HomeMy WebLinkAbout0097 HUCKLEBERRY LANE - Health �97 Huckleberry Lane
Marstons Mills P
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No. j 5 Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
9ppf ration for MispoBal 6pstrm Const urtiott Vfmit
Application for a Permit to Construct( ) Repair(✓) Upgrade( ) Abandon( ) ❑Complete System [Individual Components
Location Address or Lot No.91 a1¢,6tc rt t,o n t, Owner's Name,Address,and Tel.No. 5+4LVtn W alke r
MA(Skons A.\t4
Assessor's Map/Parcel — 9l H4%)CA ebuc% Ln. S 02' 1q2 Olyy
Installer's Name,Address,and Tel.No.5 j B 1;,x c avalC+o n Jjc, Designer's Name,Address,and Tel.No.
3'1`I 901J4t, 130 So,ndW'-%>, 5'08.417.06S3 �-box ftmova\ ont
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(min.required) Ir gpd Design flow provided - gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank 1000 qa\\on Type of S.A.S. [1) S-00 no.\\cn C�,&m6ec5
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) eve 0 r i a; n a1 6,►Jox -6%k is 'i den r
C,o�&0Ao� and. c•eolace. PVG a•cc . S.asAa�, (i1fCa(R\b ho.s 2 db ,s
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 Certificate of
Compliance has been issued by this Board of Health.
Signed Date u 20
Application Approved by Date V
Application Disapproved by Date
for the following reasons
Permit No. ��-� s C� Date Issued �� ��
P q
No. J l Fee 4!
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
4plication for -Misposal *psfirm (Construction Vermit
Application for a Permit to Construct( ) Repair(V� Upgrade( ) Abandon( ) ❑Complete System [ Individual Components
Location Address or Lot No.11 HUC.0 c:!oe(r,J �, ;,�e Owner's Name,Address,and Tel.No. S+eve Y, \4 c\1VCe r
MncS}onr> SoL 2c2 01If
Assessor'sMap/Parcel 3 �� .E;vcki,�c.cr�� Ln. ` ' ` ``
Installer's Name,Address,and Tel.No.6 {� x c n u(, ,o n (n�• Designer's Name,Address,and Tel.No.
3�y (�,ocJac !3G �jnnccw•�c. 5 U2 - c,-r.. pt��3 �-hox ! 2mo�a\ onl
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(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title '
Size of Septic Tank \0 00 al\o n Type of S.A.S. Z� 7-oc>
Description of Soil
_ Nature of Repairs or Alterations(Answer when applicable) (1, ,,,n,;o n r;,r,n\ �I_hn Y 4\.r,!
C Un(t,i iir•, n r�(1 nnla ,r (,.,,i4, l� ��( ��� ^�.•1...,-a ( ,oCt,: A\.
` 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 Certificate of
Compliance has been issued by this Board of Health.
Signed Date lei o
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. V y ' S Date Issued '1 — X tJ
----------,-,---�------------------------------------------------------------------------------------------------------------------------
� %v THE COMMONWEALTH OF MASSACHUSETTS
;1 BARNSTABLE,MASSACHUSETTS
Certificate of Comptiance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(✓) Upgraded( )
Abandoned( by
at �A,,L 1 I Q.t>Q c c L\ L n e has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.)d�Q '1515 dated l U
Installer �t.x cn \•,�x, ',, Designer NA • d- hor noky
#bedrooms Approved design flow gpd y
The issuance of this prer�mit hall n be construed as a guarantee that the system wil function as d si
Date / Inspector
---------------------------------------------------------------------------------------------------------------------------------------
No. U (f .- 19 Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
MIsposal *pstrm Construction 2nermit
Permission is hereby granted to Construct( ) Repair(,�) Upgrade( ) Abandon( )
System located at �� , .((l o c r u L n• n(<F o n- M !i c
1
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be co m feted within three years of the date of this permit. e—,
Date U Approved b ( 6
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Commonwealth&Massachusetts
6F Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
/,
v 97 Huckleberry Lane f
Property Address
Steven Walker
Owner Owner's Name
information is Marstons Mills Ma 02648 6-23-2020
required for every
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
'Important:When';filling out forms A. Inspector Information
..:on the computer, Daniel Hawkins
use only the tab
key to move your Name of Inspector
cursor-do not B&B Excavation
use the return Company Name
key.
374 Route 130
Company Address
Sandwich Ma 02563
City/Town State Zip Code
rrnv (508)477-0653 S114324
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ❑ Passes
2. ❑■ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
DanHawklns ':,Digitally signed by Dan Hawkins
rl k ''.Date:2020.06.2508:29:23-04'00. 6-23-2020
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
f
c Commonwealth of Massachusetts
ip Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not,for Voluntary Assessments
97 Huckleberry Lane
Property Address
Steven Walker
Owner Owner's Name
information is Marstons Mills Ma 02648 6-23-2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and,all of 4 and 6.
1) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
I
2) System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
' Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
97 Huckleberry Lane
Property Address
Steven Walker
Owner Owner's Name
information is Marstons Mills Ma 02648 6-23-2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
E] distribution box is leveled or replaced ❑Q Y ❑ N ❑ ND (Explain below):
The system has 2 d-boxes. The first is in poor condition and in need or removal/replacement
and the second is in working order. Tank and leaching were in working order.
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
c Commonwealth of Massachusetts
�d Title 5 Official Inspection Form
T . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
97 Huckleberry Lane
V�
Property Address
Steven Walker
Owner Owner's Name
information is Marstons Mills Ma 02648 6-23-2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS Is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
*"This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ 0 Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ 0 Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
97 Huckleberry Lane
V�
Property Address
Steven Walker
Owner Owner's Name
information is Marstons Mills Ma 02648 6-23-2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ 0 Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ a Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
❑ ❑ Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ El Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ Q Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ a Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ E 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.]
❑ El The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ 0 The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be '
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
cam, Commonwealth of Massachusetts
�n ,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
97 Huckleberry Lane
�u
Property.Address
Steven Walker
Owner Owner's Name
information is Marstons Mills Ma 02648 6-23-2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
❑ El Pumping information was provided by the owner, occupant, or Board of Health
❑ El Were any of the system components pumped out in the previous two weeks?
1-D ❑ Has the system received normal flows in the previous two week period?
❑ Q Have large volumes of water been introduced to the system recently or as part of
this inspection?
El ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
❑ E] Was the facility or dwelling inspected for signs of sewage back up?
❑ ❑ Was the site inspected for signs of break out?
El ❑ Were all system components, excluding the SAS, located on site?
El ❑ 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:
0 ❑ Existing information. For example, a plan at the Board of Health.
❑ 0 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)]
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
97 Huckleberry Lane
v
Property Address
Steven Walker
Owner Owner's Name
information is Marstons Mills Ma 02648 6-23-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
3 Number of bedrooms(design): Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
Description:
Permit on file with Board of Health 12-14-1999
Number of current residents: 4
Does residence have a garbage grinder? ❑ Yes No
Does residence have a water treatment unit? ❑ Yes No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes 0 No
information in this report.)
Laundry system inspected? ❑ Yes 0 No
Seasonaluse? ❑ Yes [R No
'Water meter readings, if available (last 2 years usage (gpd)): See below
Detail:
2019- 65,000gallons 2018- 54,000gallons
Sump pump? ❑ Yes ❑■ No
Last date of occupancy: Current
Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
i*
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
97 Huckleberry Lane
u�
Property Address
Steven Walker
Owner Owner's Name
information is Marstons Mills Ma 02648 6-23-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
NA
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
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: Owner- tank has never been pumped
1
Was system pumped as part of the inspection? ❑ Yes ❑■ No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
97 Huckleberry Lane
Property Address
Steven Walker
Owner Owner's Name
information is Marstons Mills Ma 02648 6-23-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
El Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
12-14-1999 per permit
Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No
5. Building Sewer(locate on site plan):
1 r4"
Depth below grade: feet
Material of construction:
❑ cast iron ❑■ 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: Town waterfeet
Comments(on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
97 Huckleberry Lane
Property Address
Steven Walker
Owner Owner's Name
information is Marstons Mills Ma 02648 6-23-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
411
Depth below grade: feet
Material of construction:
❑■ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
1
Dimensions: 000gallons
10"
Sludge depth:
2611
Distance from top of sludge to bottom of outlet tee or baffle
1"
Scum thickness
311
Distance from top of scum to top of outlet tee or baffle
1711
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The tank was in working order at the time of inspection. The tank is in need of pumping
at this time and should be pumped every two years for maintenance.
I
t5insp.4oc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
97 Huckleberry Lane
Property Address
Steven Walker
Owner Owner's Name
information is Marstons Mills Ma 02648 6-23-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
NA
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
NA
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
l5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
li
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�J� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
97 Huckleberry Lane
v�
Property Address
Steven Walker
Owner Owner's Name
information is Marstons Mills Ma 02648 6-23-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Orr
Depth of liquid level above outlet invert
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.):
2 d-boxes were located during inspection. The first d-box is in poor condition and is in
need or replacement/removal and the second is in working order.
l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
�m Title 5 Official Inspection Form
+' � Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
97 Huckleberry Lane
Property Address
Steven Walker
Owner Owner's(Name
information is Marstons Mills Ma 02648 6-23-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
NA
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
(2)500 gallon chambers
El leaching chambers number:
El leaching galleries number:
EJ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
i
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
�= Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
97 Huckleberry Lane
u=
Property Address
Steven Walker
Owner Owner's Name
information is Marstons Mills Ma 02648 6-23-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
The SAS was in working order at the time of inspection. Leaching chambers were
1/2 full when viewed.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
NA
Number and configuration
Depth—top of liquid to inlet invert
li
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 P Y rY
` cam 97 Huckleberry Lane
u
Property Address
Steven Walker
Owner Owner's Name
information is Marstons Mills Ma 02648 6-23-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
NA
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
I
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
L
cam, Commonwealth of Massachusetts
�v Title 5 Official Inspection Form
7 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
97 Huckleberry Lane
v
Property Address
Steven Walker
Owner Owner's Name
information is Marstons Mills Ma 02648 6-23-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells'within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
■❑ hand-sketch in the area below
❑ drawing attached separately
A
0
Front
O
B C
2
Al-16' 81.18'
A2.30' 82.11'
B3.W C3.26'
84-26' C4.43'8"
)10
l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
U
97 Huckleberry Lane
Property Address
Steven Walker
Owner Owners Name
information is Marstons Mills Ma 02648 6-23-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
■❑ Check Slope
Surface water
❑0 Check cellar
❑■ Shallow wells
No GW 16'
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
0 Checked with local Board of Health -explain:
A previous inspection report provided by Board of Health
❑ Checked with local excavators, installers -(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
A previous inspction on file at the local Board of Health was used to determine high groundwater.
Bottom of SAS is above high ground water.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
w Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
97 Huckleberry Lane
u%
Property Address
Steven Walker
Owner Owner's Name
information is Marstons Mills Ma 02648 6-23-2020
required for every
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
W■ A. Inspector Information: Complete all fields in this section.
■❑ B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
■❑ C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6 (Checklist)completed
❑ D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
COMMONWEALTH OF MASSACHUSETTS �
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS .
DEPARTMENT OF ENVIRONMENTAL PROT—,E— —
NOV 1 12003
MAN OF BARNSTABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
MAP
Property Address: 97 Huckleberry Lane PARCEL ; y
Marstons Mills
Owner's Name: Joseph and Georgette Messina LOT
Owner's Address:
Date of Inspection:
Name of Inspector:(please print) W i 1 1 i am E_ • Robinson Sr
Company Name: William E. Robinson Septic Service
Mailing Address: P 0 Box 1089
Centerville, MA
Telephone Number: (508) 775-8776
CERTIFICATION STATEMENT
1 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.1 am a DEP
approved system inspector pursuant to See ' n 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: s,�. Date: /0 ,76v D e3
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heatth-m
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design now 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 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:_ 97 Huckleberry Lane
Marstons Mills
Owner: Joseph and Georgette Messina
Date of Inspection:
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
�/ 1 have not found any information which indicates that any of the failure criteria described in 310.CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
rep ired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Ans er yes,no or not determined(Y,N,ND)in the for the following statements.if"not determined"please
expl
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unso d,exhibits substantial infiltration or exfiltration or tank failure is imminent_System will pass inspection if the
exist' g tank is replaced with a complying septic tank as approved by the Board of Health.
•A tal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indic ting that the tank is less than 20 years old is available.
ND xplain:
Observation of sewage backup or break out or Idgh static water level in the distribution box due to broken or
ObsRucted pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
appr val of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND exp ain:
e system required pumping more than 4 tines a year due to broken or obmxied pipe(s).The system will
pass ins ection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND a lain:
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 97 Huckleberry . Lane
Marstons Mills
Owner: TosPph and C; nrgPtte Messina
Date of Inspection:
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 fail' to protect public health,safety or the environment.
1. stem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
s stem 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. Sys em will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system s 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
sur ace 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 front a
rivate water supply well•• Method used to determine distance
` This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
b cteria and volatile organic compounds indicates that the well is free from pollution from that facility and
th presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
fai ure criteria are triggered.A copy of the analysis must be attached to this form.
3. Ot er:
i
3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 97 Huck1eberry Lane
Marstons Mills
Owner: Joseph essina
Date of inspection: ti— 0^CGS
D. ystem Failure Criteria applicable to all systems:
Yo 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.oudet invert due to an overloaded or clogged SAS or
cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less than',day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within I00.feet of a surface water supply or tributary to a surface
water supply.
I .
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 f^_et from a private%2=
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.]
(Yes/No)The system fails. 1 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.
Large Systems:
o be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000
g d.
Y u must indicate either"yes"or"no"to each of the following:
( e following criteria apply to large systems in addition to the criteria above)
ycs no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a smfface drinking water supply
_ 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 y u have answered"yes"to any question in Seztian E the system is considered a significant threat,ar answered
tt e in Section D above the large s stem has failed.The uAmcr or for of large system considered a
YY operator ar►Y g Y .
sign ficant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.3 4 The system owner should contact the appropriate regional office of the Department.
4
Page S of l l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 97 Huckleberry Lane
Mar�tc�nG Mi 1 1
Owner: Tnca� and georgette Messina
Date of Inspection:,/U-3 c—o
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
I// Were any of the system components pumped out in the previous two weeks?
All Has the system received normal flows in the previous two week period?
A/ 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?
4Z Were all system components,excluding the SAS,located on site?
t/ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffl/es 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 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 97 Huckleherr-yLLane
Marstons Mills
Owner: Joseph and GPnrQettP Messina
Date of inspection: j�a^.�
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual): i3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x/i of bedrooms): �!d
Number of current residents: Ao
Does residence have a garbag inder(yes or no):gr
Is laundry on a separate sewage system(yes or no): L?,O[if yes separate inspection required]
Laundry system inspected(yes or no): -0
Seasonal use:(yes or no):4, o
Water meter readings,if available(last 2 years usage(gpd)): 2 0 01 -6 8,0 0 0
Sump pump(yes or no):�U 2 0 0 2-8 2, 0 0 0
Last date of occupancy: E3--o�}
CO ME CIAL/INDUSTRIAL
Type of es blishment:
Design flo (based on 310 CMR 15.203): gpd
Basis of de gn flow(seats/persons/sgft,etc.):
Grease trap resent(yes or no):_
Industrial aste holding tank present(yes or no):_
"on•sani waste discharged to the Title 5 system(yes or no):_
Water me r readings,if available:
Last date f occupancy/use:
OTHE (describe):
GENERAL INFORMATION
Pumping Records
Source of information: 1,1 ,d -1 I li S 41
Was system pumped as part qAthe inspection(yes or no): A-a
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
TYPF/OF SYSTEM
P'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:
Ira a `7
Were sewage odors detected when arriving at the site(yes or 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: 97 Huckleberry Lane
Marstons Mills
Owner: Joseph and Georgette Messina
Date of Inspection: 60°-3&—0 3
BUILDING EWER(locate on site plan)
Depth below ade:
Materials of onstruction:_cast iron _40 PVC_other(explain):
Distance Go private water supply well or suction line:
Comments n condition ofjontts,venting,evidence of leakage,etc.):
SEPTIC TANK: +� locate on site Ian
r�
Depth below grade: �
Material of construction: t.Foncrete_metal fiberglass_polyethylene
—other(explain)
If tank is metal list age:_ Is age confi med-by a Certificate of Compliance(yes or no):_(attach a copy of
certificate) '
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: P-
Scum thickness: Y
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or battle:
How were dimensions determined:_ D C 0 r 'Z. S
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: ocate on site plan)
Depth below grade:
Material of eonstructio :_concrete metal fiberglass_polyethylene other
(explain):
Dimensions:
Scum thickness:
Distance from top of cum.to top of outlet tee or baffle:
Distance from botto of scum to bottom of outlet tee or baffle:
Date of last pumpin
Comments(on pun ing recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet vert,evidence of leakage,etc.):
7
Page 8 of 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 97 HLickl eberry Lane
Nags♦--nC Mills
Owner: IQR@ph and Georgette Messina
Date of Inspection:
TIGHT or HOL G TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade
P
Material of const lion: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: allons
Design Florcsor
gallons/day
Alarm preseAlarm levelm in working order(yes or no):
Date of last Comments( rm and (loaf switches,etc.):
DISTRIBUTION BOX: L if resent must be o ened locate( p p )( on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.): ,
PUMP CHAMB (locate on site plan)
Pumps in workin order(yes or no):
Alarms in workin order(yes or no):
Comments(note ondition of pump chamber,condition of pumps and appurtenances,etc.):
8
y
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 97 Huckl6berry Lane
Mars.tons Mills
Owner: ,TosPph and Georgette Messina
Date of Inspection:_10--7D--&3
SOIL ABSORPTION SYSTEM(SAS): 441ocate on site plan,excavation not required)
If SAS not located explain why:
Type
i Ching pits,number:_
caching chambers,number: -
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
%d s, c Z 12. t S`
o ® oa..o.6 rp ✓ �-
CESSP S: (cesspool must be pumped as part of inspect ion)(locate on site plan)
Number and onfiguration:
Depth—top o liquid to inlet invert:
Depth of soli layer.
Depth of scum layer:
Dimensions o cesspool:
Materials of co struction:
Indication of oundwater inflow(yes or no):
Comments(no condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of onstruction:
Dimensions
Depth of Is ids:
Comment (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 97 Huckleberry Lane
Marstons Mills "
Owner: Joseph and G orgette Messina
Date of Inspection: /0 3U-03
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.
I
g
v �
10
Pagel I of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: q7 Huck 1ti hPrry Lane.
Marstnns Mills
Owner. ,Jng,,-h qnd Georgette Messina
Date of Inspection: IUD 03
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:
Obtained from system design plans on record-If checked,date of design plan reviewed:
%served site(abutting property/observation hole within 150 feet of SAS)
Necked with local Board of Health-explain: ('1,S a'Ip y S
Checked with local excavators,installers-(attach documentatiW n)
Accessed USGS database-explain:
You must describe how you established the hi,
i h ground water elevation:
GS '2-0 G �t- 1r7h
11
J
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M _- TOWN OF BARNSTABLE v '
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TOWN OF BARNSTABLE Z/ V
LOCATION 9 t/v !�1�����/ L�r�� c SEWAGE # Y9-S�1/
VELLAGE ASSESSOR'S MAP & LOT/02
INSTALLER'S NAME&PHONE NO. �,77- 0 3 5"f
SEPTIC TANK CAPACITY AM0
LEACHING FACILITY: (type) 2 SDD�k,/ dry W15.11C' (size)
NO.OF BEDROOMS 3
BUILDER OR OWNER
TERMITDATE: p -/Y- q 9 COMPLIANCE DATE: /2 -A/ - Q�
Separation Distance Between the:
Maximum"Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
i
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 facility Feet
Furnished by
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No. / ` 1 Fee V '
THE COMMONWEALTH OF MASSACHUSETTS
Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
01ppYication for Miopogaf *p6tem Construction Permit
Application for a Permit to Construct(vYRepair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. q7f�!' / 4,4oe- Owner's Name,Address and Tel.No.
!?�Ir�l+57Ov,S /�irilS Diiq rOr,014C4l
Assessor's Map/Parcel !g�
Installer's Name,Address,and Tel.No. q%7— Co q y Designer's Name,Address ad Tel.No.
c�oS Ci��i O-e- 0o dA0A0--V3
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 l Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) Sao �Z
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 ealth.
Signed Date 129Q�
Application Approved by Date ����/''7
Application Disapproved for the following reasons
Permit No. Date Issued
No. / C Fee
THE COMMONWEALTHF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLEs MASSACHUSETTS
` 0(pprication for Migonl *pgtem Congtruction VeruYitx v
Application for a Permit to Construct(4o TRepair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. g (/G!�/g �, rrA�I fi/JG Owner's Name,Address and Tel.No.
f14.gi+STOHS faTri�S Qt9,7
Assessor's MV/Parcel /G 2 !g�
Installer's Name,Address,and Tel.No. to;1 Designer's Name,Address an6 Tel.No.
tfn.S- lvh 42s ✓atS td4 pc Qraaspc�S
t Iw kv"..�
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.
t Plan Date Number of sheets Revision Date
Title
Size of Septic Tank / Type of S.A.S.
"Description of Soil JA ,71/
' Nature of Repairs or Alterations(Answer when applicable):',ra5,1.0 1' `� °� - S'40 6 4411�
Date last inspected: .
Agreement: E
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 ealth.
1 Signed Date
Application Approved by ~- Date
Application Disapproved for the following reasons
Permit No. Date Issued ^Y
0
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS \
} Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( -Repaired( )Upgraded( )
Abandoned( )by doa e,v�e 0. „1
at Q7 6m,rs.0 I*Ag s rp,,�P.s /I:P./ Ahas been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. '919'6o y dated
Installer Designer J.6> o—T
The issuance of this p sh 11 nob c s ed as a guarantee that the sy t1 functi n a'�desild�
Date ' Inspector-� ————�L/�---------------- /�`Z l�� -----
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSETTS
Mi5po5ar *pgtem Con0truction 3permit
Permission is hereby granted to Construct( e air( )Upgrade( )Abandon( )
System located at l/ Allolk4 CIO, Z,4 s
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty toy
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of t ' permit.
Date: �Z J �y 9/ Approved b - r��
116199
NOTICE: 'This Form Is To Be Used For the ]Repair Of Failed
_Septic Systems Only.
CERTMCATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PER rT (WITHOUT DESIGNED PLANS)
I, Z ��•1���hd s , hereby certify that the application for disposal works
construction herrmit signed by me dated /!9 concerning the
property located at meets all of the
following criteria:
-The failed sy:;tem is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
� -The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
Ij�ere are no wetlands within 100 feet of the proposed septic system
ere are no private wells within 150 feet of the proposed septic system
�"--Ihere is no increase in flow and/or change in use proposed
ere are no irariances requested or needed
• The bottom of the proposed leaching facility will not be located less than five feet above the
maximum adiizte:d groundwater table elevation. (Adjust the groundwater table using the Frimptor
method when applicable)
• If the S.A.S. «ill be located with 250 feet of any vegetated wetlands, the bottom of the proposed
leaching faciL,y will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation,
Please complete the following:
A) Top of Ground Surface EIevation(using GIS information)
B) G.W. Elevation 2/�,
4�+the'VAX. High G.W. Adjustment .
DIFFERF:r10E B
ETWEEN A and 13
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SIGNED
(Sketch proposec'plan of DATE.
q:!catu,folder system on backj.
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ASSESSOR'S MAP NO. PARCEL G
LO-CATION SEWAGE PERMIT NO.
VILLAGE
1 TA LLER' NAME i ADDRESS
� IUILDER OR WMER
0
DATE PERMIT ISSUED
a ` II
DATE COMPLIANCE ISSUED
--1
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Q. ..........:OF........SCMSIa.W:�. ..................................
Appliratinn for Diupnutti 11orks Tonstrurtiun Errant
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at I
• L I.......1/4,Allig -
ati •. r ss ... or Lot No.
........� �f .......... �... . �>7� .................._... ........................ _.._._....__.....----.__......__... ...
Owner
Wa Address
...-
...------....................--
......_. . ....................................... ...... .............,.........
M Installer. Address .
a7i Type of Building r? = Size Lot..�0 r�.........Sq. feet
U Dwelling—No. of Bedrooms............_.................................Expansion Attic ( ) Garbage Grinder ( )
1.4 Other—Type T e of Building -.------ No. of persons....................:....... Showers —
W YP g --------•-•--------- P ( ) Cafeteria ( )
04 Other fixtures
---------------------...------. --------
.-•...----------................
....................
WW Design Flow..........15........:..................gallons per person per day.` Total dailyflow..._.. Qd..........
Design
WSeptic Tank—Liquid capacity 1�._gallons Length..�_.(i_...... Width._5..V._.. Diameter.- ...... Depth.. ..!.....
x Disposal Trench—No.............:....... Width....................Total Length.................... Total leaching area...................sq. ft.
3 Seepage Pit No.......1............ Diameter.....10......... Depth. below inlet......69..........Total leaching area.!.Vq:£:). too
Z Other Distribution box (XQ Dosing tank ( ) W .
F_4 Percolation Test Results - Performed by.._.__..�.f�L.A..............................!...-_..'.......... Date......`z ,�0 -
Test Pit No. 1..._._._._-•-:..minutes per inch Depth of Test Pit..�.c�_.....------ Depth to ground water....9 .0.0. )
LL, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
--------------------• --------------••-- .. ................................................
O Description of Soil... . K. ......................................................:N�`;-� .. ...
. w4 I1r 1T1N ...........
VY TRW " ....................................................... ..........�T� �A?IO►� pig S?ALA- '�!`! ? � ............
x .......•-•-----'--'--'---- -•.............................•---'---••-••--------..................--"----•,.. t•......TES v�,h: l� ................................
U Nature of Repairs or Alterations Answer when applicable_.__ .SYS.... ��,u�AN...................................
-•................................................•-----------------............................... ---.......::....:---•-......---------------..............................------....................
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of MI IZ 5 of the State Sanitar XCo a The undersigned further agrees not to place a system in
operation until a Certificate of Compliance has —the board of health.
Sign - ••-- ..........--..
Da.
Application Approved BY....... .. .............�;1"11
.. ...--------•-------- ......
Date
Application Disapproved for the following reasons:...................................................:........_......._..........................._.........___
................Permit No...` .. _.......o. .-------.. Issued...........................................n .....
n.......
Date '
LOW & WELLER, INC.
"Fiddler's Green Plaza"
714 Main Street, P.O. Box 119
Yarmouth Port, Massachusetts 02675
362-6868 362-8131
Registered: George Low, Jr., R.L.S.
Land Surveyors A. Paul Simard, P.E.
Professional Engineers William G. Weller, Consultant
June 8, 1987
BOARD OF HEALTH
John Kelly - Agent
Town of Barnstable RE: Huckleberry Lane
Hyannis, MA 02601 Marstons Mills, MA
Lot 119
Dear Mr. Kelly:
Please be advised that we have supervised and inspected the
installation and construction of the new sewage system for the above
referenced location. We find that the system has been installed and
completed in accordance with the approved plan.
If you have any questions, please do not hesitate to contact
US.
Very truly yours,
AF'D —�
P ul pWa
APS:kew NAL E�
-
r
No. .... _'..........� Co F$s7
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH k _
.••.�o.�-n...........OF........! Gt_ I I........
Appliratian for Disposal Works Tonsfturtion Prrmit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at.
.---...... V�t•G{5
................... ( :...��. ....................._......_..__....
` ''I�I Locati9on�.Address - or Lot No.
........_.lam , ... ..1. v�............. ..........--•--....... ....................-_................................_......-------------....................
Owner Address
a - �? ..........
........ i�t7t?r_I ..-------•.............................. ..•• RF,I A A ( .........................................................
----- ...
Installer - Address
Type of Building Size Lot..!Q:1-6a--------Sq. feet
U Dwelling—No. of Bedrooms.........-:: ........ ..........Expansion Attic ( ) Garbage Grinder ( )04 Other—T e of Building No. of persons............................ Showers — Cafeteria
tz, Other fixtures -----------------------•----.................---.......--•---••----....t..............................................................................
d
WW Design Flow.......... --------------------------gallons per person per day:_Total daily flow......„ C? _
........................gallons.
WSeptic Tank—Liquid'capacityt995a..gallons Length..C.L..."... Width__4t.c.._ Diameter---_-•-_........ Depth..... �... `
x Disposal Trench—No..................... Width....................Total Length.................... Total leaching area_...................sq. ft.
3 Seepage Pit No.......1............. Diameter.._..1.01
........ Depth below inlet...... ........ Total leaching area.2 n.:sq:--ftCt 100
Z Other Distribution box (X) Dosing tank
'"' Percolation Test Results Performed by........ _ -..W-u` `' !. , Date.....� '.� '
1 .t .jop .............
,,.a Test Pit No. 1_.L.7......minutes per mch Depth of Test Pit..1.5.&......... Depth to ground water____�� t..r?!?!?.....) ,
Test Pit No. 2................minutes per inch Depth of Test Pit................... Depth to ground water........................
a -------------------------------------------------
---------
..------------- .......:.... .........................................................
0 Description of Soil..........fzee.......P..WA....--•---.....--•----•----••... -•-----------•-•----•---•................:..............•--•-. ._..........._..
V -----•--------------•----------•-----•---------------------•------------•... ------
•-----------•--•---•-------•-•------•- -------------..... ------•.-..-..-.....
W ........----•-•••.....•-••-•••••----•--•---........•••-•--•-...-•-••-•--•--...-•-----•-•---••-•••••-••-••----•-•------•••-••--•-••--•...............•--•-•-•----------•--...............................
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 TITIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been._issrred-by the board of health.
L46
g - ...............Date ....
Application Approved By.......................,..-•--.I.:............../A4
................ .. ....- ..-.:-� l►.'--i�r
l Date
Application Disapproved for the following reasons:...............•...........................................................................................___
.............................•••.._.............._....j..........._.._.......--••••••-----•-•--•--...._........._.._._.........-------••-----......••••-••------•........---••......D�.........-•--
Permit No... .. �:-z._..:�-�. . -�C'-----_.... Issued............................................
Date
i
---------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.OF. .......... ...
..........................
fIrrtif uttte of Toutplianu
THIS IS TQ CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
• - --•------------•.......................................•-•------..................._...._.._
Installer f
at.................Z—— -...__ lJ .Q.....4 4. : .............................................a..t
has been installed in accordance with the provisions of TITLE 5`of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No._-5��__._.` ....... dated........_.L.j..0.....IS-1?
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. 1^
DATE............... ..................................... Inspector--4= ---. .... - ...........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
✓ / ��, ............. .! ..........o F..... 1..1�,�NS-•-- .......................
No....�...�.:�.... .. Fss.....
Disposal Works Tonstrurtion rrrntit
Permission is hereby granted.........^ . �.................
' . ..................................................
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System �at No.;......... .........6-n7.......... .1 ........... -hLr l.(���
� \�...--•--------...........
Street) .. ...... ..-----
as shown on the application for Disposal Works Construction Permit Dated Dated...... ........
of Health 2
...................................................... ..
f� -............
a-
DATE-------•-----=-----___
L------------•e•:---------•---------------
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