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HomeMy WebLinkAbout0015 INDIAN POND POINT - Health 1.5rIndian-Pond Point Ma_rstons Mills A=,083.013:-002 - - -- - - _77- Commonwealth of Massachusetts og3'019 - 00 a-- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 INDIAN POND POINT Property Address JAY ROSSI Owner Owner's Name / information is required for every MARSTONS MILLS t1 MA 02648 02/01/2019 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. Imngoutf rms A. Inspector Information �SY,# 135g0 filling out forms on the computer, JR use only the tab OHN P GRACI S key to move your Name of Inspector cursor-do not GRACI SEPTIC INSPECTIONS LLC use the return Company Name key. PO BOX 2119 Co r� Company Address TEATICKET MA 02536 City/Town State Zip Code 508-548-7500 S1468 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 I, that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by he Local Approving Authority 4. ❑ Fails ii Al 02/01/2019 Inspector's Signature Date The system inspector shall srs a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30f 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 �a Commonwealth of Massachusetts Z Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V, 15 INDIAN POND POINT Property Address JAY ROSSI Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 02/01/2019 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: ® 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: SEPTIC SYSTEM PASSES TITLE 5 AT TIME OF INSPECTION 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): NA t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts < p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 INDIAN POND POINT Property Address JAY ROSSI Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 02/01/2019 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): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): NA ❑ 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): NA 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 INDIAN POND POINT Property Address JAY ROSSI Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 02/01/2019 page.e. 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: NA ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or 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 t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 INDIAN POND POINT L Property Address JAY ROSSI Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 02/01/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 Y 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 1 of a public water supply 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 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 INDIAN POND POINT Property Address JAY ROSSI Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 02/01/2019 page. CitylTown 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 ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5ins .doc•rev.7/26/2018 Tit le tle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Ilk— Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 INDIAN POND POINT Property Address JAY ROSSI Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 02/01/2019 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Description: SEE ATTCHED Number of current residents: 2 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 ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d TOWN 9 ( Y 9 (gP ))� Detail: 2018: 105,000 2017: 90,000 Sump pump? ❑ Yes ® No Last date of occupancy: OCCUPIED Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,. 15 INDIAN POND POINT Property Address JAY ROSSI Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 02/01/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): NA Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): NA Grease trap present? ❑ Yes ® No Water treatment unit present? ❑ Yes ® No If yes, discharges to: NA 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: NA Date Other(describe below): NA 3. Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: NA gallons How was quantity pumped determined? NA Reason for pumping: NA t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 INDIAN POND POINT Property Address JAY ROSSI Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 02/01/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑. Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): NA Approximate age of all components, date installed (if known) and source of information: 01/11/2012 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 20" I Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC 40 PVC (R) ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doe-rev.7/2 612 0 1 8 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 15 INDIAN POND POINT Property Address JAY ROSSI Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 02/01/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 14"feet Material of construction: ®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) SEPTIC TANK IS CONSTRUCTED OF CONCRETE. If tank is metal, list age: NA years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 GALLON SEPTIC TANK Sludge depth: (8) EIGHT INCHES Distance from top of sludge to bottom of outlet tee or baffle (26)TWENTY SIX INCHES Scum thickness 6" Distance from top of scum to top of outlet tee or baffle 6" I, Distance from bottom of scum to bottom of outlet tee or baffle NA 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.): 1500 GALLON SEPTC TANK APPEARS TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY AT TIME OF INSPECTION. RECOMMEND PUMPING NOW AND EVERY 2-3 YEARS DEPENDING ON USAGE. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 INDIAN POND POINT Property Address JAY ROSSI Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 02/01/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Deoth below grade: NA feet Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): NA. Dimensions: NA Scum thickness NA Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA Date of last pumping: NA Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liqu'd levels as related to outlet invert, evidence of leakage, etc.): NA 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): NA Dimensions: NA Capacity: NA gallons Design Flow: NAgallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 INDIAN POND POINT Property Address JAY ROSSI Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 02/01/2019 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: NA Alarm in working order: ❑ Yes ❑ No Date of last pumping: NA Date Comments(condition of alarm and float switches, etc.): NA *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert BOTTOM OF PIPE Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc,): DISTRIBUTION BOX APPEARS TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLTY AT TIME OF INSPECTION. DWC-19-0033 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments .. 15 INDIAN POND POINT V� Property Address JAY ROSSI Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 02/01/2019 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: NA Type: ❑ leaching pits number: NA ® leaching chambers number: 3-500 GALLON ❑ leaching galleries number: NA ❑ leaching trenches number, length. NA ❑ leaching fields number, dimensions: NA ❑ overflow cesspool number: NA ❑ innovative/alternative system Type/name of technology: NA t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e 15 INDIAN POND POINT Property Address JAY ROSSI Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 02/01/2019 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.): 3-500 GALLON LEACH CHAMBERS WERE EMPTY AT TIME OF INSPECTION NO VISABLE STAIN LINES. LEACH CHAMBERS APPEAR TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA Depth—top of liquid to inlet invert NA Depth of solids layer NA Depth of scum layer NA Dimensions of cesspool NA Materials of construction NA Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): NA t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 INDIAN POND POINT Property Address JAY ROSSI Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 02/01/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: NA Dimensions NA Depth of solids NA Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): NA t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a ,. 15 INDIlAN POND POINT Property Address JAY ROSSI Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 02/01/2019 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 O 3 �IhSPec�vr, Al - Iq BI 38 Q o LotFAZ- (5 K_ YD A3- 452 a3- 75� A q- 55`° Bq- K5 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 r ! Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 INDIAN POND POINT Property Address JAY ROSSI Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 02/01/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 10+ FEET feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 INDIAN POND POINT Property Address JAY ROSSI Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 02/01/2019 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria) and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1S of 18 Town of Barnstable yam, Regulatory Services JY SL Thomas F. Geiler,Director MWWABM Public Health Division MAW ►`� Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644` Fax: 508-790-6304 Date:��N° 9, 2 0/2. Sewage Permit# o20ll-00- Assessor's Map/Parcel 1nhP 83 /Y Installer& Designer Certification Form LoT 2A Designer: J.D oyL i9sSOC147'�s Installer: ���(A1lJ7_V qC710A( Address: /7o Address: P c�• CAST F.9LirtayT �2s� d l�l���n5 d�/tom 5 oaft0 On `�` -�4 U I�l S��GCG�d was issued a permit to install a (date) (installer) septic system at J5 1N.D141V /$ ✓b �o,1%t17 based on a design drawn by (address) . �i .!/oyL-•� °/7�..S�C f� GJ t �'Jf"C.m �� G:�'�� 'fit-et�i .1. •...-.�x i� .tr. _ /. ..�. ... .dated. .... j .(designer)> Iycertify thafthe septic,system referenced above was installed`substantially`according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State &Local Regulations. Plan revision or certified as-built by designer flow. Stripout (if required)was inspected and the soils were found satisfactory. �P�ZN OFtf� (Ins er's Signatur P. 1 Uo OOYL£.II - No.33589 (De er's Signature) (Affix D re) sum PLEASE RETURN TO_BARNSTABLE PUBLIC HEALTH DI CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORMf�AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. gAoffice formsWesignercertification form.doc TOWN OF BARNSTABLE LOCATION �, 1h,�/ci.� �o/►� ��c�n .. - `SEWAGEff VILLAGE Mcjr5� , S ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. ,P¢/f 310- y Y SEPTIC TANK CAPACITY LEACHING FACILITY:(type) O0 5. ��a� ►: (size) 33-(o°°X /;2 /a NO.OF BEDROOMS L/ OWNER",: PERMIT DATE: COMPLIANCE DATE: 4 - ' Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility feet Private Water Supply Well and Leaching Facility(if any wells exist on site or within 200 feet of leaching facility) feet. Edge of Wetland and Leaching Facility(if any wetlands exist within 300 feet of leaching facility). feet FURNISHED BY t - ►LI 39 ` ' qq s5_� bo- Sar -7A - 5a-1 a6- 'AID g 3-►D No. a 0 - O Fee 1 5 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: i�/ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftplication for Nsposal *pstpm Construction 3prrmit Application for a Permit to Construct(t Repair( ) Upgrade( ) Abandon( ) gComplete System ❑Individual Components Location Address 9r Lot No. Owner's Name Address,and Tel.No. SD k- ?Q/-'71 Z Y /5 /N.DIA N loeA40 0,9 I nI T ./�4SD Koss Assessor's Map/Parcel /Y1 ,. $3 P192G. 3 L o T Z o �7 DIVA/9L IV �olp �a�NT I>�sta�e�' Add and wo Designer's Name Address and Tel.No.SO 9-5163-/9 j�$ o ou 5 1e u c wujj Mi C— D 0 y e'r .�jsa ci i 7cs uro�-S - O /74 CL0V6e 1&c,D W y E- FBI L mo C1 h' Type of Building: Dwelling No.of Bedrooms �7� Lot Size S7� 3SS sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) �4-940 gpd Design flow provided 'f" 3�� gpd Plan Date 3 2 - // Number of sheets Revision Date Title S/T6 �,S�GI/i9G� �Z/��✓ 07Z �i9�lIIit/ ,�Dy��: Size of Septic Tank , /��� 6.4L",Vs Type of S.A.S. /2 , 9'33 X Z`A 33• S Description of Soil A O-/0'` G0/9n7 7.sy.4 512 $1O"- 20"j/ A.D y L_O>4 j-yl2 Gilt Qc ,l4.r-c4-Ay- Lo,9M 7.SiZ 7/z 7o"-�3-5" ez G%z�4V�L co,g,erF S Nb /o 1Z� 3S z Nature of Repairs or Alterations(Answer when applicable) Gt/ SyJ 7'---1? )`-4/L 10:q/­0/9/EL L 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 Bo ea h. Signe Date Application Approved by — Date 14— Application Disapproved by Date for the following reasons Permit No. Date Issued — q :j,' :..: ��� No. a ' O Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pplication for Permit Application for a Permit to Construct Repair Upgrade s, Abandon Com lete System Individual Components PP (�) P ( ) Pg ( ) (� .� P Y ❑ P Location Address r L�N. x, p fin/T Ow�3er's Nan Adfl ess,and Tel.No. ,j k 90 / 7/Z � P ny") /cCDsr, Assessor's Map/Parcel M 83 1, 9e . /3 L o T Z /jZ3/��/ ,�p,v� �Oi/V 7- Installer' N ee Adds and T' N Designer's Name t�ddress,and Tel.No. S-D 9 --5 G3-/99j� -f C 6A)5U vUto* O,� --0� .T DoYL r �}Ss0C1,97' S �r �fulV �``o ->�1c�- 0 /7O CL.oVt=r FiC-cL 7> wV �, F.9L Type of Building: Dwelling No.of Bedrooms �7G Lot Size ?7, 35S sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures . i 1 Design Flow(min.required) gpd Design flow provided �-� `f r gpd '***Plan Date 3 2 - // dumber of sheets Revision Date '` Title S/Tc 7� S r wig G /2< 4 i✓ f'U 2 �/fI S o Dl/ �t Size'of Septic Tank SAL LOA✓ Type of S.A.S. /2 , k33 ,,k z 'X.33• S Description of Soil a O / 7,Sys `VZ- ,V/o o 11.S1 N-b �. Qc S/cT c4_A / L_oym 7,sr2 7/2 Za' -j' V/ y �� 5- 2 4CCa-Yn,OA,Vy sT � ,, 2 g ? Nature of Repairs orAlterations(Answer when applicable) /V<"G✓ Syl T��J Fat /1/c!7/�Q`j/EL L /i✓G 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 s ; Compliance has been issued by this Board ofHea A/ Signed i- Date /// r '' __ l - Application Approved by S Date Application Disapproved by Date ' for the following reasons--7 Permit No. d Date Issued �— q THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY Ahat the O}n.site Sewage Disposal system Constructed(� Repaired( ) Upgraded( ) Abandon( )by �� t ' at has been constructe in ac rdance with the provisions of Titles and the for Disposal System Construction Permit No. dated L' Installer ��- 1 Designer #bedrooms 9 Approved design flow L gpd The issuance of this permit shall not be construed as a guarantee that the system willHfanctiaon asr& igned. j l Date 1 ;' / Inspector -------- ----- -------------- -- -- - ------ _ No. go I I" 0 g�-- Fee /S THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Disposal �&pstem ConstrUction permit Permission is hereby granted to Construct( ) e p air( ) Upgrade( ) Abandon( ) System located at I.5 v 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 completed within three years of the date of this permit._ 0 A V5 _[,(—I � Date � Approved by Town of Barnstable P# , Department of Regulatory Services n a Public Health Division Date I j 200 Main Street,Hyannis MA 02601 Date Scheduled l o o Time <, � Z) Fee Pd. ►Soil Suitability Assessment for Sewag De sposal Performed By: �y/�/, 0 OyL E� PG;5- Witnessed By: s4m-4,7 LOCATION& GENERAL INFORMATION T' - 4 712 Location Address q �(? / �� /L� 1 -4/l 4 Owner's Name 1A50%J g,0 5,51 ✓vl,. ^.�`t'l j Address 41 /A161,o4 it/ �CTi✓�!./� J��T/ Assessor's Map/Parcel: j4l; 93 4kc- 13 LO"j 2 Engineer's Name cJ,-bOIL- NEW CONSTRUCTION REPAIR Telephone# 13 Q $-5 C Land Use V11 efA7 &S/fi�/VT/If L slopes 3b J J p ( ) Surface Stones V6 y FE Distances from: Open Water Body O© ft possible Wet Area // ��nn �ft Drinking Water Well ft Drainage Way N ft Property Line 2!!� ft Other SKETCH:(Street name,dimensions of to exact locat ions ttons of test holes 8c perc tests,locate wetlands fn proximity to holes) ,f„ 7.s, m � , i �.l 3� Lg'i 3 223`° Parent material(geologic) �'D 95,�- 519,00/A Depth to Bedrock Depth to Groundwater. Standing Water in Hole: /Vy Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: In, Depth to weeping from side of obs.hole: in, Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor _ AciJ,groundwater Level PERCOLATION TESL' Date I .30 /0 Time A, 41 Observation � t�. Hole# 7' 2- --� Time at 9" Depth of Pero ) Time at 6" Start Pre-soak Time @ /D:J :OU Time(9"-6") End Pre-soak 'Z 4 G.f L lI'0 2 Z t!, //1 2 0 :2 0(Zq 6.41 Rate MinJlnch 2- 2� Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one (1)week prior to beginning. Q:1SEPT10PERCFORM.DOC I DEEP-OBSERVATION HOLE LOG Hole# T/ Depth from Soil Horizon Soil Texture .Sdil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. i tenry,96 Graven o y sy,e -1/y4 Zi'- 3�" c s� o 4-4y 7,5YX /Z 3G '=-130 CZ XsrSAN /DY/Z % (/ut'�LL- DEEP OBSERVATI Ty ON HOLE LOG Hole# Z Depth from Soil Horizon Soil Texture Soil Color Soil Other Ili Surface(in.) (USDA) (Munsell) hluttlin- g (Structure,Stones,moulders. onsi ten % ravel s 13 2" c 2 CO i�-1iVO ivYA DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. Gravel) 22 - 3 4, - siLr GLR`/ / Lc�; 7 SYlZ it �;,-�,. •. C v �s, _ � � V'r� y 51)- Ay %o/,,e 7/ DEEP OBSERVATION HOLE LOG Hole#- - Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consi ten Lo,9I-Y7 7,3y2 /D"-Z Z " c G-D.gr� 314 � ZZ',_ 3 ' C, si �T c�9� 7 51V2��� (n Er).54/Vo /aYr 7/f 71. Flood :Insurance Rate Map : p Above 500 year flood boundary No— Yes ✓__-__ Within 500 year boundary No '!� Yes Within 100 year flood boundary No:V Yes _ Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? -� If not,what is the depth of naturally occurring pervious material? I Certification I certify that on M 3 (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the required training,expertise and experience described in 310 CMR 15.017. Signature ' v Date Y73 Q:4SEPT lCIPERCFORM.DOC i _ 7_ - 1►► _ 56 6[o(:) X Zr'-= "t\)S r7 ( ( I qus � UZS r C• e I ' 40 CONS 21- S;Ab aoc?:� S �a AA te s t2v to tJ z a � , r �. 0 1 5- 0 12-0 46mo 4 �g t / I Go 6a- JLu- - --- tl // i1 l0 1 j A i At42's {k-135t 251 1? P11c,�L74�'1 ���� �- t I�JSutr-or� '0< lw mil. See.� �� 2"��-. 2_..x� C.►��N 6- soy�16•oL v� �3o /AISJL -P-ace_ SZrafl - l 6°6r- I I i i J '? J Z d'X eta"X 1.0 i, ( S � PT i to fFT ILL Ito -ip zf I I o t + { a V • r �y ` 1 _ I X 20 x l p �z r►- t� I - -ti I 12L. APPROVELY9V: - (' -:SCALE: i ;DATE: . HUMC®i YX'f� M1111ed"OM No.WOOIIWAi1RIDIT• . _ • tt � I • f -. . ff ti - Taal°� I� I 5 f 1":fw DRAWN'.. OATE.P �."ter ! - ..... �a ,.s �t' REVISED ,rf DRAN(IN({,'IUtABER I pq � ; . ; ., i Am ` s SCALE:1 a, APPROVED BY: DRAWN BY - DATE: REVISED rat f { i /�.9cE G.9NE w&L,c) 140 7,9 S '- _ r \ 30 J � ENCH M ;AkA� f, ,e �1 LA�� o4/RPOR7` � S3 to E J'� h , , t I J r 40 log 16 (. 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