Loading...
HomeMy WebLinkAbout0125 HIGHPOINT ROAD - Health 125 Highpoint Road Marstons Mills P A 027 028 t I I its COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION FRECEILE TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 125 Highpoint Road Marstons Mills, MA 02648 Owner's Name: Jo-Ann Somma MAP Owner's Address: P.O. Box 177 PARCEL ' 0 Z: Forestdale, MA 02644Z Date of Inspection: September 9, 2003 !CT Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 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 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 Nee Further Evaluation by the Local Approving Authority Fail Inspector's Signature: Date: September 11, 2003 The system inspector shall subm' 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 I Page 2 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 125 Highpoint Road Marston Mills, MA Owner: Jo-Ann Somma Date of Inspection: September 9, 2003 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: 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: 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: 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 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 125 Highpoint Road Marstons Mills, MA Owner: Jo-Ann Somma Date of Inspection: September 9, 2003 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. 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 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 I Page 4 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 125 Highpoint Road Marston Mills. AM Owner: Jo-Ann Somma Date of Inspection: September 9, 2003 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow ✓ 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 I 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 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.] No (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 System: 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) 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 125 Highpoint Road Marston Mills. MA Owner: Jo-Ann Somma Date of Inspection: September 9, 2003 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: Yes No ✓ 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(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 125 Highpoint Road Marstons Mills. MA Owner: Jo-Ann Somma Date of Inspection: September 9, 2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 3 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system (yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied 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): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped 2 years ago-per owner Was system pumped as part of the inspection (yes or no): 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: Feb. 21101 -per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 125 Highpoint Road Marstons Mills, MA Owner: Jo-Ann Somma Date of Inspectiion: September 9, 2003 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron 40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting, evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 2' Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 6" Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage. The outlet cover was 12"below grade. GREASE TRAP: None (locate on site plan) Depth below grade: 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: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7 Page 8 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 125 Highpoint Road Marstons Mills, MA Owner: Jo-Ann Somma Date of Inspection: September 9, 2003 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box, etc.): The D-box was level. No solids were present. There did not appear to be any signs of backup or failure from the leach field. The cover was 13"below grade. PUMP CHAMBER: None (locate 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.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 125 Highpoint Road Marstons Mills, MA Owner: Jo-Ann Somma Date of Inspection: September 9, 2003 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits, number: ✓ leaching chambers,number: 2-500Qa1. drywells (25'x 13') 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.): There did not appear to be any signs of failure. The bottom to Qrade was approximately 7. CESSPOOLS: None (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 or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): PRIVY: None (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.): 9 Page 10 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 125 Highpoint Road Marstons Mills. AM Owner: Jo-Ann Somma Date of Inspection: September 9, 2003 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. a 01 � d � 3a as a a3S y- O 3 3 S� -7 S" 10 Page 1 1 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 125 Highpoint Road Marston Mills, AM Owner: Jo-Ann Somma Date of Inspection: September 9, 2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25 +/- feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record- If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using the Barnstable topographic map and the Cape Cod Commission water contours map the maps were showing approximately 25'+/-to ground water at this site This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 YOU WISH TO.OPEN A BUSINESS? For Your Information: Business certificates(cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town(which you must do by M.G.L.-it does not give you permission to operate.) Business.Certificates are available at the Town Clerk's Office, I'FL,367 Main Street,Hyannis,MA 02601 (Town Hall) t DATE: Fill in please: APPLICANT'S YOUR NAME: (BUSINESS YOUR HOME ADDRESS: LEPHONE # Home Telephone Number NAME OF NEW.BUSINESS T- YPE OF BUSINESS p IS THIS,A HOME OCCUPATION- _YES �NI3 Have you been g'lveh.apprbval#rvm.tho btiildin diiiision�. YES NO ' ADDRESS OF BUSINESSIf R, MAP�PAIGEL,NUMBER When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd.&Main Street) to make sure you have the appropriate permits and.licenses required to legally operate your business in this town. 1. BUILDING CO MM SI ER'$ FFI E. This individual h 's en inf, r ne any permit requirements that pertain to this type of business. Auth ized.Si ature** _ CO MENT �` IQ V 2. BOARD O t, EALTH This individual t Me infor e h per i requirements that pertain to this type of business. A thonz Si ture* i COMMENTS: 3. CONSUMER AFFAIRS(LICENSING AUTHORITY This individual ha en info ad of th e s n requirements that pertain to this type of business. � � � A Authorized Signature* COMMENTS: n TOWN OF/BARNSTABLE + 'LOCATION /2S �oiy7" �c� SEWAGE # /- D 92 .VILLAGE 4fxootVOVJ 4' Ajy,//s ASSESSOR'S MAP & LOT-D 22- D28 INSTALLER'S NAME&PHONE NO. 477-03Y j �oSLi ��/ �;•,p®S SEPTIC TANK CAPACITY /000 GA� LEACHING FACILITY: (type) (size) N.O. OF BEDROOMS BUILDER OR OWNER FhKMITDATE:1 - 4 y- Ul COMPLLkNCE DATE: -C .� l O/ Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 acility). Feet .Furnished by i } V t i TOWN OF BARNnST,�ABLE LOCATION I a fad /` C. SEWAGE # Cl l r 0 g a VILLAGE ✓f'1' ` S ASSESSOR'S MAP & LOT OX7- oc� INSTALLER'S NAME&PHONE NO. ^EPTIC TANK CAPACITY LEACHING FACILITY: (type) o�- S� rb wcl(s (size) oZ Sx /3 T10.OF BEDROOMS 3 BUILDER OR OWNER J 0"4.144.. SC9 Mi+'l PERMTTDATE: 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 acility) Feet ' Furnished by Tn X' -" I ro • ' 11 t, I � Q a a3 s y7 O 3 ti TOWN OF BARNSTABLE L�10EYITON /2 4 �O/0 _g SEWAGE # O/- 092 VILLAGE Zif0 P0,,g S ASSESSOR'S MAP & LOT'Q 2 INSTALLER'S NAME&PHONE NO. /77-�QI Z f ,/S40W4 SEPTIC TANK CAPACITY /000 LEACHING FACILITY: (type) 2-500 e-VI-/lS (size) NO. OF BEDROOMS _` BUII DER OR OWNER ''','PERMITDATE: 2 -20- O! COMPLIANCE DATE: 1"O/ Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Welland 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 acility) Feet Furnished by S ' 4 7 L_ 1 a TOWN OF BARNSTABLE LOCA'JON 12T—�> inp e7"L c2 ck rwRGm_#' V?LLAGE I 1 a(-n5�rfs� ASSESSOR'S MAP 6i LOT SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL PUBLIC WATER BUILDER OR OWNER 1 c ren G Na �� DA TAB �o�rPi�IA�i�E ISSUED: VAR NCH-G A_NlfED:Yes No � ,_ �� t /�� \Y C � \ c ✓�� \\) (` � �� �� O �_ � ` �� _�— -� CN Irt �� �� s N T�wr or�AsTABLEti► S. e r SE wACE ASSESSGR'S Ajj&'VIMA 3s I�OT` INSTALLER'S NAME& SEp'!ZC TAvx CALF c£TY � r MGfIFrTG FACII.3` -tom) Na OF-%EDRO-() lS BU"BR OW t3jN"t ER PERRdITDATE C(?lVfi=T.t ►NCE DATE:' Sapatatian Dcstance Breen�e Ad ustdd Groundwater Tabte to the Boriom oflamhing Fac�t�ty Feet Maximiun P ivate'tatar:Supply Ell aridLeac ing Fac ltt3► Elf anY w exist: Feet. as site or ahttun?AQ feet of ies�clung faccY) Edge p£V hga' is Feellnde d within 3(iEl;feet of teaelun factlit)►] ce, 6 G / ,3. a5 3- /,� ' Fee s'—� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Yes 0ppYicatiou for Dtoomt *proem Com5tructiou Verna Application for a Permit to Construct(L.) epair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. /.�{5� /�y pV j j Owner's Name,Address and T 1.No. Assessor's Map/parcel Installer's Name,Address,and Tel.No. Designer's r4ame,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot 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 Ss3 h�Jc/ Nature of Repairs or Alterations(Answer when applicable) i yT!¢�� ' S 06 /91, ull<-/ '1/ "Jro 0 n- Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed Date 2- a- C/ Application Approved by / Date Z—Z-V—C1 Application Disapproved for the following reasons Permit No. -Z uy /—0 9 Z Date Issued 7/ r/ C � ` o: " Fee _/ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYication for Migooal *pgtem Construction Permit Application for a Permit to Construct(, 44. epair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. / S t7/CIGj j�U v/T/Q Owner's Name,Address and Tel.No. �/, .y1://.S Her✓�:y S�iT� Assessor's Map/Parcel / 6.:4 028 of 12�f ,l�il./` Installer's Name,Address,and Tel.No. e/"/7- U 3 4/9 Designer's ame,Address and Tel.No. Jds-ef?�i U� /,3ayros Jr„-e�o� D< /3.�vrHo_s I Type of Building:,,, Dwelling No.of Bedrooms .3 Lot 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 S.g N�1z1 r Nature of Repairs or Alterations(Answer when applicable) Zvi 17-,Ao S O6 t1, u/"?/ y 'Sro Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system tt in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this)3oard of Healt . Signed Date 2- o- v/ Application Approved by Date Z— 7.0— U l Application Disapproved for the following reasons dof a Permit No. 7"ejU I— d Z Date Issued -------------------- ------------------ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( G-Mepaired( )Upgraded( ) Abandoned( )by Jos Li 0, rar.^aS at Pof yr �o ltq HSToh "1 1 has been constructs in ac ordance with the provisions of Title 5 and the for Disposal System Construction Permit No.74V/- 01 Z dated Z U 7-vv Installer b Jos clo� L& A"i- c"5 Designers U� The issuance of this permit hall qpt be construed as a guarantee that the sys el -11 fu t�io designed:' Date Z/ Z'� Inspector 0 G� 1' lei --------------------------------------- No. Fee ' . O 2 7 ,0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS ligosal bpstem Construction Permit Permission is hereby granted to Construct( 4-)-Repair( )Upgr de( )Abandon( ) System located at / 2 5' H, 1-2a/� r 1v/irr!5/vyS 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:Constructio must a completed within three years of the date of this it. Date: 2�TiU U/ Approved by=''/ 6 � 1/6i99 NOTICE: This Form Is To 'I e Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH .kND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (-WITHOUT DESIGNED PLANS) he:eby certiry that the application for disposal works construction permit signed by me dated concerning the propery Located at 125- t-V,r RV //, meets all of the Following criteria: ,oO�T-he failed system is conne^ed co a residendal dwelling only. i nere are no commercial or business uses associated with the dwelliins. The soil is classined as CLASS I and the pe:cpladon rate is less than or eoual to 5 minutes pe: inca. �Tze:e are no wetlands within 100 Feet of the proposed septic system ne:y are no private wells within 1J0 fey;of the proposed sez)dc srse n There is no inczease in flow and/or change in use proposed here are no variancys requested or neyded. �7n oottotn of the proposed leaching facility-will riot be located less than Eve [eyt above the ma.amurn adjusted—,-oundWate:table elevadon. (?adjust the z-oundwater table using the Frimptor method when applicable] • If the S.A.S. will be located with'f0 e--, of an-i vegetated wetlands, the bottom of the proposed leac.iing facility will not be lecaced !ess than ouneyn re`,,above the ma.,cirn urnadjured 9youndwater cable elevation, Please complete the following: A) Too of Ground Suracy =l(riad on using ( , GIS intormacion) f B) G.W. Elevadon _the :NLA2C --igh G.W. Adjustment . _ 2 DT—:=RE`+CE 8ET,',,-E`ti a,and 3 f/9, 4001, (Sketch proposed plan of sysem on bac:c1. q: c.ich faidr..:-t . 1 . <k i� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System torn-Not for Voluntary Assessments 125 Highpoint Rd Property Address Chase Bank clo N.E.Prop. Solutions, Braintree Ma. Owner Owner's Name information is Marston's Mills Ma 02648 6/7/10 required for every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your Vance Steve Young cursor-do not Name of Inspector use the return v key. Company Name � P.O. Box 1592 Company Address Manomet MA 02345 eB'0 Cityrrown state Zip Code 508-759-5603 s1686 _ 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 t« =' Title 5(310 CMR 15.000).The system: ` g_ -- ® Passes ❑ Conditionally Passes ❑ Fails 'y " ❑ Needs Further Evaluation by the Local Approving Authority . , 6/7/10 Inspector' '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 the same or different conditions of use. t5ins•09/08 Title 5 Official Inspection Form:Subsurface ge Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments yr 125 Highpoint Rd Property Address Chase Bank c/o N.E. Prop.Solutions, Braintree Ma. Owner Owner's Name information is required for Marston s Mills Ma 02648 6/7/10 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: 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•09= Title 5 Official In spection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 125 Highpoint Rd Property Address Chase Bank c/o N.E. Prop. Solutions, Braintree Ma. Owner Owner's Name information is Marston s Mills Ma 02648 6/7/10 required for every page. Cityfrown State Zip Code Date of Inspection B. Certification (cunt.) 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): f ❑ 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 obstructedpipe(s). The Y q p P 9 Y 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-09/08 Tice 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts qi .U lag Title .5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 125 Highpoint Rd Property Address Chase Bank c/o N.E. Prop. Solutions, Braintree Ma. Owner Owner's Name information is required for Marston s Mills Ma 02648 6/7/10 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ - The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well*". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory,for 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 125 Highpoint Rd Property Address Chase Bank c/o N.E. Prop. Solutions, Braintree Ma - Owner Owner's Name information is required for Marston s Mills Ma 02648 6/7/10 every page. cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the.last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The R 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•09/08 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 °( 125 Highpoint Rd Propery Address Chase Bank Go N.E. Prop. Solutions, Braintree Ma. Owner Owner's Name information is required for Marston s Mills Ma 02648 6/7/10 every page. citylrown 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? ❑ N 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? . 0 ❑ 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): 330 t5ins•09/08 Title 5 Official Inspmton Forth: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 y< 125 Highpoint Rd Property Address Chase Bank c/o N.E. Prop. Solutions, Braintree Ma. Owner Owner's.Name information is required for Marston s Mills Ma 02648 6/7/10 every page.. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 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)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 6/1/10 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on.310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. yt 125 Highpoint Rd Property Address Chase Bank Go N.E. Prop. Solutions, Braintree Ma. Owner Owner's Name information is required for Marston s Mills' Ma 02648 6/7/10 every page. Cityrrown state Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (d yes, attach previous inspection records, if any) ❑ Innovative/Altemative 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•09M Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 125 Highpoint Rd Property Address Chase Bank c/o N.E. Prop. Solutions, Braintree Ma. Owner Owner's Name information is required for Marston s Mills Ma 02648 617/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components,date installed (if known) and source of information: 9 yrs per as-built Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): . Depth below grade: feet Material of construction: ❑ cast iron ❑ 40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints,venting,evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 12" 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: 8x5x5 Sludge depth: 4" t5ins-09= Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y< 125 Highpoint Rd Property Address Chase Bank cto N.E. Prop.Solutions, Braintree Ma. Owner Owner's Name information is required for Marston s Mills Ma 02648 6/7/10 every page. C41rown State Zip Code Date of Inspection D. System Information (cunt.) Septic Tank(cunt.) 261 , Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 8" Distanc6 from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? measure stick/estimated Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): TANK INTEGRITY OK INLET AND OUTLET BAFFLE OK .LIQUID IS LEVEL WITH THE OUTLET INVERT Grease Trap (locate on site plan): Depth below grade: feet Material of construction: y ❑ 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•09= Title 5 Offal Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts IMMI Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "< 125 Highpoint Rd Property Address Chase Bank c/o N.E. Prop. Solutions, Braintree Ma. Owner Owner's Name information is required for Marston s Mills Ma 02648 6/7/10 ,. every page. City/Town State Zip Code Date of Inspection D. System Information (cunt:) Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day, fi 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-09/08 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 125 Highpoint Rd Property Address Chase Bank Go N.E. Prop. Solutions, Braintree Ma. Owner Owner's Name information is required for Marston's Mills Ma 02648 6/7/10 every page. Citylrown, state Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box, etc.): . .INTEGRITY OK NO STAINING ON WALLS OF BOX ABOVE THE INVERT LINE AND NO EVIDENCE OF SOLIDS CARRY-OVER 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.): Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09= Title 5 Official lnspecbon Form:Subsurface Sewage Disposal System-Page 12 of 17 NN Commonwealth of Massachusetts Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "< 125 Highpoint Rd Property Address Chase Bank c/o N.E. Prop.Solutions, Braintree Ma. Owner Owner's Name information is required for Marston s Mills Ma 02648 617/10 every page. City/Town State Zip Code Date of Inspection D. System Information (con't.) Type: ❑ leaching pits number: ® leaching chambers number2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: _ ❑ innovative/aftemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): only 3"of effluent on bottom of dry well, indicating leaching system to be working adequately at this time. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top.of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts MAN; Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments rr 125 Highpoint Rd Property Address Chase Bank c/o N.E. Prop. Solutions, Braintree Ma.. Owner Owner's Name information is required for Marston s Mills Ma 02648 6/7/10 every page. Cityrrown 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.): soil is dry in area with avg. veg. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09= Title'5(Wide]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 "Y 125 Highpoint Rd Property Address Chase Bank Go N.E. Prop. Solutions, Braintree Ma. Owner Owner's Name information is required for {Marston s Mills Ma 02648 6M10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System:°Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate Where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately a O o a a3 s y7 O 3 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y� 125 Highpoint Rd Property Address Chase Bank Go N.E. Prop.Solutions, Braintree Ma. Owner Owner's Name information is required for Marston s Mills Ma 02648 6/7/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ❑ Check Slope ❑ .Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 25 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: 2/20/01 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: per plan on file Before filing this Inspection Report, please see.Report Completeness Checklist on next page. t5ins•09106 Trtle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 125 Highpoint Rd Property Address Chase Bank Go N.E. Prop. Solutions, Braintree Ma. Owner Owner's Name information is required for Marston s Mills Ma 02648 6/7/10 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17 s A 0 7- n/ _ a ........ THE COMMONWEALTH OF MASSACHUSETTS BOARD �OF HEALTH ✓ ..........OF......a. .!'!%7.: GJ.1. .------------------------------------- Appliration -for 4iipoiial Worho Tomitrurtion Prrutit Application is hereby made for a Permit to Construct (f✓) or Repair ( a Individual Sewage Disposal System at, l� uGe� /jI'on•Address �1 �j�4�� ner Address Pa Installer Address U Type of Building Size Lot.... ® ...Sq. feet Dwelling� . of Bedrooms---------,,--I.............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures ----------------------------------------------------------------- W Design Flow(.—�_______________________ O.�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--_-___-_----__-t_ Total leaching area_.-.-.--_--_---__---sq. ft. Seepage Pit No......../`---------- Diameter....Z.r.......... Depth below inlet_. _'_ ... Total leaching area.... ---sq. ft. Z Other Distribution box ( d,-T Dosing tank ( ) aPercolation Test Results Performed by................................... �.. Js .............. Date--•-------•------------ y � s T-e9�t Pit No. 1................minutes per inch Depth of Test Pit-.l� ____ Depth to ground water. �._.. 'u 44 Test Pit No. 2.....40__._.__minutes per inch Depth of Test Pit----- Depth to ground wafer—A, _ P ®----------------------------� -------- --�•----------•---•-...................... Description of Soil ............................. - {S9.c = - wx ...9r 9 >--•------�-------�_�----..�. � S O�l e ...... 1 a _ �� I M6c�©04.EJ_ _ - � ---------------------- - r --- U � Nature of Repairs or Alterations—Answer when applicable.. a_A._._T,._, --•-------------------``-��0`�=,J-`-__---Yam.``----- Agreement: . � 01� AY �a The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been 'Z d b the board of health Sign, d ------------------------- Date Application Approved By................... C......-• S l?� �f�2 _1 ... Da e Application Disapproved for the following reasons:---•---•----•--•----------------••---------•---.....--•---------•--•-----•--•--.........--------•--------•--•--- .................................................-..................................................................................................------ ----- - ---- ------- ------ ------------------ D Permit No......................................................... Issued ate -7�-... Date No..... - ' , r FuE.................................� THE COMMONWEALTH OF MASSACHUSETTS BOARD - OF HEALTH ApOra`Vou'-for 43-Wpoiial Works Cnom Uurtion 13rrmit Application_is hereby made for a Permit to Construct (4, ) or Repair ( ) an Individual Sewage Disposal Systemsat:., c...... f... #r ids'.' fa f� ....�/r� Ji"-'�f�.�%Location-Address / , ov s Lot wJr11y o �L A. Address W Installer Address Q Type of Buildin�g Size Lot... ._. ......................Sq. feet U Dwelling- No. of Bedrooms---__-_-- -----------------•_--_----_-Expansion Attic ( ) Garbage Grinder ( ) per, Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) P I - Other fixtures ----------------------------------------------------- W Design Flow---__________.................:..;6._._gallons per person per day. Total daily flow................ ----------.....gallons. WSeptic Tank "''Liquid capacity°l� ygallons Length......:......... Width---------_..... Diameter-------.-------- Depth---------------- x Disposal Trench—No- ____________________ Width-------------------- Total Length____._______.__.__.. Total leaching area_.._.__.___..._____sq. ft. Seepage Pit No......../.......... Diameter... Depth below inlet_.46..:'..6..... Total leaching area... ft. Z Other Distribution box (-.,j Dosing tank ( ) Percolation Test Results "- Performed by......:............................ .......................................... Date------------------ Test Pit No. 1................minutes per inch Depth of Test Plt -____ Depth to ground watt, Test Pit No. 2..... .......minutes per inch Depth of Test Pit.... :. '.' . Depth to ground wate"t� -/- ------- ---- / Description of Soil__/G'''.�_. ... ✓�.. `� = ' rf✓Gcd �s.. V ." •----���s......... d --�'-o�r i `---- M -------------- -•!Aflj--------`�-------/Y------------` -''+�l/�---- j t-`�`�.�, � ____E 90 `GISTS U Nature of Repairs or Alterations—Answer when applicable-------------------------------------------------------- -- - _-_- ---- ------------------------•-----.....- ------- ------•------------•------••-•------•--------------- •---------------------------------------- ---------- ----- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system.in operation until a Certificate of Compliance has been s d by the board of hea h. Signed! .. . _ {... � _ ---- - r, y^�,.. Date Application Approved By ' �' =--.. ••... rt -- ------------ Date Application Disapproved for the following reasons:.............................•---------_--------------_--•---_--------_----------------------------------------- --•-----•----------•-------------------------------------------------------- Date PermitNo.--------•-_----------•-- ----...................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS - _ BOARD OF HEALTH mwrrtif irate of TOutphaurr -= THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( ) by------------------------------------------------------------------------------------------------------------------------ -- I ,,atle G ./ at ------------_-------_ f " � 'r 'l'"f �!'ca`>7! C ��---- �z�t f✓ .....................................� has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No----- . ___-----_-------_---- dated ' .� .?�� _______..___. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU AS A GU ANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE-------------------------------------------------------------------------------- Inspector---•--. -------- --------------------•-- THE COMMONWEALTH OF MASSACHUSETTS l BOARD OF HEALTH ............ . �. ..�° of..- ..... . ..---... ..... .....--------------..........------.... ,- No.•---• -•---- FEE RnVwial lVarkii Qlangtrurtion rrrmit Permission isilereby granted-------------------••------------------------------ •----•------------- ............................................................... to Constr ct ( or Repair ( an,Individual sewage D,is .os System / ,x at No.- •--- - _...A;�-�/24Zr7 f �........................d1.Z:2? "'J"'° --- -- '` � " =----------- ----- . . Street .,W ,, as shown on the application for Disposal Works Construction Permit No.r _ = �`Dated = -�- - ---------•-•-----------•----------•------------------------------•-----_--------------.................. Board of Health ' DATE-------------------------------------------------------------------------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS 'S 1 - - • v r r M6�= CIVIV'alr/ � • r 4 i r . ~ 0.3� eplz t-, O 0 /.yr =�? 2 /av= a Alf" y � �'f�,. //� �i� ✓.�1 yQ�/�/ ��� � .r T O O O p p f%7`., :' �C/�ilC/ �'G?//Q�J i•l/�v use. .. /� l: n� O O O O O //'/G��� a, . O O O O O �. // T //� ,a 'a ? "; .e r— ��_ .-: - _ _.-;.:.. .► '— .�C�r� �i�af/�l'Q �Gvb�T/D/L5 • // S �r�. ors phi /ate drQ � � - - �i ii /- �i7T - ;��y �,oaQaa/' or7 �hQ�, ova ► • � �Q" " alTd �ha/ �V2Qy . � L f y O BERT MASs9� * y McGLOME \ r ii!• No. 12057 N S � - � � ,G►t/JTLLt�.jf � ,� Ale � •` .. .i Fib � - � .. "146 der ff } Z0,7 ac O., 67,,17c2 ���....' ,.,y,... . _ ,�` � _ - wig!/ f�� �s�•�•�1s 6� 71