HomeMy WebLinkAbout0071 WALNUT STREET (M.MILLS) - Health 71 Walnut Street
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Commonwealth of Massachusetts P/9- 0�
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
71 Walnut street
Property Address
Gendron
Owner Owner's Name -R
information is ;
required for every Marston Mills ✓ Ma 02648 8-14-18
page. Cityrrown State Zip Code Date of Inspection ryy`
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information /- /3 300
on the computer,
use only the tab Chad hathaway
key to move your Name of Inspector
cursor-do not HPS
use the return Company Name
key.
P.O.Box
151
� Company Address
Forestdale Ma 02644
Cityrrown State Zip Code
774 274 2581 12866
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
8-14-18
I49p4cto s Sig ure Date
The syste inspector shall tays
a copy this inspection report to the Approving Authority(Board
of Health or DEP)within 30f c eting this inspection. If the system has a design flow of
10,000 gpd or greater, the ior and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 Walnut street
Property Address
Gendron
Owner Owner's Name
information is required for every Marston Mills Ma 02648 8-14-18
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Septic is in good working order. No failure criteria was encountered during inspection. Industry
reccomends pumping solids tank every 2 years to prevent clogging and early leaching failure.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
I
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
y Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
71 Walnut street
Property Address
Gendron
Owner Owner's Name
information is required for every Marston Mills Ma 02648 8-14-18
page. Citylrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes(cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 Walnut street
Property Address
Gendron
Owner Owner's Name
information is Marston Mills Ma 02648 8-14-18
required for every
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
** i
This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and.nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
71 Walnut street
Property Address
Gendron
Owner Owner's Name
information is required for every Marston Mills Ma 02648 8-14-18
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2 day flow
Required pumping more than 4 times in the last year NOT due to clogged or
❑ ® q P P 9 Y 9g
obstructed i e s . Number of times pumped:
ppO p P
❑ ® 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
El ® tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 71 Walnut street
Property Address
Gendron
Owner Owner's Name
information is required for every Marston Mills Ma 02648 8-14-18
page. Citylrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5msp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
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f
Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 Walnut street
Property Address
Gendron
Owner Owner's Name
Information is required for every Marston Mills Ma 02648 8-14-18
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. 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
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
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L
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 Walnut street
Property Address
Gendron
Owner Owner's Name
information is required for every Marston Mills Ma 02648 8-14-18
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit resent. Yes No
P ❑ ❑
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: owner pumped Jan 2018
I
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
P
Reason for pumping:
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System form -Not for Voluntary Assessments
w 71 Walnut street
Property Address
Gendron
Owner Owner's Name
information is required for every Marston Mills Ma 02648 8-14-18
page. Cityr'rown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
tank unknown leaching and Dbox 2008
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 2.25
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 20+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
no evidence of leaks or poor venting
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f
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
9 P Y rY
71 Walnut street
Property Address
Gendron
Owner Owner's Name
information is Marston Mills Ma 02648 8-14-18
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
2'
Depth below grade: feet
Material of construction:
concrete metal fiberglasspolyethylene other ex lain
® ❑ ❑ 9 ❑ ❑ (explain)
)
1000 gal H10
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 8'6x 65" 1000 gal
Sludge depth:
2°
Distance from top of sludge to bottom of outlet tee or baffle
32"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle
20"
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
tees in place. no visable cracks or leaks
t5insp.doc-rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
L
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 71 Walnut street
Property Address
Gendron
Owner Owner's Name
information is required for every Marston Mills Ma 02648 8-14-18
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 Walnut street
Property Address
Gendron
Owner Owner's Name
information is required for every Marston Mills Ma 02648 8-14-18
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Dbox in good condition no carry overs no decay or cracks
t5nsp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 Walnut street
Property Address
Gendron
Owner Owner's Name
information is required for every Marston Mills Ma 02648 8-14-18
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No'`
Alarms in working order: ❑ Yes ❑ No"
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
" If pumps or alarms are not in working orders stem is a conditional ass.
P P 9 � Y P
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 1)13x25'x2'
3) 3050 chambers
El leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
T e/nametechnology:yp of
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
I i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
^ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 Walnut street
Property Address
Gendron
Owner Owner's Name
information is required for every Marston Mills Ma 02648 8-14-18
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System(SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
inspection trhrough 4" pvc port system dry no staining
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids Layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-.Not for Voluntary Assessments
71 Walnut street
Property Address
Gendron
Owner Owner's Name
information is required for every Marston Mills Ma 02648 8-14-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
71 Walnut street
Property Address
Gendron
Owner Owner's Name
information is required for every Marston Mills Ma 02648 8-14-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
l!J
0 2
a 3
L)
3 q3.S ' 3_ o
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Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
71 Walnut street
Property Address
Gendron
Owner Owner's Name
information is required for every Marston Mills Ma 02648 8-14-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wel s
Estimated depth to high ground water: lot el. 60 per town gis mappingfeet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Town GIS mapping lot el 60
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
Commonwealth of Massachusetts
.�9 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 Walnut street
Property Address
Gendron
Owner Owners Name
information is
required for every Marston Mills Ma 02648 8-14-18
page. Citylrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6 (Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 18 of 18
••'••� BARRY W.PERE►iNS C.E.,R.S.
01" OF
� BARRr • HEALTH INSPECTOR
W.
PERMS SEPTIC SYSTEM:
No.1016 Inspection,Certification,
Perc.Testing and Design
P.O.Box 721
Mattapoisett,MA 02739 Tel.(W8)758-2511
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address of property 71 Walnut St. �e (Marston Mills)
owner's name Vetrans Administration D
Date V Inspection June 11, 1995 . 5 1995
PART A U N
CHECKLIST Wjkm Dry.
Check if the following have been done:
Y Pumping information was requested of the owner, occupant, and Board of
Health.
N VACANT
None of the system components have been pumped for at least two weeks
and the system has been receiving normal flow rates during that
period. Large volumes of water have not been introduced into the
system recently or as part of this inspection.
NA As built plans have been obtained and examined. Note if they are not
available with N/A.
Y The facility or dwelling was inspected for signs of sewage back-up.
_Y The site was inspected for signs of breakout.
Y All system components, excluding the SAS, have been located on the
site.
o t t onl
The septic tank manholes we
Y re 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.
Y The size and location of the SAS on the site has been determined based
on existing information or approximated by non-intrusive methods.
_ The facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance of SSDS.
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8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
if res i&n!ta'1al
, MA7-Vnumber, ,o:f edrooms
umber .of current residents
1_ garbage grinder, yes or no
yes laundry connected to system, yes or no
seasonal use, yes or no
If nonresidential, calculated flow:
Water meter readings, if available: vacant since 1994
1994 Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information:
none
no System pumped as part of inspection, yes or no
if yes, volume pumped
Reason for pumping: recently pumped since last occupied
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)
Other (explain)
Approximate age of all components. Date installed, if known. Source of
information:
U TMCJWN
NO Sewage odors detected when arrivingat the site es
y or no
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
Yes
SEPTIC TANK:
(locate on site plan)
depth below grade: 22"
material of construction: _concrete metal FRP other(explain)
dimensions: 1000 Gal.
sludge depth
distance from top of sludge to bottom of outlet tee or baffle
scum thickness
distance from top of scum to top of outlet tee or baffle
distance from bottom of scum to bottom of outlet tee or baffle
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,
depth of - liquid level in relation to outlet invert, structural integrity,
evidence of leakage, recommendations for repairs, etc. )
Parped sinee last-tise- in=et= and eutlet baffles ip,�6aet.
DISTRIBUTION BOX: Y MUST BE REPLACED
(locate on site plan)
NA
depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal, evidence of solids carryover,
evidence of leakage into or out of box, recommendation for repairs, etc. )
NTST RF. RFPT.A(Tan ' RADT Y RR=! `T'Qp 'AND SIDES
PUMP CHAMBER: no
(locate on site plan)
pumps in working order, yes or no
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs, etc. )
10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS) :
(locate on .site plan, if possi excavation not required, but may be
approximated by non-intrusive methods)
If not determined to be present, explain:
Type
leaching pits and number
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions
overflow cesspool, number
Comments:
(note condition of soil , signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc. )
` No signs ot tallure.
CESSPOOLS (locate on site plan) : no
number and configuration
depth-top of liquid to inlet invert
depth of solids layer
depth of scum layer
dimensions of cesspool
materials of construction
indication of groundwater
inflow (cesspool must be pumped as
part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc. )
no signs of failure.
PRIVY: no
(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, recommendations for maintenance or repairs, etc. )
- 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100 '
garage 71 Walnut St. (rear)
deck porch
inlet
0
out septic tank
A B
tank inlet 48' 35'
tank outlet 48' 41.2'
D hox 50.3 59.8'
Odi.stribution box
seepage pit #1
seepage pit #2
DEPTH TO GROUNDWATER
No W6 depth to groundwater
method of determination or approximation:
12
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of
determination in all instances. If "not determined", explain why not)
. No Backup of sewage into facility?
-No Discharge or ponding of effluent to the surface of the ground or
surface waters?
Nn Static liquid level in the distribution box above outlet- invert?
diy
_1'a Liquid depth in cesspool <6" below invert or available volume< 1/2 day
flow?
TTn Required pumping 4 times or more in the last year?
number of times pumped
—No _ Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
Is any portion of the SAS, cesspool or privy:
No below the high groundwater elevation?
No within 50 feet of a surface water?
No within 100 feet of a surface water supply or tributary. to a surface
water supply?
—Na- within a Zone I of a public well?
TTn within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, not the SAS) ?
No
within 50 feet of a private water supply well?
No less than 100 feet but e gr ater 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 analy:
for coliform bacteria, volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
13
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
Name of Inspector W. Perkins
P �'rY
Company Name Barry W. Perkins R.S.
P Y
Company Address P.O.Box 721 Mattapoisett, MA. 02739
Certification Statement
I certify that I have. personally inspected the sewage disposal system at
this address and that the information reported is true, accurate and
complete as of the tine of inspection. The inspection was performed and
any recommendations regarding upgrade, maintenance and repair are
consistent with my training and experience in the proper function and
manitenance of on-site sewage disposal systems.
Check one:
_X I have not found any information which indicates that the system fails
to adequately protect public health or the environment as defined in
310 CMR 15. 303 . Any failure criteria not evaluated are as stated in
the FAILURE CRITERIA section of this form.
I have determined that the system fails to protect public health and
the environment as defined in 310 CMR 15. 303. The basis for this
determination is provided in the FAILURE CRITERIA section of this
form. OF
Inspector' s Signature
Date -✓� �� / 9 yS Ht
Original to system owner `�� �lr�
Copies to:
Buyer (if applicable)
Approving authority
71 Walnut St. Barnastable
1
Distribution box is badly broken and Dust be replaced.
TOWN OF BARNSTABLEq 0
LOCATION MAP.S+pt,) ��.� SEWAGE # y 5 -17I (o
VILLAGE °7( WA I;yt)(" :42�&ASSESSOR'S MAP & LOT��
INSTALLER'S NAME & PHONE NO. lUC Rg,61'N -7-75 97 7,
SEPTIC TANK CAPACITY i,oo® CAI
—r—
LEACHING FACILITY:(type) , J �{ ize) � ®
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
) OR OWNER 4�l�//Ir
DATE PERMIT ISSUED: q s
DATE COMPLIANCE ISSUED: 9I11 4S
VARIANCE GRANTED: Yes Now
7xv
.S°•
r
ASSESSORS MAP NO: ,C � -
?.�l 7/6 PARCEL NO: __-----mod _ 3 0 0 0
No.. .... _ .. F>�s......... ...................
THE COMMONWEALTH OF MASSACHUSETTS-
BOARD OF HEALTH
TOWN OF BARNSTABLE
Applirativtt for Uivj-pv3M1 Work3 Tomitrurtiutt Permit
Application is hereby made for a Permit to Construct ( ) or Repair (x ) an Individual Sewage Disposal
System at:
71 Walnut St Marstons Mills
----•-•--------------•------..........._.....__.....----•-•--------------------------------------- --------•-----•-----•--••-----------------•-•---•--------------------••--...----------•--•--------
Location-Address or Lot No.
Tina Cobb
Owner Address
VJ_E._...Rob_i-sno...Se- c---So-ru x-ice------•--___--•- P,.Q Bo ---1-051- -•-Cont-er--v11-1-&------•-------------------
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling— No. of Bedrooms.-3----------------------------------------Expansion Attic ( ) Garbage Grinder (
aOther—Type of Building ---------------------------- No. of persons------------------------- .. Showers ( ) — Cafeteria (
0.t Other fixtures ------------------------- ----- - -
W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
RS Septic Tank—Liquid capacitv------------gallons Length-.-------------- Width................ Diameter................ Depth................
W Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
x
Seepage Pit No...................... Diameter...............----- Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by------------------------------------------------------------------------- Date........................................
a
Test Pit No. I................minutes per inch Depth of Test Pit.........-.--------- Depth to ground water--------------..........
f1 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
04 • ---------•------------------------------•-...------------------•-•-•-----•-•-------------------•-------•---------------------------------.._...._...---......
0 Description of Soil............sar+d-----•-----------------------------•----•----------••-----------------
x
c,
x - --------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alteration,—Answer when applicable.-..__�.,_. S al-1--- =box._. .Titl.e...V___________________
-.leach...trench.-•-•-- o.--------�. Y ---- ---
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Complia ce has b 'en i ued by the boa of health.
Signed ...:':
-- -------------------------------------
--------------------- -----------' Dace....-----= ----
Application.Approved — ... ......... - `^ �7
xs-- ce
Application Disapproved for the following reasonr: ------------- ---------------------------------------------------- ------------------------------------------- ..._..-
-------------- ...............---------/--------.............---------"----._.............._------------- ------------Dace------------------
(_j ........---------- --------- -
Permit No. ------..� '�.1_. l-....�....
......
Issued 9^... `��
..............
Date
i
s �y
No.. ..� �ta 6 ( F�$3 0.0 0.............
THE COMMONWEALTH OF MASSACHUSETTS.
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratinii for Bi-aipnittl Worbi Cnnititriirt"inn ramit
Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal
System at:(-,/'
71 Walnut St Marstons Mills
...................................................................•••.......................... ............................................................. .........-==.....................
Location-Address or Lot No. se
Tina Cobb
......................_.......................................................................... ----•---------------•---......--•--•-•--••......-----•--.....•--•-_...............----------.....
Owner Address
W GaaF• >�o3�_a,srao p} e---Sa-�' oe.--------------- ?�.� jai 108Q EEC:t� �ai1l�-----------•---•-•--------.
t Installer Address
UType of Building Size Lot....................�,.., Sq: feet
,.., Dwelling— No. of Bedrooms.3---------------------------------_------Expansion Attic ( ) Garbage Grinder
Pk Other—Type of Building ____________________________ No. of persons___---_-__-__-_-----_----_ Showers ( ) — Cafeteria
Q' Other fixtures -----------------------------------------------
w Design Flow...................►........._........_..__gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity........___gallons Length---------------- Width--------------- Diameter......... befp/th................
x
Disposal Trench—No_ ____________________ Width..................... Total Length---------------------To'tal leaching area....................sq. ft.
Seepage Pit No---------------------- Diameter-------------------- Depth below inlet..........---------- Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by------- ------•---•----......---•-------------•--------•----------•------- Date........................................
a
Test Pit No. I----------------mtnutes per inch Depth of Test Pit-------------------- Depth to ground water--____-______-_-___-_---
Gil Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Deptk to ground water..._-______--__-.._-___.
P4 •----------•------------------------------------------------------------••--•---•----••••-•---------.........................................................
0 Description of Soil------------. -----------------------------------------------------------------
------------------------------------------------------------------------------
x
c.� -
w
U Nature of Repairs or Alteration—Answer when applicable.___-instsa1- -_-D--bp�c_..and-. .1.e...V...................
•---leach.-trench.-------���� ------... t �•---•---- --� �.. ; ---------------------------------
Agreement: 1. d
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
_ the provisions of TITLE 5,of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has ben i ued by the boa of health.
Signed .... .;...-.--- ------- --- --- 9`�� --
Application.Approved B Cx. -- ..�* - ----------- `.. 7 r
.-... .....-'�Da�e`---- ---- -
Application Disapproved for the following reasons: ......-....__..__....._...._....._-----------_-----
{ ' Dare
i
Permit No. ... -.... `-- -��. ._..... Issued �*^...�` r ..............
Dare
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
U ertifirate of LLLlmylianve
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( 3t )
by -----W-.E.o....Ro-b-isson...-Septic----Sorvi-ce------Insta- ller---------------------- ---- ---------.------------------..----.-------- -------
71 Walnut St Marstons Mills
at .. ------ ----------------------------------------------------- -----------------------.---------------...--------------------...---------------------- --------------...----------------------------------------------
has been installed in accordance with the provisions of TITLE of The State Environmental Code as described 4L_
the application for Disposal Works Construction Permit No. dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOf BE CONSTRUED AS A GUARANTEE THAT THE '
SYSTEM ILL FUNCTION SATISFACTORY.
DATE..... ....... .._... .... /... - Inspe,tor .... � ...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE - 30.00
No ........ FEE........................
�in�nn�il nrk� �nn�trnrtinn �prmit
Permission is hereby granted....... o. Robisnn_.-Sept-jc der.ViCe.................... .................................
-. _
to Construct ( ) or Repair ( an Individual Sewage Disposal System
atNo.....71....walnut...Et...KarStoag---JAil.l JAilla-------------------------------------------------------------------------------------------------------------
Street /
as shown on the application for Disposal Works Construction Permit��~z/!//.
•-•---•-•••--•---•--- ---4
Board of Health
DATE .'... -----------••......
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION I'ERM11' (WI'TIIOUT DESIGNED PLANS)
1, , hereby certify that the application for disposal works
construction permit signed by me dated 9 concerning the
property located at �� d X r le. meets all of the
following criteria:
• There are no wetlands within 300 feet of the proposed septic system
• There are nb 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(low and/or change in use proposed
• There are no variances requested or needed.
SIGNED 1 DATE:
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
IAttach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted).
I
- o G k
No. •- 71 t Fee V t/
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: '
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
pplicattou for 33igpo5al *p5tem Cou0tructiou Permit
Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑.Complete System ❑Individual Components
Location Address or Lot No. y-� u/lfj" U7 S ,6kR- lco A®j
Owner's Name,Address;and Tel.No.
T0��i�-
Assessor's Map/Parcel b
tc>1��/ h'! IUC�EiQ .�`!-�iPEiU/YII=�/�'
Installer's Name,Address,and Tel.No. Desi ner's N e,Ad ress an T 1.No�
��T//f� 5?" /,►'v�n�/s 3'I1c� o. T3oJ� � � .
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( )
Other Type of Building �15 No.of Persons Showers( ) Cafeteria( )
Other Fixtures Design Flow(min.required) !30 G P J-D gpd Design flow provided :;)J 71 �/ / gpd
Plan Date �--//�JD� Number of sheets °r� Revision Date
Title
Size of Septic Tank / d Type of S.A.S. ��s�
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health. _ c
Signed u/ - Date aD
Application Approved by 1� ' 9,4 Date
Application Disapproved by: Date
for the following reasons
Permit No. ;Ld v g ' 0,51 Date Issued-----------------------------------------
-- ,
No. d�0 G� o�' Fee V t/
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
` - PUBLIC HEALTH DIVISION,- TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Application for Ttgpogal 4pgtem Con%tructtou Permit
Application for a Permit to Construct( ) Repair(W�grade( ) Abandon( ) ❑.Complete System ❑Individual Components
Location Address or Lot No. // ��U/ Owner's Name,Address;and Tel.No. Edq t7) �,' ✓ lk A)Z)J
"'l7�i11-57 0/11/
Assessor's Map/Parcel v G
Installe>w s Name,Address,and Tel.No. Designer's Name Address and Tel.No. t
G"PbtVr/1tG ST /��I+Ais/s J na_., ,�-'v, /�oX 9 el. C. �HUrw is�� frGt.
Type of Building: #
Dwelling No.of Bedrooms Lot Size r�L 5 sq.ft. Garbage Grinder
Other Type of Building /C/ys- No.of Persons Showers( ) Cafeteria(
Other Fixtures (/ p
Design Flow(min.required) 730 gpd Design flow provided gpd
Plan Date -Z/l/D7 Number of sheets `Z Revision Date
Title
Size of Septic Tank / 0 O 0 Type of S.A.S. �7 �O$� /� X '�
i
Description of Soil A
f
Nature of Repairs or Alterations(Answer when applicable)
7
Date last inspected:
r
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued b`y this Board of Health. _
Signed ✓ G��i1; �f/ Date G?G�
Application Approved by '> Date
Application Disapproved by: Date
for the following reasons
Permit No. go Cog — 05 1 Date Issued a -0
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (1;-�'Upgraded ( )
Abandoned( )by
at � / W11.4101T Sr /1;7,1101 has been constructed in accordance a
with the provisionsJof Title 5 and the fo �ijsposal System Construction Permit No. 2-OU�' OS.� dated _a
Installer /(�tiJ 1)� J.fYV{ i�� Designer Y
#bedrooms Approved design flow gpd
The issuance of this permit shakll n91 be construed asia guarantee that the system�d 1 fuhnption as
deessigne f�N y
Date 4 r 0 Inspector i� `O�i '1 � .
----------------------- ----1f----- ---.
No. ;ao � ,o S( ---- (O�J
Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS
wtgpoot 6p9tem Con5tructton Permit
Permission is hereby granted to Construct ( ) Repair ( 4--l' Upgrade ( ) Abandon ( )
System located at r� / W14�4V617- Sr AV 612,
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title S and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this permit(
Date a f I` yo Approved by
U
7
Town of Barnstable
Regulatory Services
Thomas F. Geiler, Director
• BAWMABtE
Public Health Division
1639. 16' Thomas McKean, Director
" _ 200 Main Street,Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer & Designer Certification Form
Date: ' " �i 't:b Sewage Permit# (���-�C�� As
sessor's MapiParcelJL�',�--0
Designer: %�� Ir✓`<'_"^ �_ `� K f Installer:
Address: Address: __2 >o/tJz1'-1(-C ST_
On (,!JILL111W DIA26'02— was issued a permit to install a
(d e) (installer)
septic system at l/V AI L, �V r 1 based on a design drawn by
(address)
011 rl pie Vl dated
(designer)
I certify that the septic system referenced above was installed substantiallv according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box ancUor septic tank.
'
I certify that the septic system referenced above was installed with mayor changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow.
17
!off DAF�dREjN M. yG
IIv�EYERV �1
(Installer's S1gnatu e) o. 1�I40 j
-C/51 N
f SO I TAR\P�
(Designer's Signature) (Affix Designer's Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF
CONIPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE
RECEIVED BY THE B:�RNSTABLE PUBLIC HEALTH DIVISION. THANK YOU.
Q: Health/Septic/Designer Certification Form 3464doc
V
�_ f TOWN OF" ARNSTABLE p�
LOCATION �l WALNUT Sr SEWAGE#��or 6571
VILLAGE Q; / � ASSESSOR'S MAP
y&&PARCEL
INSTALLERS NAME& V"PHONE NO. ff' -4 'J I o t
SEPTIC TANK CAPACITY /0 0 d
LEACHING FACILITY:(ty e) 5 (size)?X
NO.OF BEDROOMS
r
OWNER
PERMIT DATE: COMPLIANCE DATE: /
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching ility) Feet
FURNISHED BY 1
./
/Z/,
TOWN
N ARvSTABLE
LOCATION _ Z/ WALNUT S� � I
SEWAGE O OS-1O-
VILLAGE_D / �-ASSESSOR'S MAP&PARCEL -GG
INSTALLERS NAME&PHONE NO. W(a/-A
SEPTIC TANK CAPACITY O D D
LEACHING FACILITY:( e) _ 65 (size) zol k
NO.OF BEDROOMS
OWNER N ar
I
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility.(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leachin ility) Feet
FURNISHED BY
1 I
. _
� Y
i
I �
Town of Barnstable. P#
Department of Regulatory Services `(
s' Public Health Division Hate
ss �e$ 200 Main.Street,Hyannis MA 02601
+ Fee Pd.
Date Scheduled ® Time
$ozl Suitability Assessment. or Sewage Disposal
Performed By: � /"! Witnessed By:
i
LOCATION& GENERAL INFORMATION
Location Address' VVP(LN 07 STMET Owner's Name be-
MA-1Z_STor4S M l(,LSD AA j Address 7l NkUN VT- ST M.Mf05
Assessor's Map/P�rcel: 14' 067 f Engineer's Name D yt M MCyL�,
NEW CONSIRUtION REPAIR Telephone# SOt� 362- .292_1;
Land Use RP;S 0612lm Slopes Surface Stones
Sbo i ' ?L�''ft Drinkin Water Well ��A
Distances from: Open Water Body ft ,•Possible Wet Areas g ,
Drainage Way 7 ft Property Line > ( � ft Other ft '
SKETCH:($beet name,dimensio6s'of lot,exact locations of test holes&pere tests,locate wetlands in proximity to holes)
17
Fib Pflyj Pao
o ail ���� • , ••I
Uj
I
X
:z art
t L' M
i
I
Parent matec='—1(geologic 0,#W Depth to Bedrock 'V
Depth to Groundwalar. Standing Water in Hole:' I Weeping froth Pit Race
I
Estimated Seasonal high Groundwater '
DtTER1b1IN4TION FOR SEASONAL HIGH'WATER TADLE
Method Used:
,
ln.
Depth Clbperved standing in obs.hole: _ _in. Depth to Sall tnatticst
Depth tofweeping from side of obs.hole. I ` jn, Oroundwatcf AdJuetment -
Index Wel!# Reading Date Index Well level .� Adj.factor•,,�,� Atl�.Groundwater Level—
Reading
PERCOLATION TEST
Observation I Time at 9" .�..
Hole#
78�t
Depth of Pere Time at 6"
Start Pre-soak Time.@ ION
t t Time(9"•6") .— --
End Pre-soak -�Q
Bate MinJlnch 2 MrNl,
Site Suitability Assosment: Site Passed X Site Failed:. Additional Testing Needed(YIN)
Original:.Public H41th Division Observation Hole Data To Be Completed on Back--- ---
***If percolation test is to be conducted within 1o0' of wetland,you must first notify the
Barnstable C44servation Division at least one(1)week prior to beginning.
DEEP OBSERVATION:HOLE LOGHole
Depth from Soil Horizon Soil Texture Soil Color Soil Other
.Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consis enc %Gravel)
b aaA Gn p S�S
1 Z``-132t' G Mev. and Z Sy �y
y _
t DEEP OBSERVATION HOLE LOG. Hole#.
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell Structure,Stones,Boulders.
. •�:- ). Mottling
Consiktencv.%Gravel)
k $4'1111
D 7,2" 8 SA+'1 g
2z4 a0" a lot 6/9
- `°°"��"-��'au 1��.. Sid z•��l
9
DEEP OBSERVATION HOLE LOG Hole
Depth from Soil Horizon Soil Texture Soil Color Soil Other t i
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
' l Cons•ste c o G vel
•
T
DEEP OBSERVATION HOLE LOG Hole# 914
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.
Flood Insurance Rate Man:
Above 500 year flood boundary No_ Yes ,
Within 500 year boundary No X Yes
Within 100 year flood boundary No Yes•;.,
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist,in all areas observed throughput the
area proposed for the soil absorption system? -
If not,what is the depth of naturally occurring pe vio�ial?
Certification
I certify that on q c( (date)I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that,the above anal sis was performed b me consistent with
De Y P Y
P
r'ence described in 3.1 MR 15.017.
the required tr ' ,expertise and expe 0 C
a
Signature Date
Q:\SEPTIC\PERCFORM.DOC
CO.MMO.X EALTH OF MASSACHtiSETTS
1; EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
;<< F DEPARTMENT OF ENVIRONMENTAL PROTECTION
0\E WINTER STREET, BOSTOK DLL,0210E i61 292-550e
TRUDY CORE
Secretan
ARGEO PAUL CELLUCCI DAVID B. STRL-HS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address:71 Walnut St . Name of Owner John/ Tina Cobb
Mar s t o Mill , MA Address of owner:_ game
Date of Inspection: 6.-.XS 7
Name of Inspector:(Please Print)Wm. E . Robinson Sr.
I am a DEP approved systerrl inspector rsuant to Section 15.340 of Trde 5(310 CMR 15.000)
Company Name: Wm. E . Robinson Septic Service
Mailing Address: PO BOX 1089, Centerville , MA
Telephone Number: �'7 5_8 0
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:
_ Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails l I
Inspector's Signature: Date:
The System Inspector shall submit a copy o1 this inspection report to the Approving Authority(Board of Health or DEP)within thirty (30)days of
completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS f
G 00 ,
,r 1104
H��vppsT �b
19
revised 9/2/98 Page Iof11
N
i� ✓nnied on Recq-ued Paper .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM +
PART A `
CERTIFICATION(continued).
"ropertyAddrgss: 1Walnut St . , Marstons Mills, MA
Owner: Tina ob
Date of Inspection: g
INSPECTION SUMMARY: Check 10, C, or D:
A./ SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES: r
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair, as-approved by the Board of Health, will pass.
Indicate es, no, or not determined (Y, N, or NO). Describe basis of determination in all instances. If "not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
� r
�-J
f
1
n
revised 9/2/98 Page 2of11
s
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION Icorttinued)
Property Address: 71 Walnut St . , Marstons Mills, MA
Owner: Tina Cobb
Date of Inspection:C .Z 6__9 /q
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require furher evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
11 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE.BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or
tributary to a surface water supply.
The system has a septic:tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septi--tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).
1 OTHER
I
revised 9/2/98 Pagc3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM `
PART A
CERTIFICATION Icontinued)
t
Property Address: 71 Walnut St . , Marstons Mills , MA
Owner: Tina Cobb Q
Date of Inspection:
D. SYSTEM FAILS:
You ust indicate either "Yes" or "No" to each of the following:
1-have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes o
Backup of sewage into facility.or system component due to an overloaded orclogged SAS or cesspool.
_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 day flow.
_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipets).
Number of times pumped_.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E. LA GE SYSTEM FAILS:
You mu t indicate either "Yes" or "No" to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a 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: .
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public
water supply well)
The ow er or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office o the Department for further information.
revised 9/2/98 Page Aof11
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 71 Walnut St . , Marstons Mills , MA _
Owner: Tina Cobb
Date of Inspection:
Check if the following have been done:You must indicate either "Yes" or "No" as to each of the following:
Yes No
1� Pumping information was provided by the owner, occupant, or Board of Health.
_ None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
/ inspection.-
As built plans have been obtained and examined. Note if they are not available with NIA.
✓ _ The facility or dwelling was inspected for signs of sewage back-up.
✓ _ The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
All system components,excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
/ The size and location of the Soil Absorption System on the site has been determined based on:
Existing information. For example, Plan at B.O.H.
AZ _ Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of,distance is unacceptable)
115.302(3)(b)]
_ The facility owner(and occupants,if different from owner) were provided with information on the proper maintenanr4a.4f
Subsurface Disposal Systems.
revised 9/2/98 Page 5of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
rroperty Address: 71 Walnut St . , Marstons Mills , MA
i
Owner: T na Cobb
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow:`/S,5 g.p.d./bedroom.
Number of bedrooms(desN' n): Number of bedrooms (actual):
Total DESIGN flow
Number of current residents:
Garbage grinder(yes or no): ,,eiv
Laundry(separate system) (yes or no)/.li J ; If yes, separate inspection required
Laundry system inspected (yes or no)
Seasonal use (yes or no):-IL-0
Water meter readings, if available (last two year's usage(gpd): 1998 161 , 000 gal.
Sump Pump(yes or no):,A- 1997 101, 000 gal.
Last date of occupancy: ,-.7 S
COMMERCIAL/INDUSTRIAL:
Type o stablishment:
Design fl w: gpd 1 Based on 15.203)
Basis of sign flow
Grease tr p present: lyes or no)_
Industrial aste Holding Tank present: (yes or no)_
Non-sani ry waste discharged to the Title 5 system: (yes or not_
Water m ter readings, if available:
Last dat of occupancy:
OTHE .(Describe)
Last occupancy:
GENERAL INFORMATION
PUMPING RECORDS an sou ce of information:
System pumped as part of inspection: (yes or no),,&,0
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF STEM
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)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other �✓
APPROXIMATE AGE of all components, date installed lif known) and source of information:
Sewage odors detected when arriving at the site: (yes or no1�C)
revised 9/2/96 Page 6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'ropenyAddress: 71 Walnut St . , Marstons ..Mills, MA
Owner: Tina Cobb
Date of Inspection:
BUI ING SEWER:
(Coca a on site plan)
Depth below grade:_
Mater I of construction:_cast iron_40 PVC_ other(explain)
Dista ce from private water supply well or suction line
Diem ter
Co ents: (condition of joints, venting, evidence of leakage,-etc.)
SEPTIC TANK:_
(locate on site plan)
Depth below grade:
Material of construction:Zncrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal,list age_ Wage confirmed by Certificate of Compliance_ (Yes/No)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:f6
Scum thickness:31—'el J �.
Distance from top of scum to top of outlet tee or baffler , I
Distance from bottom of scum to bottom Qf outlet taA or baffle:
How dimensions were determined: d rZ:--
'omments:
(recommendation for pumping, condition of inlet and outlet tees or affles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.) .�n- /l✓ �?� i.— =S
GR SE TRAP:
(loca-t on site plan)
Dept below grade:_
Mat ial of construction:_concrete_metal_Fiberglass _Polyethylene_otherlexplain)
Di nsions:
Sc m thickness:
D' tance from top of scum to top of outlet tee or baffle:
istance from bottom of scum to bottom of outlet tee or baffle:
ate of last pumping:
Co ments:
Ire ommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
ev dence of leakage,etc.)
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'top"Address: 71 Walnut St . , Marstons Mills pi MA
Owner: Tina Cobb
Date of Inspection:
Tl T OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
(Iota ie on site plan)
Depth below grade:_
Maten 1 of construction:_concrete_metal_Fiberglass_Polyethylene_otherlexplain)
Dimen ons:
Capaci : gallons
Design ow: gallons/day
Alarm resent
Alarm evel: Alarm in working order: Yes_ No_
Date f previous pumping:
Com ents:
(co ition of inlet tee, condition of alarm and float switches,etc.)
DISTRIBUTION BOX:(/
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, eviden of�solids carryover evid a of I ka g into or out, f box, etc.) -
PUM CHAMBER:_
hocat on site plan)
Pump in working order: (Yes or No)
Alar s in working order(Yes or No)
Com ants:
(not condition of pump chamber, condition of pumps and appurtenances, etc.)
revised 9/2/96 Page 8oflI
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'rop"Address: 71 Walnut St . , Marstons Mills , MA
Owner: Tina Cobb
Date of Inspection:e'—,,2 S$ 5,
SOIL ABSORPTION SYSTEM(SAS):_✓
(locate on site plan, if possible;excavation noz required, location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number:_
leaching chambers,number:_
leaching galleries, number:
leaching trenches, number, length:_
leaching fields, number, dimensions:
overflow cesspool, number:_
Alternative system:
Name of Technology:
Comments:
Inote condition of soil, signs of hydraulic failure, level of pondin , damp soil, condition of vegetjtion,.etc.) /
L•-�te - G & L�7. . s.=.��t/ a �'•�et� �e`'��d� �ie o �o h�1
7� 7 :
A,w t�L/
SPOOLS:_
(lo ate on site plan)
Num er and configuration:
Dept -top of liquid to inlet invert:
Dept of solids layer:
)epth of scum layer:
Dimen ions of cesspool:
Materi Is of construction:
Indicati n of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comm nts:
(note c ndition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRI _
(loc to on site plan)
Mat vials of construction: R Dimensions:
Dep of solids:
Com ants:
(not condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
r
revised 9/2//98 Page 9ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'roperty Address: 71 Walnut St . , Marstons Mills , MA
owner: = Tina Cobb
Jate of Inspection;
i
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
x,y`
revised 9/2/98 Page 10of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION Icorttirmed)
ropertyAddress: 71 Walnut St . , Marstons Mills, MA
Owner: Tina Cobb
Date of Inspection:
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
JC
Estimated Depth to Groundwater/,�-Feet
Please indicate all the methods used to determine High Groundwater Elevation:
/ Obtained from Design Plans on record
y Observed Site (Abutting property, observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators, installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
le
revised 9/2/98 page ilorn
i
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAI
DEPARTMENT OF ENVIRONMENTAL PROTECT
ONE WINTER STREET, BOSTON MA 02108 (617)292-5500 � X
INSPECTION ' TRI E
FAILED ry
2
ARGEO PAUL CELLUCCI B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 71 Walnut Street, Marstons Mills, MA Name of Owner: Tina Cobb
Address of Owner: Same
Date of Inspection: June 7, 1999
Name of Inspector: (Please Print) James M. Ford
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: James M. Ford
Mailing Address: P.O. Box 49, Osterville, MA 02655-0049
Telephone Number: (508)862-9400 Map: 149
Parcel. 067
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. Th•�inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
_ Passes
Conditionally Passes
_ Needs Further I
ion By the Local Approving Authority
✓ Fails
Inspector's Signature: �% Date: June 7, 1999
The System Inspector shall sui a copy of=his inspection report to the Approving Authority(Board of Health or DEP) within thirty(30)days
of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer, it applicable,and the approving authority.
NOTES AND COMMENTS
revised 9/2/98 Page Iof11
Printed on Recycled Paper
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 71 Walnut Street, Marstons Mills, MA
Owner: Tina Cobb
Date of Inspection: June 7, 1999
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. 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.
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, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
the septic tank, whether or not metal,is cracked, structurally unsound, shows substantial infiltration or exfiltration,or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health)
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
® The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
revised 9/2/98 Page 2of 11
r
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 71 Walnut Street, Marstons Mills, MA
Owner: Tina Cobb
Date of Inspection: June 7, 1999
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
® Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 (1)(b)
THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of 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 AND SAFETY AND
THE ENVIRONMENT:
The system has a septic tank and soil absorption system(SAS)and the SAS 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 the SAS is within a Zone 1 of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis for colifotm bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
revised 9/2/98 Page 3of11
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 71 Walnut Street,. Marston Mills, MA
Owner: Tina Cobb
Date of Inspection: June 7, 1999
D. SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
✓ I have determined that one or more of the following failure conditions exist as described.in 316 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
✓ Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
✓ _ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
✓ Liquid depth in cesspool is less than 6" below invert or available volume is less than'/z day flow.
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped—
✓ Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
✓ Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
✓ Any portion of a cesspool or privy is within a Zone 1 of a public well.
✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either "Yes" or"No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
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:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public
water supply well
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 Page 4of11
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 71 Walnut Street, Marsions Mills, MA
Owner: Tina Cobb
Date of Inspection: June 7, 1999
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
✓ _ Pumping information was provided by the owner,occupant,or Board of Health.
✓ _ None of the system components have been pumped for at least two weeks and the system has been receiving nominal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
✓ _ As built plans have been obtained and examined. Note if they are not available with N/A.
✓ The facility or dwelling was inspected for signs of sewage back-up.
✓ — The system does not receive non-sanitary or industrial waste flow.
✓ _ The site was inspected for signs of breakout.
✓ _ All system components,excluding the Soil Absorption System,have been located on the site.
✓ _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for conditions of baffles
or tees,material of constriction,dimensions,depth of liquid,depth of sludge,depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
✓ _ Existing information. For example, Plan at B.O.H.
✓ Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
[15.302(3)(b)].
✓ _ The facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of
SubSurface Disposal Systems.
revised 9/2/98 Page 5ofll
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 71 Walnut Street, Marstons Mills, MA
Owner: Tina Cobb
Date of Inspection: June 7, 1999
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 110 g.p.d./bedroom.
Number of bedrooms(design): n/a Number of bedrooms(actual): 3
Total DESIGN flow n/a
Number of current residents: 6
Garbage grinder(yes or no): No
Laundry(separate system)(yes or no): No ; If yes, separate inspection required
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last two yearg;usage(gpd): 1998-161,000 gals.; 1997-101,000 gals.
Sump Pump(yes or no): No
Last date of occupancy: Currently Occupied
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: gpd(Based on 15.203)
Basis of design flow
Grease trap present: (yes or no) _
Industrial Waste Holding Tank present: (yes or no) _
Non-sanitary waste discharged to the Title 5 system: (yes or no)
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
Not pumped since 1995 Per owner
System pumped as part of inspection(yes or no): No
If yes, volume pumped: gallons
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)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed(if known)and source of information: 9111195 per as built
Sewage odors detected when arriving at the site: (yes or no) No
revised 9/2/98 Page 6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 71 Walnut Street, Marstons Mills, MA
Owner: Tina Cobb
Date of Inspection: June 7, 1999
BUILDING SEWER: _
(Locate on site plan)
Depth below grade:
Material of construction: _cast iron _40 PVC _other(explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting,evidence of leakage,etc.)
SEPTIC TANK: ✓
(locate on site plan)
Depth below grade: 20"
Material of construction: ✓concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age_ Is age contimued by Certificate of Compliance_(Yes/No)
Dimensions: 8'6" x 4'10" x S' (1000 gal.)
Sludge depth: 4"
Distance from top of sludge to bottom of outlet tee or baffle: 28"
Scum thickness: S"
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: I "
How dimensions were determined: Measuring stick
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.) The baffles were present. The liquid level was even with the outlet invert. There were no signs of leakage.
Recommend being pumped.
GREASE TRAP: None
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal Fiberglass _Polyethylene _other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
revised 9/2/98 Page 7ofII
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 71 Walnut Street, Marston Mills, MA
Owner: Tina Cobb
Date of Inspection: June 7, 1999
TIGHT OR HOLDING TANK: None (Tan1k must be pumped prior to,or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present:
Alarm level: Alarm in working order: Yes_ No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX: ✓
(locate on site plan)
Depth of liquid level above outlet invert: .2"
Comments:
(note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box, etc.) The box was level. Liquid
level was above outlet invert and backing up from leaching trench.
PUMP CHAMBER: None
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms in working order: (Yes or No)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
revised 9/2/98 Page8ofII
a
n
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 71 Walnut Street, Marstons Mills, MA
Owner: Tina Cobb
Date of Inspection: June 7, 1999
SOIL ABSORPTION SYSTEM (SAS): ✓
(locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods)
If not located,explain:
Type:
leaching pits, number:
leaching chambers, number:
leaching galleries,number:
leaching trenches,number, length: 2'x 4'x 60' (per as built)
leaching fields,number,dimensions:
overflow cesspool,number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.)
Trench was not dug up.liquid was backing up in d-box. Trench is in hydraulic failure.
CESSPOOLS: None
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow(cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.)
PRIVY: None
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.)
revised 9/2/98 Page 9ofII
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 71 Walnut Street, Marstons Mills, MA
Owner: Tina Cobb
Date of Inspection: June 7, 1999 Map: 149
Parcel: 067
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
Wnlinu-T- Sr
I
� 3�c-
f I l
-7 �t ,l
1
I
I
a9 „
36 L
revised 9/2/98 Page 10of 11
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 71 Walnut Street, Marston Mills, MA
Owner: Tina Cobb
Date of Inspection: June 7, 1999
NRCS Report name
Soil Type
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater _Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site(Abutting property,observation hole,basement sump etc.)
Determined from local conditions
✓ Checked with local Board of Health
Checked FEMA Maps
Checked pumping records
Check local excavators, installers
✓ Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
Using Barnstable topographic and water table contours maps. Maps are showing 20+/-to groundwater at this site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty
or guarantee that the system will f inction properly in the future. There have been no warranties or guarantees, either expressed,
written or implied, relating to the system, the inspection and/or this report.
revised 9/2/98 Page 11of11
►` Zell] I A
0
LEGEND vD �R
\ oZ DftkN�.M I B E��� H M A R I! PROPOSED CONTOUR .CAD DE
I :-11 H 98 PROPOSED SPOT GRADE. ER
c-1140 PK NAIL IN DRIVEWAY — Tp
ELEVATION = 6 9. j j — 98 —— EXISTING CONTOUR NF 6 IDGE .y` HST
j 4NITA?,\ BARNSTABLE GIS DATIJKd + 96.52 EXISTING SPOT GRADE
ANITAR\ . 1 06'• D Q' W— EXISTING WATER SERVICE ! �� v� 0
040
F
+ (9 . TEST PIT o 9 P 11 p0
j--- — — — — ------------— — — — — — —----------- — — — 1 50.00 f t 1� �
o� Npr '9L, ZI�$jz�
LLJ
cn
! II LOCUS MAP N.T.S.
i
PANED DRIVE'dVA.I' I I
I ! W GENERAL NOTES:
1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL
BOARD OF HEALTH AND THE DESIGN ENGINEER.
2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS
I ! I OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE
{-- LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW:
Existing Leach Pit j TH-1 j - 310 CMR 15.405 (1) (B):
(See Note 10) I I I ( n 1) UP TO A 1.5 FT. VARIANCE FROM 310 CMR 15.211 TO ALLOW
LEACHING TO BE UP TO 4.5 FT BELOW GRADE VS REQ'D 3 FT. (VENT PROVIDED)
I I 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR
I I TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE
DESIGN ENGINEER.
4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING
(� W FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN
O j Z Z z I I I w ENGINEER BEFORE CONSTRUCTION CONTINUES.
_ ES N I i w ! > 5. ALL ELEVATIONS BASED ON ASSUMED DATUM.
�D I 10, I Q 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF
\ � II THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF
J ! I HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION.
7 \ — W I I 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE.
TM-2 `\ 'O ` y � O I 1 i
8. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED
o \ Lid d W TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR.
5 FT SOIL REMOVAL j 7 41 O —1 I i I / 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY
I 7 W I I � THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING
(see note 18) / Y� j W CONSTRUCTION.
10. EXISTING LEACH PIT TO BE PUMPED, CRUSHED AND REMOVED
11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION
o
I 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY
1 t �� / / j I AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY
13. NO PRIVATE WELLS WITHIN 150 FT. OF PROPOSED LEACHING
14. ALL PIPING TO BE 4" SCH 40 ® 1/8-/FT (UNLESS SPECIFIED OTHERWISE)
15. THE DESIGN OF THIS SYSTEM DOES NOT ALLOW
j bOVe Ground Pool \ / j FOR THE USE OF A GARBAGE GRINDER
I \ 1 I 16. NO WETLANDS WITHIN 100 FT. OF PROPOSED LEACHING
1 17. REMOVE ALL UNSUITABLE SOILS 5 FT. AROUND LEACHING TO
I \ EL. 64.05/62.05 (LAYER VARIABLE) OR TOP OF C2 LAYER AND REPLACE WITH CLEAN
t I \ MEDIUM SAND.
1
\ / I
- - - - - - - - - - - - - - - - - - - —- ------------ - - - -/---------------------------
160.00 ft bc, PROPOSED SEPTIC SYSTEM UPGRADE PLAN
r o
71 WALNUT STREET, MARSTON MILLS, MA
Prepared for: Bernice Standish
MAP: 149 Engineering by: Surveying by: SCALE DRAWN JOB. NO.
SURVEY REFERENCE: 1 LOT.•067 DARREMM,MEYER,R.S. Eco—Tech BnvYronmentaY 1"=20' DMM
i'
PLAN OF LAND BY BARNSTABLE SURVEY CONSULTANTS INC. DEED BOOK. 12397 PO Boxsef (508) 364-0894
DATED: FEBRUARY 1971 DEED PAGE.262 EASTSANDWICH,MA02537 DATE: CHECKED SHEET N0.
508-362-2922 02/18/08 DMM 1 of 2
4
ELEV. TOP vent required
FOUNDATION
(Existing)
= 69.62 �•.�F.G.EL: 69.5 � F.G.EL: 69.0 F.G. EL: 69.0 � FINISH GRADE= 68.8-69.0
MAINTAIN 2% MIN SLOPE OVER LEACHING AREA
i
COVERS TO WITHIN 6 OF GRADE
6" INSPECTION PORT
L _ 25 SANITARY TEE W/IN 6" OF FINISH GRADE
,.
6"El,
4" SCH 40 PVC L = 12'.. ° ° ° a ° ° ° ° ° ° ° °
6-
(MIN.) 10 I 14„ ® S= 1% (MIN.) e" p S= 1% (MIN.)
TEE'S ARE TO BE
:.r...,. 4' SCH 40 PVC INV.65.95
INV.66.33 INV. 65.75 ° ° ° ° ° ° °
GAS PROP -
^� EXISTING OUTLET BAFFLE OSED DB 3
-. .. . •.. .• :. H-10 DISTRIBUTION BOX
25' I
INV. 66.58 EXISTING 1000 GALLON SEPTIC TANK
NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING
PIPE INVERTS PRIOR TO CONSTRUCTION muex vAeR/ 9" MIN.
2) D-BOX SHALL BE SET LEVEL AND TRUE TO sac PER TI TLE 5
GRADE ON A MECHANICALL COMPACTED SIX
Of (�ss9� INCH CRUSHED 2 TONE BASE, AS SPECIFIED IN BREAKOUT EL. = 64.5
310 CMR 52
INV. ELEv.=64.0
DA M. r^ 3) REPLACE EXISTING 1,000 GALLON SEPTIC
R N TANK WITH 1500 GALLON SEPTIC TANK DOUBLEJY'wASHWASHEDsnw- ' OE 24„ 30 5"
No. 1140 IF FAILED, DAMAGED, OR UNDERSIZED.
�
SEPTIC SYSTEM PROFILE 4) INSTALL INLET & OUTLET TEES AS REQUIRED lNl/ER�C/�E�� BOTTOM EL.= 62.0
�----48" 50" 8"
sANITAW\ ol
SEPARATION 5.45 FT. L 146" _ I
INFILTRATOR 3050 SPECIFICATIONS SOIL ABSORPTION SYSTEM (SECTION)
BOTTOM OF TH-1 EL 56.55 H2O LOADING)
SOIL LOGS P #: 12046 DESIGN CRITERIA
NUMBER OF BEDROOMS: 3 SEDROOMM
DATE: FEBRUARY 15, 2008 SOIL TEXTURAL CLASS: CLASS 1 (0.74 GPD/SF) (PER ATTACHED SIEVE ANALYSIS)
SOIL EVALUATOR: DARREN MEYER, R.S., CSE DESIGN PERCOLATION RATE: <5 MIN/INDAILY FLOW: 110 G.P.D.
° WITNESS: DONALD DESMARAIS HEALTH AGENT DESIGN FLOW: 330 G.P.D.
GARBAGE GRINDER: NO (not designed for garbage grinder)
INLET END Elev. TH- 1 Depth Elev. TH-2 Depth SEPTIC TANK: 330 gpd x 2 = 660 gpd USE EXIST. 1,000 GALLON SEPTIC TANK
(OPEN) 69.5 0" 69.05 0"
A LOAMY SAND A (330) = 445.94 S.F.
. 10YR 3 2 LOAMY SAND LEACHING AREA REQUIRED:
/ 10YR 3/2 .74
a.s" D1A ACCESS PORT FOR INSPECTION. 69'0 B s" f 68.38 B s' USE THREE (3) INFILTRATOR 3050 UNITS (H20) WITH 4 FT. STONE
SANDY LOAM SANDY LOAM ON THE SIDES & 1.3 FT. STONE ON ENDS: 25' L x 12.16' W x 2'D
10YR 5/8 10YR 5/8
1 BOTTOM AREA: 25 x 12.16 = 304 SF
67.25 Cl 27" 67.22 C1 22" SIDE AREA: (25 + 12.16) X 2 X 2 = 148.64 SF
SANDY LOAM 1 TOTAL SQUARE FEET PROVIDED = 452.6 vs. 445.94 REQ'D SANDY LOAM
. o 0 0 " . . . o .
" tOYR 6/8 10YR 6/8 DESIGN FLOW PROVIDED: 0.74(452.6 S.F.) = 334.95 G.P.D. vs. 330 G.P.D. req'd
63.5 72" 64.05/62.05 60"/84"
C2 MEDIUM C2 MEDIUM PROPOSED SEPTIC SYSTEM UPGRADE PLAN
SAND 1 SAND
INFILTRATOR 3050 2.5Y6/4 PERC 064.05 2.5Y6/4 71 . WALNUT STREET, MARSTON MILLS, MA
Prepared for: Bernice Standish
NOMINAL CHAMBER SPECIFICATIONS
Engineering by: Surveying by: SCALE DRAWN JOB. NO.
SIZE (W x H x L) 51 " x 30" x 85.4
58.5 132" 56.55. 150" DARRENM.MEYER,R.S. Eco-Tech Enwironmente! N.T.S. DMM
" PO e0x 991
WEIGHT 80.0 LBS. PERC RATE <2 MIN/IN. ("C2" HORIZON) PERC RATE <2 MIN/IN. ("C2" HORIZON) E4STSANDWICH,MA02537 (508) 364-0894 DATE CHECKED SHEET NO.
NO GROUNDWATER OBSERVED NO GROUNDWATER OBSERVED 506-3522922 02/18/08 DMM 2 Of 2