HomeMy WebLinkAbout0354 LAKE SHORE DRIVE - Health 354 Lake Shore Drive
Marstons Mills N
A = 014 004
k
TOWN OF BARNSTABLE
LOICATION / £ � SEWAGE #
VILLAGE � ' � � � L i' ASSESSOR'S MAP & LOT—!3'
tliSq9iE-�S NAME&PHONE NO.j
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SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
t NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: 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
�tEAR 5
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Commonwealth of Massachusetts .
_ Title 5 Official Inspection Form -
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
,M 354 Lakeshore Drive
Property Address
Frank Destefano
Owner Owner's Name
information is required for every. Marston Mills Ma. 02648 12/16/13
pager City/Town- State Zip Code.- Date of Inspection -
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms
on the computer,
use only the tab
-1. Inspector:
key to move your cursor do not �1*67.
I
Ricky L. Wright.
use the return
key. Name of Inspector
B&B Excavation
Company Name
14 Teaberry Lane
Company Address
Sandwich Ma. :. 02644
Cityrrown State Zip Code
(508)477-0653 S14595 -
Telephone Number License.Number
B. Certification
certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15000). The system:
® Passes. ❑ Conditionally Passes ❑ .Fails
Needs Further Evaluation by the Local Approving Authority
12/16/13
Insp ctor'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 is a shared system or
has a design.flow of 10,000 gpd or greater, the inspector and the.system owner shall submit the...
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer,.if applicable, and the.approving,authority.
*"*This report only describes conditions at the time of inspection and under the conditions of use
at that time..This inspection does not address how.the system will perform in the future under
the same or different conditions of use. - -
� V
I
t5ins•3%13_ :: Title 5 Official Inspection TSSUb, ace Sawage;Disposal System-Pagel of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
354 Lakeshore Drive
Property Address
Frank Destefano
Owner Owner's Name
information is required for avery Marston Mills Ma. 02648 12/16/13
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ one or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined"(Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with,a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M W 354 Lakeshore Drive
Property Address
Frank Destefano
Owner Owner's Name
information is required for every Marston Mills Ma. 02648 12/16/13
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/al'arms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ diistribution 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):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
64 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 354 Lakeshore Drive
Property Address
Frank Destefano
Owner Owner's Name
information
equir d o r e Marston Mills Ma. 02648 12/16/13
required for every
page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
*"This system passes if the well water analysis, performed at a DEP certified laboratory, for 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.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/ day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
� Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w 354 Lakeshore Drive
Property Address
Frank Destefano
Owner Owner's Name
information is required for every Marston Mills Ma. 02648 12/16/13
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ 0 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.
❑ M 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.
❑ M Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No.
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts ..
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
354 Lakeshore Drive .
. Property Address
Frank Destefano
Owner
Owner's Name
information i e
required for every Marston Mills Ma. 02648 12/16/13
..
page. Cltyrrown - State Zip Code. - Date of Inspection
C. Checklist ..
Check if the following have been done. You must indicate"yes" or"no as to each of the following:
Yes No
® Pumping information was provided by the owner, occupant, or Board of Health
Were:an of the.s stem com onents pumped out in the previous two weeks?
❑ � Y Y P P P
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.
Z.
❑ 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)]
D. System Information
Residential.Flow Conditions:
Number of bedrooms(design): 3 . Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203.(for example: 110 gpd x#of bedrooms): .
330
t5ins-3113.::: Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
354 Lakeshore Drive
Y
Property Address
Frank Destefano
Owner Owner's Name
information is required for every Marston Mills Ma. 02648 12/16/13
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 3
Does residence have a garbage grinder? ❑ Yes ® No
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 n/a
9 ( Y 9 (gP ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes- ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
354 Lakeshore Drive
Property Address
Frank Destefano
Owner Owner's Name
information is required for every Marston Mills Ma. 02648 12/16/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: B&B Excavation
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1000
gallons
How was quantity pumped determined? site glass
Reason for pumping: maintence
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)
e
❑ 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):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
G M , 354 Lakeshore Drive
Property Address
Frank Destefano
Owner Owner's Name
information is required for every Marston Mills Ma. 02648 12/16/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
Tank original to dwelling leaching upgraded in 2000
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2.5
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: >20feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
At time of inspection building sewer appeared to be in good working order no sign of leakage.
Septic Tank(locate on site plan):
Depth below grade: 1.5
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gal.
Sludge depth: no sludge
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 354 Lakeshore Drive
Property Address
Frank Destefano
Owner Owner's Name
information is required for every Marston Mills Ma. 02648 12/16/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle no sludge
Scum thickness no scum
Distance from top of scum to top of outlet tee or baffle
no scum
Distance from bottom of scum to bottom of outlet tee or baffle no scum
How were dimensions determined? scour stick
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
At time of inspection septic tank appeared to be in working order,Tees present no sign of back-
up.Liquid level equal with outlet invert.Pumped as part of inspection.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 354 Lakeshore Drive
Property Address
Frank Destefano
Owner Owner's Name
information is
required for every Marston Mills Ma. 02648 12/16/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 354 Lakeshore Drive
Property Address
Frank Destefano
Owner Owner's Name
information is
required for every Marston Mills Ma. 02648 12/16/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 0
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
At time of inspection D-box appears to be structurally sound no sign of leakage.
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.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
w Title 5 official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�^M 354 Lakeshore Drive
Property Address
Frank Destefanc
Owner Owner's Name
information is required for every Marston Mills Ma. 02648 12/16/13
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: (2)500gal
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
At time of inspection leaching appears to in working order no sign of hydraulic failure.Water level was
16" below invert at time of inspection.
Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
i —
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
354 Lakeshore Drive
Property Address
Frank Destefano
Owner Owner's Name
information is required for every Marston Mills Ma. 02648 12/16/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on'site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
354 Lakeshore Drive
Property Address
Frank Destefano
Owner Owner's Name
information is Ma. 02648 12/16/13
required for�every Marston Mills
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
.............
S�
�9� I
.. o
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System+Page 15 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 354 Lakeshore Drive
Property Address
Frank Destefano
Owner Owner's Name
information is required fcr every Marston Mills Ma. 02648 12/16/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: >12feet
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: 6/19/2000
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.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
354 Lakeshore Drive
Property Address
Frank Destefano
Owner Owner's Name
information is required for every Marston Mills Ma. 02648 12/16/13
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
3SHSf
COMMONWEALTH OF MASSACHUSETTS
Z W EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
m + d DEPARTMENT OF ENVIRONMENTAL PROTECTION P
MAP
A 350 MAIN STREET
WEST YARMOUTH,MA LOT
�O 508-775-2800
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
C3
Map 014 Par 004 :'
Property Address: 354 Lake Shore Drive C3 Ca
Marstons Mills,MA. 02648
Owner's Name: Kim Primpas C!>
N >
Owner's Address: 354 Lake Shore Drive —p
Marston Mills,MA. 02648 to
Date of Inspection March 5,2004 N
Ci l r
Name of Inspector:(please print) James D. Sears %D rn
Company Name: A&B Canco
Mailing Address: 350 Main Street
West Yannouth,MA 02673
Telephone Number: 508-775-2800
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was perfonned based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: - �-
67
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 tot he buyer,if applicable,and the approving authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that time.
This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 1
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 354 Lake Shore Drive
Marstons Mills,MA. 02648
Owner: Kim Primpas
Date of Inspection: March 5 2004
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CM 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes: N/A
One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.
The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"
please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,
exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing
tank is replaced with complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval
of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health)"
broken pipe(s)are replaced
obstruction is removed
ND explain:
Title 5 Inspection Form 6/15/2000 2
Page 3 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 354 Lake Shore Drive
Marstons Mills,MA. 02648
Owner: Kim Primpas
Date of Inspection: March 5 2004
C. Further Evaluation is Required by the Board of Health:N/A
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 salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of 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 detenmine 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:
Title 5 Inspection Form 6/15/2000 3
Page 4 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 354 Lake Shore Drive
Marstons Mills,MA. 02648
Owner: Kim Primpas
Date of Inspection: March 5 2004
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:N/A
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 pits less than 6"below invert of available volume is less than'/2 day flow
—� Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the SAS,cesspool or privy is below high ground water elevation
N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply
N/A Any portion of a cesspool or privy is within a Zone 1 of a public well
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well
N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (This system passes if the well water
analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic
compounds indicates that the well is free from pollution from that facility and the presence of
ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this fonn.)
NO (Yes/No)The system fails. 1 have detennined 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 detennine what will be necessary to correct the failure.
E. Large Systems: N/A
To be considered a large system the system must service a facility with a design flow of 10,000 gpd to
15,000 gpd.
You must indicate either"yes"or"no to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—1WPA)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 is 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 5 Inspection Form 6/15/2000 4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 354 Lake Shore Drive
Marstons Mills,MA. 02648
Owner: Kim Primpas
Date of Inspection: March 5 2004
Check if the following have been done. You must indicate"yes"or"no"as to each of the following
Yes No
✓ Pumping infonnation was provided by the owner,occupant,or Board of Health
✓ Were any of the systern 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 stem Absorption S SAS has been determined based on:
P Y (SAS)
Yes No
✓ Existing information. For example,a plan at the Board of Health.
✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable)[310 CMR 15.302(3)(b)]
Title 5 Inspection Form 6/15/2000 5
Page 6 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 354 Lake Shore Drive
Marstons Mills,MA. 02648
Owner: Kim Primpas
Date of Inspection: March 5 2004
FLOW CONDITIONS
RESIDENTIAL
Number of Bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 330
Number of current residents: 1
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): YES
Seasonal use(yes or no): NO
Water meter readings,if available(last 2 years usage(gpd)): 2002—46,000 Gal/2003-50,000 Gal
Sump pump(yes or no) NO
Last date of occupancy: Present
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203):
Basis of design flow(seats/persons/sqft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: To be pumped after inspection
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: gallons—How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank Attach copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
D-box and leaching 2000 permit#2000-365
Were sewage odors detected when arriving at the site(yes or no): NO
Title 5 Inspection Form 6/15/2000 6
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 354 Lake Shore Drive
Marstons Mills,MA. 02648
Owner: Kim Primpas
Date of Inspection: March 5 2004
BUILDING SEWER(locate on site plan):
Depth below grade: 6"
Materials of construction: Cast iron 40 PVC _ other(explain)
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK(locate onsite plan):
Depth below grade: 2'
Material of construction: concrete metal fiberglass polyethylene
other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 GALLON PRE CAST
Sludge depth: 2"
Distance from top of sludge to the bottom of outlet tee or baffle: 28"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 8'
Distance from bottom of scum to bottom of outlet tee or baffle: 16"
How were dimensions detennined: As built and tape
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):Main tank at working level,tank at Tout let cover at 12",out tee,
no sign of leakage or overloading.
GREASE TRAP(located on site plan) N/A
Depth below grade:
Material of construction: concrete metal fiberglass _ polyethylene other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
Title 5 Inspection Form 6/15/2000 7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 354 Lake Shore Drive
Marstons Mills,MA. 02648
Owner: Kim Primpas
Date of Inspection: March 5 2004
TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain)
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no)
Alarm level: Alarm in working order(yes or no):
Date of last pumping
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: 4 (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 0
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.,): D box is 30"below grade,one line in one line out,d box is clean,no sign of over
loading or solid carry over.
PUMP CHAMBER: N/A (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Title 5 Inspection Form 6/15/2000 8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 354 Lake Shore Drive
Marstons Mills,MA. 02648
Owner: Kim Primpas
Date of Inspection: March 5 2004
SOIL ABSORPTION SYSTEM(SAS): ,/ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching chambers,number: 2
leaching galleries,number
leaching trenches,number,length
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of
vegetation,etc.)Leaching is two 500 Gallon dry wells with cover at 2'top of leaching at 40"
CESSPOOLS: N/A (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwa-,er inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.):
PRIVY: N/A (locate on site plan)
Materials of Construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
Title 5 Inspection Form 6/15/2000 9
I
Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Proper",Address: 354 Lake Shore Drive
Marstons Mills, MA. 02648
Owner: Kim Primpas
Date of Inspection: March 5 2004
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.
� F
0
,I r
`.
L/3�
Title 5 Inspection Form 6/15/2000 10
Page 1 i of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 354 Lake Shore Drive
Marstons Mills,MA. 02648
Owner: Kim Primpas
Date of Inspection: March 5 2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to groundwater 50.5 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observation 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:
USGS well data well sdw 253 at 50.5
Zone B 4.5
ADI 46.0
i
L�
I
TOWN OF BARNSTABLE .007
LO( AT10N��/ �' t�� ��"`� r SEWAGE
ole
VILLAGE V,0W �0/11 11,/f� ASSESSOR'S MAP & LOT
/`t �OV
INSTALLER'S NAME&PHONE NO. eo,�J e�GU 2��r����
SEPTIC TANK CAPACITY Za22 efgZ14g.) p'
LEACHING FACILITY: pe)O?r �° �&�ir'-(size) 025
NO.OF BEDROOMS
_44
BUILDER O OWNE eC'
y
PERMTTDATE: COMPLIANCE DATE
e.
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility ' Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) _;< Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) > Feet t
Furnished by
4 <
Wk
n"
No. ti; Fee �j U
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Zippricatiou for 30iopooal bpgtem Conotruction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System O Individual Components
Location Address or Lot No. 3S q �4 e_S�Oy e 0r. Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
Installer's Name,Addr*,&t Te1Ajq00 Designer's Name,Address and Tel.No.
350 Main Street
W. Yarmouth, MA 02673
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other TI pe of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow 3 3 0 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank /OlsD Type of S.A.S.
Description of Soil fA,,4�1•
Nature of Repairs or Alterations(Answer when applicabl ) L 1 J' 4(( C �� �3 d X '-o
of - eirn g,a-( ��+-VJ,I/-C w Y r S
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board f ea
Signed Date '� y
Application Approved by Date
Application Disapproved for the following reasons
Permit No. 74/y—36.E Date Issued G Zo
TOWN OF BARNSTABLE
LOCATIONS/S/ 14(2- 6// l�ke— SEWAGE # 1
VILLAGE ASSESSOR'S MAAPP & LOT 'D6
INSTALLER'S NAME&PHONE NO. � �1�✓1Ci I?
SEPTIC TANK CAPACITY
LEACHING FACILITY: pe) � (, / al�ex (size)
NO.OF BEDROOMS
BUILDER O OWNE
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility
Feet
-Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
1 Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility). . Feet
Furnished by
- --
3� S' ^i
No. � Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
2paplication for Mie;pooal *patent Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System El Individual Components
Location Address or Lot No. j�� 46-.W Owner's Nam ,Address and Tel:No.
Assessor's Map/Parcel 0 — 0041 'o f )O t 7 /)uvi CAf7 4v N• /.
Installer's Name,AddressApt'eSNCANCO Designer's Name,Address and Tel.No.
350 Main Str_—o IJ114
W. Yarmout� , tv!A o,'h'
Type of Building:
K 'Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other TI ype of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow 3 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank O Type of S.A.S.
Description of Soil fA iY
Nature of Repairs or Alterations.,Answer when applicabl ) -�n �� ' "x o
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board oflHe
Signed i /f Date G
Application Approved by
Date
Application Disapproved for the following reasons
S
Permit No. 3 Date Issued
--------------- ----- '--------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS i
Certificate of Compliance
THIS IS TO CERTIFY,th the On-site Sewage Disposal System Constructed( )Repaired( Upgraded( )
Aban? �e ( ) y
at � '��°`r`= ?°y�' / r L as been construc ed i accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.74W— &.S date./d/
Installer I u Designer
The issuance ofrff�is permitlsh�all not�be construed as a guarantee that the systern w311"unct ofn asidesigned./
Date l �`!f ��` Inspector A
- U I - 1
V
---------------------------------------
z, -� _?C s
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
liopooal 6potem Construction Permit
Permission is hereby ranted to Cops ct( )Repair( -�p rade( )Abandon,( )
System located at `+u✓c
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:Constru tio n}x►�a completed within three years of the date of t
Date: / Approved by _✓.
` J
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)
I, :J �( ( _ , hereby certify that the application for disposal works
construction permit signed by me dated 4 - ( �_ v , concerning the
property located at meets all of the
following criteria:
./. The failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
There are no wetlands within 100 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 applicable]
�• 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)
B) G.W.Elevation +the MAX.High G.W. Adjustment. f• = T
DIFFERENCE BETWEEN A and B
SIGNED : U 41 � � DATE: D'c�
[Sketch proposed plan of system on back].
q:health folder:cert
II�[
2�:UR
� � b
i
i
� ?A
No.... -1.......... Flms.. ...................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD
Vd-- - -- -------------
1 Appliratiun for Ehap oal Works (�omitrurtion rrulit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Sy teas at* /
Location-Address 1 z � or Lot No.
............................................. ............................ .. . . -_ .
Y a
C,,ner Address
�-----•-• -•-----•---•-•--•----- -•------------------------•--- --•--...-•--•-•-----..._.
Installer Address
dType of Building/ Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms______________________________......
_Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons___________.________________ Showers ( ) — Cafeteria ( )
a' Other fix
W Design Flow__ts____________ ___......___p_______ lions per person per day. Total daily flow___________---------- .___--.___gallons.
WSeptic Tank—Liquid capaci lons Length------_-------- Width................ Diameter---------------- Depth______-_..____.
x Disposal Trench— o_.................... Width_____._...__..._.. _ T f - n ______ __ f Total leaching area____.__ sq. ft.
Seepage Pit No. Diameter_ _ f ow it ............... d_ Total leaching area--- � s
Z Other Distribution box ( ) Dosing`tank ( )
aPercolation Test Results Performed by-----------------------------------------------------------------••-•---- Date........................................
Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water____________________-_..
114 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_______....___-_____-_-.
---------------------F
---_ ---- . - • -- ---•-----.........................................................
0 Description of Soil------ 6--------------- --- ._...... d e�G�
x
U ----------------------------------------•-------------------------- --------------••---- •--------••-•-•--•----•---•••••-•--••••-••--•••---••...•••---•-•••••••••--••--•--•••••-••--------------
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 Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b en issued d of health.
Signed---- --•- - --------------"------------------------------------------------ �� `�- -------
Date
Application Approved By - ,� ----- ...........� /____
-
----- ----------------------------------------Date
Application Disapproved for the following reasons--------------------------------- --------------------------------------------------------------------
----•-•--------•---------•-----------••••-••••••••--••-••-•-•••-----•--•----------•-------•-•-•--------•••-•----------------------•--•-----------•--•--------••••••••••-•••_._..--------------•-•-------
Date
PermitNo......................................................... Issued----- - ---— ------
Date
No;.1�4.......... ....................
THE COMMONWEALTH OF MASSACHUSETTS
B 0 A R DWF HE L , H
Vel.sn. _. ..............OF. a
... ................................................................................
Appliration for Uiopasal Works Towitrurtiou Vrrmit
.Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
Syst -`at:
................. ..... *.......... ..... ... .... .-P .4 -
` ; -----------------------------------------
or Lot cation ,Address N
...... ........ ... .............................. .. .. .. . . .. ...... .... . .
.........................................
dre's
�vner
........... .................. ....rid" ----------------------------------------
Installer Address
Type of Buildi Size Lot.............................Sq. feet
U
Dwelling2No. of Bedrooms-_---__--_-''' _ _....Expansion Attic Garbage Grinder
O4 Other—Type of Building ........................... No. of persons............................ Showers Cafeteria
Other fires .4................
.................................................................................... ... ...............
Design Flow.. ................ 6r
...,fallons per person per day. Total daily flow........... r—--------------------gallons.
------------ er __
P4 Septic Tank—Liquid capaci4...........zallons Length................ Width----_---_-.--_-- Diameter--_.-.-..-_-___- Depth.............--.
Disposal Trench— o.____________________ Width.................ztTat-JwLen 7
'j;_� -_. Total leaching*area... sq f t.
)AR
ow -------_&.. Total leaching area--- ----------SQ. ft.
Seepage Pit No......r............ Diameter.L�'��It.�11.5
7
Z Other Distribution box Dosing tank
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit_-______--_____-____ Depth to'ground water---_-------------------
Test Pit No. 2................minutes per inch Depth of Test Pit............_....... Depth to ground water---------------__-_--.-.
,
........... �..i......... ................................................................
0
Description of Soil........./ ................................. _ ..
--------------------------------------------------------------------/.....................i.........................
U
---------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable----------------------------------------------------------------------------- ..............
.....................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The.undersigned further agrees not to place the system in
operation until a Certificate of Compliance has en issued Eby'flTerboard of health.
• S .... ................................................................ -----------------..........
Date,
Application Approved BY--- , �'
----------------- -------------------
K
Date
Application Disapproved for the following reasons-------------------- ............. .........................................................................
----------------------------------------------------------------*---------------------------- -------------------------------------------------------------------------------------------
Date
PermitNo......................................................... Issued--------------------------------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.........r414
..............OF..... ..................................
(Irdifiratr of Tontphatta
THIS IS TO ,CER TIFY,/That the Individual Sewage Disposal System constructed or Repaired
by...........................
....................................................... ---- -----------..................................................................................
................. .......... ... ...... J
at. . A4 f!........ ---/--' - _".'i.".........J...;�.'.l',..
-)-/- ,--A----
_-
h
as ---------------------------------been installed in accordance with the provisions of Article of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.., .............................. dated.... � ...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WI FUINCTION SATISFACTORY.
................... Inspector......
DATE------ ..... .................................... ..............................
0,00..W. .......... ...... .......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH Y
OF
No........ ---------- ... .............................................
FEE
-"/) -'-j
Permission -
is h P
ereby granted.............. .. ........................................................ ...... ......... ------
to Construct•(<-�oor Repair an Individual Sewage Disposal System
at No.--- ...... ------------------------------- ------------- ...................
...................!:�..L...
Street
as shown on the application for Disposal Works Construction Permit No.-_-'_ J
..Z---------- Dated...... .
............
----------- -----------
Board of Health
DATE.............. = ............. .....................
FORM 1255 Hoe" &�'WARREN, INC.. PUBLISHERS