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HomeMy WebLinkAbout0037 CINDERELLA TERRACE - Health 37 CINDERELLA TERRACE MARSTONS MILLS _ A= 047 - 099 / Commonwealth of Massachusetts ,? Title 5 Official Inspection Form i; Subsurface Sewage Disposal System Form-Not for Voluntary Assessments A 37 CINDERELLA TERRACE Property Address GEORGE BEAULIEU -C/O 8 SETTLERS LANE DENNIS MA 02660 e . Owner Owner's Name information is required for every MARSTONS MILLS ✓ MA 02648 2/28/2020 page. City/Town State . Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information tilling out forms (� (LfN 08 on the computer, use only the tab Christopher Maki key to move your Name of Inspector cursor-do not Cape Cod Septic Services use the return key. Company Name 350 Main St. Company Address W Yarmouth MA 02673 City/Town State Zip Code . . n 508-775-2825 SI-14423 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 3/5/2020 nspector'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 DER The original form should be sent to the system owner and copies sent to . the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form � a Subsurface Sewage Disposal System Form-Not for Voluntary.Assessments 37 CINDERELLA TERRACE Property Address GEORGE BEAULIEU -C/O 8 SETTLERS LANE DENNIS MA 02660 Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 2/28/2020' 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: ® 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 IS IN WORKING CONDITION 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes"; "no"or"not determined" (Y, N, ND) for the following statements:If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and,if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y . . ❑ N ❑ ND (Explain below):. l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments V 37 CINDERELLA TERRACE Property Address GEORGE BEAULIEU-C/O 8 SETTLERS LANE DENNIS MA 02660 Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 2/28/2020 .page: . Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (coat.): ❑ 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): t 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 15.30.3(1)(b)that the system is not functioning in a manner which will protect public health,. safety and the environment: t5insp.cloc-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 �o} Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 CINDERELLA TERRACE Property Address GEORGE BEAULIEU C/O 8 SETTLERS LANE DENNIS MA 02660 Owner Owner's Name information is required for every MARSTONS MILLS MA 02648" 2/28/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless.the Board of Health (and Public Water Supplier, if any) determines that the system Is functioning in a.manner that protects the public health, safety and environment:. ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has aseptic 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, CIO gged 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•.fey.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts l? Title 5 Official Inspection Form Subsurface Sewage Disposal System Form =Not for Voluntary Assessments 37 CINDERELLA TERRACE Property Address GEORGE BEAULIEU -C/O 8 SETTLERS LANE DENNIS MA 02660 Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 2/28/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to Ali Systems: (cont.) Yes No 0 ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged. SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than '/Z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the 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. jo 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. ❑ ED Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] - ❑ ® . The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems;you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18. Commonwealth of Massachusetts Title 5 Official, Inspection Form M Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 CINDERELLA TERRACE w Property Address GEORGE BEAULIEU-C/O 8 SETTLERS LANE DENNIS MA 02660 Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 2/28/2020 page. City/Town 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 3.10 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? ❑ Z 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 of issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 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 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �o 37 CINDERELLA TERRACE Property Address GEORGE BEAULIEU-C/O 8 SETTLERS LANE DENNIS MA 02660 Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 .2/28/2020 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design)`: 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes Z No If-yes,discharges to: Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑.Yes ® No Laundry system inspected? ® Yes ❑ No Seasonaluse?` ❑ Yes ® No PD Water meter readings, if available last 2 ears usage d 18- 14 GP ( Y 9 (gp ))� '18- 142 GFD Detail: Sump pump? ❑ Yes ®- No Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 'R 10 Subsurface Sewage Disposal System.Form -Not for Voluntary Assessments 37 CINDERELLA TERRACE Property Address . GEORGE BEAULIEU -C/O 8 SETTLERS LANE DENNIS MA 02660 Owner Owner's Name information is required for eve. ry MARSTONS MILLS MA 02648 2/28/2020 page., City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow.(based on 310 CM 15.203): Gauons 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: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: l5insp.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 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments l 37 CINDERELLA TERRACE Property Address GEORGE BEAULIEU -C/O 8 SETTLERS LANE DENNIS MA 02660 Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 2/28/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool Privy ❑! Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 11-13-1978 PER PERMIT#77-43 ON FILE AT BOH Were sewage odors detected when arriving at the site? ❑. Yes ® No 5. Building Sewer(locate on site plan): 11 Depth below grade: 18 feet Material of construction: ®cast iron ❑40 PVC ❑ other(explain): — - Distance from private water supply well.or suction line: 10+ feet Comments (on condition.of joints, venting, evidence of leakage, etc.): LINE CHECKED WITH SEWER CAMERA AND WAS FOUND TO BE CLEAN AND PROPERLY PITCHED t5insp.doc•rev.7./26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts pi TitleTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 CINDERELLA TERRACE Property Address GEORGE BEAULIEU -C/O 8 SETTLERS LANE DENNIS MA 02660 Owner Owner's Name information is required for every MARSTONS MILLS MA .02648 2/28/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 1211 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 GALLON Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle 1„ 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 How were dimensions determined? ESTIMATED Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1000 GALLON TANK IN GOOD CONDITION. TEES IN PACE AND CLEAN. TANK AT NORMAL OPERATING LEVEL. COVERS 11 BELOW GRADE t5lnsp.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 Subsurface Sewage Disposal System. Form - Not for Voluntary Assessments 37 CINDERELLA TERRACE Property Address GEORGE BEAULIEU -C/O 8 SETTLERS LANE DENNIS MA 02660 Owner Owner's Name information is. required for every MARSTONS MILLS MA 02648 2/28/2020 page. City/Town State Zip Code .Date of Inspection D. System Information (cont.) . 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal, ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: .Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must.be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete . . ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 37 CINDERELLA TERR ACE Property Address GEORGE BEAULIEU=C/O 8 SETTLERS LANE DENNIS MA 02660 Owner Owner's Name information i every required for every MARSTONS MILLS MA 02648 2/28/2020 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 EVEN 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.): DISTRIBUTION BOX LEVEL AND WATERTIGHT t5insp.doc•rev.7/26/2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 CINDERELLA TERRACE Property Address. GEORGE BEAULIEU -C/O 8 SETTLERS LANE DENNIS MA 02660 Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 2/28/2020 page. Cityrrown State Zip Code Date of Inspection - D. System Information (cont.) 10. Pum;p Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ Noy Alarms in working order: ❑ Yes ❑ No` Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarm r s are no in working order,t o system is n P p 9 a conditional ass. Y. p .11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type � leaching pits number: 1 -5X6 W/STONE ❑ leaching chambers number: ❑ 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 37 CINDERELLA TERRACE Property Address GEORGE BEAULIEU -C/O 8 SETTLERS LANE DENNIS MA 02660 Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 2/28/2020 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.): 1000 GALLON 5X6 PIT WITH STONE FOUND IN OPERATING CONDITION WITH NO VISIBLE STAINING. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth-top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): f t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of.Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 CINDERELLA TERRACE V Property Address GEORGE BEAULIEU -C/O 8 SETTLERS LANE DENNIS MA 02660 Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 2/28/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of.construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding; condition of vegetation, etc.): l5insp.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 o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 37 CINDERELLA TERRACE Property Address GEORGE BEAULIEU -C/O 8 SETTLERS LANE DENNIS MA 02660 Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 2/28/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below drawing attached separately t5insp.doc-rev.7/26/201.8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage.Disposal System Form -Not for Voluntary Assessments 37 CINDERELLA TERRACE Property Address GEORGE BEAULIEU C/O 8 SETTLERS LANE DENNIS MA 02660 Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 2/28/2020 page. City/Town 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: 1 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: DISPOSAL WORKS PERMIT 77-43 FROM 1978 ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database explain: You must describe how you established the high ground water elevation: APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT. DESCRIPTION OF SOIL STATES NO GROUNDWATER ENCOUNTERED TO 12' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doo-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form to Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 37 CINDERELLA TERRACE Property Address GEORGE BEAULIEU -C/O 8 SETTLERS LANE DENNIS MA 02660 Owner Owner's Name . information is required for every MARSTONS MILLS MA 02648 2/28/2020 page. City/Town 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 .—,---ss �� re 19 �o s � 6 �o r� .�_ _ B L0- UTCATT"', SEWAGE PERMIT NO. d , ,"', T e rv, t ? 7 -3 VIL I AGE _ I N S T A LLER'S NAME & ADDRESS /arc /, eo 11 sT B U I L D E R OR OWNER p � � � 1 � DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED ��_� _21 . � �� �e �� �© s� G d to �r No..........1` �.<. Flan.... -s....�..�...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........... . ...Town.,-,.........O F....BAi ns tab l.s...---.................................................... Appliration -fur Uiipnsal Works Cnotu4rurtion Pumit Application is hereby'made for a Permit to Construct (x ) or Repair ( ) an Individual Sewage Disposal System at: Lot_ k7__Cinderel. a..Te ,.. rs Qr> ..Mills_ AABaeB.Sars...mp.14.7-...Lot.-.99)--------------•----•-•--- Location-Address or Lot No. Cind el_l_ B lders, k! .. .--BQ 9 $$--Sax�drai�h, ' Q2�6 ---------------------------- wner .� . � Address � Installer Address d Type of Building Size Lot...22.27 .......... feet U Dwelling o. of Bedrooms---3_--------------------------------------Expansion Attic ( ) Garbage Grinder aOther—Type of Building ............................ No. of persons_..._-__---_________--__-._- Showers ( ) — Cafeteria ( ) a' Other fixtures ---------------- W Design Flow................:�.....1�........_........ alions per person per day. Total daily flow.........�_____---_____-_---.-.---.-..gallons. WSeptic Ta11 -�-Liquid capacitya tllons Length---------------- Width..._............ Diameter---------------- Depth.....____-.----- x Disposal Trench—No. .................... Width�............... _ tal Length _____._. r... Total leaching area....................sq. ft. Seepage Pit No._-_-.-_---/....... Diameter../ __ e ............. Total leachingare' ..._.._____.._sq. it. Z Other Distribution box ( ) Dosing tan ) - /a X 7— 7 � ~' Percolation Test Results Performed by �.-. _-_._•___________________ Date--__---_-_---._.__-_---.--_--_.---_.__.. Test Pit No. 1----------------minutes per inch Depth of ' st Pit-------------------- Depth to ground water...----_.--...._--.._-.. f= Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water--.--._.--_.__-.._--.... Q+' --------------1------ � --- -- Descri Description of Soil C - `� - - �� ' l2 � x m W -- W ___________________________________________________________________________________________________•--.---.----__-----------_--_.---_-___-----___----__---.-____.--.--.__.--..--_---__-_-_-_________--. UNature of Repairs or Alterations—Answer when applicable----------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------- ------------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b issued by the board of hem t , Signed. ....... ' ---- ------------------------------ Date Application Approved By------�7 �1�'�. � '$ _'_ _`.7.t ---------- Application Disapproved for the following reasons:........... ..-------•--••-----•--------•---------•------•--•-•-•----•-------------•-----•----•••------•-••--•-..........--------•------•--......--------------------........---•---•---••---------------•--•------- Date PermitNo......................................................... Issued........................................................ Date No........ ----•-•• F�$....��....`........_ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............. . ..Towwr............OF....Bax;no able...... ....................................._.... A;iV irtttiun -fur R_qpniitti Works Tomitrnrtinn Vrrn it Application is hereby`made for a Permit to Construct (8 ) or Repair ( ) an Individual Sewage Disposal System at: Lot.17_Ciadexella.T,erracP_,..&x8tans_XiUS_ ...(Aeseleoxs-._Haa_147:_'-kt.199)-----•----•-•------•-•--. Location-Address or Lot No. Ciad ell ca ilders,, n ........................................ ...Bow 9 8, Sa si is ,.. .� 56 ............................ ner i Address W ... .......................... Installer Address Q Type of Building Size Lot___ZZa273----------S f et U Dwelling go. of Bedrooms___3......................................Expansion Attic ( ) Garbage Grinder (Nil Gaa, Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) dOther fixtures ------------------------------------------------------------------------------------- ----------------------- W Design Flow.................;�:_:. .......___..�_._"1llons per person per day. Total daily flow__........__..__________.____.........gallons. WSeptic Tack Liquid capacity/� tllons Length................ Width._____._....._. Diameter------.._______ Deptli.________.__... x Disposal Trench—No.•___________________ Width------------- ota gth --- Total leaching area--------------------sq. ft. Seepage Pit No.____......�_._.___ Diameter__ � 1J_. e`p letl_/__�...rr(..._...... Total leachin ctr .................sq. it. z Other Distribution box ( ) Dosing tan] ) /- X ?- 7 -7 `-' Percolation Test Results Performed`by.._.Ci� Glvr-.-_-_r a�- 7-- a - ------------------------ Date------...---------------------------.... Test Pit No. 1................minutes per inch Depth of "I st Pit-------------------- Depth to ground water.........------......... (s Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water._.__.__..__---______--- -------------- > -------=----------------------------- Description of Soil----------0--- S ✓I �� �L=....................... ^� x ------------------------ -- - ------------------•-•-- ---------------------------------------------------------------------------------------------------------------------- -------------------------- V Nature of Repairs or Alterations—Answer when applicable_---------------_................._.....___--------------------------------------------------- ---------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI 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. Si ed............. - t Application Approved By...... --�-f'}-�---- j --•`�- -----77 �-��------------ Date-----•-•--•--- Application Disapproved for the following reasons__________________________________________ --------------------------------------------------------------------------------------------•------......------------------------------------ ---------------------------------------------------------- Date PermitNo......................................................... Issued........................................................ Date. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....�. "' 'j.........OF................! .Gc--z.�` __ ................................................... �Prfi$irate of T"lomplianrr G'A T IS CE1- IFY, Tha e f idual Sewage Disposal System constructed ( ) or Repaired ( ) _. ._.__ � Installer has been installed-in accordance with the provisions of Ai I of The State Sanitary C de as described in the application for Disposal Works Construction Permit No.___. - ....._.. ............ dated_..__j.....I/_.._.7.7.'............... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........... - .`_. .................................... Inspector------- --- THE COMMONWEALTH OF MASSACHUSETTS 1 BOARD OF HEALTH ..----------------------------------- -------- OF.............� �''���" No------- ...... FEE........................ 1RriVn,ittt nr nnfrn it/ rrmtf Permission ts. her y granted....-.Ar ...... --------G`-----� -__ =_l___ to Construc�( , or Rep ' ( )An�Ind!(Ifual Se e Disposal Sysi , L- - G _ • -- - ' Street / as shown on the application for Disposal Works Construction Per No.- _ ��Dr - �- `--�-` DATE Board of Health ��: -�--------------------------•--•••---•--•--• FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS 44. a6ze,=i � ' ..� •� ,� ,Y .. ..t ice' : . F�- �=�".. - 3/3/2020 ShowAsbui It(1700x 2800) LO CAT I" II //// T SEWAGE PERMIT NO; 4 -7 \-1 h a e r!'�A/.4 I YrC(0 17 3 VILLAGE �llar_s%� �a �nr.%/s o4J7-a99 INSTALLER'S NAME A ADDRESS BUILDER OR OWNER A s DATE PERMIT ISSUED DATE COMPLIANCE ISSUED M/ https:/fitsq Idb.tovm.barnstable.ma.us:8431/Home/ShowAsbuilt?mp=047099&sq=1 1/1 l Yam` T -- ---/__�J--- -- ----------No � Fee • BOARD OF HEALTH TOWN OF BARNSTABLE application_*fl eif Con5tructionAertnit Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair (N)an individual Well at: r Ag Location — Address Assessors Map and Parcel Owner Address Installer — Driller Address �— Type of Building Dwelling-----_— - ----_---- -- Other - Type of Building-------------------------------- No. of Type of Well__��— !�� -- -;— --- -- --- Capacity------------------------ ----------- Purpose of Well Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Heelthto Well Protection Regulation — The undersigned further agrees not to place the well in operation until ate of o plia a has been issued by the Board of Health. Signedell----4--- - - ----__---_ - —__ . 7daXte/, Application Approved By----- - - - — -- ate Application Disapproved for the following reasons:--- - --- --------- - date Permit No. — - _— - -- Issued -- date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate ®f Compliance THIS IS TO C Rj�F�Y(, Th th Individual Well Constructed ( ), Altered ( ), or Repaired ( ) by---- 1�,V aV V ----------------------t------------ - V, at ---- _- Ins a � � --- --ems--- J has been installed in accordance with the provisions of the Town of Barnstable Bold of Health Private Well Protection Regulation as described in the application for Well Construction Permit No_ 3—�A��Dated —— ---- - THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE—------------- —- - --— ----- — - Inspector---------- -- ----__ —--_- --- -- ;r No. Fee— ;-Z ------------ BOARD OF HEALTH TOWN OF BARNSTABLE 0ppiication-*rVell Con0ruct ion Permit Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair (k)an individual Well at: Location — Address Assessors Map and Parcel _ i /_ s __ '� l1�zJ — ---------- ------—----------------------—------------ Owner Address - ------ ------------------------------------ ------------------------------------------------------ Installer — Driller / Address Type of Building y Dwelling--------------------------------------------------------------- Other - Type of Building ------- No. of Persons--------------------------------- Type of Well--''2 -P1�� ------------------------------- Capacity--------------------------------------- -------------------------------- ------ Purpose of Well-=)(5 rs ice° - -- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Ce�icate of Co pliance has been issued by the Board of Health. Signed- -(�_-1-�C -- date Application Approved By--- - - T ate Application Disapproved for the following reasons:------------------ -,-------_----------____---------_ ------------------------------------------------------------------------_-_-_-_-______--------------------------________--_________,_-_-___-__---___ —A date Permit No.I't -- ----------------------- Issued-------------------------------------------- date D e, -- BOARD OF HEALTH TOWN OF BARNSTABLE Certificate (Of f Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( ) r bY----.. - P� �------------------ = - ----------- ------------------------------v / j Installer- at ll�l ,/) f I -- L- - 1 r l// �[%_� ---�_I_ 11/! has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit N -� �41)ated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS'A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE--------------------------------------------- ------------------- Inspector-------------------------------------------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Yell Con5tructionvermit z' No.l'-�>---(�-=�--` � Fee-- J._----- � O Permission is hereby granted-- /- r �--- to Construct ( ), Alter ( ), or Repair (%) an Individual Well at: Street as shown on the application for a Well Construction Permit /.P �T 3 -- -2 - Dated ---------------------=------- Board of Health DATE - -?' r'� �--------------------------------------------