HomeMy WebLinkAbout0043 TROTTERS LANE - Health 43 TROTTERS LANE;MARSTONS 1V11� .5
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TOWN OF BARNSTABLE
LOCATION J '(1�1U'1 'r-Q L n AGE'# 7�y1--)P
VILLAGE A SESSOR'S MAP&PARCEL
'S NAME&PHONE NO. r�IC—/
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) 9- (size) CSC)
NO.OF BEDROOMS _
OWNER 11 k Cyr�p
PERMIT DATE: C(+3IoK44AA;GE DATEe
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
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Back of House
13
66
2
78 �`
a TOWN OF BARNSTABLE s�
1 C'AT10N TJi�40 ka 4e SEWAGE#
VILLAGES � �! Q.� ASSESSOR'S MAP &LOT 0y
04510EVO1e S NAME&PHONE NO. /i y n el. 52L
SEPTIC TANK CAPACITY /000 S �nl �"J
LEACHING FACILITY: (type) �.C.o�L i (site) /006
NO.OF BEDROOMS
BUILDER O WNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) o Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
LOU
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TOWN OF BARNSTABLE
LOCATION q3 —5 IQ�L� SEWAGE # 3
VILLAGB ��y��� i��� /ASSESSOR'S MAP&LOTd y 7 Z
INSTALLER'S NAME&PHONE NO. ��J^J'�GOT�/ � ✓�'�. 7�/�� /
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type)) &27 &9,0)— (size) X/D /
NO.OF BEDROOMS 3
BUILDER OR OWNER L—IaZ �
PERMITDATE: I L h�4 COMPLIANCE DATE: �L
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 Z
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) 40 Feet
Furnished by
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
43 Trotters Lane
Property Address
Bank of America
Owner Owner's Name
information is Marstons Mills
required for MA 02648 July 26, 2012
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:When filling out A. General Information
forms on the 1
computer,use 1. Inspector: yv�
only the tab key
to move your Patrick M. O'Connell
cursor-do not use the return Name of Inspector
key. Septic Inspection Services Co.
Company Name
r� 189 Cammett Road
Company Address
Marstons Mills MA 02648
City/Town State Zip Code
508-428-1779 SI 12855
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
6 &—� �_ July 26, 2012 Job# 12-116
I pector'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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 43 Trotters Lane
Property Address
Bank of America
Owner Owner's Name
information is Marstons Mills MA 02648 Jul 26, 2012
required for y
every page. City✓rown 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:
Tank was not in need of pumping at time of inspection, leaching pit was empty with a stain
line @ 1/3 capacity.
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•11/10 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
43 Trotters Lane
Property Address
Bank of America
Owner Owner's Name
information is Marstons Mills MA 02648 Jul 26, 2012
required for y
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 43 Trotters Lane
Property Address
Bank of America
Owner Owner's Name
information is Marstons Mills MA 02648 Jul 26, 2012
required for y
every page. Cityrrown State ZipCode 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_day flow
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
f
fN Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
43 Trotters Lane
Property Address
Bank of America
Owner Owner's Name
information is MarstonS Mills
required for MA 02648 July 26, 2012
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
43 Trotters Lane
Property Address
Bank of America
Owner Owner's Name
information is MarStons Millsrequired for MA 02648 July 26, 2012
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
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal -System Page 6 of 17
Y 9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
43 Trotters Lane
Property Address
Bank of America
Owner Owner's Name
information is required for Marstons Mills MA 02648 July 26, 2012
every page. Cityfrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Unknown
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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
43 Trotters Lane
Property Address
Bank of America
Owner Owner's Name
information is Marstons Mills MA 02648 Jul 26, 2012
required for y
every page. Cityrrown 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: None
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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
43 Trotters Lane
Property Address
Bank of America
Owner Owner's Name
information is Marstons Mills
required for MA 02648 July 26, 2012
eve Cit /Town
every page. Y State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Unknown
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
'
Depth below grade: 1
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.):
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: 8.5' long x 5.2'wide- 1000 gal.
Sludge depth:
2"
t5ins•11/10
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
43 Trotters Lane
Property Address
Bank of America
Owner Owner's Name
information is Marstons Mills MA 02648 Jul 26, 2012
required for y
every page. Citylfown 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
28"
Scum thickness
2"
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.):
Liquid level was found at bottom of outlet invert and tees were intact.
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
l5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4M , 43 Trotters Lane
Property Address
Bank of America
Owner Owner's Name
information is Marstons Mills MA 02648 Jul 26, 2012
required for _Y
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
w 43 Trotters Lane
Property Address
Bank of America
Owner Owner's Name
information is Marstons Mills MA 02648 Jul 26 2012
required for Y
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ 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:
l5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
43 Trotters Lane
Property Address
Bank of America
Owner Owner's Name
information is Marstons Mills MA 02648 Jul 26, 2012
required for y
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: One 6x6 pit
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Pit was empty at time of inspection with a stain line at 1/3 capacity.
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-11/10 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
43 Trotters Lane
Property Address
Bank of America
Owner Owner's Name
information is Marstons Mills MA 02648 Jul 26, 2012
required for y
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):
M I
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
i
Commonwealth of Massachusetts
Title 5 '- Official Inspection Form
p
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
43 Trotters Lane
Property Address ----
Bank of America
Owner Owner's Name
information is Marstons Mills---.--. MA 02648 Jul 26, 2012
required for ._ y
every page. Cityrrown 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
Back of House
13
66
2 78 ��
Commonwealth of Massachusetts
a Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
43 Trotters Lane
Property Address
Bank of America
Owner Owner's Name
information is required for Marstons Mills MA 02648 July 26, 2012
every page. City/rown 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: 20+
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:
USGS topo map and town GIS.
You must describe how you established the high ground water elevation:
Town groundwater contour map shows water at el. 55 and topo map shows property at el. 80.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
4 r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
43 Trotters Lane
Property Address
Bank of America
Owner Owner's Name
information is Marstons Mills MA 02648 Jul 26, 2012
required for Y
every page. Cityfrown 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
15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
. . 0/0 - �3
bl/
• No. FEE
THE COMMONWEALTH OF MASSACHUSETTS
�jAZ MASSACHUSETTS
�kyyfirativn for (gIInstrurtion jJermit
Application is hereby made for a Permit to Construct( ) or Repair Pl� an On-site Sewage Disposal System at:
Location dress or Lot No. Owner's Name,Address and Tel.No.
IX,4,.57ia S M►9 cLs,
Installer's Name,Address,and TeI.No. Designer's Name,Address and Tel.No.
4:77 WI) 1209 iK.t,S
M� T) or-4.S / W LLS /V14- oral vy-
Type of Building:
Dwelling No. of Bedrooms Garbage Grinder
Other Type of Building No. per Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow -730 gallons per day. Calculated daily flow 3-73 gallons.
Plan Date '7,t F TI Number of sheets Revision Date
Title
Description of Soil
Nature Qf Repairs or Alterations(Answer when applicable p � ��S�E �1A A— �Uoo
7,s..l [,EA-U 4 lV i� —1'WL/ o J PO C-b 0 y )- U� WAZ+4-Ed S Zjt.Je_ i7�
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction e of the aforedescribed on-site sewage disposal
system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a
Certificate of Compliance has be�issed is oard of Health.
Signed Date
Application Approved by Date `'
Application Disapproved for the following reasons
Permit No. � Date Issued
r
^ �k, No. : ". FEE
THE COMMONWEALTH OF MASSACHUSETTS
MASSACHUSETTS
,ppyfi attun for VisVvsa1 ,,Sgstem (funstrurtion jJerntit '
Application is hereby made for a Permit to Construct( ) or Repair(O<) an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No.
/14,4AS7 0 r JS Mbl L L4 M4 0�.I&q 7- y-3 i�07"T /L 3 G/�r•J�
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
((:^ w 1 a 1 124 g
eM J UPS /►W L L-f i /VIA- a.-LbV
Type of Building:
Dwelling No. of Bedrooms Garbage Grinder
Other Type of Building No. per Persons 'Showers( ) Cafeteria( )
Other Fixtures
Design Flow -730 gallons per day. Calculated daily flow 3G gallons.
Plan Date / l
t9 77 Number of sheets Revision Date
Title
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) �4 D lJ �Z ,.5�/W fl-` (0 0 0
—714 E. rx(-rr7N E- _S& L Y.)E ,
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction a • e of the aforedescribed on-site sewage disposal
system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a
Certificate of Compliance has bee iss ed by s ' and of Health.
Signed Date
Application Approved by Date ""r 0 ww_
Application Disapproved for the following reasons J
Permit No. 's Date Issued 1-7%*1.-
�HE COMMONWEALTH OF MASSACHUSETTS D—I 3
A'e-04�LL MASSACHUSETTS
Cfertifirate of Q-11-araptiattre
THIS IS TO CERTIFY that the On-site Sewage Disposal System installed ( ) or rep edd//re (6 on
by _ISatC'�t�TTI C0 N sT�L.0 to iyn► for
at ` /t-S L,1i\l& ) ^fs M I1�4 3 as een constructed in
accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Use of this system is conditioned on compliance with the provisions set forth below:
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. This
Certificate expires on
DATE "� `" Inspe�ior�
THE COMMONWEALTH OF MASSACHUSETTS
No. , MASSACHUSETTS FEE
�iS o$tt1 5g8teitt (gonstrurtion Ferutit
Permission is hereby granted to CA to i) 7 GG+J s 7JU`�7G'J
to construct( ) or repair(o.�_an On-site Sewage System located at
A114-A-i—,L Jj 11A i Lki
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her
duty to comply with Title 5 and the following local provisions or special conditions.
All construction must be completed within three years of the date below��
DATE �f Approved b
FORM 1255(ev.3/95 A.M.SULKIN CO.-BO�TON,MA
t
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
hereby certify that the application
on for di
sposal works
construction permit signed by me dated_������ , concerning the
property located at Y,2 &,fyJL meets all of the
following criteria:
• There are no wetlands within 300 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
SIGNED : DATE: 9G
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
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7 '� dt �f..Y`�`,X+��! �}'::�` '`�•v�T'�3^'" ite. � t..,t �F �,q }3 .. x
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19
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No.8420
Y
1
O/STEM
su - J(�
F. LEGEND CERTIFIED PLOT PLAN
T1N0 SPOT ELEVATION OxO
IM NO'�`• K CONTOUR —— p
`ffU11NED SPOT ELEVATION
r;t#lSNEID CONTOUR 0
APPt OVED = BOARD OF HEALTH
SAJ111SIRS1.A, WASl
�wt`fiE — AGENT SCALE DATE
LDRE_D_6£_£NGINEER/NQ CQ 1N 7io
_. CLIENT _ _.__'�.__ I CERTIFY THAT THE PROPOSE[
77 U V �. BUILDING SHOWN ON THIS Pt AN
EOISTERE - RE819TeRED jog N0.
i -i. '.: By,
_'�_� CONFORMS TO THE ZONIN6 LAWS
�. •` CIVIL IAND - i _
'` t~ E 81NEER aURV -- — OF BARNSTABLE , MA98•
�Q MAIN s� CH. By= 2 n n._ �/1 dMAIN
ST - -
.i A U }i MASS. NYANNtS, MASS. I
y T NEST , _ Of _ DOTE RES. LAND BURVEYO
l
BORTOLOTTI`CONSTRUCTION, INC. &
765 WAKEBY,ROAD,MARSTONS MILLS,MA 02 4 J[9[9�9
508-771-9399 508428-8926 FAX: 508428-9399
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION
' . PART A
CERTIFICATION
Property Address:
Date of Inspection: Inspector's Name:
Owner's Name and Address:
d.
CERTIFICATION 9TATF. ENT! . . a
I certify tltatI.have personally,,inspected the sewage disposal,system at this address,and that:the informs-
tion repotted below is,true,accurate and complete as of the time of inspection:ite,inspect,on was,,. r-
formed based on my training and.experience in the proper function and maintenance of on-site.sewage
disposal stems. The System:
7 Passes ,
Conditionally:l?asse
Needs Further Ev tion Local Aproving Authority.
Fails
Inspectors Signature: — Date:
The System Inspector shall submit a copy,of this inspection report to the.Approving autitority within thin-
ty(30)day,SLof completing ties inspection.`If.tite system is a shared system or.has;a design flow of10,000
gpd or greater, the inspector and the system owner shall submit the report to,the(,apprtpriate regional
office,of.the Department.of Environmental Protection. The original should be sent to.tl�e,system owner
and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY-
A)SYSi M PASSES:
l have not found any information which indicates that the system violates,any of the failure
criteria as defined in 310 CMR 15,303. Any failure criteria not evaluated are,indicated
below., a
B)SYSTEM CONDITIONALLY PASSES;
One or,more,system components need to be replaced or repaired. The system,upon comple-
tion of the replacement or repair, passes inspection.
Indicate y4 nor,or not determined(Y,N,OR ND).Describe basis of determination in all instances: If
"not deter�' ed%explain why;not. ,
The septic tank is metal,cracked,structurally unsound,shows.substantial infiltration or
ekfiltration,or tank,failure is,imminent. The system mill pass inspection if.the existing sep-
i tic tank is replaced with a conforming septic tank as approved by The Board of Health.
i Sewage backkup or breakout.or high static water.level observed,in the distributioq.box is due
I to broken or obstructed i p'pe(s)or due to a broken,settled or.uneven distribution box. The
system will pass inspection if(with approval of The Board of Health): -
i 1
_ C1 SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM
to PART A '
.� CERTIFICATION(continued)
Broken pipe(s)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
C)FURT#ER 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)SYS7;'EM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE"'
SYSTEM•'ISNOT FUNCTIONING IN'A'MANNER WHICH'WILL PROTECT
`PUBLIC HEALTH'AND SAFETY'AND'THE ENVIRONMENT
Cesspool or privy is within 50 Feet of a surface water ,
Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a
2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND'IPUBLIC'WATER�-
SUPPLIER,IF.APPROPRIATE)DETERMINES THAT THE SYSTEM LS`F(fNCTION k t
IN ON A MANNER,-THAT PROTECT
•THE.PUBLIC HEALTH AND SAFETX AND r {,i
ENVIRONMENT:
:.
The system has a septic tank and soil absorption system and is within 100 Feet to a surface
`,water supply or tributary to-a surface water,supply.
The system has a septic tank and soil absorption system and is with a Zone I of a publc'
i -water supply well:. . '
PP Y
The system has a septic tank and soil absorption system and is within 50 Feet of a private
water supply well.
The system has aseptic tank and soil absorption system and is less than 100 Feet but 50 j
Feet or more from a private water supply well,unless a well water analysis ttof' aillfform
j., bacteria and volatile organic compounds indicates that the well is .free from polludont`rom
the facility and the presence of ammonia nitrogen and nitrate nitrogen iseq»al to or kiss ?
than 5�PPm� g
D)SYSTEM1AILS: k w'`
I have determined that the system violates one or more of the following failurd critoria as de ted
in 310 CMR 15.303. The basis for this determination is identified below. Th ,Board of Heaithd
should be contacted to determine what will be necessary to correct the failure r
s 1' Backup of sewage into facility or system component due to an overloaded:or'clogged°SAS
or cesspool.
Discharge or.ponding of efluent to the surface of the ground or surface waters due to an
1' overloaded or clogged SAS or cesspool.
w . +£.,
x Static liquid level in the distribution box above,outlet invert dge,to,an ovetloaded`or clog-
1 god SAS or•cesspool
4 } ., ♦ . : ;
j Liquid depth in cesspool is less than_6"below invert or available volume s`less than 1/2
-di
yfl ow.
,.,
'Required pumping,more than 4 times in the last year NDI due to.clogged or obstructed
pipe(s). {Number of times pumped
I �1
SUBSURFACE SEWAGE DISPOSAL SYSTEMINSPECTION FORM
PART A
CERTIFICATION (continued)
Any portion of the Soil Absorption System,cesspool or privy is below the high'groundwater
elevation.
Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to
a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or.privy is within 50 Feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 Feet but greater than 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)LARGE SYSTEM FAILS:
The following criteria apply to a large system in addition to the criteria above: j
The design flow of a system is 10,000gpd or greater(Large System)andthebystem is'a gn'fic ant. '
threat to public health and safety and the environment because one or,more of the following,
„conditions exist:
The`system is within.400 Feet'of a surface drinking'water supply
- The system is within 200.Feet of a tributary to a surface drinking water supply .q:3_
w I The system is located in a'nitrogemsensitive area'Intenm Wellhead,Protection.' a tl
(IWPA)or a mapped Zone 11 of a public water supply well '"' ^ '_'' '
The owner or operator of any such system shall bring'the system and facility into full compliance with the
groundwater treatment program requirements of 314 CMR 5.00 and 6:00.' Please consult"the local"'
regional office of the Department for further information. i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
i
Chock if the following have been done:
,Pumping information was requested of the owner,occupant,and Board of Health`s j
Hone of the system components have been pumped for atleast two weeks and the systeii'las
,been receiving normal flow rates during that period. Large volumes of whir lave 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'witl N/A. . A
The facility or dwelling was inspected for signs of sewage back-up.
t/; The stem does not receive non-sanitary :.
system tart'or industrial waste`tlow:
The site was inspected for signs of btakout.
system•components,excluding the Soil Absorption System,have been located on site;
✓a The septic tank manholes were uncovered,opened;and the interior"of the'septic tank wss in-
ed for condition of battles or tees;material of construction,dimensions,depth of§liquid,
A of sludge,depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on
existing information or approximated by non-intrusive methods.
-3-
1 � f r 1• 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM'INSPECTION FORM
PART B
CHECKLIST(continued)
The facility,owner(and occupants,if.difl'erent from owner)were provided with information on
.the proper maintenance of Subsurface Disposal System
,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
( PART C
SYSTEM INFORMATION
il.. FLOW CONDITIONS i
RESMVNTIAL: /!
Design Flow: 3 aahons Number of Bedrooms:_ Number of Current,Itesidents; l7
Garbage Grinder:�gi Laundry Connected To System: Seasonal UseWO
,Mejer;Readings if • able: '.Water; , ,
Last Date'160Occupancy: '
CO M ER AIANDUST IAi ;.
8n y,, p (y
Type of Estabhshment. 7� . .,
- Design Flow: aaltons/da Grease Tra Present: es or no)`
Industrial Waste Holding Tank Present: - - - -
Non.Santtaryr,WasteDischarged To The Title V System: '
Water.Meter,Readin s .If Available:' Last Date of Occupancy-,
e g
OTHER: Describe)
Last Date of Occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System Pumped as part of inspection:- Nc) If yes,volume pu k' ons
Reason.for pumping:
TYPE OF SYSTEM:.
Septic Tank/Distribution Box/Soil Absorption System
Single Cesspool
4 Overflow Cesspool
Privy
/Shared.System(If s,attach previousinspection records,if any)
_tom ' +Y'
Other(explain):
:•.,.,,., rH ,3 u.t.+.,, �r,.. ,.,, v 9i.�� ,, t. s,.. .�:"5 t, g. 'tl ., �f..`t. ?, ';a. Id .,.r,': ;.,,•5..g._
t,
PROXIMATE AGE''of all co ponents;date installed(if known)and source of informatton:
Sewag or6detected wfien arriving of the'site:
it
i
,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
GENERAL INFORMATION (continued)
i;
SEPTIC TANK: ✓
Depth below grade: Material of Construction: P concrete metal FRP_Other s i
Dimi(explain)-
ans: - Sludge Depth: 07" Scum Thickness:
Distance from top of sludge to bottom of outlet tee or baffle: 31
? Distance from bottom of scum to bottom of outlet tee or baffle: AP
Comments:!(recommendation for pumping,condition of inlet and outlet tees or b es,depth,of llquidy ..
!; level in relation t utiet invert,structural integrity evidence of leak ge,etc.)
;1•
"i
fr
f GREASE TRAP:
3 ,
Depth Below Grade: Material of Construction: concrete metal FRP Other
(explain) !! — — �.•;
. ;' Dimensions: y Scum Thickness:
Distance from top of scum to top of outlet tee or baffle:
Comments; (recommendation for pumping,condition of inlet and outlet tees or.baffles,depth of liquid
4evel In relation to outlet invert,structural integrity,evidence of.leakage;etc:)
_. ; ..
TIGHT OR HOLDING TANK:
Depth Below Grade: Material of Construction: concrete metal FRP Other(explain)
9 _
Dimensions; Capacity: gallons Design Flo%%,- kallons/day
Alarm Level: ;;.
Comments: (condition of inlet tee, condition of alann and float switches. etc.) 7 ,.w
DISTRIBUTION BOX:
Depth of liquid level above outlet invert: /
Comments:Oote if level and distribution is equal,evidence of solids carryover,evidence of leakage into
or out of box,etc.)
PUMP CHAMBER:,�(� . .. .
,
Pump is in`Woking_older:Comments:+(note condition of pump chamber,condition of pumps and appurtenances,'ctc:)''•
� -5-
i j
i
ti 1
E
f
Ir
{
• 1
,
. .'. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
' PART C
SYSTEM INFORMATION (continued)
SOIL ABSORPTION SYSTEM(SAS): Mp ,`
(Locate*site plan,if possible;excavation not required,but may be approximated by non-intrusive.
methods) 'If not determined to be present,explain:
Leaching pits,number: / Leaching chambers, number: Leaching galleries,number
Leaching trenches,number,length:
Leaching fields,number,dimensions: 3
Overflow cesspool,number: t
Comments: (note condition of soil,signs of hydraulic failure vel of ponding,condition of vegetation,'°
etc.) ;. .'/ /,
CESSPOOLS:
Number i i d n5guration:` Depth-top of liquid to inlet invert:
P P 9 "
Depth of solids layer: Depth of scum layer: Dimensions of Cesspool:```
Materials of construction: Indication of groundwater:
Inflow(cesspool must be pumped as part of inspection)
Comments: (note condition of soilk,signs of hydraulic failure, level of ponding,condition of vegetation,, .
etc.)
PRIVY: A)(
Materials of construction: Dimensions:
Depth of Solids: _. . y
Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.) ,
fti
-6-
SUBSURFACE SEWAGE DISPOSAL' SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references, landmarks or benchmarks. '
Locate all wells within 100 Feet.
DEPTH TO GROUNDWATER:
Depth to groundwater: 7-r Feet �
Method of Determination or Approxima 'on: J-
-7-
RAIN
BORTOLOTTI CONSTRUCTION INC. L _
765 WAKEBY ROAD,MARSTONS MILLS, �
MA 02648 VFE8 1 5 ���
508-771-9399 5118-428-8926 FAX: 508-428-9399 tt»�
F Oh
ti
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A `CERTIFICATION
Property Property Address: �
Date of Inspection: ( (, Inspector's Name:
Owner's Name and Address:,T ,P
d
CERTIFICATIONSTATEMENT:
I certify that I have personally inspected the sewage disposal system at this address-and that the informa-
tion reported below is true,accurate and complete as of the time of inspection. The inspection was per-
formed based on my training and experience in the proper funct.iou and maintenance of on-site sewage
disposal systems. The System:
Passes
Conditionally Passes
Needs Further Ev uation By ie L al Aproving Autliorily
Fails
Inspector's Signature: 1AV25V Date.
The System Inspector shall submit a opy of this inspection report to the Approving authority within thir-
ty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional
office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY-
A)SYSTEM PASSES:
1 have not found any inforni.m' n which iiidicales Ihat the system violates any of the failure
criteria as defined in 310 C115.303. Any failure criteria not evaluated are indicated
below.
B)SYSTEM CONDITIONALLY PASSES;
One or more system components need to be replaced or repaired. The system, upon comple-
tion of the replacement or repair, passes inspection.
Indicate yes, nor,or not,determined(Y,N,OR ND). Describe basis of determination in all instances. If
"not determined",explain why not.
The septic tank is metal,cracked, structurally unsound, shows substantial infiltration or
exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep-
tic tank is replaced with a conforming septic tank as approved by The Board of Health.
Sewage backkup 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):
- 1 -
- FORM
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECT
ION
' PART A
CERTIFICATION (continued)
Broken pipe(s)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).
if with a
The system will pass inspection ( pproval of The Board of Health):
Broken pipe(s)are replaced
Obstruction is removed
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 of
the system is failing to protect the public health, safety and the environment.
1)SYSTEM WILL PASS UNLESS BOARD OF IfEALTH.DETERMINES THAT THE
SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE
PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 Feet of a surface water
Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh.
2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER
SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTION-
ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 Feet to a surface
water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is with a Zone I of a public
water supply well.
The system has a septic tank and soil absorption system and is within 50 Feet of a private
water supply well.
The system has a septic tank and soil absorption system and is less than 100 Feet but 50
Feet or more from a private water supply well, unless a well water analysis for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from
the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm.
D) STEM FAILS:
I have determined that system
'n the stem violates one or more of tine following failure criteria as defined
in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health
shou be contacted to determine what will be necessary to correct the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS
or cesspool.
ace of the ground or surface waters due to an
Discharge or ponding of eiluenl to the surf,
overloaded or clogged SAS or cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clog-
ged SAS or cesspool.
Liquid.depth in cesspool is less than G"below invert or available volume is less than 1/2
day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed
pipe(s). Number of times pumped
-2-
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater
elevation.
Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to
a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50,Feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 Feet but greater than 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)LARGE SYSTEM FAILS:
The following criteria apply to a large system in addilion to the crileria above:
The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant
threat to public health and safely and the environment because one or more of the following
conditions exist:
The system is within 400 Feet of a surface drinking water supply
The system is within 200.Feet of a tributary to a surface drinking water supply.
The system is located in a nitrogen sensitive area interim Wellhead Protection Area
(IWPA)or a mapped Zone 11 of a public water supply well.
The owner or operator of any such system shall bring the system and facility into full compliance with the
groundwater treatment program requirements of 314 CMIZ 5.00 and 6.00. Please consult the local
regional office of the Department for further information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Check if the following have been done:
✓Pumping information was requested of the owner,occupant,and Board of Health.
_ None of the system components have been pumped for atleast 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.
t/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.
t� 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 site.
=The septic tank manholes were uncovered, opened, and the interior of the septic tank was in-.
spected for condition of baffles or tees,.material of construction,dimensions,depth of liquid,
I/ 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 or approximated by non-intrusive methods.
-3-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST(continued)
V The facility owner(and occupants, if different from owner)were provided with information on
the proper maintenance of Subsurface Disposal System
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
v_PARTC
SYSTEM INFORMATION
FLOW CONDITIONS
RESIDENTIAL*
Design Flow: 33algallons Number of Bedrooms: .�_ Number of Current Residents:
Garbage Grinder: Sys Laundry Connected'I'o (em: )OS Seasonal Use: /\/t
Water Meter Readings, if vailable:
Last Date of Occupancy: 01-re f
COMMERCIAL/INDUSTRIAL: Wo
Type of Establishment:
Design Flow: gallons/day Grease Trap Present: (yes or no)
Industrial Waste Holding Tank Present:
Non-Sanitary Waste Discharged To The Title V System:
Water Meter Readings, If Available: Last Date of Occupancy:
OTHER: Describe)
Last Date of Occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of infonna 'ow. in
System Pumped as art of inspection: 1 If es volume pumped:Y P P P 1� Y � P P gallons
Reason for pumping:
TYPE OF SYSTEM:
_L,,/ Septic Tank/Distribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool
Privy
Shared System(If yes,attach previous inspection records, if any)
Other(explain):
APPROXI-MATE AGE of all components,date installed(if known)and source of information:
C,rS- lI t`'o el G( C roc>caJ
Sewage odors detected when arriving at the site: �u
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
GENERAL INFORMATION (continued)
SEPTIC TANK: V �
Depth below grade: Material of Construction:� concrete metal FRP Other
(explain)
De the
Dimisions:�. 5 ' (o ' Sludge—,Y g p l' Scum ThiCkness:_�a
Distance from top of sludge to bottom of outlet tee or baffle: 3 �/
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid
level in relation to outlet invert, structural integrity,evidence of.leak ge,
a4-41)r,e r Cvct/d usP 22i '11'a�2�r� 12
GREASE TRAP:L�
Depth Below Grade: Material of Construction: concrete metal FRP Other
(explain) — --
Dimensions: Scum'I'hickncss:
Distance from top of scum to top of outlet lee or baffle:
Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid
level in relation to outlet invert, structural integrity,evidence of leakage,etc.)
TIGHT OR HOLDING TANK:
Depth Below Grade: Material of Construction:_concrete_n►etal_FRP_Other(explain)
Dimensions: Capacity: gallons Design Flow: gallons/day
Alarm Level:
Comments: (condition of inlet.tee, condition of alarm and float switches,etc.)
DISTRIBUTION BOX:
Depth of liquid level above outlet invert:/00r,�'�f �LvLLf'
Comments: (note if evel and distribution is equal,evidence of solids carryover,evidence of leakage into
or oyt of box,etc.�rs�
0 i/�SijJE'�yS77rr
0 '
PUMP CHAMBER:
Pump is in working order:
Comments:.(note condition of pump chamber,condition of pumps and appurtenances,etc.)
-5-
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PAR'I'C
SYSTEM INFORMATION (conlinued)
SOIL ABSORPTION SYSTEM(SAS):
(Locate on site plan, if possible;excavation not required,but may be approximated by non-intrusive
methods) If not determined to be present, explain:
Type:
Leaching pits, number:Leaching chambers, number: Leaching galleries,number:
Leaching trenches, number, length:
Leaching fields, number,dimensions:
Overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure level of ponding,�,ondition of vegetation, .
etc.) Z/ UG o
.- . Q3
CESSPOOLS::
Number and configuration: Depth-top of liquid to inlet invert:
Depth of solids layer: Depth of scum layer: Dimensions of Cesspool:
Materials of construction: Indication of groundwater:
Inflow(cesspool must be pumped as part of inspection)
Comments: (note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
PRIVY:
Materials of construction: Dinicnsions:
Depth of Solids:
Comments: (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,
etc.)
-G-
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references, landmarks or benchmarks.
Locate all wells within 100 Feet.
I
i
I
k", O
DEPTH TO GROUNDWATER: i
Depth to groundwater: Z 7 Feet
Method of Determination or App oxin►alion �0,�//�!� i^��9 l�J �� ,7
1-,L/-,0Aer A,1 �AQ
-7-
( LOCATION SEWAGE PERMIT NO.
,La`r -,t:i I 9 '7-7 s"C
VILLAGE i r c)-r 'iF`L S 44
r
IN�B �.STA ( LEER'S NAME & ADDRESS
c�- ,lam I a 1 L oe l-L 5 PL to t�C.
B"U It D E R OR OWNER
DATE PERMIT ISSUED 77
DATE COMPLIANCE ISSUED
14
r _ T
F,B..$15.._00..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town OF......Barnstable
....................................................................................
Appliratiun for DiipuiiFal Works Toustrurtiun ramit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at:
lot #19 Trotters Lane ..............1ot±19..............................................................
•- -L cation.Address or Lot No.
Innovative builders, Inc. Bea Stt ,Westfield. MA-•••„-
..- .................. _... .......................................
ner Address
W � 150 Walnut Street W._--Barnstable
............................................. .`c " _-. ... ..._.......... ......................_...................................._L .... ........
Installe Address
d Type of Building Size Lot... 20,000-+n..Sq. feet
Dwelling%No. of Bedrooms____.__three--__•(3)_•_____,__,__Expansion Attic (no) Garbage Grinder .(no)
Other—Type of Building ... . p """" (no)_________ _______ No. of ersons__..__.._. _..._.._ ____ Showers — Cafeteria n
Q' Other fixtures .....................•---.--_---_.
W Design Flow____._...55______________________________gallons per ,person per day. Total daily flow__._._._:3:30�.. gallons.
WSeptic Tank—Liquid capacity-_1-000.gallons Length---4 a........ Width..8a.......... Diameter._-_-_------- Depth.....4_........
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.......... Diameter.........1.0...... Depth below inlet.........(.......... Total leaching area.....2fi6......sq. ft.
z Other Distribution box ( ) Dosing tank ( _)
aPercolation Test Results Performed by.__ �r !-! f.�.._ !"f e ____________________ Date__ `� ..... /
a P�*� Pit No. 1................minutes per inch Depth of Test Pit........ . ..__. Depth to ground water__/U_dd4t-_'�au><d
Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
. ------------------------------------- ...............................................................................
O Description of Soil... f ° = 1-----------------•-•----•-
rWi
V .........-•-•--------•-----•---------------------------•--•-•-•-•----•--•------••---..__._.......................--------•-------------•----........---------------------•--......---•--...........----•-
W
x -•-•---------------•---------------•-----•-•--...--••---•------------•-•--------•--------•••----•----•---•-•-•--••-._.._.....----••---------•-•-----------------------.................................
UNature 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 TITL LE 5 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 hea th.
Signe .....mil--1,. ".��a... �- ••....:-�
Date
Application Approved By....._..;.=- ____ ._.__ � _� 7
Date
Application Disapproved for the following reasons:......................-•--...---•--•--•------•--------•---•--------------------.........--••-•------•---•••-•--
-•-•.............................••----•----•-----------•.....---••--------------•-•--•--•-•--------.....•-----------------.•------•------•----------------•----------
PermitNo......................................................... Issued.......6 .------------•--•----• .................
Date
00
N)� .................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town Barnstable
..........................................OF..........................................................................................
pfiration for Disposal Workii Tomitrurtion "amit
V
Application 'is hereby made for a Permit to Construct ( X) or Repair an Individual Sewage Disposal
System at:
lot #19,Trotters L -ne lot #19
waid Tjy",;;.....*............... .. ......*------------------*.......*------------*----------"----------------------------------------
innowitive ers, Inc. 55 Broid Strco!-r-L' %stfield. M&
................................................................................................. .................................................2.................................................
� John A-Ito Owner Address
150 W Inut Street. W. Barnstable
.................................................................................................. .................................................................................................
Installer Address
Type of Building Size Lot...�2AP.Q+-...Sq. feet
Dwelling A No. of Bedrooms................................hre (3) no)
9 ...........Expansion Attic (no) Garbage Grinder
Other—Type of Building ............................ No. of persons...,. .17.77.77.7..... Showers (lo) — Cafeteria (no)
Othnfixtures ................................................................ ......................................5§0. .........................................
Design Flow...............-----------gallons per person t er day. Total daily flow....... ::.._..........................gallons.
Septic Tank—Liquid capacity1000..gallons Length_4 .... Widl:0� ......... Diameter...".`...._. Depth.._4..........
I Length.................... Total leaching area....................sq. f t.Disposal Trench—No. ...... 1............ Width.................... TOta
Seepage Pit No........I............ Diameter.......19........ Depth below inlet....._.._,------- Total leaching area... .......sq. f t.
Z Other Distribution box Dosing tank —7
Date.. .......................Percolation Test Results Performed by-.-,--.. 't"A.6---------- --------------- F�.... /
Test Pit No. 1................minutes per inch Depth of Test Pit._____._.........._. Depth to ground�Water./V?ItK....ov
Test Pit No. 2................minutes per inch :Depth of Test Pit___.................11............. Depth to ground water____._.............._...
.................................... .........................................
0 7----------
Description of
--------------------*.......----------------......----------------------- --------------------------------------------------------------*----------- -----------*---------------
...............I......................................................................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable...................z..........................................................................
'7........................................I......................... ....................................................................... ........................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 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 boa 'd Of 1-1
.............. .............................. ... ..........
Date
Application Approved By... . ........... ... . .. ........... ..........
Date
Application Disapproved for the following reasons:....................................t2...........................................................................
........................................................................................................................................................................................................
Date
( Issued--------------
---No......... . ................................ ...... ..............
Date THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............OF....... ...............................
T
(9rdifiratr of TfifiPffiturr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (i, or Repaired
by.......----------...THIS
n---A-,-Ito................................................................aller
.....................................................................................................
at lot #19 Trotters.'L Installer
ne------------------------------------------------------------- ----------------------------------------------*----------------------------------------------------------------------
has been installed in accordance with the provisions of E 5 of The. State Sanitary Code as described in the
application for Disposal Works,
Construction Permit No,61-4�t4................... dated-?------- ...................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ inspector..!....................................... ..........................................
THE COMMONWEALTH OF MASSACHUSETTS
N t BOARD . ....HEALTH
. k.4.,...........OF....... ..ff... . ....................................... ... . ... FEE.. S...............
Permssoryjseherebygranted.-.. .................................................................. ......................................
to, Cor�stryu or Rep;ir�u,�---' Ian�Inidual '�geIVpo; ,, stem. . . .... ......................
o-----
at N ...j ....... ...... .. ........................
Street
as ae .....
shown on the application for Dispos� Works Construction Per NO. L. Dated..d7--;L.?..-..7.................
...........................
ee�
^,,,Board of Health
DATE-----_.......................... ............................................
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
R
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441-11
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� BUNIfSIS �
r - No.3420
e013TE��pP
NO su
LEGEND CERTIFIED PLOT PLAN
EXISTING SPOT ELEVATION OxO
ENIS' 144' CONTOUR--; -t— 0 . .: ZQ7- t 9 207-7'
•FIMSHED. SPOT 'ELEVATION *r. S77aitfS 1 C.L S
FIRIS 14ED CONTOOR ._ � ...
APPROVED , BOARO OF HULTH
SAAR SUatgoXASSO
OAT1 A,6EOT �.. r
SCAL.E. ./ �� DA7E x �1/ia
R D6 ELM I E+E�$`lA� Ca 1 CERTIFY THAT THE PROPOSED
. _,�,,.......,.....r...._�.
r ,
EGlST AE LE131ST,E tCD J{3g NO. r_ BUILDING SHOWN t?Pd THIS Fl Ate
CIVIC. LAMD CONFORMS TO THE ZONING LAV)S
D` OF BARNSi'ABL E t
33 NO MAIN ST- 719 MAIN ST Get,-BY t` F' g 7/2-7II� A HYMMSSpSS_ NEgTF. E 5b YA t t' i1ASS, �.
�
REG. LAUD SURVEY+On
�; oom—
/O /aT. M/N.
CONCRETE 4"PVC P/PE CLEAN SAND
EL, /lID. CODERS M/N. PITCH
e. Xg",OER FT.
_ CONCRETE
COVET?
�• y L/Qt!/D LEYEL � ,• ;• -,ias•r ' '•' ;1•. � - � ,
a �� '. 2"LAYER
4"CAST
•
IRON P/PE /OGC7 0 0 o e CIF• /1B"-3�B„
Y'¢ MIN. P/TCW GAL. • d • • • • • • • n v4
%4"PE/t /T SEPTIC T.4/V K D I ST. o o A f • • , , • . o 4 /NA SyFO S727NE
Q D O
v ' °EFFECT/VC • 3/do
:�•:a.. . .. ,. . • •A o ! ► i DEPTH � � � � � o = ASXED STONE �
f • • • • • •
O o
o a u 0 • • e • • • • f y •�p PRECAST SFEPA GE
!NI/BRT E'L E�/AT/ONES a : f e • . . . ba o P/7 OR EQU/v.
/NYERT AT 041/1-1)/NG 7, cT 6 FT. D/AM.
l/YLET SEAT/C Ti4NK 9 t�. FT• L O FT. O/.AM• C SEE T.4BULATJON>
OlJ7LE7- SEPTIC TANK 9 6.3 FT.
INLET D/STIR/BUT/ON BOX '-/ FT s-EC7-/QN aF. GROvNo WA7i 6R TABLE
OdTLETDISTRJBtITION BOX 9 6 .0 FT SE,I�VAGE O/SPOSA L .SYSTEM
/NL.FTSEE'PAGE'• /SIT 9 S. Z FT, ?ABULATIDAI
L EACH/JVG o'/T
SCALE : .%q." � /•- D" O/MENS/ON A 3 FT. •
DES/GN' CRITERIA 01Aj4NS/GN $ —4, er.
NUMBER OF BEQROOMS 3 DIMENSION C_ -FT
CARpAGE Q/SlPOSAL. 4IN17-
TOTAL ,F1T/MATED F'LOH/ O GAL.14DAY .SOJL TEST
A/U148ER OF•SEEPAGE P/73—/ 7?
SIDFLEACHlNG PER PIT /B9 sQ /►T. -SOIL LOG ,�3ATE OF sQI L TEST
79 TEST F/T w/- TEST P/T awz RESULTS /'d/T/VESSED BY �' �
490TTOA'I LEACHING PER PIT $Q. FT. REI?C04 ATIOiV RATg 0+ !►�/N�IlMCH.
TOTAL LEACH/NG AR--A SQ. F7• E4�`IAT/0N
RFS.t Rt�E LEACNl N6 AREA► 2-" b $Q. FT. L O
M s o r L p -/- l9
O� ROBERT '�:,` �� • cS T > > /L• .5
F
BI1NIKt5 !1,5
tr°•22162 0./� fy Ss4 n`� & EL DREDGE FN&1AljWRING C07/NC.
90^�CISTS 7/2 MAIN Sr. 33 "0. MAIN`ST
F`rS'ONAL Fa�a+� qYA VIV 15, MA S5. so. Y,-4 RMOVTX,MASS.
IVO WA'r-E'/Z c�unlL7 JOB NG. O� Fs- SHEET 2•-OF _