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HomeMy WebLinkAbout0085 KERRY DRIVE - Health 85 KERRY DRIVE MARSTONS MILLS A = 060 028 ' y No. —2—() �� — V� � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS es ftpliLation for Misposal 6pstpm Construttiolt J)rrmit Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System OLKn-dividual Components Location Address or Lot No. 1551 �(l t�� N\ Owner's Name,Address,and Tel.No. Assessors Map/Parcel Installer's Name A d ess and Tel. Designer's Name Address and Tel.No. C�CA. 0 2,C.6p Type of iiding: 4 0O �I 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 Y� .+� gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of or Alterations(Answer when applicable) � I> L'i t �0 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 o Health. Sig Date Application Approved by RC Date 2- Application Disapproved by Date for the following reasons Permit No. 2 o Date Issued f No. G 2L9 Fee THE COMMONWEALTH OF MASSACHUSETTS , Entered in computer''' r PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS implication for Misposai *pstpm Construction Permit Application for a Permit to Construct( ) Repair(4/T Upgrade( ) Abandon( ) ❑Complete System [gndividual Components 0 Location Address or Lot No. 7 WXxK �j ` M N i Owner's Name,Address,and Tel.No. Assessor's Map/E 0(00 Cl Xy n . Installer's Name,Ado mess and Tel.No. Designer's Name,Address,and Tel.No. Scoff \Z 0krj (Vta O 1f.61 Type of Iuilding: Dwelling No.of Bedrooms �l f Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( )+Cafeteria( ) Other Fixtures Design Flow(min.required) +" I 1 gpd Design flow provided iv gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) k ray Q Q7 ($C})G t- .-) ( t� Q� 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 o Health. ter,,,..•�*'"''f t ) n Sig(ned�l�(1�/ Date Application Approved by L/(1> I n, _ Date 1/1/ -2 2 1 Application Disapproved by Date for the following reasons Permit No. ) .2 G'l 7Date Issued 31 /I ( ? r THE COMMONWEALTH'OF MASSACHUSETTS r,a�l�u► �� ��� BARNSTABLE,MASSACHUSETTS CPrtlfItate of Comphance THIS IS TO CERTIFY,that the On-site -Sewage,Disposal system Constructed( ) Repaired(V Upgraded( ) Abandoned( )by (,�t1 L� �'hI�•�V1 i at �-Z VAX f"4 t rA • r t^ has been constructed in accordance p t p y 20a.�-077 l a g with the provisions of Title 5 and the for Disposal System Construction Permit No. ated ,3 (r Installer C,.A M it(-t-^VL Designer #bedrooms IV) Approved design flow gpd The issuance of this permit§hall not be construed as a guarantee that the system will fi�onas designed.igned. Dater` Inspector - - ------- --- -- - --------- ----- ------ - - No. G a v� . o '7 7 Fee _. THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS MIsposar *pstem Construction VPrmit Permission is hereby granted to Construct( ) Repair(V,*T Upgrade( ) Abandon( ) System located at aC a{{••t f f V �.-bsy�. AA 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., Date 1 ( ( ( ? 3 Approved by C - C..{� TOWN OF BARNSTABLE —0 �O LO('OTION SEWAGE # WOO VILLAGE- � A ESSOR' MAP & LOT ® Q Q U INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: ©d COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �11 Po a �2 v �- al t di t2_ Fro Lpi CATION SEWAGE PERMIT NO. ViF VILLAGE I N S T A LLER'S NAME & ADDRESS 'R4 G�Njaixu sAie ea GL_ �� "', Ky _ u-sojSAD isg" A U I L D E R OR OWNER $�� L-.o ea> :TV74 `k. TY) c- o"mNtf-0. 1'CARt0 c- i3kQL.. DATE PERMIT ISSUED 9 _i � _�� DATE COMPLIANCE ISSUED 07/0 I� i V'R OT ! 4, c _ 1 r - �Xoo- oz6 Commonwealth of Massachusetts - Title 5 Official Inspection Form 10 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �~ 85 Kerry Drive Property Address Corey&Molly Boudreau Owner Owner's Name information is Marstons Mills ✓ MA 02648 2/17/20 required for every page. City/Town State Zip Code Date of Inspection y 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, Brett Hickey 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 " J Company Address Sandwich Ma 02563 City/Town State Zip Code r�aa, (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that: 1 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 4 DOWN�W 9re9w W Brett Hickey „.�W k..aa. �.��W� — 2/17/20 Dm.1D19W 191Q.9V 1 L'i'09' 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 Commonwealth of Massachusetts Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Kerry Drive Property Address Corey&Molly Boudreau Owner Owner's Name information is Marstons Mills MA 02648 2/17/20 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: The system was in working order at the 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments f" 85 Kerry Drive" .: Property Address Corey&Molly Boudreau Owner Owner's Name information is Marstons Mills MA 02648 2/17/20 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): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 c� Commonwealth of Massachusetts - Title 5 Official Inspection Form Io Subsurface Sewage,Disposal System Form -Not for Voluntary Assessments 85 Kerry Drive Property Address Corey&Molly Boudreau Owner Owner's Name information is Marstons Mills MA 02648 2/17/20 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 watei 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: f **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 ❑ El clogged of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ a 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 �a Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1" a 85' V" Property Address Corey&Molly Boudreau Owner Owner's Name information is Marstons Mills MA 02648 2/17/20 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 ❑ a Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ 0 Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow ❑ a 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. ❑ a 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. ❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ El 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.] ❑ Q 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 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 Commonwealth of Massachusetts Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Kerry Drive Property Address Corey&Molly Boudreau Owner Owner's Name information is Marstons Mills MA 02648 2117/20 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? ❑ E 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) ❑ El Was the facility or dwelling inspected for signs of sewage back up? El ❑ 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? ❑ o 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. ❑ ❑. 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 Otfidal Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts 1- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments,�. rry -.M .,,. ,..,_ :_.;�:���r: .?•gin sai . :.:-.� ;.:�:�,N.u�, t ¢.. Property Address Corey&Molly Boudreau Owner Owners Name information is Marstons Mills MA 02648 2/17/20 required for every page, City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 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/GPD Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes Q No Does residence have a water treatment unit? ❑ Yes 0 No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes F!] No information in this report.) Laundry system inspected? ❑ Yes ❑Q No Seasonalluse? ❑ Yes [E No Water meter readings, if available(last 2 years usage (gpd)): See below Detail: 2018=66,000 2019=108,000 Sump pump? ❑ Yes K No Last date of occupancy: January 2020Date 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 la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - 85 Kerry Drive Property Address Corey&Molly Boudreau Owner Owner's Name information is Marstons Mills MA 02648 2/17/20 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- date of last pump is unknown 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 ,9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t ' ~ -85:Keny:Drive va Property Address Corey&Molly Boudreau Owner Owner's Name information is Marstons Mills MA 02648 2/17/20 required for every page. CityrTown 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: 2000 Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): 1 r6° Depth below grade: feet Material of construction: ❑ cast iron ❑■ 40 PVC ❑ other(explain): Town water Distance from private water supply well or suction line: feet Comments(on condition of joints,venting,evidence of leakage, etc.): t5insp.doc-rev.7/26/2018 Ti6e 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 9 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form 1$ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Kerry Drive Property Address Corey&Molly Boudreau Owner Owner's Name information is Marstons Mills MA 02648 2/17/20 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 611 Depth below grade: feet Material of construction: [01 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 1211 Sludge depth: , 2411 Distance from top of sludge to bottom of outlet tee or baffle 411 Scum thickness 5" Distance from top of scum to top of outlet tee or baffle 1411 Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? 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. t5insp.doc•rev.7/2 6120 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Corey&Molly Boudreau Owner Owner's Name information is Marstons Mills MA 02648 2/17/20 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: NAfeet 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 t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I� Subsurface Sewage Disposal System Form Not for Voluntary Assessments �I 9 P Y rY 85 Kerry Drive Property Address Corey&Molly Boudreau Owner Owner's Name information is Marstons Mills MA 02648 2/17/20 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): 0" 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.): The d-box was in working order at the time of inspection. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 c Commonwealth of Massachusetts rM p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Ke . Property Address Corey&Molly Boudreau Owner Owner's Name information is Marstons Mills MA 02648 2/17/20 required for every page. Cityfrown 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: ❑ leaching chambers number: (4) infiltrators El Reaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts 1� Title 5 Official Inspection Form Io Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Kerry Drive Property Address Corey&Molly Boudreau Owner Owner's Name information is Marstons Mills MA 02648 2/17/20 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. 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 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 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Corey&Molly Boudreau Owner Owner's Name information is Marstons Mills MA 02648 2/17/20 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts r� Title 5 Official Inspection Form l� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Kerry Drive Property Address Corey&Molly Boudreau Owner Owner's Name information is Marstons Mills MA 02648 2/17/20 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 e 1 .i Ai. A = ", t5insp.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 to Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 'tJ Property Address Corey&Molly Boudreau Owner Owner's Name information is Marstons Mills MA 02648 2/17/20 required for every 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: > 5' below SASfeet Please indicate all methods used to determine the high ground water elevation: El Obtained from system design plans on record If checked,date of design plan reviewed: 10/25/00oats ❑ 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: A plan on file at the local Board of Health was used to determine high groundwater. 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 ✓ w c� Commonwealth of Massachusetts - Title 5 Official Inspection Form I a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . 85 Kerry Drive Property Address Corey&Molly Boudreau Owner Owner's Name information is Marstons Mills MA 02648 2/17/20 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: ❑■ 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 f . 3 t5insp.doc-rev.7/26/2018 " Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 Aar 10 0; V\&OU.` �oVatre o�.v K:VI;M-Y IDM\VS . Vt VlkPV7—*SlZfl 5 rA k\S r M—A 'VO ol c„ a - A IL SEE PP s. Ex�St C. vrctK Commonwealth of Massachusetts Title 5 official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form Inspection results must be submitted on this form or on the official Title 5 Inspectoq Form dated 6/1512000. Inspection forms may not be altered in any way. A. Certification 1. Property Information: 85 Kerry Dr. ot'1�5'0 da 8� Property Address Willis Owners Name saa Owner's Address Marston Mills MA 02648 Cityrrown State Zip Code Date of Inspection: 3123107 Date 2. Inspector: Frank Nunes III Naive of Inspector saa Company Name 25 Deer Ridge Rd Company Address Mashpee MA 02649 City/Town State Zip Code 508.272.6433 Telephone Number t.i .. Certification Statement: I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection c was`performed based on my training and experience in the proper function and maintenance of on site L sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: T. 1 ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Furt r Ev uation the Local Approving Authority 3/23/07 Inspectors Sign PW4Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system.owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in t4 future under the same or different conditions of use. Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Risposal_System^ Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 85 Kerry Rd Property Address Marston Mills MA 02648 City/Town State Zip Code 3123107 Owner's Name 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: Pumping suggested every 2-3yrs. to prolong the life of the system 13) 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 a the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: n/a Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Risposal System Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cunt.) 85 Kerry Dr Property Address Marston Mills Cityrrown State Zip Code Owners Name Date of Inspection B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or.high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ❑ distribution box is leveled or replaced ND Explain: n/a ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: n/a C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system Is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Rjsposal System^ Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 85 Kerry Dr Property Address Marston Mills Cityrrown State Zip Code Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (cont.): 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: n/a Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Pisposal System Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cunt.) 85 Kerry Rd Property Address Marston Mills City/Town State ZipCode Owners Name Date of Inspection D)System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent.to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 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 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 Dgp certified laboratory,for coliforrn bacteria and volatile organic compoljpds indicates that the well is free from pollution from that facilityand 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. 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. Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Poposal_System^ i Commonwealth of Massachusetts Title 5 Official Inspection Form ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 85 Kerry Dr. Property Address Marston Mills Cityrrown State Zip Code Owner's Name Date of Inspection E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. YES NO ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Pisposal System i Commonwealth of Massachusetts . Title 5 Official Inspection Form Not for Voluntary Assessments ` Subsurface Sewage Disposal System Form B. Checklist 85 Kerry Dr Property Address Marston Mills Cityrrown State Zip Code Owner's Name Date of Inspection Check if the following have been done. You must indicate"yes" or"no"as to each of the following: YES NO ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part Q is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(p)) Title 5Tem late.doc•11/2004 Title 5 Official I Inspection Form:Subsurface Sewage Pisposal System Commonwealth of Massachusetts Title 5 Official Inspection Form ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information 85 Kerry Dr Property Address Marston Mills City/Town State Zip Code Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: occupied DAle CommerciaUlndustrial Flow Conditions: Type of Establishment: n/a Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Risposal System^ Commonwealth of Massachusetts lugTitle 5 official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 85 Kerry Dr Property Address Marston Mills Cityrrown State Zip Code Owner's Name Date of Inspection General Information Pumping Records: Source of information: owner Was system pumped as part of the inspection? ❑ Ye§ ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: I W25/00 per as built Were sewage odors detected when arriving at the site? ❑ Yes ® No Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage pisposal System^ Commonwealth of Massachusetts Title 5 Official Inspection Form ° Not for Voluntary Assessments r` Subsurface Sewage Disposal System Form C. System Information (cont.) 85 Kerry Dr Property Address Marston Millis Cityfrown State Zip Code Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: 14" feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10' feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 9" 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 ❑ Yes ❑ No certificate) Dimensions: 1000g Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle >12" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle >2" How were dimensions determined? measured Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage pisposal System Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments y� Subsurface Sewage Disposal System Form C. System Information (cont.) 85 Kerry Dr Property Address Marston Mills Cityrrown State Zip Code Owner's Name Date of Inspection Comments(on pumping recommendations, inlet and outlet tee or baffle condition, stryptural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No adverse conditions exist Grease Trap(locate on site plan): Depth below grade: n/a feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ gther(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, stryptural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: n/a Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage gisposal System Commonwealth of Massachusetts . Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cont.) 85 Kerry Dr Property Address Marston Mills City/Town State Zip Code Owner's Name Date of Inspection Tight or Holding Tank(cunt.) Dimensions: n/a Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Level w/the bottom of the 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.): D-Box is 2'6" below grade.No adverse conditions exist. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage(7sposal System^ Commonwealth of Massachusetts . Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 85 kerry Dr. Property Address Marston Mills City/Town State Zip Code Owner's Name Date of Inspection Comments(note condition of pump chamber, condition of pumps and appurtenances, qtc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: SAS Consists of 4 infiltrators. Bottom of SAS is approximately 6 and is dry at this time. Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No adverse conditions exist Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts Title 5 Official Inspection Form ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 85 Kerry Dr. Property Address Marston Mills City/Town State Zip Code Owner's Name Date of Inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration n/a Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: n/a Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M •y` C. System Information (cont.) 85 kerry Dr. Property Address Marston Mills Cityrrown State Zip Code Owner's Name Date of Inspection 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. l � I r C EOa Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage pjsposal System Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 85 Kerry Dr Property Address Marston Mills City/Town State Zip Code Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: 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: #82 Kerry Dr. NGW at 12' per file ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: see above Title 5Template.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System No.f Vv w� .. `Fee r' THE COMMONWEALTH OF MASSACHUSETTS Entered in eamputer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,, MASSACHUSETTS OtppYication for dig og r *pgtem t�Congtruction Permit Application for a Permit to Construct( . )Repair Upgrade( )Abandon( ) O Complete System 04udividual Components Location Address or Lot No. 4�/���q_f VN9—._0 Owner's Name,Address and Tel.No. Assessor's Map/Parcel 0 Install s N Address,and Tel. Designer's Name,Address and Tel.No. rS Type of Building: Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures r Design Flow 'r33 gallons per day. Calculated daily flow `t� gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. a L—T'Al Description of Soil rY —' O�i2 Ce_ &K� Nature of Repairs or Alterations(Answer when applicable) � /�4" n—� (�✓i�. �� �GVC.ry T ul/�a L.1 if dZS 11..1 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 h Y this Signed ate Application Approved by ate Application Disapproved for a following reasons Permit No. Date Issued x lk THE COMMONWEALTH OF MASSACHUSETTS Entered in ceiinputer: Yes -TOWN OF BARNSTABLE MASSACHUSETTS . HEALTH DIVISION ° PUBLICs 2pplitation for 0to v ar bp!tem Construction Permit Application for a Permit to Construct(. )-Repair Upgrade( )Abandon( ) ❑Complete System [ dividual Components Location Address or Lot No. / t•�.5� Owner's Name,Address and Tel.No. Assessor's Map/Parcel .. L cu InstaUer's N Address,and Tel. Designer's Name,Address and Tel.No. d o s 5r, l Type of Building: ' Dwelling No.of Bedrooms _ Lot Size - sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures G Design Flow gallons per day. Calculated daily flow 3 ! gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank (--��`��v Description of Soil Nye 1 C O�A°i? e ��b�t -� r J Nature of Repairs or Alterations(Answer when applicable) �' r/ e�' f c t Y � c I vtv, c 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-bee e y is Btiar ealth Signed �J, o 7 ) ate Application Approved by of J f bate Application Disapproved for the following reasons J k Permit No. — Date Issued , .. THE COMMONWEALTH OF MASSACHUSETTS t BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CER1IFZ;that t On-site Sewage is,osal System Constructed( )Repaired( )Upgraded(V< Abandoned( )by � � '�' at ,, . �', art - V h s b constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No, ated Installer Designer ',/f n The issuance of this pe sh l not l construed as a guarantee that the sys ei -I function as des��d. j1J Date ti I. `7 Inspector /�! �' & iJ = er t �+ ; � . ---�—�T =---------------------- No. Fee ✓ / THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS �i oar �p�te on�truction Permit Permission is hereby granted to Construct( )Repai ( )Upgrade( )_Abandon ( ) System located at j and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. ^� Provided:Construction ust be c mpleted within three years of the date of this pe� Date: � Approved by / 1 1/6/99, NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated 0 concerning the property located at S �v� (�v �(,�l� meets all of the following criteria: 4�/This failed system is connected to a residential y s dential 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. • There are no wetlands within 106 feet of the proposed septic system There are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed ;/There are no variances requested or needed. The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when ap,licable] • If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility 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 Elevation(using GIS information) 1 B) G.W.Elevation the MAX. High G.W.Adjustment _ DIFFERENCE BETWEEN A and B CA SIGNED : DATE: /e✓�3 [Please Sketch pry7orplan of system ack]. NOTICE Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert J G-�/ �, ., '�. ,_�:r 0 l,�_ c' TOWN,OF BARNSTABLE LOCATION io I I SEWAGE # V 00 VILLAGE Mti I'Y�' A ESSOR' MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS_ BUILDER OR OWNER PERMITDATE: u �2 COMPLIANCE DATE: o � 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 it air 1 �2 n t , ] Commonwealth of Massachusetts 3 Executive Office of Environmental Affairs Department of REcEivEO Environmental Protection FEB 2 8 1997 0 William F.Weld Governor 1IOtM1rNOFBgp► gg S.r,yy cEooxee if HEALTH DEFT. LE , EA David B. Struhs Commissioner �p Q SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 6 v PART A G poe, yy� ,,� CERTIFICATION Property Address: b `� �eyr( l ����A 16- Address of Owner: Date of Inspection:P (If different) Name of Inspector: . GiJfJ/� /�• ,r, t.�•j 5 Company Name, Address and Telephone Number: f CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sew disposal systems. The system: Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature- Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be seni to the system owner and copies sent to the buyer, if applicable and the approving au; ,orit\. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM ASSES: • // I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, . passes inspection. , Indi at es, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/1 5) 1 One Winter Street • Boston,Massachusetts 0210E • FAX(617)556-1049 • Telephone(617)292-SM d Printed on Recycled Paper - SUBSURFACE SEWAGE: DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) •Property Address Owner: _ Date of Inspection: B] SYSTEM'CON DITIDNALLY,�PASSES (continued) Sewage,backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)o�due to a broken, settled or uneven distribution_box. The system will pass inspection if(with approval of the T° Board of Health): broken pipe(s);are replaced obstruction is removed distribution box is levelled or replaced The system required umping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with ap roval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER HICH WILL PROTECT THE PUBLIC HEALTH AND 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) S TEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT T E SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: 03 f _. _ .fa_ . I �.4. I nr- ,Ir: :.:' •Un d11u tUli alJ�Ul'i..i Ufl Sy5tel11 nlw a i. iii• ivu Cam. .v u �Li .0 .w..� .,::rN�'�' ... ..� . '-�' .., .. surface water supply. The cv ipn. ha_ a septic tank and se. r .ion system and is within a Zone I of a public water supply well. The system has a septic tank, ,,,Id soil abs-3.-pilon system and is within 50 feet of a private water supply well. The sy>ten, ha, a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply- well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollw-,,.)n from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm• DI SYSTEM FAILS: I have determined that the s :::: .s®violates one or more of the folioiving failure criteria as defined in 310 CMR 15.303. The basis for this determination is identifier!! below. The Board of Health shoo:.; t:e contacted to determine what will be necessary to correct I failure. Backup of sewage into facility or system component due to an 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 cesspoc;, (revised t ' 5/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: 0- r� Date of Inspection: a�i��' 2 Dj SYSTEM FAIL (continued): 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARG E SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flo\N of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public heath and safety and the environment because one or more of the following conditions exist: 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 suppij well: The owne or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requireme is of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST �7 �l Property Address: Owner: Date of Ilnspection: 0, Check if the follow' have been done: P pi ng information was requested of the owner, occupant, and Board of Health. / None the system components have been pumped for at least two weeks and the system has been receivin normal flaw Y g rates d 'ng that period. Large volumes of water have not been introduced into the system recently or as part of this inspectkm. As ilt plans have been obtained and examined. Note if they are not available with N/A. The cility or dwelling was inspected for signs of sewage back-up. T system does not receive non-sanitary or industrial waste flow T site as inspected for signs of breakout. system comp ents, excluding the Soil Absorption System, have been located on the site. _T septi ank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or ees, terial of construction, dimensions, depth of liquid, depth of sludge, depth of scum. T e size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. _The facil; ov.• _. .! ccc.,^,ant , i c': i rc r, +r'­ o,tar': ,vpre provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/951 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM IN ECTION FORM ART C S INf Property Address:Own o Date Date of Inspection: FLOW CONDITIONS RESIDENTIAL. Design flow: allons Number , be oms: Number of c rrent resid ts: �� Garbage grinder (yes or no): Laundry connected to system (yes,or no): Seasonal use (yes or no): 1 Water meter readings, if a ailable: Last date of occupancy: P cY: COMMEI�t.:I AUI N DUSTRI AL: Type of es t blishment: Design flow: gallons/day Grease trap pr ent: (yes or no)_ Industrial Waste olding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter reading , if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and \ofin mation: System pumped as part of inspe on: (yes or no If yes, volume pump d gallons Reason f ing: TYP, M YSTE Septic tank/distribution box/soil absorpti n system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach pre ious inspection records, if any) Other (explain) APPROXIMATE AGE of all components date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) (/re (revised 8/15/95) 5 I - s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATI ontinued) r�Property Address: Owner: v Date of Inspection: o� TIGHT OR HOLDING TANK:_ (locate on site plan) Depth below grade:�l Material of construction: ncrete _metal _FRP_other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) .Depth of liquid level above outlet invert: Comments: (note if ie\ei and ciuuiuui—f. e.t ;u--,,, of; !i ca :}c•cr, e,ider,ce of leakage into or out of box, etc.) PUMP CHAMBER, (locate on site pla ) Pumps in workin order:(yes or no) Comments: (note condition o pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 L- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C (SYSTEM INFORMATION (/ ,J ued) Property Address: ery Owner: Date of Inspection: SOIL ABSORPTION SYSTEM ( AS):J� (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comment (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet i vert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool:. Materials of construction: Indication of ground.:a:c- inflow (cesspool must be p mped as p rt of inspection) Comments: (note condition of soil, signs hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:_ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition o soil, signs of hydraulic fail re, level of ponding, condition of vegetation, etc.) (revised 8/15/95) 8 f% . F SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTE4INFOR ' Property Address: �S Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' 0 �Q l go 49 DEPTH TO GROUNDWATER (f/Depth to groundwater:—Z,-&t 'I ' method of determination or approximation: (revised 8/13/95) S NoIC.:&.? • FEs...S.0 ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town.............OF................Ba.rnq-iTs3.ble.......................................... Allp iration for Uiopootti Workii Tontrnr#ion Permit Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal System at: ..........................L o t...10...KIr K:rY...P__X:j.vg.................... ----......-- .. Location-Address or Lot No. Marstons Mills ........--•-------•.........................................•-••---..._......-- ........... ..............r................................................................................... "� crw- Address ..................................... . ..... ......._..-•-•-------...._........................................................................ Installer Address dType of Building Size Lot....21.t 983-•-•--_Sq. feet Dwelling—No. of Bedrooms..__.-Thre......................................Expansion Attic h/� Garbage Grinder Other—Type of Building ............ /A......... No. of persons.....II/A............... Showers (Va) — Cafeteria (Va) a' Other fixtures ............N/A.................................................................... Design Flow............5.5_...........................gallons per person per day. Total daily flow...........A3.Q.........................gallons. 1:4 Septic Tank—Liquid capacity_l,-QQQ_gallons Length...8'6....... Width._.A'1D"__- Diameter--- ./A..... Depth....S_'$".. W x Disposal Trench—No........N,I.A__.. Width...._.N,/A..... Total Length......I1T./A...... Total leaching area....... „lA.....sq. ft. Seepage Pit No..........1......... Diameter.._...._.lQ-'..... Depth below inlet..._...6.11........ Total leaching area.._._26.6.....sq. ft. Z Other Distribution box (X ) Dosing tank ( ) ~' Percolation Test Results Performed by.........A.A.-M..-4...R_B.-K........................... Date.....A,/3.fz/__8.4............... Test Pit No. I...4...2.....minutes per inch Depth of Test Pit........12'__.. Depth to ground water.......n_o11e_.,... 4 4 Test Pit No. 2___.............minutes per inch Depth of Test Pit.................... Depth to ground water........................ a --•-------•-----•-•--••-•••---•---...---••--•-•...............................................••---..........__...---.......---•-••••--••••••-•-------•_--••- O Description of Soil................. ........ (-4-.1,22-)....med.i.um...S- d-------------•------------ x V -----------------------•---------------••----------••----------••----------------•-------......-----......._..------------..._...._..-•------------•---........_._...............•---••-•--=------------ W ----•--•-•••-- -------------••----•••-•••-•-•-•---•-•----•-----••-••••••-••••---•-•••••---••-•-----------••--••-------•-•••••------•-----•••-•-----•...•--•-•-•-•--••----------------•---.......-•--••-- UNature of Repairs or Alterations—Answer when applicable............................................................................................... ..........................................................•------•-•-•-••--•-••-••••.....................__....._..-•---•----------•---•-•..........•--••-•--•-•-•••---•.....•-•---...--••--•-•--_---•. Agreement: The undersigned agrees to install the aforedescribed. Individual Sewage Disposal System in accordance with the provisions of TITI U 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. e .............-� .�........................ . �. .........._. Application Approved BYZtlfollowinggl ..........................•-•--•-•--•--.._.....••••-•......•••••__••-- ./._.. ---- Date Application Disapproved f reasons: .................... ...............................................••....-•_.._...._........•----------...•--.....-••-•••••-----•-•---------------------•••--•--•--•...-•-•--•--•--.....--•--------------•--•-••---...._.._. Date PermitNo....................................................... Issued_....................................................... Date No........... ..,� t- FE$.... C................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ' _._.. ...?oWn............OF........ Barnstable D ........ :. .......................................... Appliratiun fur ttl Workri Tomitrnr#iun rumit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at: . Lot 10 Kerry Drive .............•- ...........----••--- •---...----•---......---...._..--------------•--------------•-•-•-----.....--•......_......•--_... Location-Address or Lot No. Mar Stons Mills .................................................................................................. .........._..--•...................•-------...._............._._..........................-....... Owner Address W Installer Address 2 3,98 3 Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.._...three Expansion Attic (n/0 Garbage Grinder (1/� Other—T e of Building I'd/� No. of ersons.......��A............... Showers a YP g �� A•-•• P ( �`) — Cafeteria 04 Other fixtures .............NL---•-•-••-•---•-----••-•--•-........-•--•-....••--•••--••-------•._...•--••----•--....-----•-----.............__.._.....---•--_.... W Design Flow........... 55.........................gallons per person per day. Total daily flow.__....__._ 3a.._....--_-___._______._gallons. WSeptic Tank—Liquid capacityli=gallons Length,_. ° ".__._ Width....!1`:LQ°'._ Diameter...NIA.... Depth..... x Disposal Trench—No._._.._.N/A.... Width.......N/A.... Total Length......N/A..... Total leaching area.......VA....sq. ft. Seepage Pit No..........l__..._._ Diameter.........1Q.1... Depth below inlet........?`........ Total leaching area...... E�....sq. ft. Other Distribution box X Dosing tank Z ( ) g ( ) '-' Percolation Test Results Performed by.......... M. �...R.B.E. Date......4/30/84 2 12° none l Test Pit No. 1...�.._....__.minutes per inch Depth of Test Pit__ ______ _ ____ Depth to ground water. ....__. Lti Test Pit No. 2................minutes per inch Depth of Test Pit..._................ Depth to ground water........................ P4 ----•------•----------------•-------•---_....._..........--•---...........------_....-----_.... --.....---------••------•----•- ••....... O Description of Soil.................t 0-4 ) loam, s.s. , clay 4-_•12 ) medium sans x . _..._'.--•.............•------•••••------•••---•-•--_..... ( •--- ----•----.....----•-...._._.._...-----.........._..•-•.......•- U •-•..............•------•-•---------•.......--•-----••••••-- --•••---•---••-•...-•---•------..._..---•--------.........--•-----••-••- 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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of Health. ed. ......._-•.... ...............................................•-.._.._......-• a4, ApplicationApproved By............. ---•--••••-•--.......-----......---••------•--•-•-•--....._._._._...___._.._.---- Date Application Disapproved for t.e owing reasons:---•---••-------•.......................•---•----•------••-•-••----------------•--------•--•----•...._._......_ __.........•--•------•-•••-----•-•-----••--••-•••••-------•...................••.....---........................--•----•---•--•---...----..._•--------•-•--•-----••----•••••-•-••-----••-•••.••--•---•--- Date PermitNo..-...................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town, Barnstable Trdif iratr of Tnmplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( X) or Repaired ( ) by Robert B. Our Co. ._ •--••--•............ ...................................•-----•- ---••--•----------- ........... •---------------------------------- _........... er at_________________ Great Western Road, No. HIarw .... ich, MA E ................................................................................-_......._..._..__......_............. has been installed in accordance with the provisions of TITI �,S 1 State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated................................................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.......................................... . 1 .................. Inspector...------•-- --_v.. -------------------•-••----......-- ... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH y! ..........................OF.................................... No."--.................. FEE........................ Diuvuual urkp unutr ion Hermit Permission is herebygranted........... I..-----•••---•---------••--•......-•••••......................... to Construct ( r Repair (J ) an Individual Sewage Disposal System atNo................. l ........ ....... ............. Street as shown on the application for Disposal Works Construction Permit•No-:`� ............. Dated.......................................... .-�. -------- - ------ Board of Health DATE................................................................................ FORM 1255 A. M. SULKIN, INC., BOSTON Massachusetts Water Resources Commission/Division of Water Resources _ WATER WELL COMPLETION REPORT WEL LOCATION Address I b i City/Town C G.S.Quadrangle Map Grid Location Owner Address%A!5: —AAAr n&1Zsar .t Q WELL USE CONSOLIDATED WELL Domestic Public ❑ Industrial ❑ Type of Water-bearing Rock Other Water-bearing Zones METHOD DRILLED 1) From To Rotary(type)—&q-:!L�Cable ❑ 2) From To Other 3) From.To.' 4) From To CASING Depth to Bedrock Lengthy Diameter'-2 Type "��0C_ UNCONSOLIDATED WELL STATIC WATER LEVEL Water-bearing Materials Feet below land surface M0 Sand: fine❑ medium❑ coarse rV bate measured — Gravel' fine❑ medium❑, coarse❑ Screen: GRAVEL PACK WELL _ g k� v�3'Slot# len th � from to Yes [� No Split Screen(or 2nd screen) WATER QUALITY TESTS MADE Slot# length from to Chemical Biological ❑ Depth To Bedrock PUMP TEST Drawdown feet after pumping days hours at GPM. How measured Recovery feet after hours. LOG of FORMATIONS COMMENTS: (On well or water) Materials From To " o' DRILLER, . Firm CLIFFORD WELL nRIF I Ihfr 0 Address 1 65 Blue Rack Road City Re gi ration No . J erator s Signature ease p ant 1rrr y 414 f 10"/81.184843 " • It - 3 .N Opp < ( 00p T I .o : �� �}F —T' / ILA (vt r 5 0 /=_k 0 NT.f <�, C _ _ N $- . l Sr_=j.. RSE. ?E :tg r No 10911:p M GIs iSS�ONAI 1 8 OO. � c F:IiC' CAIQ — ELDR -f ��; . LE�3END(!%c2�� 63 I I t\ �`049T-IN0 SPOT ELEVATION 0.,O' Sac= �� � ll � ,,.�s FTING -CONTOUR -- ® - '-:. . :Fc CERTIFIED PLOT " a, N . �'0 ` SPOT ELEVATION. ` ; 14 .,COXTOU.R --- O 'he location o£ any ex�s�ting under 1�ound sewerage, , - IN other utilities shown. on -trIs plan is appr9x7: t� on1 as determined from records and/or vexbal i��aflxmatlon. The' contractor is •xespons�.ble` fore.the �v t ry �f at on of..the,existing locations in the Meld. SCALE = 0 DATE ,?/ ! /g k x RE®GE. ENGINEERING COi i CL NTf--- --- I CERTIFY THAT THE PROPOSED +� d E01$TRL• RE019TERD J4�1NO '�` 3 BUILDING SHOWN ON THIS PLAN IVIL CONFORMS- TO THE' ZONING LAWS t x R E OF ':BARNSTABLE , MASS. 12` MAI N STREET °' ' CN...@Ys • c}k HYAN.N I S-* MASS. SHEET.T .OF 4i��ATi REG. LAND SURVEYOR .. . . :r ,� N ,.ie, w s -, ,. s• .,`S e '' .' .:,.. x.�p ..c.'3, ,..�•,. t a'a ✓ ::k�.. 1f m+.:-^,a,. .� �3.''- .k _,.,f.# ", a 7''r. 4,k:: ..f,Y` 'l .J':.....f: .f,.. a. e..i. A` Y-..u.- ,.:7�:E . +� xk.Xe 13,y "i.•.v N!w•�c}.�[ ^:��r U... YS'. .,ff•., b d• YX.a.*. t'r.M+ 4.•,•, i" � .��..e�� I R:'4-.. .s,l d. tk•, S"y, '"$C.. . ti. �.. ..`�,.. �sy+L2X "� .°".-: �Y` .&��"�^' ..:. .,5.. ,:a „ 1L�v t• -.�-.. �r�. a,4.',r r.. •� ,-'E�-� h..t�.r=a i ,��� ,,.ti:.,,�.:, �:... .Yc:;.. -- ,,.; ,,,. ...,. ,,._ _ -. .k... ,-.r r _. ,r,. _.. _'i ram.:....,, ;�......, .•c.:,. 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Conductivity (micromhos/cm) 114. 500.0 Iron m) 0.25 Nitrate-Nitrogen ( m) 4.72 10.0 Sodium m) 12, 20.0 7 I • Water sample meets the recommended limits for drinking of' all above tested parameters. II. Based only on results of the parameters tested for this sample, the water is suitable for drinking but may present the problems checked below: A. XX Water sample has higher than average levels of 'Nitrate. Future monitoring is recommended (2-3-times per year)"to ,e`stablish any upward ;trends 'b, B. The low pH of the. wa ter may shorten .the useful life of the house's plumbing., C. Water may present aesthetic problems (taste, odor, staining) due to D. Water sample has high'levels of sodium. • Persons"on low •sodium'diets should consult their doctor. III. Due to one or more of the reasons checked below, this water sample is unfit for human consumption: A. High Bacteria B. High Nitrates REMARKS: CC: Barnstable Board of Health CC: Clifford Well Drilling 7/17/84 Labors ry Director i <. efiJ Ex�lanation of Test Results' - . Total'Coliform Bacteria Coliform bacteria are.an indicator of the sznitary quality of a water supply..Water supplies may become contaminated from malfunctioning septic systems,cesspools and surface runoff. A total coliform count of zero indicates that your water supply,is.saf.e and approved for human consumption. A total coliform count of greater than zero is most often.the result of acc dental'contamination_of the sample bottle,through improper sampling methods. For this reason, it would be:advisable to retest any well water that is not approved. PH y a pH is the.measure of acidity or alkalinity of the water: On the pH scale, the number 7 is neutral, less than 7 is acidic and more than 7 is alkaline. The pH of water,on Cape Cod tends to be acidic in the range-of S.O to 6.5 Conductivity + Conductivity.is'wmeasure of the dissolved saltcs'in solution. Amounts in excess of 500.micromhos'_rn are generally considered unacceptable and may have a laxative effect upon users. Iron The presence of :iro.n'in 'water in-concentration of .3_ppm or greater may: give the water a bittersweet astringent taste cause an unpleasant odor,-often gives the water a,brownish,color.and cause staining of laundry. and porcelain. The average concentration of iron in Cape Cod's water is ,2 - .6 ppm. Although the presence of iron in water may cause.the problems listed 'above,'it is-not considered deleterious :to.`healt'h. 'Iron may be removed by,use of.an iron removal system Nitrate nitro en The Massachusetts Drinking`Water.lZegulatie,,is have set aAaximum contaminant level for nitrates At.10 ppm: Excessive concentrations may cause methemoglohinemia (an infant diseme).and have been suggested to form potentially carcinogenic nitrosamtnes Coniaminatr'0 sources'it clude'"fertilizers,'cesspools and industrial wastes., i r Copper Due to the acidic naiure.of the water;on Cape Cod,;copper tends to leach from pipes. This normally does not present a.health hazard; however,concentrations in excess of 1.0 ppm may cause a metallic taste and/or a bluish green stain on porcelain fixture. Sodium A concentration of sodium over 20 ppm is only of concern to people who are on a low sodium diet. If the . water supply has more than 20 ppm sodium,it is up to the people who are on.such a diet to find another source of drinking-water or contact their doctor to determine if consuming the water is advisable. 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