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HomeMy WebLinkAbout0072 WATERS EDGE - Health 72 WATERS EDGE:✓ ' A=062.042 �CTrsa�?S rs it l! u: Commonwealth of Massachusetts 0 - aq� R Title 5 Official Inspection Form lI; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments . 72 Waters Edge Property Address Gayle & Bruce Rosewell ' Owner Owner's Name r j information is Marstons Mills MA 02648 02/20/2020 required for every ' page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered iri any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information (5 1* /41/3 on.the.computer, use.only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. 52 Rivers End Road Co Company Address Teaticket Ma. 02536 City/Town State Zip Code few 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 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 D2/21/2020 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection pect on 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 �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .V 72 Waters Edge Property Address Gayle& Bruce Rosewell Owner Owner's Name information is required for every Marstons Mills MA 02648 02/20/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This 4 bedroom house has an H-10 1500 gallon septic tank with an D-Box feeding 3-500 gallon chambers with stone. At the time of the inspection there were no visible failure criteria found. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltrati6n or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts rn Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments u— 72 Waters Edge Property Address Gayle& Bruce Rosewell Owner Owner's Name information is required for every Marstons Mills MA 02648 02/20/2020 page. CitylTown 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.7/26/2018 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 72 Waters Edge Property Address Gayle& Bruce Rosewell Owner Owners Name information is required for every Marstons Mills MA 02648 02/20/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts �- Title 5 Official Inspection Form <I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Waters Edge V� Property Address Gayle& Bruce Rosewell Owner Owner's Name information is required for every Marstons Mills MA 02648 02/20/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® _ Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ] ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 a , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Waters Edge Property Address Gayle& Bruce Rosewell Owner Owner's Name information is required for every Marstons Mills MA 02648 02/20/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ' ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ 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)] I t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form F Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Waters Edge Property Address Gayle& Bruce Rosewell Owner Owners Name information is required for every Marstons Mills MA 02648 02/20/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 plus GPD Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage town water 9 ( Y 9 (gPd))� Detail: In 2019-75,000 gallons were used and in 2018-164,000 gallons were used. Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form �I � Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Waters Edge Property Address Gayle& Bruce Rosewell Owner Owner's Name information is required for every Marstons Mills MA 02648 02/20/2020 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form <'I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 72 Waters Edge Property Address Gayle& Bruce Rosewell Owner Owner's Name information is required for every Marstons Mills MA 02648 02/20/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septuc 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: 1998 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 39"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: town water feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Waters Edge Property Address Gayle& Bruce Rosewell Owner Owner's Name information is required for every Marstons Mills MA 02648 02/20/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 30"tee" Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: H-10 1500 gallon Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 34" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? sludge judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of inspection the liquid level was at working level and the tee's were in place. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ti0 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Waters Edge Property Address Gayle& Bruce Rosewell Owner Owner's Name information is required for every Marstons Mills MA 02648 02/20/2020 page. Cityrrown 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 I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 C Commonwealth of Massachusetts P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Waters Edge V� Property Address Gayle& Bruce Rosewell Owner Owner's Name information is required for every Marstons Mills MA 02648 02/20/2020 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 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At the time of the inspection the liquid level was at working level and there were no visible signs of leakage or solids carryover. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Waters Edge Property Address Gayle& Bruce Rosewell Owner Owner's Name information is required for every Marstons Mills MA 02648 02/20/2020 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 order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts �- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% 72 Waters Edge V� Property Address Gayle & Bruce Rosewell Owner Owner's Name information is required for every Marstons Mills MA 02648 02/20/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection no visible failure criteria was found. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form iii Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Waters Edge Property Address Gayle & Bruce Rosewell Owner Owner's Name information is Marstons Mills MA 02648 02/20/2020 required for every page. Cityrrown 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Waters Edge Property Address Gayle & Bruce Rosewell Owner Owner's Name information is Marstons Mills MA 02648 02/20/2020 required for every page. Cityrrown 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 `^ Q S•b Lj% l 4- tcX t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 q? c 4 VTOWN OF BARNSTABLE LOCATION Co>` f%cu � FJG� SEWAGE tt qV) VILLAGE ///arJ1tl%.r AAJ ASSESSOR'S//MAP&'I/d INSTALLER'S NAME&PHONE NO._!fo%�dlo1�� Cati��rrx ji0 J y� 0/f SEPTIC TANK CAPACITY /30o GsL LEACHING FACILITY:(type)PV G,l 1,W i C,6.4-�4t (size) /3 r�l 37,t�(.2•� NO.OFBEDROO a c BUILDER OR �i.�ir /�•iht�r��nr L�It v ll/ PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility f Feet Private Water Supply Well and Leaching Facility (If any wells exist �� Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist �f/�9 Feet within 300 feet of leaching facility) Furnished by Fe"} ,3 I� 16 31'6 d y�' a c Commonwealth of Massachusetts p Title 5 Official Inspection Form ��iI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .......... !% 72 Waters Edge Property Address Gayle& Bruce Rosewell Owner Owner's Name information is required for every Marstons Mills MA 02648 02/20/2020 page. City./rown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 14 plus feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: I augered a hole at a lower elevation and I shot it with a transit to show 4 plus feet of seperation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 , y c� Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v., 72 Waters Edge Property Address Gayle& Bruce Rosewell Owner Owner's Name information is required for every Marstons Mills MA 02648 02/20/2020 page. CitylTown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of'Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 f Commonwealth of Massachusetts a&a'0�� W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Waters Edge Property Address Bruce Rosewell a Owner Owner's Name p.a information is required for every Marstons Mills Ma 02'648' 11/3/16 page. City/Town State Zip Code Date of Inspection C..7 Inspection results must be submitted on this form. Inspection forms may not be altered in-Ay way. Please see completeness checklist at the end of the form. . Important:When filling out forms A. General I.nforrnation on the computer, use only the tab 1. Inspector: key to move,your cursor-do not Michael DiBuono use the return key. Name of Inspector DiBuono Sewer and Drain rab Company Name 8 Johns�ath _ Company Address rerun S Yarmouth Ma 02664 City/Town State Zip Code E-08-364-9587 _ S103522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 11/7/16 Inspecto`r's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DER) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 �0 T _ Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Waters Edge Property Address Bruce Rosewell _ Owner Owner's Name information is Marstons Mills Ma 02648 11/3/16 required for every _ pa City/Town State Zip Code Date of Inspection 9e. ,., B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/ always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System contains a 1,500 GI septic tank as well as a concrete distribution box and three 500 GI chambers in stone. B System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Waters Edge M Property Address Bruce Rosewell Owner Owner's Name information is required for every Marstons Mills Ma 02648 11/3/16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution'box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, .safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts N W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Waters Edge �M Property Address Bruce Rosewell Owner Owner's Name information is Marstons Mills Ma 02648 11/3/16 required for every —_ page. City/Town State Zip Code Date of Inspection B. Certification cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary.to•.a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or_less than 5 ppm, provided that no other failure criteria are triggered. A copy.of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ® Discharge or ponding of effluent to the surface of the ground or surface waters El due to an overloaded or clogged SAS or cesspool El ® 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal.System Form - Not for Voluntary Assessments 72 Waters Edge - Properly Address Bruce Rosewell Owner Owner's Name information is required for every Marstons Mills Ma 02648 11/3/16 page. City/Town State Zip Code Date of.inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal,to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd... ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E). Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—'IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15,304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 p Commonwealth of Massachusetts Title 5 official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Waters Edge Property Address Bruce Rosewell Owner Owner's Name information is required for every Marstons Mills Ma 02648 11/3/16 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have !urge volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the..interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria:related to,-Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4--- Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Waters Edge 9 Property Address Bruce Rosewell Owner Owner's Name information is required for every Marstons Mills Ma 02648 11/3/16 page. City/Town State Zip Code Date of Inspection D. System Information Description: System contains a 1,500 GI septic tank as well as a concrete distribution box and three 500 GI chambers in stone. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) El Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 365 GPD 9 ( Y 9 (gp ))� Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 72 Waters Edge Property Address Bruce Rosewell Owner Owner's Name information is required for every Marstons Mills Ma 02648 11/3/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other (describe below): General Information Pumping Records: Source of information: 2014 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ InnovativeiAlternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments, 72 Waters Edge Property Address Bruce Rosewell Owner Owne.'s Name information is required for every Marstons Mills Ma 02648 11/3116 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: installed 1999 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): System is vented at the roof Septic Tank (locate on site plan): Depth below grade: 1.5feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) 1500 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 " Commonwealth-of Massachusetts y_ ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4M r 72 Waters Edge 9 d Property Address P Y Bruce Rosewell Owner Owner's Name information is required for every Marstons Mills Ma 02648 11/3/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) 24" Distance from top of sludge to bottom of outlet tee or baffle — .. 3" Scum thickness Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No evidence of Ieaking,Tees and or baffles in place at time of inspection. 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Waters Edge �M Property Address Bruce Rosewell Owner Owner's Name information is required for every Marstons Mills _ _Ma 02648 11/3/16 page. CityFrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tees are in place and levels are normal. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: - Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 CommonWealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Waters Edge Property Address Bruce Rosewell Owner Owner's Name information is Marstons Mills _ Ma 02648 11/3/16 _ required for every — _ _ page. CityTown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Levl and at normal level Comments (note if box is level and distribution to outletsequal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms'in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t51ns•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 . Commonwealth of Massachusetts W Title 5. Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Waters Edge Property Address Bruce Rosewell Owner Owner's Name information is required for every Marstons Mills _ _Ma _02648 11/3/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits = number: ® leaching chambers number: 3 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil,•condition of vegetation, etc.): No signs of failure Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer — Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts ' W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Waters Edge Property Address Bruce Rosewell Owner Owner's Name information is Marstons Mills Ma 02648 11/3/16 required for every -- page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): No ponding no break out Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Waters Edge Property.Address Bruce Rosewell Owner Owner's Name information is Marstons Mills Ma 02648 11/3/16 required for every _ _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the-sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Waters Edge Property Address R Bruce osewell Owner Owner's Name_ information is required for every Marstons Mills Ma 02648 11/3/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10+ ft feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 1999 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ElChecked with local excavators, installers (attach documentation) ❑ Accessed USGS database --explain: You must describe how you established the high ground water elevation: Test hole data on plan as well as observation Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 _� art„✓f, l G a ICI 6Iie+OWNOFBARNSTABLE E LOCATION L �`% cG�;,l;� L'✓) ,� SEWAGE # / VILLAGE.1�����1t�uj `I�.�r� ASSESSOR'S MAP_ & LOT INSTALLER'S NAME&PHONE NO. )o, /�'Z)V, { SEPTIC TANK CAPACITY /00 Cy L LEACHING FACILITY: (type) 50,' is l `a� f'�i;;�i /.3. i (size) . NO. OF BEDROOMS -,_� € r BUILDER OI O N 3 PERMITDATE: COMPLIANCE DATE: 3 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) Edge of Wetland and Leaching Facility(If any wetlands exist Within 300 feet of leaching facility) J� Feet E Furnished by i e Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Waters Edge Property Address Bruce Rosewell Owner Owner's Name information is required for every Marstons Mills Ma 02648 11/3/16 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information— Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE op �- C' V LOCATION �o� Sr9 cva •�-J r SEWAGE # VILLAGE II�rT�avf / AS ASSESSOR'S MAP & LOT INSTALLER'S NAME$PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 32'0 Gf l 1,,4 (size) /3 r1 33, NO. OFBEDROOMS o TTY BUILDER OR Asmd&JE`,116 650 00923 PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility s f Feet Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist /j Feet within 300 feet of leaching facility) Furnished by �w b 31' f . No. Fee�— ' V ' THE COMMONWEALTH OF M'ASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ' 0[pplitation for Zigool *patent Con5truttion Permit Application for a Permit to Construct X Repair( )Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. ��� S Q,� -7 Z, �✓�y %,( wner's Name,Address and Tel.No, Assessor's Map/Parcel ���,��� of UUR ��s.��Z t r ,y a o--a-y U'`� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. `f 7/ g 1(vti S J. 'Zc� co�Gf� 7�^`��35 Type of Building: Dwelling No.of Bedrooms Lot Size 5 sq.ft. Garbage Grinder( ) Other Type of Buildings" -P No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 7 yU gallons per day. Calculated daily flow gallons. lan Date Number of sheets Revision Date Title Size of Septic Tank i 5o(,) Type of S.A.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 Certifi- cate of Compliance has been issu by this Bo of Health. Signed Date Application Approved by 1J.0v Date Z Not: 9 j�\T Fee \+ THE COMMONWEALTFIoF=N SSACHUSETTS y Entered in computer: Yes- PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Zipprication for )Di-opozal 6potem Cow6tructton 3perntit Application for a Permit to Construct(Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Lo7' 3-9 -7 2 jV r,,,1x4,) wner's Name,Address and'Tel.,No. AA Assessor'sfMap/Pazcel y 010 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �oY 7`d CO i GO 0,5� l tJ-� 11,0V Type of Building: Dwelling No.of Bedrooms Lot Size y 5 t-V sq. ft. Garbage Grinder( ) Other Type of Building 5 fjj 4 No._of Persons Showers( ) Cafeteria( ) Other Fixtures � t� Design Flow .t gallons per day. Calculated daily flow `( • gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank ! ,SUCH Type of S.A.S. `T—30 v f � C KA, + . fa4r-V2 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 Certifi- cate of Compliance has been issu by his Boar of H:alth. Signed ��_ Date Z_///A�y Application Approved by Date Z y' ocr— Application Disapproved for the following reasons Permit No. "�Z y Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, that th On-situ Sewa Disposal System Constructed( wiredUpgraded( ) - Abandoned( )by deg/'A0 7� �i hs�`-• at 'Z L✓� J FV :U, /0%1%/J has been construct d in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. C/ _F2 dated � a •L Installer Designer X^\ I The issuance of this pe y ? illesigI c he ojp/e e Date Inspector C 61 ' -I-\,\ , ------------------------------ ----- No. / J �i Fee lC�, THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS Mi0po0ar teat (Construction Vermit Permission is hereby granted to Construct('�)Repair( )Upgrade( )Abandon( ) System located at 7 Z ��VXAJ L �7G�r✓Pl�rJ - r and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this paymit. Date: Approved by�r � i� `Y✓' ��'4'J // TOWN OF BARNSTABLE f, LOCATION ��� 5�9 Gya SEWAGE # r VILLAGE 4,210'4 A1115 ASSESSOR'S MAP & LOT L14STALL.ER'S NAME&PHONE NO. 6,1,04ZL &21 Trcc,4a 2 SEPTIC TANK CAPACITY /)Zc 6�6 LEACHING FACILITY: (type) s­�o 1"4( 4 6141044 (size) /3"-e 33:f'' .2 NO.OF BEDROO .S BUILDER OR l'cJ� /{e n���`ia.% PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility S f Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) n /� Feet Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by �h C c� i TEST HOLE LOG DATE: F�P�, ti/� /995� AP BZ 0 9 SOIL EVALUATOR: --,/4NAc/ WITNESS: 8,Qx2,e Y' PERC RATE: /� C'a.v.5 Trc'�Jc' o A�J o�c !�6Cn.� Lc�.��-•> • �9 44. ,00.s>5 T ,3� ,qvy�fZ�o .•v y 6 Z.d ,,e3 y za , /08 y cc.+ t icy 4 G DESIGN DATA DAILY IFLOW: PlopM DRML z 110 GPD=y5c�GFD 19 SEPTIC TANK: z 200%= BS es GM USE:/Soo GALLON PRECAST SEPTIC TANK LEACHING FACILITY: s` USE: C s'x aA s'>e Z Aso �.9�..oryw�'tcs tt CAPACITY: E .. a%tI OF M µ�N M� \ SIDXWALL:,J'3 x z x .7� _ /3 7, wtr r�.2s DANIEI N JQ^y S o+�! y d �v r"� BOTTOM: /3 33.S x.7Z2,3 ;• ' BRAMAN G + �a � TOTAL. { O CIVIL A- V Ne.32686C yKAMv^�.U �"C���'[J5 /�-✓/i cm f _ 14 (� NOTES: �0 1. ALL PIPE TO BE 4"DIA.S('H 40 PVC. C 2. PIPE TO BE LAID LEVEL FOR 2'OUT OF DISTRIBUTION BOX. 3. RAISE ALL APPLICABLE MANHOLE COVERS TO WITHIN y 6"OF(FINISH GRADE. 4. SEPTIC SYSTEM I8 NOT DESIGNED FOR THE USE OF A tl GARBAGE DISPOSAL. SEPTIC TANK AND DISTRIBUTION BOX TO BE INSTALLED ON A 6"LAYER OF STON& 6. INSTALL GAS BAFFLE IN OUTLET TEE.:*LAYER or 3/P eEA9TONE OVER W.I 1/2'WASHED STONE ALL AROMD TOP OF FOUND. EIw 7�A v Is, 14• , vpSM7�'C, c �� 3 �✓G7 Giso 5�3 k 3 62,Z5 GZAo D ; po a � SEPTIC SYSTEM PROFILE SITE SEWAGE PLAN GENERAL TONS FOR 1. CONTRACTOR TO BE RESPONSIBLE FOR THE LOCATION OF ALL UTiUMADM AND UNDERMUMPRM A1,A4 TEAeS 4 �o!5= /t�/�/c' .�./S GC,� TO ANY EXCAVATION OR CONSTRUCTION. Low S� •� c 4� y S9 2.SEPTIC SYSTEM TO BE INSTALLED IN COMPNANCE WITH u 4 PREPARED FOR 3I9 CMR IS. T=V. 4 & TWS PLAN IS NOT TO BE USED FOR PROMTX DBTUMDYATION. £'P / �+ I 4. ALL DIUUP.=AREA$TO LOANED AND BEBDED. DATE: SCALE: ZS-q 3. CONTRACTORt TO PROVIDE 24 HOUR NOTICE FOR ANY N 1 "Aunt INSPECTIONS. r2}E� e Ac'G a�ec.�s . vy�r�',I ✓.9 wJq •' j� ,��� GE.94+,ri•�G� f�!�iTj��:,�E',�C'E'��°',,� �. ; `"• WELLER & ASSOCIATES t ' 1"S FALMOM ROAD CENHRVILLE,M& 02632 ,�1 rt TEL: (SW 7754735 FAX: (508)7754754 r - r APPROAD BY: y 13� ' t 4-1 17 7 / to Al-na l '4. J �xf. ! 1 lop :: ._. .. - i w - l,.;.J• .� y^.5r�• ,.,,��.) 2�sir ',/7�k � t �� ...' ` � � .arc •� _ � w� � r L • . .__.. SkIV 1N OF 40� sZ 3 S r FEN36791 Ss. RUM.9 ilk/ OF BRAMAN 't/� V . �`��`�`_ c a ;'•J,':s CIVIL ti U No.32666C w— flies , , S y 4 1 IV,q T< I � T73�yL• = 7S,�- ��-o,J \ l ' ,/ � •�.�/ire �' / ��• i.�/. r � I p � t O • �- /r I y 71017 • ya _ wOR OF RUM9 ,L� 35791 N c lO BRAMAN •' .. CIVIL 31686G PIE .. �� G ` TEST HOLE LOG DATE: �iu�+ /� /995� ' BZ'o 9 SOIL EVALUATOR: 4 i4 ed- WITNESS: deic� SQre,- Y PERC RATE: _ . LL;A?A-f / G'o.vS 7TVC' ,-io of o� •46fn.:s Z. oS 7 E --t% Z.c V'eAeL e c t DESIGN DATA DAILY FLOW: Plop DRMS.z 110 GPD•yye�GPD c SEPTIC TANK GPD z 200%- B8 e.GPD USE:/Soo GALLON PRECAST SEPTIC TANK / LOG JS LEACHING FACILITY: n�fva,e,o USE: �.3� 5"X 8,Sx Z $"moo)5'i9+:.,`l-ry✓49Kcs i CAPACITY: � r M tN N ,tis+Tc cy� SM EWALL:,/ 3 x z x .7,� _ /.3 7..(o BOTTOM: �o OANIEI u yG +o y� S 88AMAN N TOTAL: v Ne.32686C•" 4 6-roc.-�t7 - � , ��_�,� . ._. „• } i (,40NOTES: 1 � 1. ALL PIPE TO BE 4"DIAL SCH 40 PVC. C 2. PIPE TO BE LAID LEVEL FOR 2'OUT OF DISTRIBUTION A�"J/, ' BOX. l} 3. RAISE ALL APPLICABLE MANHOLE COVERS TO WITHIN . 6"OF FINISH GRADE. 4. SEPTIC SYSTEM IS NOT DESIGNED FOR THE USE OF A GARBAGE DISPOSAL 5. SEPTIC TANK AND DISTRIBUTION BOX TO BE INSTALLED ON A 6"LAYER OF STONE. 6. INSTALL GAS BAFFLE IN OUTLET TEL 1•LAYER OF 3/t'PEASTONR OVER 314•-1 111*WASMD STONL ALL -- AROUND TOP OF FOUND. 19L 70. v to, 16" z 3 6✓G7 G/.So 3 G3 (2r25 0 G2,c'0 SEPTIC SYSTEM PROFILEiPlNh SITE SEWAGE PLAN GENERAL rtoz'Es FOR L CONTRACTOR TO BE RESPONSIBLE FOR THE IA ATION "2 OF ALL UTiWTIEB,ABOVE AND UNDEMMOUN N PRIOR !w/47�,E5 �jX � ��i9� �/S 1-1,1GC,S TO ANY EXCAVATION OR CONSTRUCTION. 6AC y�,? S9 3. SEPTIC SYSTEM TO Ill INSTALLED IN COMPLIANCE wrr8 PREPARED FOR 3I0 CMR IS.ft T=v Yi & THIS PLAN IS NOT TO U USED FOR PROPBRTY LINE • ' 8.�'c1�•cr' �. o.S�cGf/�L L DETI B"ATION. w y �+ 4. ALL DIMRM AREAS TO LOANED AND OUDSI Q DATE: •./v.uc-.. .to �97) SCALE: RG1 LS S. CONTRACTOR TO PROVIDE 24 HOUR NOTICE FOR ANY REQUISM viSPECPIONL • �: 2E.�-1odE .9[L ��-11oe�ev.o J.t .�,cNrE,��.9G. ,{ �:.•. , . .. �S• k6 W. 9 WELLER & ASSOCIATES 1"S FALMOUM ROAD CENURVILLE,MA. 02632 r (SOS)77M735 FAX' (I")77M754 ,f r APPROVED BY: r 'i