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HomeMy WebLinkAbout0334 MISTIC DRIVE - Health • k 334 MISTIC DRIVE;MARSTONS MILLS A_ 080 029 4 o � r y Commonwealth of Massalchusetts ,F Title 5 Official Inspection Form , Subsurface Sewage Disposed System Form- Not for Voluntary Assessments 334 Mistic Drive Property Address Tesconi Owner Owner's Name information is required for every Marstons Mills MA 02648 6/9/20 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. Inspector Information Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 City/Town State Zip Code 508.272.6433 13010 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 6/9/20 Inspecto&,86naffiri 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 ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments - 334 Mistic Drive Property Address Tesconi Owner Owrer's Name information is required for every Marstons Mills MA 02648 6/9/20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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 Commonwealth of Massachusetts ,� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 334 Mistic Drive Property Address Tesconi Owner Owners Name information is required for every Marstons Mills MA 02648 6/9/20 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 Commonwealth of Massachusetts ,F Title 5 Official Inspection Form r, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 334 Mistic Drive Property Address Tesconi Owner Owner's Name information is required for every Marstons Mills MA 02648 6/9/20 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: '*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/201 a Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 334 Mistic Drive Property Address Tesconi Owner Owner's Name information is required for every Marstons Mills MA 02648 6/9/20 page. CitylTown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 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 water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10;000 gpd. ❑ ® The system fails. I have determined.that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 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 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 334 Mistic Drive Property Address Tesconi Owner Owner's Name information is required for every Marstons Mills MA 02648 6/9/20 page. Cityrrown 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 aU inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 334 IJlistic Drive Prope.ty Address Tesconi Owner. Owne's Name information is required for every Marstons Mills MA 02648 6/9/20 page. CityrFown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 Description: Engineered plan on file at BOH Number of current residents: 0 Does residence have a garbage grinder? ® Yes ❑ No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: vacant 1 year Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 334 Mistic Drive Property Address Tesconi Owner Owner's Name information is required for every Marstons Mills MA 02648 6/9/20 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) 2. Commerciallindustrial 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 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: No recent pumping per owner 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 334 Mistic Drive Property Address Tesconi Owner Owner's Name information is required for every Marstons Mills MA 02648 6/9/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1991 per BOH record Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 5. Building Sewer(locate on site plan): 3' Depth below grade: 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.): I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form '- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 334 Mistic Drive Property Address Tesconi Owner Owner's Name information is required for every Marstons Mills MA 02648 6/9/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 3'6" Depth below grade: feet Material of construction: Z concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) I-10 tank appears to be structurally sound, inlet raised to 16" of grade, due to the depth of the outlet cover scum and sludge measurements were not taken, it is suggested a riser be installed to raise the rover for inspection and maintenance in the future, If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500g Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 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 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.): Pumping suggested every 3yrs to prolong the life of the system t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts iP Title 5 Official Inspection Form to Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 334 Mistic Drive Property Address Tesconi Owner Owner's Name information is required for every Marstons Mills MA 02648 6/9/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. 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 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): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts l� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments i •� 334 Mistic Drive Property Address Tesconi Owner Owner s Name information is required for every Marstons Mills MA 02648 6/9/20 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? El Yes ❑ No 9. 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.): H-10 D-box is 4'6" below grade, cover raised to 6"of grade, no adverse conditions observed t5insp.doc-rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts ,? Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 334 Mistic Drive Property Address Tesconi Owner Owner s Name information is required for every Marstons Mills MA 02648 6/9/20 page. CityTrown 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.): * 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 ❑ leaching 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 (o Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 334 Mistic Drive Property Address Tesconi Owner Owner's Name information is required for every Marstons Mills MA 02648 6/9/20 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 chambers were video inspected and are damp at this time, no indication of past hydraulic failure 12. 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 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 IF Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 334 Mistic Drive Property Address Tesconi Owner Owner's Name information is required for every Marstons Mills MA 02648 6/9/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 t Commonwealth of Massachusetts l Title 5 Official Inspection Form J�o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 334 Mistic Drive Property Address Tesconi Owner Owner s Name information is required for every Marstons Mills MA 02648 6/9/20 page. CitylTown 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 i t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 1 c —' TOWN OF BARNSTABLE LOCATION 33 SEWAGE p �—5/7r VILLAGE !!2')- A 5 AS$ ASSESSOR'S MAP&LOT at? Ogl INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 13 04 6:d L LEACHING FACILITY:(type) Gi¢L L£f S 7` (size) NO.OF BEDROOMS,/ BUILDER OR�NNER PERMIIDATE: 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 Edge of Wetland and Leaching Facility(If any wetlands exist .. within 300 feet of leaching facility) Feet Furnished by � N i 0 � :J (A Commonwealth of Massachusetts �. IF Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l 334 Mistic Drive iProperty Address Tesconi Owner Owner's Name information is required for every Marstons Mills MA 02648 6/9/20 page. Cityrrown 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: >144" feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 1991 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: 4'seperation per compliance on file at BOH ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: TOPO mapping shows the site at 65'msl and nearby surface water at 42'msl You must describe how you established the high ground water elevation: see above 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 J 10k, Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 334 Mistic Drive Property Address Tesconi Owner Owner's Name information is required for every Marstons Mills MA 02648 6/9/20 page. Cityrrown 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 I t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 COMMONWEALTH OF MASSACfiUSETTS T EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS (ay I DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE %kINTER STREET. BOSTON. NIA 02108 61 7 292.5W 2 � TRUDY CO: WILLIAM F VELD 350 MAIN STREET Secret: Govemor WEST YARMOUTH,MA ARGEO PAUL CELLUCCI 6,a 508-775-2800 DAVID A.STRU Commissin Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM D PART A CERTIFICATION MAP 080 PAR 028 i PROPERTY ADDRESS: 334 MYSTIC DRIVE,MARSTONS MILLS ADDRESS OF OWNER: DATE OF INSPECTION: AUGUST 25,1998 CHARLES DIANA NAME OF INSPECTOR: JAMES D.SEARS I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 9310 CMR.15.000) COMPANY NAME: A&B Canco MAILING ADDRESS: 350 Main Street,West Yarmouth,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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X PASSES CONDITIONALLY PASSES NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY FAILS INSPECTORS SIGNATURE: DATE: AUGUST 26, 1998 C/ iiL 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 sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A,B, C,or D: A] SYSTEM PASSES: n n information which indicates that the system violates any of the failure criteria as defined in X I have not found Y 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: SITE OVER ALL PASSES,INSPECTION OF SYSTEM IS BASED ON CONDITION OF SYSTEM AT THE TIME OF THE INSPECTION,THERE IS NO.GUARANTEE ON THE LIFE OF THE SYSTEM. . 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 b the Board of Health,will pass. Indicate yes,no,or not determined(Y,N,or NO). Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of _ a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20) years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank is 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. Page 1 of 10 (revised 04/25/97) DEP on the World Wide Web:http://www.magnet.state.ma.un/d . r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 334 MYSTIC DRIVE,MARSTONS MILLS Owner: DIANA,CHARLES Date of Inspection: AUGUST 25,1998 B]SYSTEM CONDITIONALLY PASSES(continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced The system required pumping more than four 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 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 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 WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water V Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS 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 pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 334 MYSTIC DRIVE,MARSTONS MILLS Owner: DIANA,CHARLES Date of Inspection: AUGUST 25,1998 D]SYSTEM FAILS: You mus indicate either"Yes"or"No"as to each of the following: NIA I have determined that the system violates one or more of the following failure criteria as defined In 310 CMR 15.303.The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No 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 over- loaded 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 YZ 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 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)LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria above: NIA The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a s"gniflcant threat to public health and safety and the environment because one or more of the following conditions exist: 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 mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 334 MYSTIC DRIVE,MARSTONS MILLS Owner: DIANA,CHARLES Date of Inspection: AUGUST 25,1998 Check if the following have been done: You must indicate either"Yes"or"No"as to each of the following: Yes No N/A Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. X All system components,including the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal System. X Existing information.Ex.Plan at B.O.H. X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)[15.302(3)(b)] r (revised 04/25/97) Page 4 of 10 ;l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 334 MYSTIC DRIVE,MARSTONS MILLS Owner: DIANA,CHARLES Date of Inspection: AUGUST 25,1998 FLOW CONDITIONS RESIDENTIAL: Design flow: 440 g.p.d./bedroom for S.A.S. Number of bedrooms: 4 Number of current residents: 3 Garbage grinder(yes or no): NO Laundry connected to system(yes or no): YES Seasonal use(yes or no) N/A Water meter readings,if available(last two(2)year usage(gpd): 1996134,000/1997 175,000 Sump Pump(yes or no): NO COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gallons/day 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: _ OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: N/A System pumped as part of inspection:(yes or no) NO If yes,volume pumped: gallons Reason for pumping TYPE OF SYSTEM X 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) II/A Technology etc.Copy of up to date contract? Other APPROXIMATE AGE of all components,date installed(if known)and source of information: 1992 PERMIT#91-438 Sewage odors detected when arriving at the site:(yes or no) NO (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 334 MYSTIC DRIVE,MARSTONS MILLS Owner: DIANA,CHARLES Date of Inspection: AUGUST 25,1998 BUILDING SEWER:NIA (Locate on site plan) Depth below grade: Material of construction cast iron 40 PVC other(explain) Distance from private water supply well or suction line Diameter Comments:(condition of joints,venting,evidence of leakage,etc.) SEPTIC TANK:X (Locate on site plan) Depth below grade: 44" Material of construction X concrete metal _ Fiberglass _ Polyethylene _ other(explain) If tank is metal,list age Is age confirmed by Certificate of Compliance (Yes/No) Dimensions: 1,500 GALLON PRE CAST Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: N/A Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: N/A Distance from bottom of scum to bottom of outlet tee or baffle: N/A How dimensions were determined AS BUILT&TAPE NOTE: OUTLET COVER NOT OPENED 4'BELOW GRADE. Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,evidence of leakage,etc.) TANK AT WORKING LEVEL,INLET COVER 16"BELOW GRADE,ONE INLET WITH TEE,OUTLET NOT OPENED 4'BELOW GRADE. GREASE TRAP:N/A (locate on site plan) Depth below grade: Material of construction _ concrete metal _ Fiberglass _ Polyethylene _ other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,evidence of leakage,etc.) (revised 04/25/97) •Page 6 of 10 S ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 334 MYSTIC DRIVE,MARSTONS MILLS Owner: DIANA,CHARLES Date of Inspection: AUGUST 25,1998 TIGHT OR HOLDING TANK: N/A (Tank must be pumped prior to,or at time,of inspection) (Locate on site plan) Depth below grade: Material of construction _ concrete metal _ Fiberglass _ Polyethylene _ other(explain) Dimensions: Capacity: Design flow: gallons/day Alarm level: Alarm in working order _ Yes; _ No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX:X (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc,) NOTE:SYSTEM SIX(6)YEARS OLD,BOX LOCATED IN FRONT WITH LAWN SPRINKLERS.HOUSE FOR SALE.DID NOT OPEN BOX OR DIG UP LAWN,D-BOX NOTED ON AS BUILT ALSO LOCATED ON SITE. 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.) (revised 04/2.5/97) Page 7 of 10 . e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 334 MYSTIC DRIVE,MARSTONS MILLS Owner: DIANA,CHARLES Date of Inspection: AUGUST 25, 1998 SOIL ABSORPTION SYSTEM(SAS):X (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: 4_ leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number, alternative system: Name of Technology: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) NOTE:SYSTEM 6 YEARS OLD NO SIGNS IN TANK OF PROBLEMS.LEACHING LOCATED IN LAWN WITH SPRINKLERS,GAS LINE OVER LEACHING.ALSO T TIMBER RETAINING WALL.LEACHING AROUND 5,BELOW GRADE.LEACHING NOTED ON AS BUILT ALSO LOCATED ON SITE.8-25-98 SPOKE WITH TOM AT BARNSTABLE HEALTH DEPARTMENT ABOUT LEACHING BEING EXCAVATED.EXCAVATION IS NOT REQUIRED CESSPOOLS: NIA (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: Indicabon of groundwater: inflow(cesspool must be pumped as part of inspection) Comments:: (note condition of soil,signs of hydraulic failure,,level of ponding,condition of vegetation,etc.) PRIVY:NIA (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.) (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 334 MYSTIC DRIVE,MARSTONS MILLS Owner: DIANA,CHARLES Date of Inspection: AUGUST 25, 1998 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks Iccate all wells within 100(locate where public water supply comes into house) o+v7- 95 O 3s/• �s'� -- ------- ........... --- l✓AL L (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 334 MYSTIC DRIVE,MARSTONS MILLS Owner: DIANA,CHARLES Date of Inspection: AUGUST 25, 1998 Depth to groundwater feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained fro Design Plans on record Observation of Site(Abutting property,observation hole,basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators,installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(Must be completed) NOTE:LOT HIGH,NO SIGNS OF GROUND WATER PROBLEM. (revised 04/25/97) Page 10 of 10 THE COMMONWEALTH OF MASSACHUSETTS"N, j }6 BOARD OF HEALTH TOWN OF BAt�. RNSTABLE � t k� r utt#Uan for ispn '1 r C rnrt un [ rnt � e .k Y ��^r�� rz a��� ,- 3 s# �.� `t"'.'. �::;`' o � h.r�0.�.,�:.�.r s. �, 4• cr�..r 5n gt. a cw°� tiw r �7 m y ; y pphcation is hereby made fora Permit to Construct ( ) or.Repair ( ) an Individual Sewage Disposal k s a c+ systOffil t M r a, c a€ //��/�� / y ��(A„'' M ���fff /sue•1�/per /(�/�� ,�y'f'�•�'.- �&r, Yd J' V��y .. /[� .(.....:.` �� .�rt=.t} •.••�l• .•`v:L4R ._.[....:./.i...• ................................. _ Location Addr ss r;Dt No 3 k Yt LF OwnerJr s. a es�.t�.................................. . ►-a Instailer _.... > Size Lot.__ s Type of.Building '�,_ � Sq. feet -- :___-____Expansion Attic 1­4 ' Dwelling.-Noy ,of Belli g ) Garbage Gr ndei'(�'`')` a No of persons Showers Other ,Type .. a W s a fixtures _-_-__. (-._)_ Cafe -- .. yaw ; gas: gallons per.,,person per day Total daily flow:_. t De F gallons. c Tank Liquid capacity. gallons Length__..: Width_ Diameter................ Depth a w'Disposal2Trench No Width . Total Length ............ Total leaching area_. sq. ft. 'i-`k See e Pi`t,Nol'*�` { Diameter ,.' Pam- Depth below inlet.................... Total leaching area.. sq: ft. a Z; , Other Distribution box ( ) Dosing tank,( rcolation'Test Results Performed:by a .:...:. --•- Date....... ;"Test.Pit No. I................minutes per inch Depth of Test Pit .___:_,.. Depth to • - p ground water --• •....__... w Test Pit.No. 2::... .........minutes per inch Depth Of.,Test Pit .:._...._._:.._...Depth to ground water -_._._._. r- - Description of Soil............................................. ................r --.._.... .......................... t ................................................................................ J Nature of Repairs or Alterations-Answer whenapplicable......./VEW ••--_,••- �,t! T Vic% ........................ ---• ------ -.---- -_ ---- Agreement. The undersigned agrees to install the aforedescribied Individual Sewage Disposal System in accordance with ll the provisions of TITLE 5 of the State Environmental-Code-7he undersigned further.agrees riot to Place the € ` system,in operation unti�l.a'Certificate of Compliah" i f en i ue by.t e,board of health. a,a Signed a .x. W. �® " Application Approved.By �fe l ` ----- .................................:.. ll� { r, Application Disapproved,-for the.follouwing rearon ; .- :: 4 4 .......... :....v ................ ................ . -'........ /. :ID:€. �t : , �`-.'^ i ... - Dare Permit NO C� .... ... sr 9.;,.- Issued ... .. �A 5� s .'. ., r *}^�`°_-•-��.eenyy ""• ,x .,.w(„w w#nu.�+yw#w.� .. n�::. THE COMMONWEALTH OF MASSACHUSETTS. r BOARD OF HEALTH ' TOWN..OF,BARNSTABLE �ex#tftctt#e' C�omttr�cP THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( � ) or Repaired ( ) . ------------- by--..... ti .% cv 1 C `y `IZi;n uhi -------- ------- -------- V . at . , � l a r J ..\ -.ems t `. S - ; has been installed in accordance:with the provisions of TITLE Sx f The State Environmental 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 FUNCTIO'N'SATISFACTORY. ' ll ..... DATE ---- ®1 ---- --. Inspector ; THE COMMONWEALTH`OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARciVSTABLE' FE /1�..... . No.; ` aatt1 or Haan trim rrnt x Permission is hereby granted ...... to Construct ( or.Repair ( ) an Individual Sewage Disposal`System - at No ...... j ?'1 e_ ;rt'I� eCt CC ( U�`/ t y, _ .. y(.... �` Mtn as shown on the application for Disposal Works Constructi errrut Dated .. B� oealth ✓ y*. DATE ........ , tRHERS ;v TOWN OF BARNSTABLE LOCATION f`ST e SEWAGE # VILLAGE //-L S ASSESSOR'S MAP & LOT 6-L Q 2—r INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 1.5 O LEACHING FACILITY: (type) Ctf L L£ 5 (size) NO. OF BEDROOMS BUILDER OR�WNER PERMUDATE: 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 Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by - f } ` OWN OF BARNSTABLE LOCATION 4:07Tf'-d'Z) /911 77e_ a6c SEWAGE # 91 �;Cr_ VILLAGE 149- folee.S ASSESSOR'S MAP & LOT©kZ _ M' INSTALLER'S NAME & PHONE NO. U GOB// eOkJel - o ` SEPTIC TANK CAPACITY ��C� 2t 7_wA-v,::f LEACHING FACILITYAtype) y (size) NO. OF BEDROOMS- 19' PRIVATE WELL O PUBLIC WATE BUILDER OR OWNER /20-5S rFU/GDEzS DATE PERMIT ISSUED: e i DATE COMPLIANCE ISSUED: 2L VARIANCE GRANTED: Yes No 3 td�� N l No.......... ---------- VF i THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Allp irFation for Dispoii al Works Tonstrnrtiun Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .......... MJUZ.: Gam....- .............••---------------------------....................--------- Location-Address 1.3a1ufq.................... •----- .......Y.t412iV\., y- Owner Address Y G�I.1� �o.Jnl.S7: ,N.L�9 r4.�'Tdr�!_3 �[M._r..ld� _ Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms..r......t -----------------------------Expansion Attic ( ) Garbage Grinder ( ) a Other—Type T e of Building No. of persons............................ Showers f� YP g --------•------------------- P ( ) — Cafeteria ( ) a+ Other fixtures ......................... ----------- ... W Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid"capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width......_............. Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-------------------_ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Or( Test Pit No. 2................minutes per inch Depth of.Test Pit---:................ Depth to ground water...................... a -------------------------------------------•----...--------........-----...................•-•-•.••.......................................................... 0 Description of Soil................................................................................x W •--••••----•-------------------------------•------...---•--•-----......-•-•••---------••-••-•-•---••-------....•-•-- ---------...--•--- t --------------------- ---------- U Nature of Repairs or Alterations—Answer when applicable...____.C.V�w______________ •?'t�.:!�-._�.(..�_ .._..........._. ----------------------------------------•--•--------------------------------------------........------------------------....--------------------------------------------....-•------.....-----•-•--•---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliancasen i ue by t e board of health. Signed ....... .. - -- ------- = o®��� ���- j --------- / ;�6 te ApplicationApproved By .................. ....... ✓ -------------------- . ................................................... 1 A----� ! Date Application Disapproved for the following rearon.r: .............................. . ------.......------......----------------------------------....------.....-- -- . ------------------------------------------------------ -----------------------.....----------. ............... . ---...........................-------------------- ------------.........----------------- Date Permit No. ..---?.. lft.--.. Issued --- 1�'�-l ',��L ----....... ' Date N o.. /FmB THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appilration for Disposal Works Tonstrnrtiun Prruat Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ............ZC.... .......��.?:F T!_z.._.D.,4- f�/.;!Za1���/-:�.....�J. L.5...... - .......................................... /� Location-Address nn or Lot No. .......... t ....._._.L... ! ?l?. .1 :.;�..................... 7.;......!'E-_.!7.A?,L:s�:.. �1.r. ... ._....E.,2...... it .�� Owner Address ` / a ......... .....................•..... ...... ........2L?_..�L..�....................................... Installer Address / S feet Q Type of Building ,,. Size Lot........................... q. U Dwelling—No. of Bedrooms._.........................................Expansion Attic ( ) Garbage Grinder ( ) a44 Other—T e of Building No. of persons............................ Showers YP g ---------------------------- P ( ) -- Cafeteria ( ) Otherfixtures •----------------------------------------------------•••-•-••---••--------•--•-•-••••• •-••••......--•-••......--- ........... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................. Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-----_------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank aPercolation Test Results Performed by--•••••-•-••--•---•---••-•••••......-•-•-•••••--......----•--•-••••--•.... Date........................................ Test Pit No. I________________minutes per inch Depth of Test Pit.................... Depth to ground water......................... (Tq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ••••••••-•••••-•----••-••••••---•---•-•-••------•--••-•••....•-••-•-••------------------------------......................................................... 0 Description of Soil........................................................................................................................................................................ V ..-••••--••-•--•-•------...•••--•--••-•------•--...------•-•-•••-------•-••--•••••-•-•-------------•••-•-...-•--••------••-••-•-•-•-......•............................................................ W •-•-•-•---•-------------------•---------x ---------•----------....-•---....---------------------------------------------I---------------------- 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 Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by theboard o,f health. Signed .--- � �1(...... `�r _ts����.�r�`...------------------ --- � - - - _.. � / pace Application Approved By(........ ...��.. .. - e � Application Disapproved for the following reasons: .............................. ..................... ..... ! --.....------........--------........................................................................... ------------------------------------ . --------------------------------...---- ............................................-------------- . -. Date Permit ��" � .. � ' t... . ......... � � .......,Date, t THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE CIertifiratP of Compliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed( t/ ) or Repaired ( ) by r`' — - s ..................-------------------------------------------- (3 c t L L v t .....ti - 1at �� ,.. ....... S-------------- .............. �--S--------------... . . . has been Installed in accordance with the provisions of TITLE 5 f The State Environmental Code as described in the application for Disposal Works Construction Permit No. ..... ( ^..... ......%{�....... dated --�/.,0. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS'A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. G DATE-----------------------------3-- J --- �) .......................... --- Inspector ....------------------......... --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH q !/ TOWN OF BARNSTABLE No.,/ ^....y.�� FEEAI ... Disposal Works Tllns#rurtion rruti# Permission is hereby granted........... ----..__7............�.- ` .............--� ........: T( / v C r J , �tiS /IL.E.C_ %! e ; ..................................... to Construct (� or Repair ( ) an Individual Sewage Disposal System at No.............' %.......... .........................3 ?7L 7 rvs&e.t....../ f Yl.......t`s....(....... .........�......L�j, as shown on the application for Disposal Works Constructi n ermit No.7_/_'1 _ Dated../"�_......_.....�':7•-��.. .. ------------ DATE............. .............................. FORM 36508 HOBBS d WARREN,INC..PUBLISHERS 6/2/2020 ShowAsbuilt(1700x2800) TOWN OF BARNSTABLE LOCATION 33 O�"AYSTc 342 SEWAGE d /'Y77- VILLAGE_ A- ^/LC,$ ASSESSOR'S MAP&LOT d_L 0.1i INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 00 G'AL LEACHING FACU=:(type) GALLE}$ (size) NO.OF BEDROOM--S / BUILDER ORI��P RI C�RlrS /AA,;4 PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximm=Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Welland Leaching Facility(tf any wells ez_ist on site or within 200 feet of leaching facility) Feet Edge of Wetland and L.eaclting Facility(if any wetlands exist within 300 feet of leaching facility) Fcet Furnished by O https://itsqldb.town.barnstable.ma.us:8431/Home/ShowAsbuilt?mp=080029&sq=1 1/1 1 _ 1,WSMMPCfQl.k1 r , .YrbWp+rt'.M+tlpidYt NamSb,y 1943-5 44- 13 y - .� by .� ZOIVE RA: m � eo ,, �'� b,� �a� J so 48 W/T�t/E S SE-7-a/-;)C/r'5 � t oL c i.'C RF3'TF� min inch - 4Z52 s/ � � sz — f - 72,Ca WETLl AID'6 v 5 fi'L�TVS TC'7O .R.70 G7A - s� 1, �Svc�•�o L. 8 ror� tsv �oN -� �7. _ t : q i 1 .a0 $ AS � r W E S dJE { v 9 ` / O r� 4e Co ns � z trE _ {{ p s b sAA,l.00 SE6�T/C 4x TANK .. 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