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HomeMy WebLinkAbout0076 FIELD ROAD - Health 76 Field Road Marstons Mills <� A = 150 055 y _�_w _- - _- - -- �. ��� ��. n '1� �� � u ---��-�- 1 i �� � ' i r - Commonwealth of Massachusetts �`�� ���� - Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 76 Field Road , Property Address h+w+ Jennifer Kruczek �= Owner Owner's Name information is N' required for every Marstons Mills Ma 02648 6-20-2018 page. City/Town State Zip Code Date of.'Inspection iw,ol I,a„t Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Brett Hickey use the return Name of Inspector key. p B&B Excavation ICI Company Name 374 Route 130 Company Address Sandwich Ma 02563 Cityrrown State Zip Code (508)477-0653 S113747 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 _ 6-20-2018 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 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 P Y the same or different conditions.of use. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 76 Field Road Property Address Jennifer Kruczek Owner Owner's Name information is required for every Marstons Mills Ma 02648 6-20-2018 page. Citylrown 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: The system was in working order at the time of inspection. 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 w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 76 Field Road Property Address Jennifer Kruczek Owner Owner's Name information is required for every Marstons Mills Ma 02648 6-20-2018 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will ass 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 -- I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 76 Field Road Property Address Jennifer Kruczek Owner Owner's Name information is required for every Marstons Mills Ma 02648 6-20-2018 . page. Citylrown 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 %day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 II Commonwealth of Massachusetts i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 76 Field Road Property Address Jennifer Kruczek Owner Owner's Name information is Marstons Mills Ma 02648 6-20-2018 required for every 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 76 Field Road Property Address Jennifer Kruczek Owner Owner's Name information is Marstons Mills Ma 02648 6-20-2018 required for every page. CityrTown 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) _3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 357/GPD t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 76 Field Road Property Address Jennifer Kruczek Owner Owner's Name information is required for every Marstons Mills Ma 02648 6-20-2018 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): See below Detail: 2016-22,000gallons 2017-23,000gallons Sump pump? ® Yes ❑ No Last date of occupancy: CurrentDate Commercial/Industrial Flow Conditions: Type of Establishment: NA 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 Ma ssachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 76 Field Road Property Address Jennifer Kruczek Owner Owners Name information is required for every Marstons Mills Ma 02648 6-20-2018 page. Cityrrown 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: Owner- last pumped 5/2017 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 L Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M ,•''y 76 Field Road Property Address Jennifer Kruczek Owner Owner's Name information is Marstons Mills Ma 02648 6-20-2018 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2004 per plans Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3' feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2'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: 1000gallons Sludge depth: 4„ t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M ,•''V 76 Field Road Property Address Jennifer Kruczek Owner Owner's Name .information is required for every Marstons Mills Ma 02648 6-20-2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 32 Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was in working order at time of inspection with liquid level equal to outlet invert. Tank is not in need of pumping at this time but should be pumped every two years for maintenance. Grease Trap (locate on site plan): Depth below grade: NA 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 I Commonwealth of Massachusetts Title 5 ffi i O cal Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 76 Field Road Property Address Jennifer Kruczek Owner Owners Name information is required for every Marstons Mills Ma 02648 6-20-2018 page. Cityrrown 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: NA 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 76 Field Road Property Address Jennifer Kruczek Owner Owner's Name information is required for every Marstons Mills Ma 02648 6-20-2018 page. City/Town 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 11 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.): D-box is in working order at time of inspection with liquid level equal to outlet invert. D-box did not show signs of back up. 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.): NA * 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•3/13 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 M , 76 Field Road h Property Address Jennifer Kruczek Owner Owner's Name information is required for every Marstons Mills Ma 02648 6-20-2018 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® Ieaching chambers number: (2) 500 gallon ❑ 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.): Leaching was in working order at time of inspection with no sign of hydraulic failure. Leaching had 1" of standing water when viewed with no higher staining. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA 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 i r Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 76 Field Road Property Address Jennifer Kruczek Owner Owner's Name information is required for every Marstons Mills Ma 02648 6-20-2018 page. CityrFown 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: NA 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 M 76 Field Road Property Address Jennifer Kruczek Owner Owner's Name information is required for every Marstons Mills Ma 02648 6-20-2018 page. Cityrrown 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 C 0 D-box B A 3 2 (2)500 gallon chambers 0 1000 gallons Al-2T 131-22' B2-25' C2-35' 133-28' C3-3W l5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 76 Field Road Property Address Jennifer Kruczek Owner Owner's Name information fo is Marstons Mills Ma 02648 6-20-2018 required for every page. Cityrrown 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: No GW @ 162" 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: 4-20-04 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: Plan on file with BOH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage iDisposal System-Page 16 of 17 L - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 76 Field Road Property Address Jennifer Kruczek Owner Owner's Name information is Marstons Mills Ma 02648 6-20-2018 required for every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked E Inspection Summary D (System Failure Criteria Applicable to All Systems) completed E System Information— Estimated depth to high groundwater E 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 a• Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 76FIELD RD Property Address DUNNE Owner Owner's Name information is MARSTONS MILLS required for MA 3/14/09 every page. Citylrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out �) 2 forms on the computer,use 1. Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do not use the return Name of Inspector key. DOUGLAS A BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE MA 02632 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 *to 3/14/09 tu Date nspector 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,b00 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. Lb I � / 01 Title V Inspection Form.doc•0&06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments '< 76FIELD RD Property Address DUNNE Owner Owner's Name information is required MARSTONS MILLS MA re wired for 3/14/09 every page. Cltyfrown 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: ® 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: TANK NEEDS PUMPING CHAMBERS ARE EMPTY AT THIS TIME B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the❑for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: Obser vation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed Title V Inspection Forrn.doc•08l06 Title 5 Official Inspection Form:Subsurface Sewage Disp osal posal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments �( 76FIELD RD Property Address DUNNE Owner Owner's Name information is MARSTONS MILLS MA required for 3/14/09 every page. Clty/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: 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 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. I . ❑ 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. Title V Inspection Form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 76FIELD RD Property Address DUNNE Owner Owner's Name information is MARSTONS MILLS MA required for 3/14/09 every page. Crtyfrown State Zip Code Date of Inspection B. Certification (Cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 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 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. Tale V Inspection Form.doc•08106 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 76FIELD RD Property Address DUNNE Owner Owner's Name information is required MILLS MA re wired for 3114/09 eve ry page.e. C /T own State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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. Title V Inspection Form.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 76FIELD RD Property Address DUNNE Owner Owner's Name information is MARSTONS MILLS required for MA 3/14/09 every page. &I /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? E ❑ 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)] Title V Inspection Form.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 76FIELD RD Property Address DUNNE Owner Owner's Name information is MARSTONS MILLS MA required for 3/14/09 every page. Cityfrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms 3 3 (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): NA Sump pump? ❑ Yes ❑ No Last date of occupancy: CURRENT 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: Last date of occupancy/use: Date Other(describe): Title V Inspection Form.doc•0&06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 76FIELD RD Property Address DUNNE Owner Owner's Name required for is MARSTONS MILLS MA required for every page. City/Town Date/09 State Zip Code Date of Inspection D. System Information (cunt.) 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: INSTALLED IN APRIL OF 2004 Were sewage odors detected when arriving at the site? ❑ Yes ® No Title V Inspection Form.doc•0&06 Title 5 Official Inspection Forth:Subsurface Sewage Disposal posal System•Page 8 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 76FIELD RD Property Address DUNNE Owner Owner's Name information is MARSTONS MILLS 3/14/09 required for MA every page. Cityrr Nn State Zip Code Date of inspection D. System Information (cont.) 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 El 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: THICK NEEDS PUMPING Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 3" 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? Title V Inspection Form.doc•06I06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 76FIElLD RD Property Address DUNNE Owner Owner's Name information is required for MARSTONS MILLS MA 3/14/09 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.): TANK NEEDS PUMPING 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.): 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): Tide V Inspection Form.doc•08106 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments .'� 76FIELD RD Property Address DUNNE Owner Owner's Name information is MARSTONS MILLS MA required for 3/14/09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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 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.): BOX LEVEL NO LEAKAGE Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: Yes No Title V Inspection Form.doc•08/OS Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 76FIELD RD Property Address DUNNE Owner Owner's Name information is MARSTONS MILLS required for MA 3114/09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ 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.): 2 500 GALLON CHAMBERS 13X25X2 CHAMBERS ARE ALMOST EMPTY AT THIS TIME STAIN LINE AT ABOUT 3" Title V Inspection Form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments '< 76FIELD RD Property Address DUNNE Owner Owner's Name information is MARSTONS MILLS required for MA 3/14/09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): 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.): Title V Inspection Form.doc•08/06 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` 76FIELD RD Property Address DUNNE Owner Owner's Name information is MARSTONS MILLS required for MA 3/14/09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. ck 2� y0 1z- 2. Title V Inspection Form.doc•08106 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments GM 76FIELD RD Property Address DUNNE Owner Owner's Name information is MARSTONS MILLS MA required for 3/14/09 every 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 ground water: GREATER THAN 8.5 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: 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: OFF PLAN AT B.O.H BY ENGINEERING WORKS DATED4/07/04 Title V Inspection Form,doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 I Fee / ~ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer�v Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,, MASSACHUSETTS ZIpprtcation for 30igoof 6potem Construction Permit Application for a Permit to Construct( . )Repair(1'�)Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. 7G-70 RD, Owner's Name,Address and Tel.No. Pb&XtF HIWr Assessor's Map/Parcel �'�® � A Al;115 � �� Installer's Name,Address,and Tel.No. �j ,;� ' Designer's Name,Address and Tel.No. Type of Building: ' Dwelling No.of Bedrooms t Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 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 Zoealt men ode and not to place the system in operation until a Certifi- cate of Compliance has been issued b Bo h. Signed Date `U Application Approved by Date fJ Application Disapproved for the following reasons Permit No. BOO y-I L D Date Issued --------------------------------------- s y�„ ....... !::+w».e-.:k,��^,.,.?e.y,;y,�.y,.: .:,,.,, -.:.,-v....wAw':.L..,.. .�,,.>.a..y,.._...- ,.� -5,--�,-.,.,.....a ..�..-ae.'v.-..r 6. -- d ._ ..::may,. ,. +. -•�,;.r.,..-. s. ..r "� v-w+ .. f t = No. tl Fee JQ ThIE COMMONWEALTH OF MASSACHUSETTSA-,,k Entered in computer. _ PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pprication for Mizpaal *p!tem' Construction Permit Application for a Permit to Construct( )Repair(V)Upgrade( )Abandon( ) O Complete System O Individual Components Location Address or Lot No. 7647&0 RO, pwner'ss Name,Address and Tel.No. � Assessor's Map/Parcel ��� t A, ')/5 �^^�T AO, M Installer's Name,Address,and Tel.No. PM A( Designer's Name,Address and Tel.No. Type of Building: n U✓�1+L�k zo C Dwelling No.of Bedrooms qM5414.3 o?Sizze sq.ft. Garbage Grinder( ) Other Type of Building - No.'of Persons Showers( ) Cafeteria( ) " Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date s Title Size of Septic Tank 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 En irorlmen Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b s Boar of :ealth. Signed Date--- Application Approved by ,�.� PFDate lJ I Application Disapproved for the following reasons Permit No. )UO Ll—l�h Date Issued y-�- 'i �___------------ C O THE------ '� --------------------------__.--- t r;����. .(I►�I��I Mi ONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed Repaired SG)UPgraded ( ) Abandoned b Kr,orA at_ P�� 2�. ,��n rc�i�r. 6►�,"yl< has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. Del d tl-/6U dated Installer Designer e— _ The issuance of this permit shall not be construed as a guarantee that the sys4em-will,func�tJion as designed. p Date N r?U A Inspector - .... No.��f)tJ� �bV Fee — THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION . BARNSTABLE., MASSACHUSETTS j Mi0po5ar *p5tem Conotruction Permit Permission is hereby granted to Construct( )Repair,')Upgrade( )Abandon Mir ( ) System located at 7h e/� ��. Tr i„ , ���. 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 � ith s_72)fiv. Date: � 7 Approvedby �a t TOWN OF BARNSTABLE LOCATION RD SEWAGE # •l�6 VILLAGE 5r'Y!� MIU-< ASSESSOR'S MAP [ &,LOOT /5�—OS� INSTALLER'S NAME h&PHONE NO. �� , d T3�- ' M SEPTIC TANK CAPACITY 1020 LEA RING FACILITY: size C (tyte) (size) NO.OF BEDROOMS 3 BMDER OR OWNER PERMITDATE: z f.1 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i Wit - F L TOWN OF BARNSTABLE �. LOCATION SEWAGE # VII.,LAGE i��-r-� - �� ASSESSOR'S MAP & LOT.!g�-0.5—Z5� INSTALLER'S NAME&PHONE NO. ,13' SEPTIC TANK CAPACITY 10Q0 LEACHING FACILITY: (type) (size) 132— il n NO,OF BEDROOMS BUILDER OR OWNER PERMITDATE: -Q�di� COMPLIANCE DATE: Separation Distance Between the: Feet Maximum Adjusted Groun.dwaterrTabk to the Bottom of Leaching Facility 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 Feet within 300 feet of leaching facility) Furnished by I i 7 000 9 r r Town of Barnstable Regulatory Services Thomas F. Geiler, Director BARNSTABLE, MASS. Public Health Division i679. Alen A Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: Ck ©� Designer: Installer: Address: c(b sS '��c� �) Address: On "`e AI ,is�-ry 44bi was issued a permit to install a (date) (installer) h I septic system at "l( rt'-eJd IU ,V,M t4.C54y n s `�`1�I1.S based on a design drawn by (address) cam,. dated ` (-designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Of �. 13ETERT. (Installer's Si a McE ES C Y No.35t� (Designer's Signature) (Affix D&signer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIGHEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form k � �� �r�� �� ���- � �. F � ® � V LSD AT ION SEWAGE o c PERMIT N0. S"'/ VILLAGE INST/A LLER'S NAME & ADDRESS BUILDER R OWNER DATE PERMIT ISSUED 1 DAT E COMPLIANCE ISSUED /'_ ._ k, II r V 00 �i f� �. er No..........�Q �d Fss.. vv� --- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH / .............-.O F.......................................................................................... Allp ira#ion fur Uiipo,i al Workii Tontitrurtion Vamit . tApplication is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: _ ............................ :....._ Lo ion Ad re t No. - ... Wner `e a war---- ----------•-•----•----• `7�. ---.........._... �....L`�'-.. Installer Address Type of Building Size Lot__ ,�7m'_d-------Sq. feet Dwelling No of Bedrooms----------------L'_-_______-__________-Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons____________________________ Showers — Cafeteria ft, Other fixtures -------------------------------- . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width---------------- Diameter:_______________ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area______-_----_-------sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet..................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank( ) Percolation Test Results Performed by.......................................................................... Date........................................ a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-._--._____-___--______- ----.... -------------- -------------•----------------------------------------------------------------------------------------------•--•------------.----- 0 Description of Soil---------- •-------------------•--------.--------------------------------------------------------------------------------------------------- U ----------------------------------------------------------------------------------------------------------------------------------------------------------------------•-•-------------------------..... W -- -- -- -------------- VNature of Repairs or Alterations—Answer when applicable._4:kA✓- _____ ______________ ______ _---------------_....-.----__. ---------------------------------------------------------------------------------------•---•...------------------------------------------------....---------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of:T' E, p S of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued bb the board of health. S. ............................................................................ Date 717 Application Approved By........ / �' / 'zn to Application Disapproved for the following reasons-----------------------•-------------------------------------------------------•-------------------------.----•- -------------------------------------------------------------------------•----------------------................................ ........................ Date PermitNo......................................................... Issued....................................................... Date -T� ® r FEs THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -•...........................--- ----....OF................................_.......... �--App ira#ion for Bhivoii al Workii TouBtrnrtiun Pamit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: __................................................... .. Lo ion-Ad re M t No. .._A--- .e_. . sf '' .c�. a ►.. --.......� .A�r ........ dm Installer Address Type of Building Size Lot..449.01. ...... feet Dwelling JNoo. of Bedrooms.....................................Expansion Attic ( ) Garbage Grinder ( ) P4 Other—T e of Building No. of persons............................ Showers — Cafeteria QI Other fixtures ------------------------------------------•--- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---_--__.-__--_- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No_____________________ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (i, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ----- ODescription of Soil . -------------------------------------•--•------------------------•--------•--.-----•.------------- --•................. -------/�-� =--- - 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:I:L p 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 ..... � .....e... ... Date Application Approved By.......... •• Date Application Disapproved for the following reasons:--------•-•---•----•-------------------------------•---•---•......................=............................ ......................•-•--•-----•------------------...----•-•--------------------------•--••---•-----•----------•----•-••--•-•••----••------•-•-•-------------•-------••-.-•---•-------•--••---------•- Date PermitNo......................................................... Issued_........................................................ Date THE ,COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............. i kZ0. ....OF.............�''� G�.............................. (9rdifiratr of fauntplianre TH IS TO CE IFY at the Individual Sewage Disposal System- constructed ( ) or Repaired ( ) by......... .... . - _. . ........... ......... r ---_.___._.._ ----•-•-... Inst�ler .� 't /�i J� '�'�f/t�( '�Y••t has been i stalled in accordance with the provisions of TIi u ` of he State Sanitary Code as described in the application for Disposal Works Construction Permit No._"..�_...�.�__________________ da.ted.....'.-../..Z..'_�_�_'_.�.��___.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A OUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.......... _ =� ....:. Inspector............, ------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS t 6 BOARD OF HEA . (71 I .....OF... ..... F . .�® No.- FEE----..... ....._•_..... itun �rk5 inn nrlinn rrntit Permission ' reby granted.._,_. '__ ...Y_ to Construct/. ' ) or Repair j) an 'ndividk� Sew age i sal Syst �1 j at No ....... —d ----•--W.c-- • -- . ...�{'-�.�?. ...... !-'.... .......... Street as shown on the application for Disposal Works ConstructiVnPr�iitl__ ._ _. Dated....�z__.' �t.`�-<-__..... Board of Health.-, - DATE........ •-••---••------ ' FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS • - �,Fr p ROUTE 6 TR�L' -770F � Ed 67RICLL;r — — — LEGEND g p lvp4ent 99 f PROPOSED CONTOUR �, s �Q>� 99 PROPOSED SPOT GRADE S 4j:Jr3%4tr' E —� \\ — 40 ----- EXISTING CONTOUR D LOCUS G� x 99,46 EXISTING SPOT GRADE W TOP 109.90' TEST PIT L 0 T 54 PhD \ --W EXISTING WATER SERVICE g \ 6 20,001 S.F.f EXISTING TREE TDPFIELD DR 0.46 A C.f I + \ ��. \ O� OLD STAGE RO Map )50 \, °, \ Parcel 55 Ito \ EXlS71NG SEP77C TANK TOP EL: 96.97 LOCUS MAP N.T.S. INV.(OUT) EL: 95.6— \ EXISTING S A.S. \ (opprox. locoton) N ote: O \ TO BE PUMPED & FILLED W/ SAND As—built location of S.A.S. was moved greater than 10 feet laterally m from the approved location due to a change in soil conditions. The C� revised location is shown on the plan. Minimum pipe slopes were tiCb maintained and required setbacks satisfied. ad CN O.H.W 1CN lbLu N �n - deck `b' f bh J +$ C) �°' Drive o� o�ed ~� 4' Stone Qt o �► ti � � As.•b� /a O .0 Otigh / l J 97,57 STR/PDUT C)A,� SEE NOTE 11 i �c�l TP �`�� + c� S A`� 160.00, EL: 97.5 + �— N 43 33'40" W � Benchmark set Right Corner/Brick step �p ` OF 04ss9� E1.=99.05 (Assumed) �1 Zti �� tiG + ��. o PETER T. SEPTIC AS—BUILT PLAN + McENTEE CIVIL No. 35109 76 FIELD ROAD, MARSTONS MILLS, MA o� REG AER�� Prepared for: Robert Hart, 76 Field Road, Marstons Mills, MA S N Engineering by: Surveying by: SCALE DRAWN JOB, NO. Engineering Works Terry A. Warner P.L.S. 1 "=20' P.T.M. 30-04 �. 12 West Crossfield Road 22 Long Road DATE Forestdole, MA 02644 Harwich, MA 02645 CHECKED SHEET NO. (508) 477-5313 (508) 432-8309 4/30/04 P.T.M. 1 of 1 t od ROUTE 6 LEGEND i TREE TOP � N A moo, oo� Edge of pavement \�°°' PROPOSED CONTOUR �, s F-9971 PROPOSED SPOT GRADE s _� \ -- 40 EXISTING CONTOUR Q� LOCUS S 4�.r'4Z`1' E \ z OP -o x 99,46 EXISTING SPOT GRADE w G' 109.90' \ TEST PIT L 0 T 54 �` \ —W EXISTING WATER SERVICE TOPFIELD W \ 6 OR 20,001 S.F + �� \\ EXISTING TREE STAGE Ro Map 150 + \ °°' \ Parcel 55 it0 \ EXISTING SEPTIC TANK TOP EL: 96.97 LOCUS MAP N.T.S. INV.(OUT) EL: 95.6t \ EXISTING S,A.S O \\ (approx. location) GENERAL NOTES: TO BE PUMPED & \ FILLED W1 SAND 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL BOARD OF HEALTH AND THE DESIGN ENGINEER. ^� ��� ^4' ,� 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS m G� �� `Z OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE '�H \ �j h +oil LOCAL RULES AND REGULATIONS. ti� r 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR Dy qA \ t,,) I �• �'A �k TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE g� h �. -� N o DESIGN ENGINEER. �'` �� 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING GH,W. ~ / tit EN�NEER BEFORE THOSE WCONSRR�CTIONACO NTINUESORTED TO THE DESIGN (oob�' ti� 14. j 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF De THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF c N 1n ` A�' 1 HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. C'4 C'Q, 1?' +� f 7. WATER SUPPLY PROVIDED BY TOWN WATER. 1 �,. '�OQ� 8. THERE ARE NO PRIVATE WELLS LOCATED WITHIN 150' OF THE S.A.S. + ` 9. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. At, O 39' 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE �u 5to�e j 1 O cyP'� , THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING CONSTRUCTION. Q. � �g7,S7 / 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS \1 �� / IN THE AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF THE S.A.S. D2 :EE'NOTE 11 q1 AND REPLACE WITH CLEAN FILL AS SPECIFIED IN 310 CMR 255(3). TP' � 't� 5r j � � ' 12. SIZE AND STRUCTURAL INTEGRITY OF EXISTING SEPTIC TANK SHALL BE + 3 160.00' EL:97,5 1 EVALUATED PRIOR TO CONSTRUCTION. IF TANK IS FOUND TO BE STRUCTURALLY UNSOUND OR HAVE A CAPACITY OF LESS THAN 1000 + -F-- N 4333'40" W GALLONS, IT SHALL BE REPLACED WITH A CONFORMING 1500 GALLON TANK. t Benchmark se o � 1 ��. Right Comer/Brick step a 1� �F *SS' EI.=99.05 (Assumed) +��0 �2ti , o��Q� PETER T. 9���s +°' McENT T. PROPOSED SEPTIC SYSTEM UPGRADE CIVIL 76 FIELD ROAD, MARSTONS MILLS, MA No. 35109 �O Prepared for: Robert Hart, 76 Field Road, Morstons Mills, MA R£0/Sl -� � SS/ONAL E�G� Engineering by: Surveying by: SCALE DRAWN JOB. NO. Engineering Works Terry A. Warner P.L.S. 1 "=20' P.T.M. 30-04 9 12 West Crosssfield Road 22 Long Road DATE Forestdole, MA 02644 Harwich, MA 02645 CHECKED SHEET NO. Q1F� (508) 477-5313 (508) 432-8309 4/7/04 P.T.M. 1 Of 2 a t NOTE: TO PREVENT BREAKOUT, THE PROPOSED TOP OF FOUNDATION F.G. EL: 97.5t FINISH GRADE SHALL NOT BE < EL:95.0 EL: 99.56(EXISTING) �' FOR A DISTANCE OF 15' AROUND THE EXISTING F.G. EL: 98.9t(EXISTING) F.G. EL: 97.7±(EXISTING) PERIMETER OF THE S.A.S. MAINTAIN 2% MIN SLOPE OVER S.A.S. gopp INSTALL RISER OVER D-BOX TO 5 GALLON LEACHING CHAMBERS INSTALL RISER OVER CHAMBER E INSTALL RISERS OVER INLET & OUTLET �00 G SHOWN ON PLAN AND SET COVER/S TO WITHIN 6" OF FINISH GRADE WITHIN 6" OF FINISH GRADE IN SERIES WITH STONE ALL SIDES WITHIN 6" OF FINISH GRADE L =36' L 13'(MAX) 4" SCH 40 PVC 4" SCH 40 PVC 2" LAYER OF 1/W TO 1/2" e 10• ®m 10 DOUBLE WASHED STONE INV.EL: 96.tf�a EXISTING 14" ® S= 1% (MIN,) 6" @ S= 1% (MIN.) fa®� ®°1® 1000 GALLON INV. ELEV.=94.83 2' EFF• DEPTH ®�+®�®�1a (EXISTING) + SEPTIC TANK INV. ELEV.=95.00 3/4"-1 1/2" INV.EL: 9S.$St (D�TERMINEO FROM PUMPING RECORDS) � ¢ 5.2' 4' DOUBLE WASHED. (SEE NOTE 12-•SHEET 1) EFFECTIVE WIDTH = 13,2' STONE (EXISTING) INSTALL INLET & OUTLET TEES INV.EL: 95.6t INV. ELEV,=94.50 GAS BAFFLE TO BE INSTALLED ON (EXISTING) OUTLET TEE AS MANUFACTURED BY TOP CONIC, ELEV.=95.3 —BREAKOUT ELEV.=95.0 TUF—TITE, ZABEL, OR EQUAL D—BOX SHALL BE SET LEVEL AND TRUE TO GRADE INV. ELEV.=94,50 co�® � ON A MECHANICALLY COMPACTED SIX INCH CRUSHED BOTTOM ELEV.=92.50 STONE BASE, AS SPECIFIED IN 310 CMR 15.221(2). 1 4 2 x 8.5' 17.0' 4' 5' MIN. ABOVE BOTTOM OF EFFECTIVE LENGTH = 25.0' SEPTIC SYSTEM PROFILE T.P. EXCAVATION OR G.W. NO G.W. ENCOUNTERED NO RING SYSTEM SECTION N.T.S. BOTTOM OF TP EL: 84.0 (3) 5" DIA.OUTLETS T. 15.5' ,�— 'g--+{ z„ SOIL LOG M ENT EE ��� DESIGN CRITERIA CIVIL � No. 35109 11 DATE: MARCH 17, 2004 e/Sl - 15.5" r; 8„ SOIL EVALUATOR: PETER T. McENTEE P.E., C.S.E. NUMBER OF BEDROOMS: 3 BEDROOMS �G� s' SSIONAL INSPECTOR: NOT WITNESSED—CLASS 1 SOILS SOIL TYPE: CLASS I a„ € DESIGN PERCOLATION RATE: 2 MIN./IN. H-10 LOADING 71a�4' D—BOX Elev. TPP- 1 Depth DAILY FLOW: 330 G.P.D. N.T.S. EXISTING DESIGN FLOW: 330 G.P.D 2 BEDROOM 97'5 A SANDY LOAM 0 GARBAGE GRINDER: NO M0(1$E(#76) 97.0 B 10 YR 3/3 6 LEACHING AREA REQUIRED; (3�0) = 445.9 S.F. ��• TOF=99.56 (Assumed) SANDY LOAM 10 YR 5/8 PROPOSED SEPTIC TANK: 1000 GALLON CAPACITY (ESTIMASTED) ®®®® 0 ®®IFOE3 194.5 36" ®®®® ®®®®tea 33^ 77 C1 ®®®��®®®®�& 1 CLAY N ®��®�®a55®®� 26 _— 691 5Y 5/2 USE 2-500 GALLON LEACHING CHAMBERS IN SERIES (unsuitable) 1oa" �� SIDEWALL AREA: 2(13.2 + 25.0') X 2 = 152.8 S.F. N �j 1 88.0 C2 114" BOTTOM AREA: 13.2' x 25.0' = 330.0 S.F. / ,p TOTAL AREA: 482,8 S.F. 4" KNOCKOUT 2p�. COVER M-F SAND 2.5Y 6/6 DESIGN FLOW PROVIDED: 0.74(482.8) = 357.3 G.P.D. 4" KNOCKOUT 4 KNOCKOUT sa" 0 �� 4" KNOCKOUT S�\�� Is, 84•0 162" SEPTIC SYSTEM REPAIR/UPGRADE PERC RATE <2 MIN/IN, ("C2" HORIZON) 76 FIELD ROAD, MARSTONS MILLS, MA y NO G.W. ENCOUNTERED Prepared for: Robert Hart, 76 Field Rood, Morstons Mills, MA 500 GALLON CAPACITY, H-10 LOADING Engineering by: Surveying by: SCALE DRAWN J08. N0. CHAMBERS S.A.S. LAYOUT Engineering Works Terry A. WaraerP.L.S. NTS P.T.M. 30-04 N.r,s 12 West Crossfield Rood 22 Long Road DATE CHECKED SHEET NO. n.r.a Forestdole, MA 02644 Harwich, MA 02645 (508) 477-5313 (508) 432-8309 4/7/04 P.T.M. 2 Of 2 i