Morgan Lavelle Owner Owner's Name information is required for every Marstons Mills MA 02648 8-24-20 page. Cityrrown 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? ® � Wasthe 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.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Ix Title 5 Official Inspection Form w.. Ia'i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments +rr;, 63 Treetop Cir Property Address Morgan Lavelle Owner Owner's Name information is required for every Marstons Mills MA 02648 8-24-20 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (actual): 2 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Description: Number of current residents: 0 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 Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 8-2020 Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ws LYC6l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 Treetop Cir Property Address Morgan Lavelle Owner Owner's Name information is required for every Marstons Mills MA 02648 8-24-20 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: N/A 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 A.-I fw Title 5 Official Inspection Form N Subsurface Sewage Disposal System Form -Not for Voluntary Assessments F .P �_,_•T, ; 63 Treetop Cir Property Address Morgan Lavelle Owner Owner's Name information is required for everyMarstons Mills MA 02648 8-24-20 page. City/Town 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: 2003 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 30"feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts w� Title 5 Official Inspection Form ! i,,l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 Treetop Cir Property Address Morgan Lavelle Owner Owner's Name information is required for every Marstons Mills MA 02648 8-24-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 24"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle 26" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? 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.): Tank is in good condition with baffles installed and no e.sign of leakage. 9 9 9 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i;;t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 Treetop Cir J Property Address Morgan Lavelle Owner Owner's Name information is required for every Marstons Mills MA 02648 8-24-20 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. 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 loc. Commonwealth of Massachusetts r-� Title 5 Official Inspection Form r�l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 Treetop Cir Property Address Morgan Lavelle Owner Owner's Name information is required for every Marstons Mills MA 02648 8-24-20 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 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 with water at working level and no sign of back-up from field. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 I -- Commonwealth of Massachusetts c� 3 Title 5 Official Inspection Form c�,i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � r >k 63 Treetop Cir Property Address Morgan Lavelle Owner Owner's Name information is required for every Marstons Mills MA 02648 8-24-20 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: 2-500's ❑ 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 Commonwealth of Massachusetts ,. Title 5 Official Inspection Form i�► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a .M 1.,-•T, , 63 Treetop Cir Property Address Morgan Lavelle Owner Owner's Name information is required for every Marstons Mills MA 02648 8-24-20 page. City/Town 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.): Leach chambers in good working order and holding 3"of water with stain line at 6"below inlet invert. 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 r Commonwealth of Massachusetts �. Title 5 Official Inspection Form -li Subsurface Sewage Disposal System Form -Not for Voluntary Assessments All 63 Treetop Cir Property Address Morgan Lavelle Owner Owner's Name information is required for every Marstons Mills MA 02648 8-24-20 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 c Commonwealth of Massachusetts -, Title 5 Official Inspection Form ! i�h Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 Treetop Cir Property Address Morgan Lavelle Owner Owner's Name information is required for every Marstons Mills MA 02648 8-24-20 page. City/Town 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 C� t' t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts 3 Title 5 Official Inspection Form 04 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 Treetop Cir Property Address Morgan Lavelle Owner Owner's Name information is required for every Marstons Mills MA 02648 8-24-20 page. City/Town 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: 124 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database- explain: You must describe how you established the high ground water elevation: Ordinal design plans show groundwater at greater than 12'. 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 i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments tl,�c 63 Treetop Cir Property Address Morgan Lavelle Owner Owner's Name information is required for every Marstons Mills MA 02648 8-24-20 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 a t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 63 Tree Top Circle Property Address ;•#a Corey Enos Owner Owner's Name information is Marstons Mills Ma 02648 8-15-17 required for every page. City/Town State Zip Code Date of Inspection s Inspection results must be submitted on this form. Inspection forms may not be altered its zany way. Please see completeness checklist at the end of the form. filling out forms n A. General Information filling out forms /� [ C 7on the computer, J� J J use only the tab 1. Inspector: key to move your cursor-do not Matthew Gilfoy use the return Name of Inspector key. B&B Excavation Company Name 374 Route 130 Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113640 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 8-15-17 Inspector's Signature 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 has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 L ( Commonwealth of Massachusetts N W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 63 Tree Top Circle Property Address Corey Eno Owner Owner's Name information is Marstons Mills Ma 02648 8-15-17 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System was in working order at time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 63 Tree Top Circle M Property Address Corey Eno Owner Owner's Name information is required for every Marstons Mills Ma 02648 8-15-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will public ublic health P 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form I. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;Ms0 63 Tree Top Circle Property Address Corey Eno Owner Owner's Name information is required for every Marstons Mills Ma 02648 8-15-17 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 '/z day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 63 Tree Top Circle Property Address Corey Eno Owner Owner's Name information is required for every Marstons Mills Ma 02648 8-15-17 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 63 Tree Top Circle Property Address Corey Eno Owner Owner's Name information is required for every Marstons Mills Ma 02648 8-15-17 page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (Actual) _2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 331gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 63 Tree Top Circle Property Address Corey Eno Owner Owner's Name information i e required for every Marstons Mills Ma 02648 8-15-17 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No I Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d See below 9 ( Y 9 (gp ))� Detail: 2015-58,000gallons 2016-57,000gallons Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: NA 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 63 Tree Top Circle Property Address Corey Eno Owner Owner's Name information is required for every Marstons Mills Ma 02648 8-15-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner- last pumped 4 years ago Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 63 Tree Top Circle Property Address Corey Eno Owner Owner's Name information is required for every Marstons Mills Ma 02648 8-15-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2003 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 1 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: 1000gallons Sludge depth: 8 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 63 Tree Top Circle Property Address Corey Eno Owner Owner's Name information is required for every Marstons Mills Ma 02648 8-15-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 24 Scum thickness 4" Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 12 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 was in working order at time of inspection with liquid level equal to outlet invert. Tank is in need of pumping at this time and should be pumped every two years for maintenance. Grease Trap (locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 63 Tree Top Circle Property Address Corey Eno Owner Owner's Name information is required for every Marstons Mills Ma 02648 8-15-17 page. City/Town 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.): I Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 63 Tree Top Circle �M Property Address Corey Eno Owner Owner's Name information is required for every Marstons Mills Ma 02648 8-15-17 page. CitylTown State Zip Code Date of Inspection Q. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 11 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 was in working order at time of inspection but had heavy carry over present. 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.): NA I * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 63 Tree Top Circle 7M Property Address Corey Eno Owner Owner's Name information is required for every Marstons Mills Ma 02648 8-15-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: (2) 500 gallons ❑ 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 was in working order at time of inspection. No high staining, damp soils or lush vegetation were present. Chambers had 6" of standing water with a stain line '/z way up from bottom. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 63 Tree Top Circle Property Address Corey Eno Owner Owner's Name information is required for every Marstons Mills Ma 02648 8-15-17 page. City/Town 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: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 63 Tree Top Circle Property Address Corey Eno Owner Owners Name information is required for every Marstons Mills Ma 02648 8-15-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately REAR D D JA B 0 A2-27'6" B2-25' C1-23'6" D1-25'6" A3-33' 133-31' `...,./ 777 (D t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °^M 63 Tree Top Circle Property Address Corey Eno Owner Owner's Name information is required for every Marstons Mills Ma 02648 8-15-17 page. Cityrrown 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: No GW @ 132" 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. 3-3-03 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: Plan on file with BOH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 63 Tree Top Circle 'M Property Address Corey Eno Owner Owner's Name information is required for every Marstons Mills Ma 02648 8-15-17 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 'GSM Sv0' 63 Treetop Circle Property Address Linda Phoenix Owner Owner's Name information is required for Marstons Mills Ma. 02648 8/24/2009 every page. Cityrrown 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: A. General Information When filling out forms the r�`^ computer, r,use ✓ \ 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name P.O.Box 763 Company Address Centerville Ma. 02632 City/Town State Zip Code (508)428-4028 S14454 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority d 0-�, 8/24/2009 Inspector's Signature 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 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. l� t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage i posal System•Page 1 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 63 Treetop Circle Property Address Linda Phoenix Owner Owner's Name information is required for Marstons Mills Ma. 02648 8/24/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 63 Treetop Circle Property Address Linda Phoenix Owner Owner's Name information is required for Marstons Mills Ma. 02648 8/24/2009 every page. City/Town 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 63 Treetop Circle Property Address Linda Phoenix Owner Owner's Name information is required for Marstons Mills Ma. 02648 8/24/2009 every page. City/Town 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 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 %day flow t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 . Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 Treetop Circle Property Address Linda Phoenix Owner Owner's Name information is required for Marstons Mills Ma. 02648, 8/24/2009 every 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 triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 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 63 Treetop Circle Property Address Linda Phoenix Owner Owner's Name information is required for Marstons Mills Ma. 02648 8/24/2009 every page. City/Town 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 e inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 Treetop Circle Property Address Linda Phoenix Owner Owner's Name information is required for Marstons Mills Ma. 02648 8/24/2009 every page. City/Town State Zip Code Date of Inspection D. System Information Description: The septic system consists of a 1000 gallon septic tank,distribution box and two 500 gallon leaching chambers. Number of current residents: 1 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 2007:82,000 2008:60,000 Detail: 2007:225gpd 2008:164gpd Sump pump? ❑ Yes ® No Last date of occupancy: 8/24/2009 Date 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 63 Treetop Circle Property Address Linda Phoenix Owner Owner's Name information is required for Marstons Mills Ma. 02648 8/24/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 i f Commonwealth of Massachusetts z Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 63 Treetop Circle Property Address Linda Phoenix Owner Owner's Name information is required for Marstons Mills Ma. 02648 8/24/2009 every 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: 2003 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2' feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line. 20'+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank (locate on site plan): Depth below grade: 2'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 gallon Sludge depth: 3" t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 63 Treetop Circle Property Address Linda Phoenix Owner Owner's Name information is required for Marstons Mills Ma. 02648 8/24/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness V. Distance from top of scum to top of outlet tee or baffle 7" Distance from bottom of scum to bottom of outlet tee or baffle 13" 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.): Pump septic tank every two years.lnlet and outlet tees are in place.No evidence of leakage.Tank appears to be structurally sound. 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 15ins•0110, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 63 Treetop Circle M Property Address Linda Phoenix Owner Owner's Name information is required for Marstons Mills Ma. 02648 8/24/2009 every page. City/Town 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 63 Treetop Circle Property Address Linda Phoenix Owner Owner's Name information is required for Marstons Mills Ma. 02648 8/24/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No 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.): Box is Ievel.Box has two outlet laterals with equal distribution.No evidence of solids carryover.No evidence of leakage into or out of box. 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: t5ins•09/08 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 63 Treetop Circle Property Address Linda Phoenix Owner Owner's Name information is. required for Marstons Mills Ma. 02648 8/24/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): Sandy soil.No signs of hydraulic fail u re.Chambers had 10"of water at time of inspection.No stain line observed higher. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17. Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GSM ,•'' 63 Treetop Circle Property Address Linda Phoenix Owner Owner's Name information is Marstons Mills Ma. 02648 8/24/2009 required for every page. City/Town 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Map Page 1 of 2 Town of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Map Slze ® ® Zoom Out. ,In y R�J1 R 1C L NOWAymm W i+w I Uvclu ' r.. » ', `. a S+ is F: i. . + 1 :1 A. • I i i l J I I I' 4 I `I i 2' Feet; .... Set Scale 1" = 20 I Aerial Photos I MAP DISCLAIMER r`nn,trinhf,)nnA-,)nnQ Tnutn of Pornefehle KAA All rinhfc recent, httD://www.town.bamstable.ma.us/arcims/anDgeoann/maD.asnx?nronertvlD=1500fi4&man... R/24/2009 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 63 Treetop Circle Property Address Linda.Phoenix Owner Owner's Name information is required for Marstons Mills Ma. 02648 8/24/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of LC 50' feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record 003 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: As-Built ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 f -� Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 63 Treetop Circle Property Address Linda Phoenix Owner Owner's Name information is required for Marstons Mills Ma. 02648 8/24/2009 every page. City/Town 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 p' P No. 'A .Ud 3—��0 FEE COMM WEALTH OF MASSACHUJ E TS 1 Board of Health, APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) RepairX Upgrade( ) Abandon( ) - 0 Complete System A.dividu.1 Components Location C0 _) C Owner's Name A-A CA Map/Parcel# �r %er6e Address Lot# to Telephone# '568ZA —d Installer's Name JZA Designer's Name 5"We &MVIPU)NME-MrAL SVCS Address0,6 C�� ` � Address RQx E, RhumourK, M4 Telephone# Telephone# S Z4 F5_ 9 0 2S:!>L Type of Building "ReSX&n c tck\ / Lot Size cQZ)1 00C� sq.ft. Dwelling-No.of Bedrooms L2 '�j,y1 �Xf TI �NQ�E 13� S®C:dl Garbage grinder Qq/A Other-Type of Building �Jpm 1_ No.of persons Showers ( ),Cafeteria ( ) Other Fixtures I—ASIMM , ki Tr_tjQ A n Wk. L�AUIOMY Design Flow(min.required) (? gpd Calculated design flow Design flow provided 33(,S gpd Plan: Date ®^J Number of sheets _ 1 Revision Date ._ Title �� ++ p� �� Nl��C Description of Soil(s) -a2:r C:.c6A Soil Evaluator Form No. `, _l� Name of Date of Evaluation ]�d 3 DESCRIPTION OF REPAIRS OR ALTERATIONS 4-0 Q A)col C168 OMADO� The undersigned a s to' Fe#abo�&descfibed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to o top ceoperation until a Certificate of Compliance has been issued by the Board of Health. Signed Date T Inspections J (, No. ' J ) 0 FEE COMMONWEALTH OF MASSACHUSETTS Board of Health, MA. APPLICATION FOP, DISPOSAL SYSTEM[ CONSTRUCTION PERMIT Application for a Permit to Construct( Repair Upgrade( Abandon( - ❑Complete System,individual Components Location LU 2) �\ G 1�?. M: M ` 5 Owner's Name i Map/Parcel# M )v, f a � �y ,c (✓ Address --�y+ 0I Lot# Telephone# Installer's Name j Row��077� Designer's Name V t r� � j-��j ;;r _�r-� i �r Svc, " Address fA(� ! y1 �G�/SG�I Gl, Address Telephone# ,20`4�i�z�5 Telephone# 44 LQ,- - G .� Type of Building CA Lot Size sq.ft. 40 t:_. .Dwelling-No.of Bedrooms Garbage grinder ( lea Other-Type of Building �ta�1 _ No.of persons Showers ( ),Cafeteria ( ) Other Fixtures �—F'Ni: Cl t2 �Ct C'rlC��1 sulk 1 �i3Je.l�?.`d Design Flow(min.required) gpd Calculated design flow��5 Design flow provided . �; ..� gpd Plan: Date Number of sheets ! Revision Date Title `F` S �✓ w C _ Description ofSoil(s) � " -kk Cn'TT 0A S- (-v a Soil Evaluator No. l Name of Soil Evaluator Ear:v+ +fit `(Date of Evaluation is L1.z DESCRIPTION OF REPAIRS OR ALTERATIONS �a :C '� t? C +^ C `y ✓ 7:)! 's�E C J � The undersigned a sU11 �e described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to to s operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date Inspections No. FEE COMMONWEALTH OF� �ASSACHUS ETTS Board of Health, C r%)I b MA. ;7 CERTIFICATE OF COMPLIANCE Description of Work: ❑Individual Component(s) ❑Complete System The undersigned herep y certify that the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded ( ),Abandoned ( ) at ,has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) `nd the approved design plans/as-built plans relating to application No. -I'v"3 ``J , dated t i tr Approve s' n wi (gpd) r Installer Designer: Inspector: Date: p The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No-Uo FEE y c COMMONWLAL114 OF lM SSAC14 SETTS Board of Health, rzi ��"' MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair:(' ) Upgrade( ) Abandon( ) an individual sewage disposal system at T1`kk h n r Al• V) as described in the application for Disposal System Construction Permit NoQf)j't) (f date U? Provided: Construction shall be completed within three years of the date of this Rermit. All local conditions must be met. Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date - /` {/3 Board of Health 65� 1 TOWN OF BARNSTABLE LOCATION �` `./A SEWAGE # — VILLAGE Pi X1—AA kt-1* y� ASSESSOR'S MAP & LOT (50 0 INSTALLER'S NAME&PHONE NO. � ° ' SEPTIC TANK CAPACITY AV LEACHING FACILITY: (type) 6A (size) 17kylf NO. OF BEDROOMS 3 BUILDER OR OWNE D 41 PERMITDATE: q103COMPLIANCE DATE: f Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i PROPERTY AOORESS. 63.-Treetop_ .....Mass 02648 -------_..--------------- on the above data, I Inipeoted the septlo ,syote'ri at the- above address. ThI3 system consists of the following; R CEIVED 1 . 1 -1000 gallon septic tank. 2. 1 -1000 gallon precast leaching pit.6 'X10 ' JUN G 2001 eased n y, Inspecllon, I oertlry the following vondI 10TWN0FBARNSIABLE 3 . This is a thole ive septic tank. ( 78 Code ) HEALTH DEPT. 4 . The septic sy stem ystem is in proper working older ' s-® ® G at the present time. 5. Waste water is 42" below the invert pipe of the leaching pit. ,In SIQNATURE! Name;„ .3....K9SSimktt:. -_—..--- Company; Joj!.ph_P _ H•combor_b Son , Ynce Address ; Box-66�---__ __-- _-_____ Cents ryl11aL Ha_-02632-0066 Phone __ 508-775_3338 THIS CERTIFICATION OOCS NOT CONSTITVTC A OVARANTY OR WARRANTY C P. MACOMBER & SON, INC, �Pumpod 4 Init+llodTown Sower Connootlont 6675•ontorYY7, MA 02 632.0066 .. u , �.\ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION i TITLE 5 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 63 Treetop ri role M_arstons Mills Owner's Name: Milton Boynton Owner's Address: Sam Date of Inspection: 24 01 Name of Inspector: (please printp P. -Macomber__ Company Name: J.P. Macomber & Son Inc Mailing Address:P P.O. Box 66 C t-ntprvi 1 1 Ea i'l.a 02632 Telephone Number: 5oa-775-3332 -- 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 rraining and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section15.340 of Title 5(310 CMR 15.000). The system: //Passes _ Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signaturerbmit Date: The system inspector shallcopy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page a of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 63 Treetop Circle Mars tons MiTIs Owner: Milton Boynton Date of inspection: Inspection Summary: Cbeck A,B,C,D or E/ALWAYS complete all of Section D 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: The septic system is in proper working order ai- tha Present time. B. System Conditionally Passes: ,t//) 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. ,eQ,Q 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 ass inspection if the existing tank is replaced with a p p p complying septic tank as approved b the Board of'A metal sepric tank will pass inspection if it is structwallysound,not leaking and f aaCertificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: .�t/�,Observation of sewage backup or break out or higb static wateLtevel in th isrribu ion bo ue 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: IPA 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): brokenpipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 63 Treetop Circle Marstons Mills Owner:Milton Boynton Date of Inspection: 5/2 5/01 C. Further Evaluation is Required by the Board of Health: _6 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 ,12 Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, If any)determines that the system is functioning in a manner that protects the public health,safety and environment: �D The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. &6 The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. &�6 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 supple 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: 3 Page 4 of 1 I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 63 Treetop Circle Marstons mills OwnerMilton Boynton Date of Inspection: 1;12,/01 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No / _ !/ ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool �10 Static liquid level in the istribution box bove outlet invert due to an overloaded or clogged SAS or _ �cesspool l-4p-!m0 sc squid depth in ssp�aJ is less than 6"below invert or available volume is less than 1/2day flow �equired pumping more than 4 times in the last year NOT due to clogged or obstructed pip e(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. P y portion of a cesspool or privy is within a Zone I of a public well. y 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. (Tbis 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 formal A10 (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303. therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design now 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 a 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 has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304, The system owner should contact the appropriate regional office of the Department. 4 Page 5 of l 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:63 Treetop Circle Marstons Mills Owner: Milton Boynton Date of Inspection: 5/2 5/01 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes 7pumping 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 ? ZWere all system components,tfkluding the SAS, located on site? Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition Ae baffles or tees, material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no � Existing information. For example,a plan 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(3)(b)) 5 Page 6 of 1 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 63 Treetop Circle Marstons Mills Owner: Milton bovnton Date of Inspection: 5/2 5/01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):—1 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 13&441j1f 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): Seasonal use: (yes or no):No 9 9—1 0 0 0 0 0 98 Water meter readings, if available last 2 ears usage gallons G.P.D.= 1 3 4.25 g ( Y g (gpd)):nn_ ag� nnn ;allons G.P.D.= 134. 25 Sump pump(yes or no): At Last date of occupancy:present COMM ERCIALMIDUSTRIAL Type of establishment: 10 Design flow(based on 310 CMR 15.203): d Basis of design flow(seats/persons/sgft,etc.): ,el Grease trap present(yes or no): Industrial waste holding tank present(yes or no):�i Non-sanitary waste discharged to the Title 5 system (yes or no):�f1Q Water meter readings, if available: 11,x Last date of occupancy/use: t119 OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as pan of the inspection(yes or no): If yes, volume pumped: 0 gallons-- How was quantity pumped determined? ,y�C�/,/ � Reason for pumping: Maintenance TYPE F SYSTEM _IZSeptic tank, di6Q4bWt�e '_-_..soil absorption system ,o Single cesspool x,il Overflow cesspool 4.0-Privy &20Shared system(yes or no)(if yes,attach previous inspection records, if any) ZInnovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank 40 Attach a copy of the DEP approval &Other(describe): /4 Appr ximate a e of�al com one ts,date ir tailed(if known)and source of information: eA� � Were sewage odors detected when arriving at the site(yes or no): 6 Page 7 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTA RY ASSE SSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propeny Address:63 Treetop Circle Marstons Mills Owner:Milton Boynton Date of Inspection: 5/25/01 BUILDINC SEWER (locate on site plan) Depth below grade: /1 Materials of construction: , cast •trona40 PVC other(explain) _ D Distance from private water supply well or suction line: le'Ao' Comments(on condition of joints, venting, evidence of leakage, etc.): Joints appear ti ht.No evidence of leaka e.The system is VM .. � ' ly vented through the house vent SEPTIC TANK: (locate on site plan) Depth beloµ•grade: d� t Material of construction: concrete metal fiber lasW-, of eth lone ,P.dother(explain) g y y 7Lan.k is metal list age: certinifficate) Is age confirmed by a Certificate of Compliance(yes or no)�(anach a copy of iR Dimensions Sludge depth: �� Distance from top�ludge to bosom of outlet tee or baffle: Scum thickness: ok:Ae _ Distance from top of scum to top of outlet tee or baffle: r Distance from bosom of scum to bonom gr outlet tee or file: Hoµ were dimensions determined: f� Comments (on pumping recommendations, inlet and outlet tee or baffle condition. structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump the septic tank every 2-3 years.Inlet & outlet tees are in place.The tank is structurally sound and shows no m evidence of leakage. GREASE TRAP locate on site plan) Depth below grade: Material of construction4kconcretq/-1 meLsIV-4fiberglass�lypolyethyleno4�fother (explain): lem Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bonom of scum to bonom of outlet tee or baffle: Date of last pumping: 1pe'.4 Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease trap not present 7 \ Page 8 of I I ' OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 63 Treetop Circle MAratnnc Mi 1 1 a Owner: , Date of inspection: TIGHT or HOLDING TANM ve,(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction:2Aconcrete 441 metal4fiberglass g:�bolyethylene4lA_other(explain): /m Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: 164 Alarm in working order(yes or no): Date of last pumping: .41A Comments (condition of alarm and float switches, etc.): Tight or holding tanks are not present DISTRIBUTION BOXt'! (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 4144 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.): DiGtrihiltinn Rnx not present PUMP CHAMBER9-�d1e-(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.): Pump chamber not present 8 Page 9 of 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Addressf 3 Treetop Circle Marstons Mills Owner:Milton Bo nton Date of Inspection: 5 25 01 SOIL ABSORPTION SYSTEM (SAS):Zlocate on site plan,excavation not required) If SAS not located explain why: Located. System consists of 1 -1000 gallon tank and a 1000 gallon Precast leaching pit. Type leaching pits, number: y�leaching chambers, number: d _Ajoleaching galleries,number: 0 — leachin trenches,number, length: g � gt leaching fields,number,dimenA ions: ze overflow cesspool, number: c� innovative/alternative system Type/name of technolo //�� gY: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): Loamy sand to medt;im fine sand vegetation is normal. No signs of hydraulic afilure or Pondina Soils are dry. CESSPOOLS*,AJ6(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: p Depth—top of liquid to inlet invert: Depth of solids layer: /? Depth of scum laver: / 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.): l_Pi4RDnp1 G no D7'P4PTlf' PRIVY9>p1,f_-(locate on site plan) Materials of construction: . Dimensions: vA Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): Privy no present 9 Page 10 of 1 I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 63 treetop Circle Marstons Mills OwoerMilton Boynton Date of Inspection:5 25 01 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. �6C4 3 t3 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: 63 Treetop Circle Marstons Mills Owner:Milton Boynton Date of Inspection: 5/2 5/01 SITE EXAM Slope Q-aedov Surface water it!t/v Check cellar Shallow wells I I Estimated depth to ground water6Xfeet Please indicate(check)all methods used to determine the high ground water elevation: Obtained fro lans on record-if checked,date of design plan reviewed: erved site(abutting prope bservation hole within 150 feet of SAS) cked with oca oaz o ealth-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Used; Water contours Map Gahrety & Miller Model 12/16/94 11 n ` a•nr:nrw rRf•rTr-T.-1rnTJRf•rrTRf�-RR ae+errlt:-.'tA:T11rrTT�+•rn+7 m-'Rtu Ao7rrertrR7 �r�a�--:'..-.r...` TOWN OF BARNSTABLE BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION I•••rn�••.-::r-.ta••.rrnrirnt•+rn+n rts•m�rxe-rtnr•t+rtv7+r.7 —TI�+wnl�nw�7 en" mop 0 to 4. •••+�r-r•rr-ter�..+ -TYPI OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRESS 63 Treetop Circle Marstons Mills ' ASSESSORS MAP, BLOCK AND PARCEL # OWNERRIs NAME Milton Boynton PART D - CERTIFICATION NAME OF INSPECTOR J.P. Macomber Jr. COMPANY NAME Joseph P. macomber & SA Inc COMPANY ADDRESS Box 66 Centerville Mass 02632 Street Town or City State ZIP COMPANY TELEPHONE (508 ) 775 _ 3338 FAX CERTIFICATION STATEMENT I certify that I have personally inspected the sewage dis g posa7, system at this address and that the information reported is true , accurate, and omplete as of the time of .inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Che k one: Vv System PASSED t The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 154' 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection which I have con acted has found that the system fails to protect the jitiblic health and the environment in accordance with Title 5 , 310 CMR 15 . 303, and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . "r , Inspector Signature -S6 - , 4 , Date -o/ ne copy of this c t.ification must be provided to the OWNER the BUYER ( where applicable ) and the BOARD OF HEAL'I'll. * If the inspection FAILED, the owner or11.operator shall u d within one year of the date of the inspection, unless allowed ort required he m otherwise as provided in 3.10 Cmn 16 - 305 . partd.doc C0:1I'-%1O'.\ EALTH OF MASSACHUSETTS EXECUTI�•'E OFFICE OF Ell\'VIRO\ME\TAI AFFAIR.`, = F DEPARTMENT OF ENVIRONMENTAL PROTECTION �^4s ONE ''INTER STREET. BOSTON M-A 0210c t61;j 292-550o TRi.DT CON:. Secre:a.-. ARGEO PAUL CELLLCCI DAVID B STR'-*HS Govern- Conurdssioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Prowt reT: 6" Tr Top Circle Name of Owner McDonough liaddrs Cons 1V11��8 Address of Owner: Date of Inspection:'9--.1 9 a-.L Name.of Inspector:(Please Print)Wm. E . Robinson Sr. 1 am a DEP approved systerq inspector rsuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: Wm. E . Robinson Septic Service MwfingAddress: PO Box 10 9. Centerville • MA Telephone Number: 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-siteyage disposal systems. The system: Passes 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 (Board of Health or DEP)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. NOTES AND COMMENTS reused 9/2/98 PdF� larll n ►�• —led on Receded Pane, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A l CERTIFICATION(continued) "rop"Address: 63 Tree Top Circle , Marstons Mills awner: McDonough Date of Inspection: .. INSPECTION SUMMARY: Check A, C, or D: A. TEM PASSES: 1 have not found any information which indicates that•any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SY TEM 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. Indicate es, 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, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20)years prior to the date of the inspection: or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. 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 revised 9/2/98 Page 2 of I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Icoftnued) Property Address: 63 Tree Top Circle , Marstons Mills Owner: McDonough Date of Inspection: o7s—p7-B O--P1 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CIMR 15.303(1)(b)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 surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS 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. Method used to determine distance (approximation not valid). 3 OTHER reviseC 9��98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) A. Propertyaddress:63 Tree Top gircle , Marstons Mills O-n0r: McDonough Date of Inspection: a-,zr_a.o-4-$ SYSTEM FAILS: Yo must indicate either "Yes" or "No" to each of the following: 1 have determined that one or more of the following failure conditions exist as described 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. Yes No Backup of sewage into facility-or system component due to an overloaded orclogged 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 112 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 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 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. 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. E. LA GE SYSTEM FAILS: You mu t indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facifity with a design flow of 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: 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional offs of the Department for further information. revised 5j2/98 Pagc4or11 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART B CHECKLIST Property Address: 63 Tree Top Circle , Marstons Mills Owner: McDonough Date of Inspection: ®—G--d Check if the following have been done:You must indicate either "Yes" or "No" as to each of the following: Yes No �// _ Pumping information was provided by the owner, occupant, or 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 during that period. Large volumes of water have not been introduced into the system recently or as part of this / inspection. ✓ _ As built plans have been obtained and examined. Note if they are not available with N/A. ✓ _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. "✓ _ All system components, excluding the Soil Absorption System, have been located on the site. I _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _ Existing information. For example, Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) / (1.5.302(3)(b)1 The facility owner(and occupants,if different from owner) were provided with information on the propermaintenaarii-0f SubSurface Disposal Systems. re_Lsed �/2/98 Pagc5of11 ;Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Irop"Address: 63 Tree Top Ciircle , Marstons Mills owner: McDonough Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Desig�,sa g.p.d./bedroom. Number of bedrooms(design): Number of bedrooms(actual): Total DESIGN flow !4 5-(J Number of current residents Garbage grinder)yes or no): d Laundry(separate system) (yes or no)d,6; If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use(yes or no):/lyd 1999 90 000 gal. Water meter readings,if available (last two year's usage (gpol: g Sump Pump(yes or no)JL y 1998 56, 000 gal. Last date of occupancy:_7- CO ERCIALIINDUSTRIAL: Type f establishment: Desig flow: gpd ( Based on 15.203) Basis design flow Grease trap present: (yes or no)_ Indust al Waste Holding Tank present: (yes or no)_ Non-s nitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last ate of occupancy: O ER: (Describe) Las date of occupancy: GENERAL INFORMATION PUMPING RECORDS and rce of information: System purnfed as part of inspection: (yes or no) 1, d If yes, volume pumped: gallons Reason for pumping: TYPE S YSTEM lf/ 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) IIA Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other 6 APPROXIMATE AGE of all components, date installed(if known) and source of information: Sewage odors detected when arriving at the site: )yes or no) revised 9/2/9c Page 6(if II r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Iconon ed) 'ropeny Address:63 Tree Top Circle , Marstons Mills Owner: McDonough Date of Inspection: B DING SEWER: (Loc to on site plan) Dept below grade:_ Mate al of construction:_cast iron_40 PVC other(explain) Dista ce from private water supply well or suction line Diam ter Com ents: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK:_ (locate on site plan) Depth below grade: Material of construction:_✓concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ Is.age confirmed by Certificate of Compliance_(Yes/No) l Dimensions: Sludge depth: ��• p ) 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: 1 l Distance from bottom of scum to bottomG of outlett a o affle: How dimensions were determined: 6 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.) 5 ,w 8 C 1t GR SE TRAP: flocat on site plan) Depth elow grade:_ Materia of construction:_concrete_metal_Fiberglass _Polyethylene_otherlexplain) Dimens ons: Scum t ickness: Distan a from top of scum to top of outlet tee or baffle: Dista a from bottom of scum to bottom of outlet tee or baffle: Date f last pumping: Co ments: frec mendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evid ce of leakage,etc.) rL- revised 9/2 98 Page 7of11 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'rop"Address:63 Tree Top Circle , Marstons Mills Owner: McDonough Date of Inspection: T1G OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) Pa on site plan) Depth elow grade:_ Materia of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensi ns: Capacit gallons Design ow: gallons/day Alarm resent Alar level: Alarm in working order: Yes_ No_ Dat of previous pumping: Com ents: (cond tion of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:1 (locate on site plan) Depth of liquid level above outlet invert:` Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP HAMBER: (locate r site plan) Pumps i working order: (Yes or No) Alarms i working order(Yes or No) Comme ts: (note c dition of pump chamber, condition of pumps and appurtenances, etc.) revised 5/2/98 Page 8of11 1� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Irop"Address: 63 Tree Top Circle , Marstons Mills Owner: McDonough Date of.Inspection: SOIL ABSORPTION SYSTEM(SAS):_ (locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: . leaching pits; number:_ leaching chambers, number: leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of pond' g, damp soil, condition of vegetati n, etc.) L ` ArM ✓\3 C POOLS:_ (locate on site plan) Number nd configuration: Depth-to of liquid to inlet invert: Depth of olids layer: )epth of s um layer: Dimension of cesspool: Materials construction: Indication f groundwater: .i flow (cesspool must be pumped as part of inspection) Comme s (note c ndition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate n site plan) Materi Is of construction: Depth f solids: Dimensions: Comm nts: mote ondition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icontinued) Nop"Address: 63 Tree Top Circle , Marstons Mills owner: McDonough Jate of Inspection: 0 cr-� SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) GL �• i I 3 revised 9;Z/9R Pip-10of11 SUBSURFACE SEWAGE DISPOSAL PART C SYSTEM INSPECTION FORM r0PSYSTEM INFORMATION(cort r,,ed) Owner.e'tyAaa`es5:63 Tree Top Circle , Marstons Mills Date of Insp;� onough MRCS Report name Soil Type_ . Typical depth to groundwater . USGS Date website visited Observation .Wells checked Groundwater depth: Shallow. Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater- Feet Please indicate all the.methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property, observation hole, basement sump etc:) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (M_ust be completed) "evise.: 9/2/96 Pr�c 11 of]] oar IMA :• ?riff=�t►�)- -----r- .)�'',"""'.. . . . �ca'ioP'a r: A4Mp- yVc'Fbid'm11�anaili�y. �a a o � i r � (r 1 d LEE] b'3 -314 O , 77 SBWAGS it r � E . �,533508'S i L(ST � C �APAcmCy WWI, aW'pRti+aivt+s... , OR o . Separsttaq Nth"Batytee��a; id' Pity. 1 �W+Pr 3c11fi�t6i�wdlaa►Y aft�BtaAc e �ii�t og le�bi91�f�tlity'� ct<r Od Leac111A 1NARY��y we4lan e�isE ivl043t14i a� � L3 30 (� J-.3 r 5-3 -3/4 r3 -3I4 4. TOWN OF BARNSTABLE L(\CATION 6:3 71f&-��C:1.r�'� SEWAGE # VILLAGE ASSESSOR'S MAP & LOT 1 5 0 0 6� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /GeY,6 LEACHING FACILITY: (type) ,9,. (size) NO. OF BEDROOMS 3 BUILDER OR OWNER k\-f r 1% PERMITDATE: 3 L4 0 COMPLIANCE DATE:_3 r D Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by r i �> TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGENa ~ ASSESSOR'S MAP & LOT /S'loay6v INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY ��y .LEACHING FACILITY:(type) L d (size)��„�� , NO. OF BEDROOMS �- PRIVATE WELL OR PUBLIC WATER fK'e i BUILDER OR OWNER A�� DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No 1 dl/�/Z7'G.DLtJ ' -Wee ' s L"X�sry;v� Hods e- TOWN OF BARNSTABLE LO CATION SEWAGE # VILLAGE 0Jj(J r ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY Icy® LEACHING FACII.ITY: (type) (size) NO. OF BEDROOMS_ BUILDER OR OWNER A1,�,�51-2 124 s PERMITDATE: 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 anyLec,hing Facility (If any wetlands exist within 300 feet i cility) Feet Furnished by i r ti 0=CATIO SEWAGE PERMIT N0. VILLAGE INSTA LLER'S NAME & ADDRESS 46, BUILDER OR OWN R l DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 7.,,,.. 8--% 7-7 �� i} • �: ' ' e No........ F�$..N.................... THE COMMONWEALTH OF MASSACHUSETTS BOAR OF HEALTH ........ Appliratiun -fur Uhip ial Works Cnunutrurtiun Vanift Application is hereby'made for a Permit to Construct ((-,)--or Repair ( } an Individual Sewage Disposal Syst C - l_ _o- <• 1-6 1— ........ LocAddress .........................� _.` --C4�--........-- Owner Address In aller Address Q Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder 004 Other—Type of Building ----------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) Qf1 M Other �c ur s ------------------------------ ---------------- ---------- W Design Flow........... ....................gallons per person per day. Total daily flow........ --d--t._..........gallons. WSeptic Tank—Liquid capacity"e- gallons �Length................ Width................ Diameter................ Depth.--._-_-_-.--. x Disposal Trench—No......-••---. " otal Length.................... Total leaching area---_-•------------sq. ft. Seepage Pit No...._.._/_--_-____- Di e?er'.9WK. .._. epth below ' let____ __._./j.... Total leaching area------------------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) $0'12 - 7,s aPercolation Test Results Performed by--------------_---- ----------------------.............................. Date--------------------------------------- Test Pit No. 1----------------minutes per inch Depth of 'Pest Pit-------------------- Depth to ground water..----.----------------- 0:q Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water-..-..-------.--_-_.--.. P' -------- -- Descri t' n of Soil - or- 0- 0 6 00r•,.�.., - ---------- 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 the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b n issued,by the board oft health. Sign •------1-----�� ----------- ` p Date Application Approved BY . �..7 .7 Date Application Disapproved for the following reasons:............................... ....................•------••-•••-•--------....._--------•---•----------•••-- ................•--•---...------•----.......-•----------------•-----•--•---•-•---•-----•--•-----•-•••--•......---•----•--....._ --.--•-••------------------••--------------.------------•-••---------•--- Date Permit No......................................................... Issued........ Date r 414 4¢, THE COMMONWEALTH OF MASSACHUSETTS r <-- BOARD_ OF HEALTH >. s ......OF......".. . 5.............. t- Xplifiratiun -fur M_qp nttf Workii Tnnu#rnrtinn Punfit Application is:hereby`made for a Permit to Construct ((-)--or Repair ( } an Individual Sewage Disposal Syste%i .. ...........r��C � ')%CCe.S(lYNS ? �d ' Localio�-Address >or / 7.......................... ' .._---- ' -.....------.........-------- J C -- ..................................... Owner Address f L. ........ .................... ...`-- d re'•---•----- In/aller •-••-�--•-•----!` � Address UType of Building r 9 •,. Size Lot............................Sq. feet Dwelling—No. of Bedrooms.._ >______________________________....Expansion Attic ( ) Garbage Grinder ( �« aOther—Type of Building -- No. of persons............................ Showers ( ) — Cafeteria ( ) d Other r t;e5 ----------------------------- -- - .._ _____ allons e erson er da Total daily flow._____._ • gallons. W Design Flow =° g P ' P P Y Y � . -' g< USeptic T..nk—Liquid capacity:"::?:-' ?gallons Length---------------- Width---------------- Diameter------..-------- Depth----__-._-.----- xDisposal Trench—No............... 1dV1 __. Total Length.................... Total leaching area..-__._.____.--_-___sq. ft." Seepage Pit No.___._..�._..._._.. Di,irie er A-Pt.._. epth below �let __... Total leaching, ..................sq. it. z Other Distribution box ( ) Dosing tank ( ) , Percolation Test Results Performed by.....................•____.________________..,_----..__-_,.._._______..__. Date------__._----.------.__--------------.. Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water..-.---.__--..-.-------- (� Test Pit No. 2................minutes.per inch Depth of Test Pit..-_-_____.__-_.____ Depth to ground water-_.._....----_----_----- g ar Descr tinf Soil p A 9 a ei7 .e. M. II a.... ....... ._.. _ tr W ...--•••---- -•-------------------------- n ----• "---- t..�• h a _Nature o Repairs or Alterations—Ans,.w erw appble_ '.._U �' ...................................... --------------------------------•-....----------------------------------------------------=-------------=--------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Srg dr } ' Date Application Approved BY----- j.q Date Application Disapproved for the following reasons:................................. ---------- ................................ --•------=------------------- _..-•------•-----•-•-----••--..._._._•---•----•__.....-•--•--•--------••...-•------------------------------------------•-----. Date PermitNo...............................--------------------= \Issued........................................................ Date THE COMMONWEALTH OF MASSA'CHUSETTS � r BOARD , Orr HEALTH / ........................................O F........:............................................................................ Trrtifiratr of Tontphattrr THIS IS 70 CERTIFY, That the Individual Sewage Disposal System constructed'.(4--) or Repaired ( ) by '� G,.Gc. . r -= ----------------------------------------------------------- I Installer' bl - ----------------" '- ,1 ---- Iif 5....................... ------• -------------- ------- - -- has been installed in accordance with the provisions oft XTe State Sanitary C a ,desib in the application for Disposal Works Construction Permit N __ ________ _____ dated......____ __.__ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTIONATISFACTOR?. DATES - " Inspector �"-------- r sue•_ls- y THE COMMONWEALTH OF MASS4,,CHUSETTS BOARD OF HEALT , r p; ' S 1 'h C.tiln-t S ice. Z 1 ' rOF........................................... . . ------... No.... ••-------------- Ditivo -alFovw Ta n itrurtinn Vrrnfit Permission is hereby granted_____- ............... ._.--_----- -- --,_,-_-_--_•--_--••_.__...._- ----------------------------------------- to Construct (4"' Zr Repay ) an ndividu I se xage Dts a Syste at No 7. - C G q-- ' J C✓ii1 �/�rS CC �'� 1. sn'�a , S et as shown on the application for Disposal Works Construction Per it N�. ated a DATE_ �^ Board of Health _ ......•-----....•.------ ••---- ------------------------------•------ l FORM 1255 H062S & WARREN. INC.. PUBLISHERS �" . • t .w i } k r 1` nv ry 69 AV p wnw I tag ( L( CAT 10 C f C�". P TIT rz� Rs't 15.Ri S T C�N S �✓Z f f_.f.....:� � � Y . ' ,. \��.,� <,, .Y_,.�r M ( L-7C)t4 , , h�+ ►• �"�w t:n t "�t • l 1 'X' d jr.. �.;^tarr r` wins �, �'►-c� f 1 1 d do fC5 fa kcr, krv, v FL Atzs F.:.. NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6' BELOW GRADE ALL OUTLET PIPES FROM THE*NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V C. SECTION A -A DISTRIBUTION BOX SHALL BE �2' 10' min. from SET LEVEL FOR AT LEAST 2 FT. CONCRETE COVER G\�Existing Foundation.Foundation house to septic took f ., �OQy ' p g PROFILE VIEW OF LEACHING SYSTEM } 5.OUTLET "• -i'. 2- 7j \\ TOF ELEV 100.00 (Assumed) Septic tonk covers must be � within 6 in. of finished erode - J 1 KNOCKOUTS ZQ <7 Ci ; _ •.� Grode-over Septic TonL - 98.50 Grode over D-Box - 98.20 ode ow SAS - ELEV 98.20 - I �< O 4 I r/ si.• w r ris - ro,A.a cti+w.s su... •of rya- _ v:• ra,A.e r.�.ron. - - -ts.s- ouneT j 12 INLET r a i T T E Q \ r, 42, S = 0.02 3 HOLE H-10 DIST. BOX 3' Maximum Cover Top of SAS-Elev.=96.00 ip EXISTING S-0.10 S= 0.010' per toot 1S", a' - SCH. 40 T _I EXIST. PIPE 1.0 1.000 GAL. GREATER O FROH FOUNDATION � f 75' •�---_ Ii. 35' o 0 0 0 0 0 3'- SEPTIC TANK 0 20 o PLAN SECTION CROSS-SECTION I o » Effective DepN L7 O l� Gl l7 M fD o H-10 to ,n o 0 0 0 0 0 0 - ---r se..e=e. � U N b o 0 2 Units = 1 -2' Stone in Be Teen = 19' RACE LANE CONCRETE FULL FOUNDA , .. ,I wi o 3• 19' 3' 3 HOLE H-10 DISTRIBUTION BOX _ H 3.5 AJ 3.5'a) o SYSTEM PROFILE 6 in.of 3j 4"-/ 1/2" d v v 12' u d NOT TO SCALE LOCUS MAP l a compocted stone `, y 2$' d in Effective length wl Not to Scale c c > LT. STRIRDUT ALL AROUND I d --------------------- c ELEVATION 9LOO SOIL ABSORPTION SYSTEM (SAS) 6 in.of 3/4'-1 1/2' O - / Note Remove soil down 500 C H-20 LEACHING UNITS WIGGINS PRECAST GENERAL NOTES down to med sand lover & replace with compacted stone Bottom of Test Hole 1 Etev.-87-00 Not to Scale (elev. 91:00 ) & replace with clean coarse Bond w/perc. Note: Certification of Fill Material Required 1. Contractor is responsible for Digsofe notificotiof•, rate less than or equal to 2 min./in. before dr after placement Before and After Placement by Seive Analyses ( and protection of all underground utilities and p.pe;>. 2. The septic tank and distribution box shall to sel. level on 6" of 3/4"-1 1/2" stone. 2-16'DIAM AccEss MANHOLES 3. Bockfill should be clean sand or grovel with no stones over 3" in size. 4. This system is subject to inspection during :nsiol'afion j B by Carmen E. Shay - Environmental Services trc, p 5. The contractor shall install this system in cccord:nct F,r o LOT #52 i LOT {53 �~� LOT �#54 with Title V of the Massachusetts state code, the ripprc:ved pin- `� and Local Regulations. i \ , THE ACCESS COVERS FOR THE SEPTIC TANK. , „ L G' 6. If, during installation the contractor encounters any II INLET - 1 / a DISTRIBUTION BOX AND LEACHING COMPONENT \ I 'N 46d 26 20 OUTLET SET DEEPER THAN 6 INCHES BELOW FINISHED SOiI conditions or site conditions that are diffEreni: GRADE SHALL BE RAISED TO ,MTHIN 6' OF 1 \ from those Shown on the Soil log or in our design ! ` FINISHED GRADE \\ 1,25.00' r �,' � installation must halt & immediate notification b> � INSTALL TUF-TI?E GAS BAFFLES OR EQUALS made to Carmen E. Shay - Environmental Ser\.i'::eS, IrI, I !22• 7. No vehicle or heavy machinery shall drive Over `I1P STEEL REINFORCED PRECAST CONCRETE \ 1 �� -- 96 septic system unless noted as H-20 septic cormpotTents PLAN VIEW \\t i i _`\_� � � _ 8. Install Tuf-Tite gas baffles or equals on all cutlet tee ands � 3-24' REMOVABLE COVERS t I ! 25' i 48.5' 9. All Distribution Lines shall be 4" diameter Sc; f!d.jle <1 NSF PvC ,ip'!S. ,+ I I ,•:: .:-` r=, ; :a I 10. All solid piping, tees & fittings shall be 4 d orretei i +I 1!2•f.J, FAGHt Schedule 40 NSF PVC pipes with woter tight joiris 3' min. cleoronce p , I !REA "r.t I `� 11. Municipal Water is Connected to The Residen, Did :1:uttrl 8" min. 2 min. inlet to outlet 1} ET T ! W ! I I I p l INLET _ _-- _i --- - 6'min. OUTLET / 2 I I Properties Within 200 Feet. ----- - - {�(" Lia��d leKi u + � TEST HOLE �11 '- -=- - J-� i `� _ s -7 _,o mn- I l_ s' r Il = 98.00 �- ---- -- p-�X I O ---------- --------- ELEV- .s _ I p 1 E g v 4'-0' min. I `� 0 0-SOU Liquid depth 4 l I �' _ \ \ CO t I t , ^ THE PROPERTY LINES ARE APPROXIMATE AND ! CID COMPILED FROM THE SURVEY PLAN GENERATED BY Failed i\\-��+ 27' `\ BEARSE & LAW,SURVEYOR. OF BA,RNSTABLE, MA L 1 ,-k each Pit \\ ENTITLED " PLOT PLAN SHOWING CONCRETE FOUI\DAT�01\I 4• _10. \\ i 1\98; Approx.) Note: Remove soil down to el. 91 .00 & replace with OF LOT 56 TREE TOP CIRCLE, -M.ARSTON MILLS, ILIA", C143_D MA,( 'e-. 1g/'"" CROSS SECTION END-SECTION PROJECT BENCH MARK T� EXIST 1000 gal clean coarse sand w/�perc. rate less than or AND IS NOT INTENDED TO BE A SURVEY PLOT PLiaN TOP OF FOUNDATION + Q Septic Tank IT SHOULD BE USED FOR NO PURPOSE OTHER THAN - 100.00 Assumed +� or equal to 2 min./in. before & after placement I ELEV. - I THE SEPTIC SYSTEM INSTALLATION. � ) I (5 FOOT STRIPOUT ALL AROUND AS SHOWN) - - -_ - - SUN USE EXISTING 1000 GALLON H- 10 SEPTIC TANK ROOM 1 I I - NOT To SCALE _ `�` I reoneet+n \98, LOT #57 '\ r LOT #55 LEGEND EXISTING z BEDROOM ! DENOTES PROPCSi::C> 1 PERCOLATION TEST `` ro4x� SPOT TRADE \ t HOUSE ! Date of Percolation Test: FEBRUARY 26, 2003 `t ,� DENOTES E}:I�iTll\IG Test Performed By: CARMEN E. SHAY, R.S., C.S.E. t` t' #63 �� x 104.46 SPOT GRADE Results Witnessed By- WAIVER( Per Barnstable B.O.H.) 1 EXCAVATOR: Shay Environmental Services, Inc. \ r Percolation Rote: Less Than 2 MPI ® 84" Below Land Surface t I ',�,, 1 I'L PROPERTY LINE 1 Test Hole 96P PROPOSED CCNTOUR No. 1 - -- -- 1 - - - - - - EXISTING CONTO( ? DEPTH SOILS E M it / / ( �� 97 0 98001, M 1 Loamy i •� t1 / L Co DEEP TEST HOLE ik, Sand ! t � to rR 3/2 I 't �� --'' = '96' PERCOLATION TEST LOCIA-'iC;f'J 0"-8' A. 97.251 Loomy I \\ ' /! / \ �--� 6 FOOT STt-)CKADI_: Sand I 10 YR 5/6 \`\ / I / LOT #56 ` I 8"- 30" B. 95 50 20,000 Square Feet t/- ( -- --------------------------- Silt Loam ! G Medium 125'00 P LOT PLAI ,. Sand I PL a"- 132 25Y7/4 87. j Perc #1; s 4sd zs' zo" w / OF PROPOSED SEPTIC SYSTU� I ' J, ::► C' fm / I Depth to Perc: 84" to 102" Perc Rate= Less Tho 2 MPI PREPARED FOR I Groundwater Not Observed \ ! No Observed ESH WT K E I T H 8c R AC H A E L H A ADJUSTED H2O Elev. = None �2"0-F> CTR C-,L-E7 AT # 63 TREE TOP (40 FOOT RIGHT OF WAY) CIRCL_I_ MARSTO N MILLS , MA Desian Calculations y.. PREPARED BY: Number of Bedrooms: 2 Equivalent to 220 Gal-/Doy (330 Gol./Doy Min. per Title V) Garbage Grinder: No f ' Leaching Capacity Proposed- 330 Gol./Doy Minimum (Min. Per Title V) ' �� 7 E. S1• �( � T -. ./ - i' Septic Tank - 2 x 330 Gol. Do/ y = 660 USE 1,500 GAL- Septic lank. - �I _1 ' --- ---------' i SOIL ABSORPTION AREA: Using percolation rote of <2 min./inch THERE ARE NO WETLANDS WITHIN 200' OF THE PROPERTY. h I'i21 ENVIRONMENT-4L SERVICES, INC. ! Bottom Area: 0.74 gal/sq- ft. x 300sq, ft. _ 222.00 gallons Sidewall Area: 0.74 gal./sq. ft. x 148 sq. ft. 109.50 gallons 0 20 40 JO i r r>= P.O. BOX 627 Providing: = 331.50 gallons EXISTING LEACH PIT TO BE PUMPED & FILLED IN PLACE \s `; EAST FALMOUTH, MA 02J36 OR REMOVED IF FOUND TO BE NECESSARY TO INSTALL NEW,SAS. t Use: (2) PRECAST 500--C UNITS, HAVING A 2' EFFECTIVE DEPTH, • r=a TEL/FAX 508-548-0796 TO BE USED WITH 3.5' OF WASHED STONE ON THE SIDES AND NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE te.�... SCALE: 1 "=20' DRAWN BY: CES DATE: VARC H 2.001'3 3' OF WASHED STONE ON THE ENDS AND 2 FEET IN BETWEEN 2 UNITS. FROM THE EXISTING LEACH PITS/CESSPOOLS TO BE DISPOSED ------- '-------------- OF AS PER BOARD OF HEALTH SPECIFICATIONS. SCALE: 1"=20' PROJECT#SD393 FILENAME: SD393PP.DWG SI-IFET 1 CI::' 1 _ I �