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' Commonwealth of Massachusetts RIP IlO- � J
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
'< 180 WHITE MOSS DR e�w
Property Address
SMITH
Owner Owner's Name
information is rat
required for MARSTONS MILLS MA 02648 8-10-15 _=X>
every page. Cityrrown State Zip Code Date of Inspection
ti
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important: A. General Information
When filling out � ////O
forms on the v
computer,use 1. Inspector:
only the tab key
to move your DOUGLAS A BROWN
cursor-do not Name of Inspector
use the return
key. D.A.BROWN INC
Company Name
P.O. BOX 145
Company Address
CENTERVILLE MA 02632
10l1 City/Town State Zip Code
,508-420-4534 S14297
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
8-10-15
Ins s Ignature Date---
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions..0 use.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage isD posal System•Page 1 of 17
r Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM , 180 WHITE MOSS DR
Property Address
SMITH
Owner Owners Name
information is required for MARSTONS MILLS MA 02648 8-10-15
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
SYSTEM METT ALL MINIMUM PASSING REQUIREMENTS AT TIME OF INSPECTION. HOUSE
HAS BEEN OCCUPIED MOSTLY ON A PART TIME BASIS. FUTURE PERFORMANCE UNDER
THE SAME OR INCREASED USE CAN NOT BE PREDICTED FROM THIS REPORT
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 Fonn:Subsurface Sewage Disposal System-Page 2 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 180 WHITE MOSS DR
Property Address
SMITH
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 8-10-15
every page. Cityrrown 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,. 180 WHITE MOSS DR
Property Address
SMITH
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 8-10-15
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any:)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
180 WHITE MOSS DR
Property Address
SMITH
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 8-10-15
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other,failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 16,000 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
f
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°M 180 WHITE MOSS DR
Property Address
SMITH
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 8-10-15
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
❑ ® Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size.and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms(actual): 2per
assessing
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
d Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
180 WHITE MOSS DR
Property Address
SMITH
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 8-10-15
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
A 1000 GALLON SEPTIC TANK D-BOX AND LEACH PIT WERE FOUND TO BE IN WORKING
ORDER AT TIME OF INSPECTION
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ❑ No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ® Yes ❑ No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
2013--------------109 2014----------—---137GPD
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
a 180 WHITE MOSS DR
Property Address
SMITH
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 8-10-15
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: CURRENTLY OCCUPIEDDate
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
a g P Y ry
M SVer 180 WHITE MOSS DR
Property Address
SMITH
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 8-10-15
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
1987 PER AS-BUILT
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑ cast iron ❑ 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: Years
Is age confirmed b a Certificate of Compliance? attach a co of certificate)
g y p ( copy c te) El Yes ❑ No
Dimensions: 1000 GALLON
Sludge depth: LIGHT
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
180 WHITE MOSS DR
Property Address
SMITH
Owner Owners Name
information is required for MARSTONS MILLS MA 02648 8-10-15
every page. City/Town State Zip Code Date of Inspection
i
D. System Information (cont.)
P�
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness TRACE
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
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.):
TANK WAS FUNCTIONING PROPERLY AT TIME OF INSPECTION SHOWING SOME LIGHT
CORROSION TYPICAL FOR ITS AGE
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .
M '< 180 WHITE MOSS DR
Property Address
SMITH
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 8-10-15
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions: -
Capacity:
gallons
Design Flow:
• gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
180 WHITE MOSS DR
Property Address
SMITH
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 8-10-15
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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.):
Pump Chamber(locate on site plan):
a
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:
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
180 WHITE MOSS DR
Property Address
SMITH
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 8-10-15
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1 600 GALLON
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
PIT HAD ABOUT 2 FT OF WATER WITH NO SIGNS OF FAILURE. THE HOUSE HAS ONLY BEEN
OCCUPIED BY 2 PART TIME RESIDENTS . FUTURE PERFORMANCE UNDER THE SAME OR
INCREASED USE CAN NOT BE DETERMINED BY THIS REPORT
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
180 WHITE MOSS DR
Property Address
SMITH
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 8-10-15
every page. City[Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
180 WHITE MOSS DR
Property Address
SMITH
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 8-10-15
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•3113 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
z 180 WHITE MOSS DR
Property Address
SMITH
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 8-10-15
every page. Citylrown 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: GREATER THAN 5
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:
!NSTALLED SYSTEM IN NEIGHBORHOOD AT A LOWER ELEVATION AND HAD NO GM ISSUES
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
` M r
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 16 of 17
n .w ,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
180 WHITE MOSS DR
Property Address
-SMITH
Owner Owner's Name
information is required for MARSTONS MILLS MA 02648 8-10-15
every page. Cityfrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Assessing As-Built Cards Page 1 of 2
TOWN OF BARNSTABLE LOCATION Ly ter j .s� my,.� ne,!�C SEWAGE$ c 7—
Zyq
VILLAGE bvlet:9jov s to:ll4 ASSESSOR'S MAP&LOT 07,1—OQy
INSTALLER'S NAME&PHONE NO. 71_Dr sCoLl 771-3 616
SEPTIC TANK CAPACITY (.��60
LEACHING FACILITY-(type) I.otiG�
aO NO.OF BEDROOMS_ _PRIVATE WELL OfK BLIC WATER
BUILDER OR OWNER (- rf c 19tvt`• Loc
DATE PERMIT ISSUED: I--j u j e6 7
DATE.COMPLIANCE ISSUED: �] -G ' S 7
VARIANCE GRANTED: Yes No
http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=046143&seq=1 8/11/2015
TOWN OF BARNSTABLE
LOCATION L� l6 Wb..�c �'�04 ����� SEWAGE #
VILLAGE Wla � �s 5 ASSESSOR'S MAP & LOT ®?,l—®®q
INSTALLER'S NAME PHONE NO. 1-N.S011 -77 l-3 6t 6
SEPTIC TANK CAPACITY
�0 LEACHING FACILITY:(type) ��.G�c�� (size) �00 i,11
r
NO. OF BEDROOMS_]� _PRIVATE WELL OR{PUBLIC WATER-'
ti
-BUILDER OR OWNER C p-C h"r,,f d � Ld'S A
DATE PERMIT ISSUED: Z I u
DATE COMPLIANCE ISSUED: 7
VARIANCE GRANTED: Yes No
-�P
w4 �6
�-dL4
i'Vitlip Nu.
C6�
No PARCEL NO.: FEE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Application is hereby made for a Permit to Construct ( X.-I or Repair an Individual Sewage Disposal
System at:
or Lot o
Installer Address
Size Lot..
Dwelling—No. of Bedro
Z Other Distribution box ( ) Dosing tank ( I -
�_4 Percolation Test Results Performed by.—XV I---h"&,b"e...f*-10t&AA�UY. ..... Date.......67 1/./A�...............
Test Pit No. 1------- ....minutesperinch Ofrpth of Test Pit.................... Depth to ground /er---- -------------------
wat
The underEigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TH TL 1E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board- ofhealth.
ApplicationApproved By................................................. .................... .................. .........Z.-Ifl-157
Date
Application Disapproved
for the following reasons:................................................................................................................
................. .......................................................................................................................................................—'---`-------
~^^
�
Permit
Fx$ _m
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
,
.......OF...... s _...„ _...<...---•............................
Appliration for Bispniittl Workii Tonstrurtiott Prrmit
Application is hereby made for a Permit to Construct ( ,�) or Repair ( ) an Individual Sewage Disposal
System at
..
s rLoction- ddre or Lot o.
`�'�"*f `�!?.h! C _�• w li �„C.. ........................... .....`K._�5�. +b-_.!P_4_ #n: .......
.., Owner - Address
............................... ... 5AM '_____________________ ___..•..•............_...._...._....---•--.
a Installer Address
dType of Building Size Lot... :._l.>` ? _._Sq. feet
Dwelling—No. of Bedrooms------------_-.1............................Expansion Attic Garbage Grinder (4h )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures.........................................• •-•--•-••-••---••-•--•-•••------------------•---•- ------- ,..
Design Flow.............'`�i..'�._ .........._gallons per person per day. Total daily flow............... ��._..........__..._..gallons.
W 1�,
9 Septic Tank—Liquid capaclty_.+�_ ...gallgns Length................ Width................ Diameter---------------- Depth................
xDisposal Trencl- —No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit Nc-.-------------------- Diameter-------------------- Depth below inlet.................... Total leaching area.................sq. ft.
Z Other Distribution box ( ) Dosin tank ( )
!
'_l Percolation Test Results Performed by . '+.•_' _ r i-..�� _.�• :1_ j7---_---. Date_._.__.-.9 _L1_ _ele-•-.-_--
aTest Pit No. I........�L....minutes per inch 'epth of Test Pit.................... Depth to ground water_-_-___._-.__-____-__--.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a •- .---r------------------ - -..................-• ... . ................................................................................
O Description of Soil. ¢ - Y
x •••-------------------------•-•------•-•-••-•••---...---------•----•-•••••--•..........---•••----•••------•---------•----------•••••-••-•----•----------•-•-•--•--•-----------•------•---•----•--...._.
U Nature of Repairs or Alterations—Answer when applicable................................................................................._.._...._..._..
-•-----••--••--•-•••-•••••--•--••-----------•-------•••••-••••-•••-•••••••••---•••••................•-•-•••--•--•-•--•----------••--•--•-------•--••----•••---••--•••--•--•---•---••-•••..._............
Agreement:
The undersigned agrees to install the afor edescribed Individual Sewage Disposal System in accordance with
the provisions of TiTI E ;of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health
ate
Application Approved By.=... .�/..::..:. _.. F C.
Dat
Application Disapproved for the following reasons---------------------------------••--•-•-----------------------•----•-----------••.--------••-•---------••--•---
.............................................--••-•--------------•------•----•---.....----•-------.....----•-•--....-•-•------------------------------------------------------------------•--- -------
_. G Date
Permit No..--- _` 1 -_ Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
,1.... t� ........OF.... a .' :r� •f '•• ...................
Trrtif irate of Tompliattrr
THIS CERTIFY hatZthe Indiv ual Sewage Disposal System constructed k�) or Repaired ( )
by.. .' .� _,. ,.1
('� ..`t�j,,.� g6 6p,y� ,y Installer
at....'.'--- _W_. _.-.^'" BJ Z--...i ,f4/
_ , -•---"'"' i.l.. '' -•----.wt'? .v ..............
has been installed in accordance with the provisions of T i T'r' _5 of The State Sanitary Co,e des ribed in the
application for Disposal Works Construction Permit No-------�..._......2. ... dated......._ _Z..-1 77i............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE
SYSTEM WILL FUNCTION SATISFACTORY. .e^'DATE------------------� =--L-- .. 7 -••-----.------ Inspector.....4 .. ...ID ------
.------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........... ...:...r.................0F....... .f ti_./1. .• �.a. .< t1
r - 2 1`j .....I..................... SO
c.,
NO.. .................. FEE........ ...........�
�ot�.�#r�rtio�
Permission is hereby granted... :._... 1�.. ..�.....��.�:�..................
to Const uct (V or Repair ( ) an Individual SevcTage Disposal System /j
at �'o. :u,. t f ' :41
�2�> ....ZA;1 � rlir. n }' .._ f _taw �7.
Street
as shown on the application for Disposal.Works Construction' Permit No.....................1gted.._._,�_�`1 ....... .:�..7.....
....................................C_: %�r -----_----------
`B'oa'td of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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LEGEND
EXISTING SPOT ELEVATION 0
PROPOSED SPOT ELEVATION EM �, ��h OF A, }'
EXISTING CONTOUR ---0- --
PROPOSED CONTOUR 0 �� P"A U y� ��\A of ass
NOTE: THE LOCATION OF ANY UNDERGROUND A' �� qy i
i SEWERAGE,WELLS, OR OTHER UTILITIES SHOWN ON E v Y o R�®eN
No.,10050
THIS PLAN IS APPROXIMATE ONLY AS DETERMINED
FROM RECORDS AND/OR VERBAL INFORMATION. °��'o� G/ST 31341. ' Q
THE CONTRACTOR IS RESPONSIBLE FOR THE S/ N E � �FGI6TER�°
VERIFICATION OF THE EXISTING LOCATIONS IN tncaos`�4 � .
THE FIELD.
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N IN R AN
LEVY 8 ELDREDGE ASSOCIATES,INC. li UT
L CLIENTt&��!
ENGINEERS— LANDSCAPE ..ARCHITECTS ; JOB NO.
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PLANNERS LAND SURVEYORS . ®R. y=
899 WEST .MAIN STREET.. IV, ..�`
' .CENTERVILLE, Imo. 02632' 2�
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770rA'L ESTIMATED FLOW 330 0-4L.1DAfV SO/L TEST A/ SOIL. 7--1 ,c`� ` 011- 7Zr5 " /
N41A18- 'R 0A:- L,EACHlNS P/TS / d^gtEY. �`-ErL�!! ,e>ATE OF L SOl TEST 9///AFCo
a!/GE•Lel ACHIM6 PEAT v/T 12 �-;r Oi._�♦ 7"a�+ RFSI/LTS /T/1771VESSE,� dY T oc-
®®TTOAY 1.�9Cfl/NG PER P/T i3 $Q. FT. Z SU�Sti/v P�qCOLA71/0" RAre H
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RRS€RVE'LEACNINGAREA 2.(o S4. FT
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No 10050 LEVY & ELDREDGE ASSOCIATES. INC.
,p ,p . EL•
889 WEST MAIN STREET CENTERVILLE,MASSACHUSETTS 02632
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WALLS TO BE
ON STR I-J CTE� �., ' P—
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WI TH FR T I N SU LATI ON 3
EXiS7"ING EDOOFR WAY
TO WALK OUT
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` ELECTRICAL LEGEND
SYMBOLS DESCRIPTION
s RECESSED DOWNLIGHTS
240V OUTLET
DUPLEX RECEPTACLE
F_7F 110V INCANDESCENT BRACKET LIGHT r
110V INCANDESCENT CEILING LIGHT
DOUBLE FLOURESCENT LIGHT
$ SINGLE POLE
_ S2
DOUBLE—POLE
S3
THREE—WAY SNATCH
' $4
FOUR—WAY SWITCH
ddD
i DIMMER SWITCH
dd P2
1 20 AMP PILOT LIGHT SWITCH— 220V .
o
p
i 20 AMP PILOT LIGHT SWITCH— 110V
INCANDESCENT CHANDELIER
CEILING FAN .
® CABLE OUTLET
EAVE LIGHT(PHOTO—ELECTRIC SWITCH)
ELECTRICAL PANEL
OUTLET c
b TELEPHONE ETENSION
O SMOKE DETECTOR
O ELECTRIC MOTOR
NUMBER=HP
lk
dF - PORCH i PORCH
I
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PROPOSED'EXTEN110N MARCH 2O17 FLOOR PLAN & FRONT ELEVAIfOEd
PART OF 180 WHITE MOSS DR MARSTONS MILLS MA
KEVIN ""sans 845, l-1,0K!:D By
AA OFSTEPHEN
6}FS�c
5
uGOAN
STRUCTURAL
OUTLINE SPECIFICATIONS FOUNDATIONS M13WR A 9Nu.462 Q
GENERAL STRUCTURAL LUMBER STUD BEAFRQJG WALLS LVL BE AST
F-I:F-Vri VATS TO LINES,LID GRADES REQUIRED 70 PROPERLYINS7ALL IT POST A
FOUNDATIONS ON UNDISTURBED SOIL OR CONTROL.)'.)STRUCIL'R7L BACKFILL SI:1:.CODE CONFORMANCE _` em co
G-I:ALL.tUTJt1ALi,Il'ORKIUNSHLP AND DETAILS SHALL CDVFOR7l7'D THf:a7'H �� �
EDITION OF THE MASSACHUSETTS.STATE BLTIDINGCODE,IBC-1109,AND APPROVED BY THE PROJECT ARCHITECT.REVIOVE ALL SILT}-TOPSOIL OR SLI.I:.NiAT7ONAL FORESTPRo DL'C7SASS()CL4TI,)N"N.i77(),4ALDrSIGNSPF-CIFICATION .� �
ASCE7To 05 AND
TPRoJEC/IE RI:FEREWE'DSTIND:ARDSINCLUDED Tf1ERh'IN TII.ATARPAPPLI(Afth OBALLBONABLEIAPI.AL FROM
NG UNDER SLABS
ETE O'NGRADE.ALLEYCAI'ATIONS FOR WOOD CONSTRUCTION'INCLUDING SUPPLEMENT LBL AT �® `Ec
SUL2 AMERICAN'1NSDIUTE OF TIIIRER(T)" RUC77ON"TIMBER CONSTRUCTION ���OR WALL (J ® �G co E
G-2:THE CONTRACTOR SHALL FAMILIARIZE RMISE1F WITH THE CON7RALT F-2:ElTER1OA WALL FOOTINGS ARE TO BE PLACED ONAPPROVED SOIL,ATA STANDARDS*-,A/TCItIR Ci m w
DRAWING,S..AN7'DISLREP,INCTESSIIALI.BEBROUGHTTOTFlEAMv7'IONOP7'I1E' .MINIMUM DEPTH OF 4 F1'.BELOW THE LOWEST ADJAC'F.NTG'ROUNDSURFAC'F 2- OLIASf'1 BLOCKS �®
PROJECT ENGINEER BEFORE PROCEEDING WITH 7'71E AFFECTED WORK AN)' EXPOSED TO FREEZING.AN}'ADJUSTIfENTOP ELEVATIONS()FFOO7'INGS DUE T(1 SI.13:L'.S DF.PARTA7ENTOF COMAIERCF.-PS20 FOR LUAIBER AT ALL POSTS FROM
FIELD
CONDITIONS MUST'LM E THE EVPRESSED APPROVAL OF THE PRO ECT ® •'I
l!dR/.iT10N5 OR BLOUTITL'71O:VS OF)I.d TERINS OR DETAILS FROM THOSE J - ABOVE TO STS Fi RO ®®
1N'DIGTE'D ON THE'DRAIVT,VGS AIA}'BF.'.VIADE'ONL7'W7TH PRIOR.APPFOVAL OF'THF. ARCHITECT.ESTIMATED ELEVATION OFBOTTOMINDICATED THUS(0'-0"1. Sf.1.4:USDEPARTIIF_\TOFCO.NAIERCE�PS166FORSOFTI¢'OODPLIWOOD.
BELOW ®A NN
PROJIXTENGIVEER ® �.
F-3:SOLI.BEARING CAPACITY-NATURAL UNDISTURBED,SOIL OR CONTROLLED SL-1.5:A.iIEBIrANA60ODPRESERt'UilV.Mn7E'.ST-ISTAND,IRI)S.
G3:NO AFAI.V FRAAfIN'G(tR STRL'(71'RAI.;NFVRF.RS ARF.7'O BF.M011IFIFD.AF.TF.RF.0 OR STRUCTURAL BACKFILL HAVING AN ALLOWABLE BEARING PRESSURE OF.Wkl C/5 w ®�
CUT IV7THOLT DIE APPROVAL OF THE PROJEI.T EVGI,VLEK POUNDS PER SQ.IT SL-2A..MATERIALS
G4:PORE\'A(.TLOCATION OF FLOOR&RDOFOPENINGS,SEE ARCHITE(7UR11, F-4:BACKFIT.I.TFIF.EX(:AV'A77ONIi'/7'/1APPROI'F.DGRA.NUI.,IRMATF,RI,11.Pf.ACEDIN6 SL-1.I:SOLID LUMBER(19 PER-(:F..NTAIAXIML'Af MOISTURE C'O,V7'EV7) HANGERMECII4\'ICAO,ELECTRICAL AND SHOP DRAWINGS IN.LAYERS,AND COAIPACTEDT095%DENSITI'A7'OP77,%fUki 3i 11STURECONTENT,
AS DEFINED BYASn/DISS1,METHOD D AFTER BOTTOM OFEXCAVATION HAS BEEN SL-21.I:STUDS-2\'4,2X4,SPRUCEPIV'hRR,STUDGRADE: LVL BEAM DETAIL
G.S:THE.CONTRACTOR SHALL.BF,RESPONSIBLE FOR AL.IOBSAFFTYDURING APPROVED BI'THE PROJECTARCHITECT L.1 S .12 FR.AMING:SPRUCE'PINE FIR.NO.2-21NCHFS THICK AND WIDER
CONSTRUCTION INCLUDING BUT NOT LIMITED TO SHEMING,SHORING AND GUYING S1.21.2.1:RISE DESIGN VALUES-Fb=8'S PSI(Io(W)PSI REPETITIVE),Fc=135 PSI,
STRUCTURES,BARRIERSA.VD SIGNAGE F-5:BACKFILL AGAINST FOUNDATION FROST WALLS TO BE DONE EQUALLY A T EACH SIDE E=Mx,Kit Z
OF WALL UNLESS WALL IS BRACED ON OPPOS17ESIDE OF FILL AGAN9TMOIT-WENT I JOISTS o
S(LTIIFRN`INEV0731THEFOLLOMPIC,fNIJf 0 DEu4'A1TEUES'ENEEALL:AfBEROF INTERIOR STUD BEARING WALL
G-6:All STRUC77:RAL.DRAWINGS SHALL BE USED IN CONJUNCTION WITH THE w
AR(:N11'E(7L'RilMECHA,\'1G),ELELTRICAI.AN'll SHONORI N7NG5AND
SPECIFICATIONS CONCRETE WORK 5L11:,BASE DESIGN VALUES:T,=2Ri PSI,EI=16i0 PSI,F.=1,9 ,00'PSI. U .�
CODE CO.NFORLINCE (/)
SL-23:PARALLIA(STRAND I.L9IBER(P51)-GLUE LAA//NA TED LL'AfBER BTRAN'DS I JOISTS AND POSTS 3/4S3/4"CH,IA �714-1
ULK FULL HEIGHT L'-1
G-:IIVIFS.i OTFIFRIC'/SEI:VDICA7ED,)FLAILS SHOIVN O:\'ANl'DR1l[7NGARE TO BE C-I.I:COAfPLYVVTTH THE I.AT-FRECOALiffNDAT1O\'S OF THE F(ILLOR7NC STANDARDS; WITH THE'FOLLO}G7:\'Gb1INAIUM DESIGN VALUIii JOINT p gyp)
CONSIDERED TYPICAL FOP AL-SIMILAR CONDITIONS. C-I?:ACI 361-SPECIFICATIONS FOR SIRUCTLRA7.CONCRETE FOR BUILDINGS SL 2.3.1:BASE DESIGN 7ALL:ES IM=290 PSI,Fb=2900 PSI,E=180(KII.
EPIERIOR
GIJ AC..1 i15-DETWUN'G REINFORCINGSTEEL WALL FACE
G-&THE GENERAL CONTRACTOR SHALL BE RESPONSIBLE FOR ALL COMM-
5L2.4:PRESSURE 77(EITED OR'1f'OLN,L\'1ZED'PSL BELNS FLI VErILCOWi1BLE57RFSSES
C1.5 A 33IRCI F BUILDING
MEi'\'S.1ffTHODS,CO-ORUINATfO.V OF OTHER TRADES A1'D TECHNIQUES TO ,ADJUSTED FORSER}7CE LEVEL L Y OR J
PRODUCE'A SOUNDAND QUALIT)BUILDING.ALLDLNENSION'S,E'LE'I'ATION:SAND CIS:ACI7IA BUILON'G CODF.REQL'IRF.AffN75 FOR 67RUCTURAI.CONCRETE _
CO,\DITICINS MUST BE VERIFIED BY THE GENERAL CONTRACTOR OR RESPONSIBLEPRESPONSIBLESL-25:BOLTS,NUTS&WASHERS-ASTAI-A30 _
TRADES. C.'.,NATERLILS SL26- C(NAILS- ARLON WIRE,EXCEPT BARBED NARSATPLYIVOODSHEATHN'G. Q
C27.1:CONCRETE; APPROVED READY AIIXEO CONCRETE HAVING AN L'L77MATE GALLA.VIZED N;,W,ITEVPOSEDFRL}BN'G. p Fay-da
COMPRESSIVESTRENG7'71OFMOPS1AT28DA1S.SLUMPS-SIVCHES.
DESIGN LOADS S1:1.'..LfETiU.CONVECrORS-APPROVE_MITE%BOFPROPERII LIE&GAUCEASSHOIVVOh' #b Q24"ac.DIG75
C'-2./2 CONCRETE; APPROVED READY AIIX'FD CONCRETE HAVING AN ULTIMATE O
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