HomeMy WebLinkAbout0020 HEAD OF THE POND LANE - Health (2) 20 Head Of The Pond Lane
Marstons Mills P
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DATE9/26/02
PROPERTY ADDRESS:20-Head Of The Pond-Lane
-- --------------- ---- RECEIVED
Marstons Mills,Mass. 02648
------------------------
OCT 2 2002
------------------------
�®�I�Ifia�ALTN DEPTABLE
On the above date, I inspected the septic system at the above address.
This system consists of the following:
1 . 1 -1000 gallon septic tank. _
PARCEL •
LOT I' _
Based on my inspection, I certify the following conditions:
2. This is a title five septic system. ( 78 Code
3 . The septic system is in proper working order 1
at the present time.
4 . The leaching pit is presently dry.
5. Pumped the septic tank at time of inspection.
Heavy scum & solids layers were present.
6. Pump the septic tank every 2-3 years.
SIGNATUR
Name:- J . P . Macomber Jr .
---------------------
Corripany :Josep_h Pam— Macomber & Son, Inc .
Address :__BQx _C_Cz............
__men-t-erKtL e.,_ _Q2632-0066
Phone :--508-775- 3338
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON, INC.
Tanks-Cesspools-Leachflelds
Pumped & Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 02632-0066
775.3338 775.6412
-\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 20 Head Of The Pond Lane
Mar tons Mills,Mass, 02648
Owner's Name:Yury Gi rshovi ch
Owner's Address: 3 Hampton Road
T,Pxi ngi-on,Ma ss _ 02421
Date of Inspection: 4.126 f112
Name of Inspector: (please print)JOseph P.Macomber Jr.
Company Name: J.P.Macomber & Son Inc,
Mailing Address:Box 66 Centerville,Mass. 02632
Telephone Number508-775-3338
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true. accurate and complete as of the time of the inspection. The inspection was performed based on my
:rainine and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP
approved system inspector pursuant to Section15.340 of Title 5 (310 CMR 15.000). The system:
. �/ Passes
_ Conditionally Passes
_ Needs Further Evaluation by the Local Approving Authority
_ Fai
g
Inspector's Signature: �• Date:
The system inspector shal mit 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.
Notes and Comments
*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.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 20 Head Of The Pond Lane
Mars tons milis,mass. 02648
Owner: Yury Girshovich
Date of Inspection:9/2 6/0 2
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
C- System
100 have not found any in formationhvhich indicates that any of the failure criteria described in 310 CMR
15.303-or to 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
The septic system is in proper working order at
the nrPsent time.
B. System Conditionally Passes:
_Q 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:
4-,)6 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
obstruction is removed
distribution box is leveled or replaced
ND explain:
le�b 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:
2
Page 3 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 20 Head Of, The Pond Lane
Marstons Mi11s,Mass. 026.48
Owner.Yury Girshovich
Date of Inspection: 9 26 02
C. Further Evaluation is Required by the Board of Health:
A)d 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:
i1/O Cesspool or privy is within 50 feet of a surface water
I r' with' 50 feet of a bordering vegetated wetland or a salt marsh
,� Cesspool or privy is to g g
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.
&LO 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.
,J 2`1 The system has a septic tank and SAS and the SAS is less than 100 feet hat 50 feet or more from a
private water supply-well I*. Method used to determine distance-//;1�4
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
F .
3
Pate 4 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Properr Address: 20 Head Of The Pond Lane
Marstons Mi11s,Mass.02648
Ownery v' h
Date of Inspection: 9 26 02
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or"no" to each of the following for all inspections:
Yes No
/z ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
�4 D scharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
— logged SAS or cesspool
Static liquid level in th distribution box above outlet invert due to an overloaded or clogged SAS or
�esspool 1-41 - i-'XA6I
!�i iquid depth in4*%rvo4 is less than 6" below invert or available volume is less than '/, day now
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
f times pumped
— ny 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 I of a public well.
_ lo�v portion of a cesspool or privy is within 50 feet of a private water supply well.
c 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 qualiry analysis. )Tbis system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate ❑itrogen 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.)
(Yes./No) 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 now of l0,000 gpd to 15,000
gpd•
You must indicate either"yes" or"no" to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
%es no
_ -Zhe system is within 400 feet of a surface drinking water supply
y the system is within 200 feet of a tributary to a surface drinking water supply
P the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area- I WPA)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
•eves" 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.
4
Page 5 of I I
OFFICIAL INSPECTION FORM NO �YSTEM INSPECTION FORM
SUBSURFACE SEWAGE DISPOSAL PART B
CHECKLIST
Properry Address: 20 Head Of Th_e_Rand Lane
Ma s. 02648
Owner: Vary c'i r— hnvi Ch
Date of lospeetioo:
Check if the following have been done. You must indicate ' s" 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 ?
ZHave 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)
Z— Was the facility or dwelling inspected for signs of sewage back up ?
_ Was the site inspected for signs of break out
r
','ere all system components,�luding 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
Yes no/
4 Existing information. For example, a plan at the Board of Health.
f/ 'Deter-mined in the field (if any of the failure criteria related to Part C is at issue approximation of diztancr
ry s unacceptable) (310 CMR 15.302(3)(b))
5
Page 6 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 20 Head Of The Pond Lane
Marstons Mills .Mass. 02648
Owner: YurX GirshOvich
Date of Inspe tion: 9 2 6 0 2
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms):5A16
Number of current residents: 8
Does residence have a garbage grinder(yes or no):do
Is laundry on a separate sewage system ( es or no):,(a [if yes separate inspection required]
Laundry system inspected es or no):2eS
Seasonal use: (yes or no):
Water meter readings, if available(last 2 years usage(gpd)): 2 0 0 0—1 9, 0 0 0 ga 1 lops=5 2. 0 6 GPD
Sump pump(yes or no):&L26 2001 —1 9, 000 gallons=52. 06 GPD
Last date of occupancy:
COMM ERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):,,
Industrial waste holding tank, present(yes or no):4M
Non-sanitary waste discharged to the Title 5 system (yes or no):.1!
Water meter readings, if available: /Vl�
Last date of occupancy/use:
OTHER(describe): /J�iyl
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no):
If yes, volume pumped: it'00 gallons-- How was quantity pumped determined? e
Reason for pumping: Heavy scum & solids layers were present.
OF SYSTEM
Septic tank,distribution box,soil absorption system
Single cesspool
I; 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 systejn owner)
/(J�Tight tank iW Attach a copy of the DEP approval
Other(describe): 11610
Ap roximate aoe of ll omponents date installed (if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):
6
Page 7 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 20 Head Of The Pond Lane
Marstons Mills
,Mass. 02648
Owner: Yury Girshovich
Date of Inspection: 9/2 6/0 2
BUILDING SEWER(locate on site plan)
�t
Depth below grade: -51 _
Materials of construction:.t/Ocast iron Z40 PVC Aid other(explain): ,11,
Distance from private water supply well or suction line: /d12
Comments (on condition of joints, venting, evidence of leakage, etc.):
No evidence of leakage.The system is
ven e oug e house vents.
SEPTIC TANK: (locate on site plan) 1 000 gallons
Depth below grade:
Material of constructionXXXconcrete N0meta1N0 fiberglassNOpolyethylene
NC ther(explain) NA
If tank is metal list age:NO Is age confirmed by a Certificate of Compliance(yes or no):to(attach a copy of
certificate)
Dimensions:
Sludge depth: _
Distance from top of sludge to bottom of outlet tee or baffler
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:Pumped at time of inspection.
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of-leakage, etc.):
Pimp the SPptl r tank PvPry 2-1 Vears Inlet Ii niltlet tees Rrp
n 1 ac-P ThP tank is sttic-tirral 1 V gniindaci ShfLS nn
of leakage.Pumped tank at time of inspection.
GREASE TRAA4;(locate on site plan)
Depth below grade:/1
Material of construction:.concrete466netaLlAfiberglass,&polyethylene4other
(explain): f
Dimensions:
Scum thickness: 11W
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: A
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Grease trap is not prP-gPnt
7
Page 8 of I I
OFFICIA-L INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Propene Address:20 Head Of The Pond Lane
Marstons Mi s Mass. 02648
Owner:Yury Girs ovic
Date of laspcctioo: 9 26
TICHT or HOLDING TANKAt We-(tar-Lk must be pumped at time of inspcction)(locate on site plan)
Depth below grade: ,1
Material orconsrructio /concrete Aki metal AM fiberglassdj� polyethylene44 other(explain):
Dimensions
Capaciry, gallons
Desten Floe Ajf gallons/day
Alarm present (yes or no): �i/1�
Alarm level. Ate_in working order (yes or no):�
Daic of last pumping:
Comments (condition of alarm and float switches, etc.):
Tight or holding tanys are not-present.
DISTRJBUTION BOX: Zirpresem must be opened)(locate on site plan)
Deptn of liquid level above owlet invert: ,(/d
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 has one lateral.No evidence of solids
Carry aver No evidence of lea age - into or out
PUMP CHAMBER (loca(e on site plan)
Pumps in working order (yes or no)
Alarms in working order (yes or no):
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Pump chamber is nUL PLU:5ellL.
8
Page 9 of 1 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 20 Head Of The Pond Lane
Marstons Mi s,Mass. 02648
Owner: Yury Girshovich
Date of Inspection: 9 26 02
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required)
1 -1000 gallon precast leaching pit. 61X10 '
If SAS not located explain why:
Located: See page 10
Type
j, leaching pits, number: y
,V6 leaching chambers, number: a
leaching galleries,number:
leaching trenches,number, length: d
AJO leaching fields, number, dimensions:
IKE overflow cesspool, number: d J—
inn
ovative/altemative system Type/name of technology;//y,� 6
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
Loamy sand to medium fine sand.No signs of hydraulic failure
or ponding. Soils are dry.Vegetation is normal. The leaching
pit is presently dry.
CESSPOOL%k& (cesspool must be pumped as part of inspection)(locate on site plan)
Numtler and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum laver:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no): ey
Comments (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Cesspools are not present.
PRIV)��(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.):
Privy- is notresent
9
Padr 10 o! I I
0FFICLA INSPECTION FORM — NOT FOR VOLUNTARY ASSESSME^�TS
SUBSURFACE SEWAGE DISPOSA-L SYSTEM INSPECTION FORM
PART C
SYSTEM f1`IAORIrLnTION {conclnvcd)
„gfrr. A001C1120 Head Of The Pond Lane
O .O„Yury G .r rot` n`I 1 s_, ass. 02648
Dcic of InIgm 00: 2
SK.ITCH Of SCwnCC DISPOSAL SYSTCM
Ao oc c ilcccn oft,)( jcwl Ic dilpolil lyllfm Inclvding IIc1 10 It Ic1ll two Pcfmincnl rcf<rcncc ILA
Dc". Vn v ii Locm cit it..p ..��n,n 100 fcri. Loci" wn�rc yvblic wrlar Iv I Cmi/c,
PP y cnlcrl the bviloinj
Q
1% �N117,
IO
Page 11 of 1 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 20 Head Of The Pond Lane
Mars tons Mi s,Mass.
Owner:Yury Girshovich
Date of Inspection: 9/2 6/0 2
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 7Q feet
Please indicate(check)all methods used to determine the high ground water elevation:
No Obtained from system design plans on record -if checked, date of design plan reviewed: NA
y_F.S Observed site(abutting property/observation hole within 150 feet of SAS)
N.a_Checked with local Board of Health-explain: NA
yFS Checked with local excavators, installers-(attach documentation)
Yl*S Accessed USGS database-explain: http; //town.barnstable.ma.us.
You must describe how you established the high ground water elevation:
Used: Gahrety & Miller Model. 12/16/94 Ground water elevations above sea level.
Used: USGS: Observation welldata June 1992
Used; USGS; Technical bulletin 92-0001 Plate #2 Annual ranges of ground
water ,-al�tions. January 1992
I up Of r un
Leaching
Pit ;eet
71
ya�
Groundwater:" Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
Therefore, the vertical separation distance between the bottoo
of the leaching pit and the adjusted groundwater table is ��
feet.
11
� T.f{T t-rt1R�.TT-11•iT. JiR I.T.+TtSTTi TTT.TT..T'*`•TTT!`ITi"'CP^RTI TTCr1tJ1TLC:1L.1'S'i . .TTTTT�.�T' �.,r-..,'
TOWN OF Barnstable BOARD OF HEALTH
0 SUIISURFACR SEWAGE DISr'OSAL SYSTEM INSPECTION FORM - PART D '- CERTIFICATION
I
r••t�r•..•;. —r.t�••.:.rr.r.r..n•n:r'.ri rnis•.r.rtrrrrr-r.•rr,rt+r�mmrTrnrweo��rrsmmz-r+sn.•s� tsars«+srrtrr•so•**r'r+rr•er.•.—rrr•r-�. —..A
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRES$ 20 Head Of The Pond Lane Marstons Mills Mass.
ASSESSORS MAP , BLOCK AND PARCEL # 030-099
OWNER' s NAMEYury Girscovich
PART D - CERTIFICATION r
NAME OF INSPECTOR Joseph P.macomber Jr.
COMPANY NAME J.P.Macomber & Son Incro
COMPANY ADDRESS Box 66 Centerville Mass. 02632
Street Town or City State LIP
COMPANY TELEPHONE (508 775 - 3338 FAX ( 508 1 790 -1578
R
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
omplete as of the time of .inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one :
,Z-System PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15 , 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
System 'FAILED*
The inspection which I have con Ucted has found that the system fails to
Protect the ptiblic health and the environment in accordance with Title
5 , 3.10 CMR 15 , 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form ,
Inspector Signature `-•�
Date
ne copy of this certification must be provided to the OWNER, the BUYER
( Where applicable ) 'and the I30ARD OF HEALT'II.
* If the inspection FAILED , the owner or " parator shall u
within one year of the date of the inspection , unless allowed dortrequiredm
otherwise as provided in 3.10 CHR 16 , 305 ,
partd .doc
FILE No.534 10/29 '02 12:58 ID:EXA CORPORATION FAX:7816768599 PAGE 1/ 14
fOtypS OF OA,'RN,`,TABLE
Fax: 508-790-6304 2002 DEC 18 PM 3: 32
Attn: Donna
Pages 14:
From Yury Girshovich
20 Head of the Pond Lane
Marstons Mills, MA 02648
Phone: 781-676-8582
Barnstable Town Health Dept.
To whom it may concern:
i am considering adding a fourth bedroom to my home at the above address.
Please let me know whether my septic system satisfies the necessary
requirements. The report is attached.
You can reach me during the day at 781-676-8582.
Thank you,
Yury Girshovic
U�
CD
CD
N OISlA10 `a
rn
?c :C W8 81330 z0oz
TOWN OF BARNSTABLE
1091 DEC -6 PM 12: 33
DIVISION
FILE No.534 10/29 '02 12:58 ID:EXA CORPORATION FAX:7816768599 PAGE 2i 14
DATE 5 /26/0?___-_
PROPERTY ADDRESS:20_Head Of The Pond Lane
Marstons Mills,Mass.02648
----------
On the above date, I inspected the septic system at the above address.
This system consists of the following:
1 . 1 -1000 gallon septic tank.
Based on my inspection, I certify the following conditions:
2. This is a title five septic system. ( 78 Code )
3. The septic system is in .proper working order
at the present time.
4. The leaching pit is presently dry.
5. Pumped the septic tank at time of inspection.
Heavy scum & solids layers were present. ,
6. Pump the septic tank every 2-3 years.
SIGNATUR
Name: J . P . Macomber Jr.
CorTipany:.g2jtatj_p,� m.2jggMttx son, Inc .
Address :__EQx kEZ_-__________
0066
Phone :-_508-775=3338 --------
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON, INC.
Tan ks-Cesspools-Leachflelds
Pumped & Inst(alled
Town Sewer Connections
P.O, Box 66 Centerville, MA 02632-0066
775.3338 775-6412
FILE No.534 10/29 '02 13:01 ID:EXA CORPORATION FAX:7816768599 PAGE 14i 14
v nnnr+•-R�+r�-rr'+rrrwvrmrs'�.n�r�var�w+�vrwwro.a�nBarn$table ��r �_..`-1•-•.
TOWN OF DOA.RD OF HEALTH
SU11SURFACF SFWAGR DISPOSAL SYSTEM INSPECTION FORM - PART D CERTIFICATION
•••�r.• -.•:-:: —oiz-.-rri.nrnw-n..ri.w.r.es+rrnaan-.--•.�.'�w�r�olnvY7+nrioa*rrnomns7+'f7 swnRtir.Rwr+*v'*.�-....++.a•ra�rr r•tii—.
-TYPE GA PRINT CLEARLY-
PROPERTY INYSPEC7'ED
STREET ADDRESS20 Head Of The Pond Lane Marstons Mills,Mass.
ASSESSORS MAP , BLOCK AND PARCEL # 030-099
OWNER' s NAME Yury Girscovich
PART D - CERTIFICATION r
NAME OF INSPECTOR Joseph P.macomber Jr.
COMPANY NAMEJ.P.Macomber & Son Incfo*
COMPANY ADDRESS Box 66 Centerville,Mass.02632
Stroet Tovo or City State LIP
COMPANY TELEPHONE (508 775 _ 3338 FAX ( 508 .1 790 -1 578
� - A
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
Oecoininendat' ions
his address and that the information reported is true , accurate , and
omplete as of the time of :inspection . The inspection was performed and any
regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one :
_• j =-- System PASSED '
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
healLh or the environment as defined in 310 CMR 15 , 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED* �octed
The inspection which I h.Ave has found that the system fails to
protect the j-)ublic health and the environment in accordance with Title
5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature Date
no copy of this certification must be provided to the OWNER, the BUYER
whore applicable ) and the 130ARD OF HUALTJI.
If the inspection FAILED, thv owner or��" orator shall u s p p pgrade ' the system
within one year oP the date of the inspection , unless allowed or required
otherwise as provided in 3.10 cFin 16 . 305 .
partd .doc
FILE No.534 10/29 '02 13:01 ID:EXA CORPORATION FAX:7816768599 PAGE 13i 14
Page I of 11
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 20 Head Of The Pond Lane
nsi ars o s, ass.
Owner:Yury Girshovich
Date of Inspection: 2
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO ,Obtained from system design plans on record-If checked,date of design plan reviewed: NA
yF,S Observed site(abutting property/observation hole within 150 feet of SAS)
tM_Checked with local Board of Health-explain: j&
yES Checked with local excavators,installers-(attach documenmflon)
yE,,c Accessed USGS database-explain: http; //town.barnstable.ma.us.
You must describe how you established the hi h ground water elevation-
3sed: Gahret & Miller Model. 12/16�94 Ground water elevations above sea level.
Jsed: USGS: Observation welldata June 1992
Jsed; USGS; Technical bulletin 92-0001 Plate q2 Annual ranges of ground
Ovate lev tions January 1992
Leaching
Pit •� :eet
I
Groundwater. Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
Therefore,the vertical separation distance between the bottom
of the leaching pit and the adjusted groundwater table is
feet,
II
FILE No.534 10/29 '02 13:01 ID:EXA CORPORATION FAX:7816768599 PAGE 12i 14
� � r
• PI j( !0 0/ I I
OFFICE INSPECTION FORM - NOT FOR VOLUNTARY ASSESSME^+T5
SUBSVR.FACE SEWACe DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (cononvco)
,,,,1,20 Mead Of The Pond Lane
0„b,rYury G
i ass, 02648
D1II of In,p(cl,00 2
SK-f TCH Of SEWACE DISPOSAL SYSTEM
I>.11clt 01 '" )(-$1( 61P9141 Irlum inclvdln6 Ilcl to 11 loll w0 pcimcncnc (cfc(cncc lLAcrncjz, �.
ol.�lwnv�l Lo<1 1 lu -Ills . ,,A.n 100 I'm Logic "t" public 'wllc( cvpPly (nlc(1 1A( bviloing
PO+,A arj+v,.,s
Q
r '
10
FILE No.534 10/29 '02 13:01 ID:EXA CORPORATION FAX:7816768599 PAGE , 11/ 14
e
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 20 Head Of The Pond Lane
Mars tons s,Mass.02646
Owner: Yury Girshovic
Date of Inspection: 9 26 02
SOIL ABSORPTION SYSTEM (SAS). (locate on site plan,excavation not required)
1 -1000 gallon precast leaching pit. �;'X10'
If SAS not located explain why:
Located- See page 10
Type
leaching pits, number:
leaching chambers,number:
leaching galleries,number:.
.V�leaching trenches,number, length:
leaching fields,number,dimensions:
115 overflow cesspool, number: 6
M innovative/alternative system Type/name of technology, iy� �r/ ���
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,
etc.):
Loamy sand to ,medium fine sand.No signs of hydraulic failure
or Qndina.Soils are dry.Vegetation is norms a leaching
pit is presently dry. /
CESSPOOL%61.f (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: 0
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 or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
Cesspools are not present
PRIVY (locate on site plan)
Materials of construction: .fig
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc,):
9
FILE No.534 10/29 '02 13:00 ID:EXA CORPORATION FAX:7816768599 PAGE 10/ 14
Page I or I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Add►ess:20 Head Of The Pond Lane
Marstons Mills,Mass. 02648
Owner:Yury G r�snovicn
Date of lospeetioo; 9
TIGHT or HOLDING TANK44r W_kwik must be pumped at time of inspection)(locate on site plan)
Depth below grade: 4014
Material of consrruc dg-conerete metal&-4fiberglass4M-polyethylene&other(explai,n):
Dimensions
Capaciry gallons
Design FloN ^A& gallons/day
Alarm present (yes or rm no)aa:r:R22-
Ala level _'VA AFL in working order(yes or no):4,0-.
Date of last pumping;
Comments(condition of alarm and now switches, cte.):
Tiaht or o ing an s are not prusent.
DISTRIBUTION BOX: Zirprcscni must be opciric0loeate on site plan)
Deptn or liquid level above outlet invert: Ald
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence or
leakage into or out of box, etc.);
nistribution box has one lateral.No evidence of solids
Carry nvPr_No evidence of leakage into o
PUMP CHAMBER (locate on site plan)
Pumps to working order(yes or no).-
Alarms in working order(yes or no):
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc,):
chamber is not present.
8
FILE No.534 10/29 '02 13:00 ID:EXA CORPORATION FAX:7816768599 PAGE 9i 14
Page 7ofII
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL-SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 20 Head Of The Pond Lane
Marstons Millg_j4ass.02648
Owner: Yury Gilshoyiph
Date of Inspection: 9/2 6/0 .
BUILDING SEWER(locate on site plan)
,t
Depth below grade: g
�
Materials of construction:;V-6cast iron Z40 PVCdM other(explain): Al-4
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
No evidence of leakage.The system is
ven a oug a nouse vents.
SEPTIC TANK: (locate on site plan) 1 000 gallons
Depth below grade: It
Material of consrmctionXXXconcrete NOmetaINO fiberglassNO polyethylene
NCother(explain) NA
If tank is metal list age:NO is age confirmed by a Certificate of Compliance(yes or no):Da(attach a copy of
certificate) ��,,, , "*
Dimensions:
Sludge depth: _
Distance from top of sludge to bottom of outlet tee or baffle-C _
Scum thickness: C1
Distance from top of scum to top of outlet tee or baffle:
Distanee from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined:Pumped at time of inapecion. _
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Ailmn the cPnti nk p-vPry 7 3 years Inlet R n»tlat tapS a -P
i n plant- -Tha tankj s ci.U.Ctura lly cni]nA and chnwS_11. p<'j,.A.EncP
of leakage.Pumped tank at time of inspection.
GREASE TRAP (locate on site plan)
Depth below grader
Material of construction.-concrete4&4netabkfiberglass,4kpolyethyleneolkother
(explain): -414
Dimensions: Aff
p Scum thickness: JL�
Distance from top of scum to top of outlet tee or battle:
Distance from bottom of scum to bottom of outlet tee or baffle: _
Date of last pumping: AO
Comments (on pumping recommendations,inlet and outlet tee or battle condition,structural integrity,liquid levels
as related to outlet invert, evidence of leakage, etc.):
r'rpaSp trap i c nni- nrPseni-�
7
FILE No.534 10/29 '02 13:00 ID:EXA CORPORATION FAX:7816768599 PAGE 8i 14
Page 6ofII
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 20 Head Of The Pond Lane
marstons Mi 11s.,Kass.02648
Owner: YUrX GirshOvich
Date of inspe tion: 9 26 02
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): :0 Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Rf 3j*4*A'O
Number of current residents: B
Does residence have a garbage grinder(yes or no):.
Is laundry on a separate sewage system(yes or no):./j [if yes separate inspection required)
Laundry system inspected es or no):
Seasonal use: (yes or no):
Water meter readings,if available(last 2 years usage(gpd)): 2000-1 9+ 000 gal lops=52. 06 GPD
Sump pump(yes or no):&b 2001 -19,000 gallons=52. 06 GPD
Last date of occupancy: ex
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15,203): ' gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):,I&
Industrial waste holding tank present (yes or no):/I&
Non-sanitary waste discharged to the Title 5 system(yes or no):.�
Water meter readings,if available: /WY
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no):
if yes, volume pumped:,trtY7 gallons--How was quanti pumped determined?
Reason for pumping: Heavy scum & solids layers were present.
7TYP OF SYSTEM
eptic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
01 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 syst=owner)
Tight tank Attach a copy of the DEP approval
Other(describe): 40
Ap roximate ace of I omponents date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):
6
FILE No.534 10/29 '02 12:59 ID:EXA CORPORATION FAX:7816768599 PAGE 7i 14
page S of l I
01:FICIAl.. INSPECTION FO DISPOSAL SO STEM INSPE INSPECTION Fp�tMNTS
SUBSURFACE SEWAGEPART B
CHECKLIST
Property Address: 20 Head O d Lane
s. 02648
Owner: _ ur ,i - +n Ch
Dete of lospectioo:
Check if the following have been done. You must indicate"Yes 11 or"no" as to each of the followin
Yes w0
Pumput$ information was provided by the owner, occupant,or Board o ea t
-Zwerc am• of the systcm components pumped out in the previous two weeks
Has the system received normal (lows in the previous rwo week period'
zHave large volumes of water been introduced to the system recently or as pan of this inspection '
Were as built plans of the system obtained and examined?(I(they were not available note au N/A)
Was the facility or dwelling inspected for signs of sewage back up
was the site inspected for signs of breakout ^.
Were all system components,owl luding the SAS, located on site ?
Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition
r lne baffles or secs, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum '
o,
�. Was the facilityy owner (and occupants if different from owner) provided with information on the proper
mainten—ance of subsurface sewage disposal systems ?
The size and location of the Soil Absorption System (SAS)on the site has been determined based on
Yes no/
Existing information. For example, a plan at the Board of Health.
f� Determined in the field (if any of the failure criteria related to Pan C is at issue approximation of distance
�s unacceptable) )310 CMAR 15.302(3)(b))
5
FILE No.534 10/29 '02 12:59 ID:EXA CORPORATION FAX:7816768599 PAGE 6i 14
Paee 4 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Propertr Address: 20 Head Of The Pond Lane
Marstons Mi11s,Mass.02648
Ownery
Date of Inspection: 9
0. System Failure Criteria applicable to all systems:
You must indicate -yes" or"no" to each of the following for all inspections:
Yes No
T �/�acicup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
-l� D scharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
— �ogged SAS or cesspool
Static liquid level in th distribution box above outlet invert due to an overloaded or clogged SAS or
�esspool f.��4► l�X1C1
iquid depth in4o&tpavi is less than 6" below invert or available volume is less than 'A day now
Requureo pumping more than 4 times in the last year NOT due to clogged or obstructed pipe($). Number
�f times pumped
ny 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.
Al Any portion of a cesspool or privy is within a Zone I of a public well.
_ y portion of a cesspool or privy ,s 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 qualiry analysis. (This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen Is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.)
(YesNo) 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•
You must indicate either"yes"or"no" to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
ve5 no
Zhe system is within 400 feet of a surface drinking water supply
_ Zoe system is within 200 feet of a tributary to a surface drinking water supply
_±f 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
eyes" 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.
4
FILE No.534 10/29 '02 12:59 ID:EXA CORPORATION FAX:7816768599 PAGE 5i 14
Page 3 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 20 Head Of, The Pond Lane
Marstons Mi11s,Mass.02648
Owtier:Y v
Date of Inspection; 9 26 02
C. Further.✓voluation is Required by the Board of Health:
AoO Conditions exist which require funher evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environunent.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(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:
a 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.
f The system has a septic tank and SAS and the SAS is less than 100 feet Mgt 50 feet or more from a
private water supple well'•. Method used to determine distance
••This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered, A copy of the analysis must be attached to this form.
3, Other:
3
FILE No.534 10/29 '02 12:59 ID:EXA CORPORATION FAX:7816768599 PAGE 4i 14
Page 2 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 20 Head Of The Pond Lane
Mars tons i s, as . 48
Owner: Yury Girshovich
Date of lospectiow 9 26 02
Inspection Summary: Cbeck A,B,C,D or E/ALWA_U complete all of Section D
System Passes:
dAq_ .have no�found,�informario hick indicates that any of the failure criteria described in 310 CMR
15.303 r to 3l0xst. Any failure criteria not evaluated are indicated below.
Comments:
The septic system is in proper working order at
me
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" pleasc
explain.
AA_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:
-VQ_ 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)arc replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
S&_ 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:
2
FILE No.534 10/29 '02 12:58 ID:EXA CORPORATION FAX:7816768599 PAGE 3i 14
�-\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
i
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Proper[)-Address: 20 Head Of The Pond Lane
Marston Mills,Mass_02648
Owner's Name:ytiry Czi X:.gj3Q3z3 cI'l
Owner's Address: 3 Hampton Road
T,t-xi ng}nn_Mafgs_ 02421
Date of Inspection: 9/26 402
Name of inspector: (please print)JosePh P.Macomber Jr.
Company Name: J.P.Macomber & Son Inc.
Mailing Address:RnX 66 CAnterviIIe,Mass.02632
Telephone Number:$08-775-3338
CERTIFICATION STATEMENT
I certify that l 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
rrainin_ and cxperience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to jection 15.340 of Title 5(310 CMR 15.000). The system:
2/passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fati o /
Inspector's Sig nature; / Date.
The system inspector shal mit 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
authoriD,.
Notes and Comments
— 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.
Title 5 Inspection Form 6/15/2000 page 1
SEWAGE INSPECTIONS
LOCATION . �� � d9� DATE G% D�did
VILLAGE /¢ 7/ ASSESSOR'S MAP & LOTQ "D
�v
-INSjPECTO �A
SEPTIC TANK CAPACITY t
LEACHING FACILITY: (type)
NO. OF BEDROOMS '
BUILDER OR OWNER /d"Si1OdlC�`l
OWNER MAILING ADDRESS
r
'Z� }(.�a� 6� � Po�Q 1aa•a , �na�-S.4�s IA/..,�lls
e •/
J /
J
t
~' LOCATION SEWAGE PERMIT NO.
(Rev 0
I,L-CA G E
INSTA LLER'S NAME i ADDRESS
i,
075
I U I L D E R OR WNER
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED
!� S
a
Yuic -. ..........
THE COMMONWEALTH OF MASSACHUSETTS ���
i BOAR® OF HEALTHIS
... ................0F...... Q.r S 1`.g_!,7. ..............................................
IV Applira#ion for Diipnsttl Works Cnnnitrnrtiun ramit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at
Head of the Pond Rd. , Marstons Mills
----------------_--------_............_...-------................_--•---•---•.........._.._.... ........................................... ............................................
on o.Location-Address t N
�tm� - . .. .... _... 4� _..wee. ._. ......... Z
ner Address
Installer Address 3
dType of Building Size Lot___9__,__7_0_0...........Sq. feet
V, Dwelling—No. of Bedrooms.......3__________________________________Expansion Attic ( ) Garbage Grinder ( ) ,
Other—T e of Building No. of persons..................'--------- Showers — Cafeteria
Q' Other fixtures ----------------------------------------
W Design Flow_____________5 5____..____-____________-_gallons per person per day. Total daily flow.---_.-..3 3 0__ __________ allons.
WSeptic Tank—Liquid capacity__10 0-�allons Length 8. 6_. ��____. Width_4 ' 10" Diameter---------------- Depth 5 4"
x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No._._._-_1........... Diameter.l�,--.._-__._. Depth below inlets.�_6_7_.__.___. Total leaching area___257______sq. ft.
Z Other Distribution box ( ) Dosing tank (
'-' Percolation Test Results Performed by--__ Cape od -Survey Cnslts. Date_---4/27/83
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
2._Test Pit No. 2_______ _:__minutes per inch Depth of Test Pit.......11._.___ Depth to ground water_______________________
.......................•----•••--•-..._....-•....................•----••-•--•--•....•-•--------.....-•-••-•----..._..........-•----•...__
O Description of Soil___.__TP#1 0.0 '- 1.0 ' wood loam, 1. 0 '-4 . 5 ' clay � `a�M�ss9cy�
x 4 . 5 '-11. 0 ' coarse sand and _gravel TP#2....0 0 ' l O 'wood loam_
V
1. 0 4 . 0 cla 4 0 11. 0 coarse sand and ravel. ] m
W -••'----••••---------------• ........�'-•.---• ...........................-...'-•-'•-'•---•••'-•'•••----------- g . ..........
AN
U Nature of Repairs or Alterations—Answer when applicable......................,.-. -_---_----`--- " .......oA �654 y
--- -- --- ------- ---
Agreement: /�/� o�Fss o TEE
The undersigned agrees to install the aforedescribed Individual Sewage Disposal S/yssttem in accor N
the provisions of IT"s 4 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee s rd of health.
Signed---. ._..•. -'-----•_. ..._.. ---------------------'-•-------....-- ? _.. �_
i
Application Approved By-----•----••----'-------'-- �1
--......---'...................'----- --..._...../-_t/_3
Date
Application Disapproved for the following reasons:-----•'------•-----••-----...'---------"--------------------•--'-------------•---'--••-•••-••••'-"•••--_._...
-------•---------'---------------------'-=------------•--------••----•--....-.'---------•--•---._...__.....-'--------'--•-'----------------............................................................
Date
PermitNo......................................................... Issued_.......................................................
Date
w 1
No.-----ems--•............... �J � Fxs.............
TAE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
Town Barnstable
--.......""" """""..............OF.......................................---------------•--...........--...................
ApplirFation for DhiposFal IFnrkfi Cnnnstrnrtion nuti#
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at:
Head of the Pond Rd-. ►...Marstons Mills
:...--------------------------------- ..- •-•-•--•..._•--•-...... ........................:-::-1 ................................................
Location Address t
..... . � ...CAS-.`�t33-1A1.... -•---
VI ner Address
Installer Address
Type of Building Size Lot..9. 7..0 Sq. feet
U Dwelling—No: of Bedrooms.....-::......... �g r ..._.._.__Expansion Attic, ( ) -' �; - Garbage Grinder ( ") '' ��•�
,t ' Other—T e of Building No. of persons............................ Showers — CS s
."_:dOther fixtures -----------------------= ------------ - -
:...
W Design Flow.............. S ...... _-gallons per person per day_ Total daily flow . ......__.__•_.._ _zallons.
94_ Septic Tank— Liquid capacity 100�allons Length.--.6 7.... Width _ 10 l Diameter._.._. .... Depth 5 4��.... ,4
Disposal Trench—No..................... Width...........:...... Total Length Total leaching area .._.._._____sq. ft. 4'
. Seepage Pit No......... Diameter.1�............. Depth below inlet 5...6�.._._. Tot l leaching area...�267 ....sq. ft.
Z Other Distribution box,( ) Dosintank ( � 4�
0-4 Percolation Test Results Performed byaPE' Od Survey Cnslts. 4/ 7/8
,.� Test Pit No. 1..... Nniinutes per inc eptl t'of"`Test Pit .............. Depth to ground water.....................
Lz, .Test Pit No: 2 2 minutes per inch Test Pit Depth to ground water............
Q Descri tion of Soil....._TP#1 0.0` 1.0' wood loam, 1.0' 4 5' clay
x ( 4•.Description
0' coae. d raysl, TP#2 0_,0'-1.0.... 00d loam o� ti
............................................................... - REN�^11CK
.. 1 -0 --4.01 cl.a .0'- 1- ' con se sand :and c�rayel �. . B, TA
r e• --•-----• W
AN
r ; v 1G6A27654 y
V .Nature of_Repairs or Alterations—Answer when applicable _....._ .._.. _____ __ _ _._
---- --- ------
--------------------------------------------------------------- ---------••----•----•---------------- �......•... -•----.....
Agreement: ��� 'rFss oryTi
Th`r 'undersigned-agrees to install the aforedescribed Individual Sewage isposal System in accorda
the pro isioiis of..TL� 5 of the State Sanitary Code— The undersigned further_ agrees not to place the system in
operation until a Certificate of Compliance has been s oa d of health.
Signed... ... .. ..................................... :.
nApplication Approved.BY - ... . . �--•-• .-........................
------•--•--....... --••••-••-----
Date
Application Disapproved for the following reasons:----••---•-•-••-••--••-----•---••--•---••---•--•---•••••--••--•-•-----•-•-•---•-•-•-•-•••--•-•--•..............
�... .....................................................•••---•-------•--------••------------- -- - --------..............-. ------------------
-
{ Date.,
Permit No... .......... . ....... Issued_--
..............................................
- r Date
. THE COMMONWEALTH OF MASSACHUSETTS
� 4vs
BOARD OF HEALTH
..........................................01.F................................:....................................................
C�rr�irtt#le of Tuntrlianre
THIS JS ERTI a the Individual Sewage Disposal System constructed ( ) or Repaired......
epaired ( )
byk;....... .................----.:, ..._.._..
tat ---•-•-- •I................................................... ...................................... ---------------------------------•---
................
----------
has;been installed in accordance with the provisions of TI 71_ ' jThe State Sanitary-Code as described in, the
application for Disposal Works Construction Permit No...............:.. - 'f`dated_. . Y
THE ISSIJANC OF THIS CERTIFICATE SHALO. NOT BE CONST E® AS A GBJARANTEE THAT THE
SYSTEM WI NCTION SATISFACTORY. ,� �
DATE..: .f G -��1�............................•---•--•----------..._.. Inspector. ..................................................................
THE COMMONWEALTH OF M SACHUSETTS
BOARD OF HEALTH
C r
t r
No......................... FEE........................
nrk pion rrntit a
..��� .
Permissions hereby granted------------------------------------- ---............-.......................................................................................
to Construct R it n I divi ual vt a e Disposal �t
s I. at No.. !/�
�y ' g P
--.......-•--••-•-•---•---••....•-------••- ..... ..,...
Street '
as shown on the application for Disposal Works Construction P mit No..:.._.._...-------- .Dated..........................................
' : k ........................................................
Board of Health
,DATE= ..........................................................
FORM I255 HOBBS`& WARREN. INC., PUBLISHERS i - "�
'h� 4r'ty,�„�4.l.r ti, w.ii�� x.; �. �'�1_� � ,,,�ia��°�t'�.." � n"���r«U`�, � r'-=•.x'?� .
,� 4 ",` ✓,`.� 8 ram•- �.: �•r �...�ya= •w°- iv q, � * � .; 4iw ;r
P`�-'`� i
h r ` _ r
June 1983
r .
Mr. and Mrs. James K. Jo _.
I8`'Sh dwoo(i Path. . Joyce
-West Yarmouth; Ma. 42173
Re Variance on Ldt .9, :Head of ,the Pond.Lane� Marston a Mills*
E 9!; '^.,' .• t-., A •.' ,�4°.•,tv'� C,V
' Dear ,.Mr.,s"'and `pJoyue: `y ♦ ;a
;n #:,n \ ]�+'*: - '` Y c�� •'^, � x 'rt �� .����y'1. ' �f,, 1,., � �xt •4 tom` ',y\ ,�:J' r�"k{g '� F Y � a
t t Y021 are gr nte inq pit 128c a' variance`to-'tinsta .l`" 'septic`leaGh t
rh .� feet from >a nei-ghboring Nell,• in lieu, of,',the required 150 feet
` 61i :,Lot�'19,k H`ae�t bf the'P�nd'Road � Marstol � 2�i
\ , r , is�, t tf eh;.the fcil--.
(1} 36AIi other. Town off Barnstable` Healthrr Regulat ons and
of ,the a p tate Environmental''Code,= must 'be
' striCtXy' adhered, to..
: This variance expires July k,. ,1984
,.s Ve' truly..vaurs- , f
k Chairman
t'tµ k r,/l, • •}'c Y.�.\ .t. r 4•y r" •ti E ♦ .. � '
E bough
r
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TC}WN QF BARNSTABLE
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p.,�q �• ba.. +a.�} xy:� ,_ +i -.wv �t�. w $'�h t rtR"%fir Yr:�' �.�; f ! ' .`o t _ r ., �..'a.rx�, t c ay'%.,.
� �'#'`} �'G_ �t � t � ;� „cr f '9'�� � °i 2 r ,{,v .s 'a F_`�• yy � �x t _q .; �
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FN
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� i fi►S R�3-r T �i ��;:" ro T �' f -s a � ;-t et �.� . �' Z.. � {,` ' � { �s ..^+�, ',�. �
-
v •
Mr . & Mrs . James K. Joyce
18 Wildwood Path
West Yarmouth, MA 02173
May 24 , 1983
Town of Barnstable
Board of Health
Main Street
Barnstable, MA 02601
To Whom It May Concern:
We are requesting a variance of the minimum requirements
regarding"the placement of ou°r septic systems. We understand
that the Town' s minimum requirement is that septic systems
be 150 feet from a well .
We are referring to Lot #19, located on Head of the Pond Lane ,,
Marstons Mills . The variance we--are requesting is 22 feet.
The reason for this variance , using: the topography of our
lot, there is a large central buildable plateau. We have
had our engineers stake out our septic system, and they
have removed it as far away from the neighbors well as this
plateau will allow.
We are 128 feet from this well , which is across the street
and elevated up from our lot.
We understand that your next hearing is June 7th. If our
presence is requested please notify us. Our request is for
only 22 feet. You may contact us at the following numbers.
Thank you for your consideration.
Sincerely,
James K and -La a Joyce
Builder : Richard Gifford
Engineers :James P. Lapsley, RLS, Cape .Cod Survey Consultants
771=3244-International House of Pancakes , Jim Joyce
775-6800-WCOD Radio, Laraya Joyce
771-4491-Home
e -tip—•---'
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REVISIONS:
TEST PIT DA TA DATE OY� TESTING: � _ _ PEPC. TEST DA T,4 SEPTIC TANfC' DETAIL SE� p - - ._r D/ST. BOX DETAIL LEACHING F CAL /T Y DETA /L� NO DATE
TEST By.* .. >�,�� -�; _
, T. P.
DATE OF TESTING: TANK TO CONFORM TO TITLE 5 REOU/REMENTS. TO CONFORM TO T/rLE 5 REOU/REMENTS:
WITNESSED BY f - TEST BY = _ �r > NO. OF OUTLETS:
' '-- --- -- -- WITNESSED WI BY: ,,,K 4._1 _ ua •,�,. a
S
MAN.T ROU'G TO �HOcL L
.,-- —_,._..,.-. _—r_^_ D •°_ r, p .,,..v `` , ° F 1 N I S/I�U GRADE. ,/ d.. d d �» - II
r
o v °, ;*' T -, LOAM 9 FILL /2 MAX,
a NE
-- ---- -- — --- -- 3 CLEAR 3 CL E AR o e
0
w OUTLET PIPES ( O } �
PEA
6"MIN. 2'MIN. 6'M/N ! AS REQUIRED
DEPTH OF TEST-- , -,, ;, ;��, � i i � i '
((RATE: DIST
— _l - --ram— ---- INLET TEE — Nk
O N _ r T (� BOX
71
y --- t— { . oUrL� TEE —(� �r i / I t
I i 4 C./. IOOO- GAL.
I ' " I
.s ,:• - j INLET AND OUTLET -. 4'0' MINIMUM '. p°I t___-- I --
( OUTL ET TEE DEPTH; / SEPTIC TANK i 24
i I I DEPTH /4"AT L i OUID DEPTH OF 4' 2 6 }_—� I PRECAST OR BLOCK
TEES TO BE CAST LOUD E I, CONCRETE i r
" „ I" SEEPAGE PIT
--- T —
/RO v ACHED. 40 f ,I !9 5 .° CONSTRUCTION I' I
DEPTH OF TEST: :j 24' " 6' O` I
1 PVC. OR CAST/N �. 29 7' �.'. b. ".,> '/PLACE A CE CONCRETE TE " MIN. -----
t RATE -- --- ------- -- ---- CONCRETE °_i 34 „ 8' BOTTOM ON LEVEL SrABLEBASE /
CONSTRUCT/Ol`v
r (WATER TIGHT)
INLET TEE PROVIDED WHERE SLOPE I -------------
t 4 ; . • r; D 6. FOUNDAT/ON I, i
• . O, INLET PIPE EXCEEDS O.OB /, OR
TANK TO BEABLE TO WITHSTAND I
BOTTOM OF TANK ON LEVEL STABLE BASE UNLES /N A PUMPED SYSTEM. i
H-IGGOADING ' S`I�lDER 24°M1N ----- 112'WASHED STONE i --
I PAVEMENT OR IN DR/V. H 20
__ } 1 j I L OA D I NG UNDER PAVEMENT OR
w; ,
+
,,e. '� .9', '., 41 „`"tr .a� .. ( ,^-"rw' ., r!" " '. _ nRlV£. -_ _ /C)
}
L___-_ i
•
i
RECOMMENDED MANUFACTURE _ / t
� ------- --_ ------ --_. RECOMMENDED MA,'UJFA CTURER ,�=,�,.•��'r ' ,~ .,-: __
I ,
a (OR APPROVED EOUALI
{ OR APPROVED EQUAL
. , - " _ � � E`ER T EL E A o � _--
,tIO TES q �' T IONS
°
PLAN �'I�" W .
r?
,. ,. , h'I 5 PLAIN I_ , .. R TfrE Dt S/,�N ,.-cf�J C��,'i�,SIPcJCr /O�'�r OF , ,6•r�L .,JL .YYAc�I_- .,.:• _ .• ,.. �.,•, _- .� .-
DISPOSAL FAICIL I T r ONLY.
} I��'I,!'. A'' SUILDING
4. 2. ALL CONST FrUCTION METHODS AND MA TEJRIAL S SHALL CONFORM T111,11
MASS. D,E.Q.F, TITLE 5 AND THE_ ----='— u' - IJN I! AT SEf'T/C TANK(IN) _' _' f ,�s
_ ._ ._ ,BOARD OF „
I IN l�A, SEPTIC TANK(C UO
HEALTH !rEG/iL.A�/ = __ — . . _ 1 r �tI
T.
OHS'. I � _.-'t-� •, 1V��+�4„�.,'�,
r ' —JINV AT DIST, BOX(OUT)
c
, p
a L EACHING FACIL I TY• --_— --
t .
ROSTO MASS WOROESTE MASS
4+. HALIFAX, MASS. NORWELL, MASS.
BEDFORD, MASS, LEXiNGTON, MASS.
HYANNIS, MASS. MANSFIELD, MASS.
•2 7 CRANSTON, R.I. DERRY, N.H.
I
rr
P � SCALE ;
. .
{{+ e V
Y r
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"SIGN DA TA "
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y
T
7
. - NF
Y
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444
I-E QUI RED SEPTIC TANK:
t - - CAL.
_ J
, —
-
-
"APE
,
V
-
_ LE ��
t F IACHING R QU RED SIZE FACILITY: _
_
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V
56
,
I YANNIS, MASS. 01
_ — ----- —-- —— -- i 1`) — i 15 5
I - T w ,
_ ar
_
\ C;� •lf.
DIVISION
F
} BOS OF SUR JEYCONSULTANTS IN
li
, Y
z` ?
3,
c+`' SIZE OF LEACHING /L/TYPROVIDED ENG}SEEPING 0 SURVEYING 4 ;
a
, 0� E FAC
rt �. _�� . , PE OF SYSTEM--
I
SEWAGE DISPOSAL. SYSTEM
,
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s ' Cl '4,m+' ..o A/V� .r
:
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FOR
fi 4
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,r SCALE
: AS SHOWN
t ( ------ -- V METERS ,-
FEET 0 E,
DATE:
f CF-lI�C€�:
I
I I ,
---------------
{
� _ — - — — — FILE NO:
DJ'J.a. NO. JOB NC7.
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