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Home My WebLink About0202 WAKEBY ROAD - Health 202 Wakeby Road, Marstons Mills A= t No �........ Fizic .............. THE COMMONWEALTH.OF MASSACHUSETTS BOARD OF HEALTH ...........................................OF........................................................................................... Applirtation for Biafuual Works Tomitrar tiun Frrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal tem Sys- �t_-----._.�..................... :....._....... O� . ..fee� �� l�7� Locat Owner Address ....................................................... X---- T® CIS...... - L ........--......... Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms...-3.................................Expansion Attic ( ) Garbage Grinder aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' O he fixtures ......................... w Design Flow.:.... ................;.. ....._ allons per person p day. Total '1 flow......_,_, ..............gallons. WSeptic Tank—Liquid'capacit .-�'(✓3.-'gallons ` 'nth ...... Width--- ; ---._ Diameter--.--/`�---- Depth ......... Disposal Trench—No. _: __.. Width....`.............. Total Length.....................Total leaching area................ ._ q. ft. Seepage Pit No._.J.6�"O_...... Diameter...l v..... Depth below inlet.................... Total leaching area.YXJ_.....sq. ft. 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........................ fX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth'to ground water........................ P4 •---.....---•---------------------------------•-------•-------------.............._.._.._._...--•-••......................................................... ODescription of Soil..............................................................:......................................................................................................... x 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'I HM 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee sued by the board of health. ne -------------•------....._.........------.........-------•------------------•--• -• _.._. at 74 ApplicationAppro . ..... ......... .......................................•--•-•--............._..------ .....X = at - Date Application Disapprov f o e f ollo ing reasons:-----•--------••----••-•------••----•--•---------------•---•----------------------------•----...----..........-- .......................................•----------------•---------------......•----------..._..----------._..................-----•--------------•----•------•-----------•------------•-------•---------- Date PermitNo.................................................... Issu ........................... Date ............................ Date -•.................•-•----- , ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF.......................................................................................... Allp iration for Dhip oat Mirkfi Tamitrnrtion Permit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: �. ........ .............................................. " Loc ..................... - .......... . •----• ............................................-.................................................... lj_ _ Owner ' _ Address�,9 Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms_-_ .................................Expansion Attic ( ) Garbage Grinder `4 Other—Type of Building No. of persons............................ Showers — Cafeteria a Other fixtures . - j� f Design Flow... __ G................/.. ...... allons per person p day. Total d '1 flow...:......_....., ._-0..............gallons. WSeptic Tank—Liquid'capacit J_ 1(:fgallons h.... ...... Width....../.------ Diameter--.---X—.. Depth:e�......_.. xDisposal Trench—No._._�..._._. Width... Total Length.................... Total leaching area................ #.9q. ft. Seepage Pit No... .. .. ........ p g q.l� Diameter...�:Y._.__.. Depth below inlet.................... Total leaching area.-��.�._-.._s ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest, Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-----------_............ (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ........... •-------------------------------------------------- --•---------------- •..... •••--••-••••------------- •--------- ---------------- .... ..... •--------- 0 Description of Soil........................................................................................................................................................................ x w 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 TIT12 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' sued by the board of health. ed. --------•-------•...................••------•---..........----------•-•-•-•-.....__ _ /,Da Application Appro _'_. e' Application Disapprov f o e following reasons:-----•--------••----•--•------------------------------------••-•-------- -----------------------..._......_..... -------•------------••---••-••---•-----------------------•-•--.....---.....--------._...-•-•-•----------- Date PermitNo.......................................................... Issued-........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Tertifiratr of Toutpliatta T?IS g TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) --------------- •-------•----- ---- ., �,, ,� Installer at... ........Dz.-I------..'r.1 ,f --•-------••-•-- has been installed in accordance witl the provisions of TIT FE r o�-The State Sanitary Co as scribed in the application for Disposal Works Construction Permit No.�tl._-._�.. ................. da.ted__.�..-�.(- ...... ..................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUD AS A GUARANTEE THAT THE SYSTEM WIL FUP ION SATISFACTORY.- ,� �yy DATE..... 7 :. Inspector ... .................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH IV.. i ...........................................OF..................................................................................... N0.. i—IV....?.r..... FEE.: ....... c� ............. M15110, 1r Varks, l t rt'; rrmit � s Permission is ._....___f ...... .. �? ....._ to Cons ct epair ( } an Individual Sewage D'sr sal System . atNo..:.._:. . /...........• , ------------------------------- -- -- ---- -- / Street ��-/_ � _. .6... �-L as shown on the applicati n for Disposal Works Construction Permit No.................. ............... .................................... s-•-• -----••-•--•-•----•-•-•-.....------._.....-••---.---- �i d--o€—health DATE..... /Z ..................................................... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS L O CATION SEWAGE PERMIT NO. 'f� 4 q ,zi/:�'"- &- / VILLAGE INSET/A LLER'S NAM Il, ADDRESS B U I L D E R OR OWNER rk DATE PERMIT ISSU D DATE COMPLIANCE ISSUED k _ O .� r �jl►JGIL— FA COR40M No ;GActBAGE GwNo�Q. DI�r,LY FLOW s I10 X 3 = Z,3o G.P P. 5EPT%G-,;q`A►JK 's 'a30x15C).% A9%G.Ro u5c loon GAL. AAOZ4 = kr Z• .S..� s �el3 t t VJ I LL.I'. ., AIAP!\ J N Y E • ��Y�i'�W` iv•ro`P� Vj��GD✓. TD W17/ i-//N/L S ? 1000 INS• "AM S p►ST. INV. Gay. t .Sva�vl,, I INS e�x yyGTANK 9 qyo-. .f! 44 Gqo p � DH 8 INV. INY. I o Per N/l3 .ilEp • , STm�v�- . �. � 3 , J , GE2TIFIGp pLoT PLAtJ , PRoFILF-- ' 1.o 4 4-r ►o N /y,Q,�sTc�/S /'7/GGS/ I N o' CAL F_ p�.P.N R E F S cZEN GE i 1HER6oN GOMPL.`(5 yjI TO S D�1N ��N ,C o7- � 9 A►J D S 6T 1aAG1C R.6 Q V I R.6 M E NTH o f 14-1'� ro W N O F $PQtJ STAE3 LG_ AND I".:, f`l ,l',f� ?/7 ,oG BS LOCP.TED MIT IW T TuIS � GL oCoIFAKJ IN DATE REG I�Z T� WIM 1 NG• u eY EYoe'S26.D'I-Au DS PL&KI5J�T 4tn5Ca osTEQ.vILLC- - ass• 1=F E.'r Suou l u 5' u M E NT 5 u Qv t+Y 'r N E D 5 5 / f: �LIJGE✓S�i� ' NoT DIC ,u5EOT0 0ETEFZ!^INE LoT' �_ II-IE�j A P P LIGA►-IT' - --.. v . N ti 3/ 9�•3 9 •G • � 9z•� 9.3. z ...moo 9y 4 93.9 0. Pir S- �.EX�s r' �ccuz P,P-�•�i�� 97 idr /ov, 7 99 '� i • _ 9 P`U F�a t O ALAN �r J014's C. ro. 25,: I COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION �11.0 Mq y 2 00 4?h-, TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 202 WAKEBY RD MARSTONS MILLS,MA 02648 L29 Owner's Name: HAYDEN Owner's Address: 202 WAKEBY RD MARSTONS MILLS,MA 02648 Date of Inspection: 5/14/01 Name of Inspector: (please print) JOHN GRACI Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes _ Conditionally Passes _ Needs Further E3pluation by the Local Approving Authority Fails Inspector's Signature: Date: 5/14/01 The system inspector shall submit. opy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspecti n. 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 THE SYSTEM PASSES TITLE V INPECTION. RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. ****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. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 202 WAKEBY RD MARSTONS MILLS,MA 02648 L29 Owner: HAYDEN Date of Inspection: 5/14/01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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 SYSTEM PASSES TITLE V INPECTION. RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEMS USEFULL LIFE. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined" please explain. n/a The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a F Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 202 WAKEBY RD MARSTONS MILLS, MA 02648 L29 Owner: HAYDEN Date of Inspection: 5/14/01 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: r, _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 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 tEnk 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 n/a "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: n/a z Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 202 WAKEBY RD MARSTONS MILLS,MA 02648 L29 Owner: HAYDEN Date of Inspection: 5/14/01 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X. Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nLa. X Any portion of the SAS,.cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. _ X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this forma _ (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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. Page 5 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 202 WAKEBY RD MARSTONS MILLS, MA 02648 L29 Owner: HAYDEN Date of Inspection: 5/14/01 Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period`? X Have large volumes of water been introduced to the system recently or as part of this inspection '? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out'? X _ Were all system components,excluding the SAS, located on site 9 X _ 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 ? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems 9 The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no X _ Existing information. For example, a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CM 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 202 WAKEBY RD MARSTONS MILLS,MA 02648 L29 Owner: HAYDEN Date of Inspection: 5/14/01 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents:0 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): NO Seasonal use:(yes or no): YES Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons-- How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box, soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1984 Were sewage odors detected when arriving at the site(yes or no): NO Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 202 WAKEBY RD MARSTONS MILLS,MA 02648 L29 Owner: HAYDEN Date of Inspection: 5/14/01 BUILDING SEWER(locate on site plan) Depth below grade: 8" Materials of construction:_cast-ron _40 PVC Xother(explain): 20 PVC Distance from private water supply well or suction line: n/a Comments(on condition of joints, venting,evidence of leakage,etc.): THERE IS TOWN WATER SEPTIC TANK: X(locate on s'te plan) Depth below grade: 2" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000G L 8' 6".H 5' 7" W 4' 10"" Sludge depth: I" Distance from top of sludge to bottom of.outlet tee or baffle:33" Scum thickness:3" Distance from top of scum to top of outlet tee or baffle:8" Distance from bottom of scum to bottom of outlet tee or baffle: n/a 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.): THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. GREASE TRAP: _(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a 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: 202 WAKEBY RD MARSTONS MILLS,MA 02648 L29 Owner: HAYDEN Date of Inspection: 5/14/01 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE 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.): THE DISTRIBUTION BOX IS STRUCTURALLY SOUND. PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a lrage 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 202 WAKEBY RD MARSTONS MILLS,MA 02648 L29 Owner: HAYDEN Date of Inspection: 5/14/01 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 4' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: nla n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): THE LEACH PIT IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY.THE PIT WAS EMPTY AT THE TIME OF THE INSPECTION. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): n/a Page 10 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 202 WAKEBY RD MARSTONS MILLS,MA 02648 L29 Owner: HAYDEN Date of Inspection: 5/14/01 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. I� Lke B Mo A � g C- M aJ , � A �r o � aNL a Page 1 1 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INI+ORMATION(continued) Property Address: 202 WAKEBY RD MARSTONS MILLS,MA 02648 L29 Owner: HAYDEN Date of Inspection: 5/14/01 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a NO Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) YES Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: USGS MAPS AND CHARTS- 12+FEET y °cIME T° Town of Barnstable Regulatory Services BMWv MASS, Thomas F.Geiler,Director 039. �0 A'Eo39�0. Public Health Division Thomas McKean,Director 367 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 DATE: � o . dxz��9 RE: Zo Z The Barnstable Health Division has reviewed the Title 5 septic inspection form for the above referenced property. The following comments listed below are deficiencies according to 310 CMR 15.300 and the Town of Barnstable Health regulations. Please re- inspect the system, if necessary, complete a new report form or revise the pages pertinent to the deficiencies listed and resubmit the report to this office within fourteen (14) days: 41 (JIfL 1 C,v `61 g,r'O-y t' 120/1 L iv Wt I vt R-V�7 Q sepdef.doc 0hge 11 of II OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 202 WAKEBY RD MARSTONS MILLS,MA 02648 L29 Owner: HAYDEN Date of Inspection: 5/14/01 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 10+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER BOTTOM OF PIT TO 10' NO WATER ENCOUNTERED 11 A Q-a A Commonweotth of Massachusetts Jolm Grad __.. Executive Office of ErMorwrltentai Affairs D.E.P. Title V Septic Inspector Department of P.O. Box 21 I9 Environmental Protection Te 6�sj)56'4 <<>�� sG4-6R1'3 0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR -- _7 PART A y CERTIFICATION `� e•.;� fSi9 202 Wakeb Rd. Marstons Mills �` U^ Property Address: y Address of Owner: Date of Inspection:12116195 (If different) 44 Name of Inspector:John Gracl Nickerson Company Name,Address and 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-site sewage disposal systems. The system: X Passes _ Conditionally Passes _ Needs F rther Evaluation By the Local Approving Authority _ Fails / Inspector's Signature: Date: 12110196 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B,C,or D: A] SYSTEM PASSES: X I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. 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 completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined", explain why not.) The septic tank is metal, cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11/15195) One Winter Street • Boston,Massachusetts 02108 9 FAX(617)556-1049 • Telephone(617)292-5500 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 202 Wakeby Rd.Marstons Mors Owner: Nickerson Date of Inspection:12110196 _ Sewage backup or breakout or high static water level observed in the distribution box is 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 leveled 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] 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 THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 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 volatile organic compounds indicates that the well is free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm. 3) OTHER D] SYSTEM FAILS: _ I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged cesspool. SAS is in hydraulic failure. (revised 11115195) 2 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 202 Wakeby Rd.Marstc ns Mills Owner: Nickerson Date of Inspection:12110196 D] SYSTEM FAILS(continued) Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers 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] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria: The system serves a facility 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: 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 bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 11115195) 3 I f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 202 Wakeby Rd.Marstons Mills Owner: Nickerson Date of Inspection:12110190 Check if the following have been done: X Pumping information was requested of the owner,occupant, and Board of Health. X None of the system components have been pumped for at least two weeks and the 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. nlaAs built plans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. X All system components,excluding the Soil Absorption System,have been located on the site. X 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. X 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. X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. I (revised 11115195) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 202 Wakeby Rd.Marstons Mills Owner: Nickerson Date of Inspection:12110196 FLOW CONDITIONS RESIDENTIAL: Design flow: 330 gallons Number of bedrooms: 3 Number of current residents: 2 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings,if available: nla Last date of occupancy: n1a COMMERCIAL/INDUSTRIAL: Type of establishment: n1a Design flow:6 gallons/day Grease trap present:(yes or no) No Industrial Waste Holding Tank present: (yes or no) No Non-sanitary waste discharged to the Title 5 system: (yes or no) No Water meter readings,if available: n1a Last date of occupancy: n1a OTHER: (Describe) nla Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System has not been pumped in the last two years. _ System pumped as part of inspection: (yes or no)Yes If yes,volume pumped: 1250 gallons Reason for pumping: mainatenance. TYPE OF SYSTEM X Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes,attach previous inspection records,if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source information: 19 years Sewage odors detected when arriving at the site:(yes or no) No (revised 11115195) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 202 Wakeby Rd.Marstons Milts Owner: Nickerson Date of Inspection:12110f96 SEPTIC TANK: X (locate on site plan) Depth below grade: 2' Material of construction:X concreate_metal_FRP_other(explain) Dimensions: L 8'0'H 5'7"W 4'10' Sludge depth:3' Distance from top of sludge to bottom of outlet tee or baffle: 24" Scum thickness:1' Distance from top of scum to top of outlet tee or baffle:6' Distance form bottom of scum to bottom of outlet tee or baffle: 17" 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.) Septic tank and all components are structurally sound.Recommend pumping system every one to two years for maintenance. GREASE TRAP: (locate on site plan) Depth below grade: n1a Material of construction: _concrete_metal_FRP_other(explain) Dimensions: nla Scum thickness:n1a Distance from top of scum to top of outlet tee or baffle:n1a Distance from bottom of scum to bottom of outlet tee or baffle: n1a 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.) nla (revised 11115195) � 6 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 202 Wakeby Rd.Marstons Mills Owner: Nickerson Date of Inspection:12/10196 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: Na Material of construction:_concrete_metal_FRP_other(explain) Dimensions: n1a Capacity: n1a gallons Design flow: n1a gallons/day Alarm level: n1a Comments: (condition of inlet tee, condition of alarm and float switches,etc.) Na DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: n1a Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.) nla PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) nla (revised 11115105) 7 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 202 Wakeby Rd.Marstons Mills Owner: Nickerson Date of Inspection:12110196 SOIL ABSORPTION SYSTEM (SAS):x (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: nla Type: leaching pits,number: 0•x4'Leach pit leaching chambers,number:n1a leaching galleries,number: n1a leaching trenches,number, length: n1a leaching fields,number,dimensions:n1a overflow cesspool,number:nla Comments:(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.) Leach pit was 112 at the time of the inspection It Is structurally sound CESSPOOLS: (locate on site plan) Number and configuration: n1a Depth-top of liquid to inlet invert: n1a Depth of solids layer: n1a Depth of scum layer: n1a Dimensions of cesspool: n1a Materials of construction: n1a Indication of groundwater: nfa inflow(cesspool must be pumped as part of inspection) n1a Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) nla PRIVY:_ (locate on site plan) Materials of construction: n1a Dimensions: n1a Depth of solids: rya Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PrlvyComments (revised 11115195) r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 202 Wakeby Rd.Marstons Mills Owner: Nickerson Date of Inspection:12110196 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' �CC Dec a A AA DEPTH TO GROUNDWATER Depth to groundwater:12 feet method of determination or approximation: USGS Maps and Charts (revised 11115195) 9