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Home My WebLink About0603 MISTIC DRIVE - Health 1 603 MISTIC;'DS'-Qt MARSTONS MILLS A=079:066 TOWN OF BARNSTABLE LOCATION QC7 3 ��S��'C (`. SSE# -L n - VILLAGE ��1'I iS ASSESSOR'S MAP&PARCEL E49TAEERIrS NAME&PHONE NO. ,�tc'n�`LlC n►ud l -l� _ri'l SEPTIC TANK CAPACITY l'S o 0 LEACHING FACILITY:(type) LJ^ SOO C`,h, (size) NO.OF BEDROOMS. LI OWNER ¢ PERMIT DATE: ATE` IIanI 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 4j4 hr4l`4l 4 r4� '.4l 4 . ~f f'v ••fl •f Jy f J f J of 4�4l 4�4l4 ,4l 4 \ 4+41 4 f Jv f f ! f f ! ! f ?•v! ' 4 1 \ 4 4 4 4 \ 4 4 ♦ 4` •4 \ ♦ 4 4 �4� l4 l4" 4 \ \ 4 � • 4 4 4 4 4 25 V4^ 68 65 Back Yard ?4 7 s t Commonwealth.&Massachusetts Title 5 official Inspection Form (9 Subsurface Sewage Disposal System form -Not for Voluntary Assessments 603 Mistic Dre Property Address A Jeanne Beardsley Owner Owner's Name information is Marstons Mills Ma 02648 3/5/16 required for every page. City/Town State Zip Code Date of Inspvtion �J. 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, �1- use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain rea Company Name 8 Johns path Company.Address S Yarmouth Ma 02664 City/Town State Zip Code 508-364-9587 S103522 Telephone Number License Number B. Certification 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 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 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation b_y the Local Approving Authority 3/7/16 nspector'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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System -;yPage�1 of]77 Commonwealth of Massachusetts Title 5 ®fficial Inspection For Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 603 Mystic Dr Property Address Jeanne Beardsley Owner Owner's Name:... information is required for every Marstons Mills Ma 02648 3/5/16 page. Citylrown 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: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System contains a 1500 Gallon concrete septic tank as well as a Dbox and 4 Chambers. No signs of hydrualic.loading.or.p.ush back to tank or dbox at time of inspection. 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 Title 5 .Official Inspection Form Subsurface Sewage-Disposal System Form-Not for Voluntary Assessments 603 Mystic Dr Property Address w Jeanne Beardsley Owner Owners Name information is required for every Marstons Mills Ma 02648 3/5/16 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/alarms 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): ❑ 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): 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Q Commonwealth of Massachusetts F Title 5 official° Inspection Form Subsurface-Sewage Disposal System Form,-Not for Voluntary Assessments ,M 603 Mystic Dr Property Address Jeanne Beardsley. Owner Owner's Name..... information is required for every Marstons Mills Ma 02648 3/5/16 page. City/Town 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 supplyvwell.*.*... 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 o�cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 603 Mystic Dr Property Address Jeanne Beardsley Owner Owner's Name information is required for every Marstons Mills Ma 02648 3/5/16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more tharr-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 groundwater elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a 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 Title 5 Official Inspection Form, Subsurface Sewage Disposal System Form Not for Voluntary Assessments 603 Mystic Dr Property Address Jeanne Beardsley Owner Owner's Name information is required for every Marstons Mills Ma 02648 3/5/16 page. Cityfrown 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 any of the system components pumped out in the previous two weeks? ❑ ❑ Has the system received normal flows in the previous two week period? ❑ 0 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)] D. System Information 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 t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusefts W Title 5 official Inspection Forte Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 603 Mystic Dr Property Address Jeanne Beardsley Owner Owner's.Name,........ information is requi-ed for every Marstons Mills Ma 02648 3/5/16 page. City/Town State Zip Code Date of Inspection D. System Information Description: System contains a 1500 Gallon concrete septic tank as well as a Dbox and 4 Chambers. No signs of hydrualic,load ing-or-push back to tank or dbox at time of-inspectton: Number of current residents: 2 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 years usage(gpd)): Detail: 219 Gpd Sump pump? ❑ Yes ❑ No .Last date of occupancy: 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 ` 1 setts Commonwealth of Massachu Title 5 Official Inspection Formr Subsurface Sewage-Disposal System Form-Not for Voluntary Assessments 603 Mystic Dr Property Address Jeanne Beardsley Owner Owners Name information is required for every Marstons Mills Ma 02648 315/16 page: Cityrrown 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: Pumped in 2009 Recommend pumping Was system pumped as part of the inspection? ❑ Yes ® 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)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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts . Title 5 official Inspection Form Subsurface'Sewage Disposal System Form -Not for Voluntary Assessments 603 Mystic Dr Property Address Jeanne Beardsley Owner Owner's Name... information is required for every Marstons Mills Ma 02648 3/5/16 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: 17'Years Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: aftfeet Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): System is vented at the roof Septic Tank(locate on site plan): Depth below grade: 2ft feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) 1500 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins 3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5.®fficial Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 603 Mystic Dr Property Address Jeanne Beardsley Owner Owner's Name information is required for every Marstons Mills Ma 02648 3/5/16 page.. Citylrown 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 24 11 Scum thickness 311 Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle 1"Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No evidence of leakin ,Tees and or baffles in place at time 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 l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts 1. -Title 5 Official-.Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 603 Mystic Dr Property Address Jeanne Beardsley Owner Owner's Name information is J required for every Marstons Mills Ma 02648 3/5/16 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.): Tees are in place and levels are normal. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts_ Title 5 official; Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 603 Mystic Dr Property Address Jeanne Beardsley Owner Owner's Name, information is required for every Marstons Mills Ma 02648 3/5/16 page. Cityrrown 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 Dbox is level and at normal level 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.): No signs of carry over 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•3I13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection F®*-rn _ Subsurface Sewage-Disposal System Form-Not for Voluntary Assessments M 603 Mystic Dr Property Address Jeanne Beardsley Owner Owner's Name information is required for every Marstons Mills Ma 02648 3/5/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): 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 . y Commonwealth of Massachusetts f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments w 603 Mystic Dr Property Address Jeanne Beardsley Owner Owner's Name- information is required for every Marstons Mills Ma 02648 3/5/16 page. City/Town Satet 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.): No pondirrg-no break out 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.): l5ins•3113 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 603 Mystic Dr Property Address Jeanne Beardsley Owner Owner's Name information is required for every Marstons Mills Ma 02648 3/5/16 page. Citylrown 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: Gheck•one-of-the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 _ BARNSTAcLE, Location , 603 Mistic Drive Village : Marstons Mills Septic 1500 Gallon Septic Tank Owner, Brian Beardsley PUMPING `nTSTORY 2/15/02 1500 Gallons (3 ' Solids) f L l ip-h f /-S �1 �- � 14.E ' _ ,j�1I • Commonwealth of Massachusetts �j Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 603 Mystic Dr Property Address Jeanne Beardsley Owner Owner's Name— information is Ma 02648 3/5/16 required for every Marstons Mills page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 10+ft Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ 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: Property sits high on a hill with a cranberry bog across the street Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 4 Commonwealth of Massachusetts Title 5 Official Inspection Four, Subsurface Sewage Disposal System Form-Not for.Vol untary.Assessments 603 Mystic Dr Property Address Jeanne Beardsley - Owner Owner's Name. information is Ma 02648 3/5/16 required for every Marstons Mills page. City I Towown 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 603 Mystic Drive _ Property Address Brian Beardsley OwnerOwner's Name ------_._____.._......__......_........__- ......__ ._ ._. ..,....._......_.. ..---.._.__...___.....__.._...-- --- information is _ required for Marstons Mills -MA.—, 02648 __.,January 29, 2014 _ ...... __. _..._.__...._.. every page. CityFrown 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 filing out A. General Information forms to theccmpu (� r,use 1. Inspector: only the �\ only the tab key to move your Patrick M. O'Connell cursor-do not use the return Name of Inspector key. Company Name 1.6-41 PO Box 1487 Company Address Marstons Mills MA 02648 City/Town State Zip Code 508-776-4186 S112855 Telephone Number License Number B. Certification 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 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 co Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority _ January 29, 2014 Inspector's Signature_ " Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the systetr. s a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system o�mner 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. t5ins•3113 1 fie 5 Official Insp .o orm Subsurface Sewage Disposal System•Page 1 of 17 , � Commonwealth of Massachusetts ��~��N�� ~��^��^��N Inspection ��N~07�� ~ KU�N~= �� m~�� N8~~�==� �° "~� ��~~�U~~" . �-~~. " . . Subsurface Sewage Disposal System Form ' Not for Voluntary Assessments G03 Mystic Drive -- pmne�'Auo�x ��-��--�-�---- ----- ---------- ' Brian Owner Owner's wemo information is required for MarstonnMiUu M.___________ A 0�S48___ __Jan a 29 2014 every page. City/Townntute Zip Code Date mInspection B' Certification /oonL> ~ Inspection Summary: Check A.B.C.D or E/always complete all ofSection D A> System Passes: - | have not found any information which ind�a�st�gany of the hai�neo�emadeec�bed in 31OCW1R 15.303orin 31OCK�R 15304exio1. Any failure criteria not evaluated are indicated below. Comments: Tank was not in need of pumping at time of inspection, leaching chambers had 4-5"of standing water. - --��`��--_-____ -. ��. ��'�� 8) System Conditionally Passes: D One or more-systemcomponents as described in the"Conditional Pass'.' section need to be replaced or repaired. The oyatem, upon completion of the replacement o/epoir, as approved by the Board of Health, will pass. Check the box for"yes", ''no"o/''not dotennined" (Y, N. ND) for the following statements. If"not detannined.^ please explain. . The septic tank is metal and over2U 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 ofHealth. ' °A metal septic tank will pass inspection ifiiis structurally sound, not leaking and ifa Certificate of � Compliance � Cnmp|ianoeindicnhngthat the tank i» less than 2O years old isavailable. Fl Y N ND (Explain below): ' , . x -..........^-------- -------------'----------------- . ^ . . ��'ma RIP n Official Inspection Form Subsurface Sewage Disposal System-Page zm`, ^ ' . ` | | r, Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 603 Mystic Drive Property Address Brian Beardsley Owner Owner's Name ---------- _-.._.._.._...._._ ..... _.... ..-_.._....._._.... information is required for Marstons Mills MA 02648 Januar 29, 2014 _.._..._... _ ..- .... ._, .. _..._ ...._.... - --- — ----—-- everyipage. CityrTown 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/alarms 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): ❑ 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): 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 15ins•3/13 - 1 the ti Official Inspection Form Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form Not for Voluntary Assessments 663 Mystic Drive Property Address Brian Beardsley ----.----------_.....__..._. Owner Owner's Name information is r Marstons Mills MA 02648 Janua _29, 2_0.14_ _ required for ----- -- -.. ..-._....... y every page. Cityrrown 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 aseptic 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 El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 0 ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool 0 ® _ Liquid depth in cesspool^is less than 6" below invert or available volume is less than day flow t5ins•3/13 Subsur':.:e Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 603 Mystic Drive Property Address Brian Beardsley Owner Owner's Name information is Marstons Mills MA 02648 January 29, 2014 required for every page. City/Town State Zip Code Date of Inspection B. Certification (coot.) Yes No ❑ ® 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 hick ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a 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•3113 1 ate 5 Oufivai inspection Form SuUsi.olace Sewage Disposal System•Page 5 of 17 .1 Commonwealth of Massachusetts Title 5 Official Inspection Form 1.1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 603 Mystic Drive Property Address Brian Beardsley Owner Owner's Name information is Marstons Mills MA 02648 January29, 2014 required for _.__. --------- - — every page. City/Town 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, occui.ant, 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? El ® 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, mate,-,al 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): 4.... - Number of bedrooms (actual): 4--- - DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 440 15ins•3113 Title S ofhcaai Inspection Form Subsurface Sewage Disposal System•Page 6 of 17 f�. Commonwealth of Massachusetts r� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 603 Mystic Drive Property Address Brian Beardsley..._.-_.-_._ ._...___...._ Owner Owner's Name information is Marstons Mills MA 02648 January 29, 2014 required for —_ _---._._..._..__.._. _ every page. City/7own 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 years usage (gpd)): N/A IrrigationSystem and Pool Detail: ----------------- . ........ Sump pump? ❑ Yes ® No Currently Last date of occupancy: Occupied. Commercial/Industrial Flow Conditions: Type of Establishment: -------------- -- ---- Design flow(based on 310 CMR 15. ): Ga Hon s 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 - - - - - ---- -- --- t51ns•3113 1 Me 5 Ofhcia.inspecoon Form Subsurface Sewage Disposal System-Page 7 of 17 _ t s Commonwealth of Massachusetts Title 5 Official Inspection Form IS Subsurface Sewage Disposal System Form Not for Voluntary Assessments a 603 Mystic Drive _Property Address Brian Beardsley _- — - Owner Owner's Name information is required for Marstons Mills MA 02648 January 29, 2014 _.. _._._....__ ..._...--------- - _-- every page. City/Town State Zip Code Date of Inspection D. System Information (cost.) Last date of occupancy/use: -.......... _.__-__.___._ Date Other(describe below): General Information Pumping Records: None Source of information: _.. _.... ..._...._.. .---.._._...--------.._._---..----__-.— Was system pumped as part of the inspection? ❑ Yes ® 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 ElShared system (yes or no) (if yes, attach previous inspecti:n 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 l/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval ❑ Other(describe): t5ins•113 Title,'•Ofhuai Inspectjon Form SunSurface Sewage Disposal System•Page 8 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form (% Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 603 Mystic Drive Properly Address Brian Beardsley _ _ _ Owner . .. _. _ ..-..- ........ .. ..... ........ -..------------------ Owner's Name information is required for Marstons Mills MA 02648 January 29. 2014 _ . ..-__... every page. City/Town State Zip Code Dal,:of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Compliance date:12/14/98 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: f. feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: --- - feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: te et.... ...... ...._..___-:.__-_...;._._.._,..._...----____-. 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 10.5' long x 5.8'wide- 1500 gal_ Dimensions: 3" Sludge depth: -- -—= 15ns•3/.3 1!!e`I O'fWIR!Inspection 1nrm Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form i Form Not for Voluntary Assessments Subsurface Sewage Disposal System o y 603 Mystic Drive Property Address Brian Beardsley Owner --._. Owner's Name information is Marstons Mills MA 02648 January 29, 2014 required for — every 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 29 Scum thickness 3 Distance from top of scum to top of outlet tee or baffle 6 10" Distance from bottom of scum to bottom of outlet tee or baffle ' Measured How were dimensions determined? . - - -- ._ ....__..- Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level was at bottom of outlet invert and tees were intact. 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•3113 - Hip S Off¢iat Inspection Form SubSLlrface Sewage Disposal System•Page 10 of 17 f v Commonwealth of Massachusetts r� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ''•�� .�� 603 Mystic Drive_Y Property Address Brian Beardsley Owne= --- Owner's Name information is required for ars January Mtons Mills MA 02648 Janua 29, 2014 requi -------- ._.__ -----------------_---- every page. Cityffown 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 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 tSins•3:13 Title`i Offirial Inspection Form Subsurf¢:..Sewage Disposal System•Page t t of 17 4 Commonwealth of Massachusetts r� Title 5 Official Inspection Form t� 1=� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 603 Mystic Drive __- ... _.._.......... --------- Property Address Brian Beardsley _ Owner Owner's Name information is Marstons Mills MA 02648 January 29, 2014 requiredfor — ---- ------..__._..._......_.._. .. ._ .-- - - - - - every page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): 11 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.): No solids or high stains present. 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: 15ins•3113 - 1'n1e Of4ciat Inspection Form Subsurfac a Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts A Title 5 Official Inspection Form rb� Subsurface Sewage Disposal System Form Not for Voluntary Assessments 603 Mystic Drive Property Address Brian Beardsley---, Owner — Owner's Name information is required for -y Marstons Mills MA 02648 Jan. ar 29, 2014 — -- -.._._._...._.... ... . . .. . _ _ _--- - u- ---------- every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: --- -- ® leaching chambers number: Four 500 galdrywells. ❑ 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.): Chambers had 4-5"of standing water and no evidence of surcharge 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•3113 Tilly S ot6aal Inspecl,on I-orm Subsurfs(=Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 603 Mystic Drive Property Address Owner Brian Beardsle`y___ __ Owner's Name ---------...-- requiretifo is Marstons Mills MA 02648 January 29, 2014 required for y every page. CitylTown 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.): 15ins•3/13 141e 5 Official Inspection Form Subsuiiace Sewage Disposal Syslem•Page 14 of 17 Commonwealth of Massachusetts M14 EN Title 5 Official Inspection Form z• Subsurface Sewage Disposal System Form 7 J=. - Not for Voluntary Assessments 603 Mystic Drive Properly Address Brian Beardsley Owne, Owner's Name nformaUon is required for Marstons Mills MA 02648 January 29 2014 every page CilvrTown - ....:....,..... >u� -.,: ndr• Dare of nspeciion • D. System Information (cont Sketch Of Sewage Disposal System Provide a view of !f)e 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 n drawinn attarhprlTT W0 Canarof clv '. .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . '. 25 68 Back Yard 65 74 7 Commonwealth of Massachusetts' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 603 Mystic Drive Property Address Brian Beardsley Owner. Owner's Name -----_-_. -- requiretifo is Marstons Mills MA 02648 4 January29, 2014 ..- required for , — ------ -- ------ every page. City/Town - ,. State _ Zip Code Date of Inspection D. System Information (cont.) -- --------------- Site Exam; ® Check Slope ® Surface water ® Check cellar , ® Shallow wells a F " " Estimated depth to high ground water` 20 feet Please indicate all methods used to determine the high-ground water elevation: ❑ Obtained from system design plans on record p If checked, date of design plan reviewed -- --- Date + Observed site (abutting property/observation hole within 150 feet of SAS) r Checked with local°'Board of Health -explain ,t Checked with local excavators, installers: (attach documentation) _� ❑° Accessed USGS database - explain You must describe how you established the high ground water elevation Low area on opposite side of road is considerably,lower In elevation than SAS. --- e Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 - -'-filte 5 Olhcial Inspection Form Subsurfe, Sewage Disposal System•Page 16 of 17 x Commonwealth ofMassachusetts ��^�� Official � Inspection Form N �� 8�~8�� U�� " Title �� .�Q � "~=°~~U U. "~° � ��~=~~ "~~" " Subsurface Sewage Disposal System Form ' Not for Voluntary Assessments 8O3 Mystic Drive _ _ _ _ _ _ _... ...... .... Property Address Brian Beardsley Owner Owner's Name information is �om�noK8iUs MA U2648 J 2Q 2O14 required for ---' -_--_ - - - - - -- everypane. :nr-r»wn State Zip Code Date mInspection E. RepoUt Completeness Checklist Z inspection Summary: A. 8, C. D. orEchecked Z Inspection Summary D (System Failure Criteria Applicable toAll Systems) completed Z System |nfonnahon - Eshmoteddepm \ohighgroundwater Z Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file � |� | � ��-zm` `.le,Official Inspection Form nubsu^="sewage oiso=wSy,em'Page//w,` � Z 203 499 041 US Postal Service Receipt for Certified Mail No Insurance Coverage Provided. Do not use for International Mail See reverse Sent mzzs Strgpt tuber P State, ode Postage $ Certified Fee Special Delivery Fee Restricted Delivery Fee u� Return Receipt Showing to Whom&Date Delivered a ReWrn Receipt Showing to Whom, Q Date,&Addressee's Address 0 TOTAL Postage&Fees $ c7 Postmark or Date O u_ Cl) d i w 'I Stick postage stamps to article to cover First-Class postage,certified mail fee,and !I charges for any selected optional services(See front). 1. If you want this receipt postmarked,stick the gummed stub to the right of the return address leaving the receipt attached, and present the article at a post office service I window or hand it to your rural carrier(no extra charge). 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the Q return address of the article,date,detach,and retain the receipt,and mail the article. �r- 3. If you want a return receipt,write the certified mail number and your name and address on a return receipt card,Form 3811,and attach it to the front of the article by means of the gummed ends if space permits. Otherwise,affix to back of article. Endorse front of article a RETURN RECEIPT REQUESTED adjacent to the number. Q 4. If you want delivery restricted to the addressee, or to an authorized agent of the C addressee,endorse RESTRICTED DELIVERY on the front of the article. M 5. Enter fees for the services requested in the appropriate spaces on the front of this receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. L`oL 6. Save this receipt and present it if you make an inquiry. 102595-97-s-0145 a oFtMElp Town of Barnstable • $BARNSrnst E Department of Health, Safety, and Environmental Services M . 1639• Public Health Division ♦0 P.O. Box 534, Hyannis MA 02601 Office: 508-8624644 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health November 23, 1998 Peter Ford 603 Mistic Drive Marstons Mills,MA 02648 ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned by you located at 603 Mistic Drive, Marstons Mills was inspected on November 9, 1998 by Robert Bortolotti, a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00)due to the following: • Back-up of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. You are ordered to bring the septic system into compliance within two (2) years of receipt of this order letter. Therefore, the septic system shall be repaired or replaced on or before November 9,2000. First, you must hire a licensed Town of Barnstable septic system installer to submit a sketch diagram of a proposed system to the Town of Barnstable Health Division Office (Town Hall, 367 Main Street, Hyannis) that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code,Title 5. In the meantime, you shall ensure that no raw sewage backs-up into the dwelling or discharges onto the surface of the ground or into surface waters. You must maintain the system by hiring a licensed septage hauler to pump the septic system whenever it is necessary. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BO' OF HEALTH Thomas cKean, R.S., CH.O. Agent of the Board of Health q\health\dbfiles\title5 i.doc fordhvp/q/Is Town of Barnstable Department of Health, Safety, and Environmental Services BARNSPABM y ' Public Health Division EDN1°�A 367 Main Street, Hyannis MA 02601 Office: 508-790-6265 Thomas A McKean,RS,CHO FAX: 508-790-6304 Director of Public Health TO: on Y11�5�; lD�.ie. DATE: _f 15, 2 kf— yl�e -.nS AA(I cf5-2co k9 ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned by you located at ve GI,iGS� dl"� was inspected on hw, 9 , 19-(E , by Fc6r, 4or a Massachusetts licensed septic inspector. T The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: 1 ® c io � �e re ly Lt You are ordered to ng the septic system into compliance withi -� cons men s Su'' 5 , � first, you must hire a licensed Town of Barnstable septic system installer to su mit sketch diagram of proposed replacement septic system component(s) to the Town of Barnstable Public Health Division Office (Town Hall, 367 Main Street, Hyannis) that will 6 bring the septic system into compliance with 310 CMR 15.00, The State Envir _ Code, Title 5. ba �.� In the meantime, you shall ensure that no raw sewage discharges onto t e surface of the ground or into any surface waters. You must maintain the system by hiring a licensed septage hauler to pump the septic system whenever it is necessary. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health gUrcaithWbtUnttitldi.da r 121ap BORTOLOTTI CONSTRUCTION,INC. �0t'/ 7 r 765 WAKEBY ROAD,MARSTONS MILLS, MA 02648 to k 3 l `� 508-771-9399 508428-8926 FAX: 508428-9399 99g SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION i _O PART A CERTIFICATION Property Address: G ab2� Date of Inspection: / �S/ Inspector's Name: Owny 's Namq and Adidres�,� CERTIFICATION STATEMENT! , I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection.The inspection was per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The System: Passes Conditionally Passes Needs Further Ev on B Local•Aproving Authority Fails Inspector's Signature: Dater The System'Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty(30)days of completing this inspection. If the system is a shared system or has a design now of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the 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. is INSPECTION SUMMARY- A)SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair, passes inspection. ' Indicate yes,nor,or not determined(Y,N,OR ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal,cracked,structurally unsound, shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup 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): - 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ., PART A Cyr CERTIFICATION (continued) .. ; Broken pipe(s)replaced ' Obstruction.is removed ` Distribution Box is levelled 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: ` 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 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 LSIFUNCTION- ING IN A MANNER'THAT'PROTECT:THE PUBLIC HEALTH AND:SAFETY AND THE ENVIRONMENT:'.; ;. The system has a septic tank and soil absorption system and.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 is with a Zone I of a public i water supply well.. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 Feet but 5.0 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 the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less'' than 5 ppm. . . _ D) STEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 3 1P CMR 15.303. The basis for this determination is identified below. The Board of Health slioiAd be contacted to determine what will be necessary to correct the failure. yN1 Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent 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 clog- ged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less-than 1/2 flow: Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ' 2- S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. ' Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 Feet of a private water supply well. Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following ' conditions exist: - The'system is within 400 Feet of a surface drinking water supply} , The system is within 200 Feet of a tributary to a surface drinking water' pply The system is located in a nitrogen'sensitive area Interim Wellhead Protection Area (IWPA)or a mapped Zone 11 of a public water supply well.". 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. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: P / roping information was requested of the owner,occupant,and Board of Health. ✓None of the system components have been pumped for atleast 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. /'As-built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. _`fhe system does not receive non-sanitary or industrial waste flow. = -The site..was.inspected for signs of breakout. �system components,excluding the Soil Absorption System,have been located on site: _j/rThe septic tank manholes were.uncovered,opened,and the interior of the septic tank' in- spected for condition of baffles or tees,material of construction,dimensions;depth of liquid, /depth of sludge,depth of scum. V The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3- }A cxt v` yy y.S 3 t l i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,PART B CHECKLIST(continued) ' The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -PART C, . .. SYSTEM INFORMATION 1 FLOW CONDITIONS RESIDENTLAI.• �/ Design Flow:—dons Number of Bedrooms: 7" Number of Current Residents: Garbage Grinder: Laundry Connected To System:•I� Seasonal Use: Water Meter Readings,if yailable: Last Date;of Occupancy: CO MF.RCIA11IND TST IAi. of Fsfablshment: `Design F1Qw:= Qallons/day- Grease Trap Present: (yes or no) Industrial'rite Holding Tank Present: Non=Sanitary Waste Discharged'To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source.of information: qhz System Pumped as part of inspection:_ If yes,volume pumped: eons Reason for pumping: TYPEfif SYSTEM: _IZSeptic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records, if any) Other(explain). fi OXIMATE A E 1 components,date installed(if known)and source-'of. information '--Sewagelodors detected when arriving at the site: 106 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM a; RTC ' GENERAL.INFORMATION (continued) SEPTIC TANK: is Depth below grade: Material of Constriction: ✓ concrete metal FRP—falter (explain) Dimisions: , _ Sludge Depth: Scum Thickness:- Distance from top of sludge to bottom of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments:(recommendation for pumping',condition of inlet and outlet tees or b es,depth of liquid level in relation to outlet invert, structural integrity,evidence of le.3kage, GREASE TRAP: -��- Depth Below Grade: Material of Constntction:—concrete—metal— FRP_Other (explain) Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: ry? Comments: (recommendation for pumping,condition of inlet'and outlet tees or baffles,,devth of It uid . level in relation to outlet invert,structural integrity,evidence of leakage. etc:) M i TIGHT OR HOLDING TANK: , Depth Below Grade: Material of Construction:—concrete—metal—FRP—Otlter(explain) Dimensions: Capacity: gallons Design Flo«: gallons/day Alarm Level: Comments: (condition of inlet tee, condition of alarm and float switches. e(c.) DISTRIBUTION BOX: 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.) PUMP CHAMBER: -..... .. .. . _ _ . .. ,.. _._ Pump is in woking order. ... „,Comments;'(note condition of pump chamber,condition of pwnps:and appurtenances, - -5- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM(SAS):_L (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: _0_�'Leaching chambers,number: Leaching`galleries,number: Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number: Co : (note condition of soil,signs of hydraulic fai ure level of ponding,conditi of vegeta ' , etc.) v .i / _ t CESSPOOLS: 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(cesspool must be pumped as part of inspection) Comments: (note condition of soilk,signs of hydraulic failure, level of ponding,condition of vegetation,: etc.) PRIVY: Materials of construction: Dimensions: Depth of Solids: Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) -6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM kit: SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. i i10 DEPTH TO GROUNDWATER: Depth to groundwater: Z Feet Meth of Determination or A proxi do l-f'o �"7�� Ire 07 �✓�', l� !l -7- SENDER: I also wish to receive the p ■Complete items 1 and/or 2 for additional services. ' w ■Complete items 3,4a,and 4b. following services(for an w ■Print your name and address on the reverse of this form so that we can return this extra fee)• card to you. 9 0 ■Attach this forth to the front of the mailpiece,or on the back if space does not 1. ❑ Addressee's Address i permit. t 4) ■Wdte'Retum Receipt Requested'on the mail place below the article number. 2.❑ Restricted Delivery to ■The Return Receipt will show to whom the article was delivered and the date a delivered. Consult postmaster for fee. 0 v 3.ArtiC a Addressed to: 4a.Article Number E 4b.Service Type � ❑ Registered 1p Certified Ic p'� of W 6" [I Express Mail ❑ Insured 0 N Q ❑ Return Receipt for Merchandise ❑ COD ; 0 7.Date�of z Pe livery ' p 5.Received By:(Print Name) 8.Ad essee' Address(CM if req este W and fee is paid) t ¢ t— g 6.Signature: Addressee rAgent) a°. X ' kn PS Fo 11, D tuber 1994' ` ' 102595-97-B-0179 Domestic Return Receipt n. 1 r Firla�s�ail UNITED STATES POSTAL SERVICE Off, �I C1�� `pOSta9er&�Fe�S P81d E o,Print your na e;ad&ss,/6nd ZIP Code in this box o v. Public Health Divisloq r : 'own of Barnstable i p Box 534 t'42ssachusetts 0260, i 1 I r y 10/9197 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 ENGINEERED PLANS) t:. �b�.Piereby certify that the application for disposal works ct' n ermit signed b me dated d L ///!� concerning the constru 10 p g y � g property located at 4XI Meets all of the following criteria: :/7 ere are no wetlands located within 100 feet of the proposed leaching facility wells within 150 feet of the proposed septic stem ere are no private i s p p P Y w and/or change in . There is no increase to flow g use proposed posed There are no variances requested or needed. VII f the proposed leaching facility will be located within 250 feet of any wetlands, the bottom of the proposed leaching facility will=be located less than fourteen (14) feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) B) Observed Groundwater Table Elevation(according to Health Division well map) SIGNED DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER t" (Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. ,t q:health folder cat. - -- �, �*:.+"Pr rya.'ts TOWN OF BARNSTABLE I.v s'nGN ��J� ./�I�� C � . SEWAGE It ?S(� VMLAGE �/� des /��/�s ASSESSOR'S MAP& LOT O 7 f INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY Lrl` %Jr /✓�� LEACHING FACILITY: (type) y— ✓r®©dal eX PAI I'(size) N0.OF BEDROOMS C BUILDER OR O '1 PERMITDATE: �� ! �g COMPLIANCE DATE: / ��•� �, Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Sf Feet Private Water.Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) A-11 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) lU�� Feet Furnished by �- O s Az � e �o . 0 1 �7�� No. — Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zippricatiou for �Digogal *pgtem Cougtructiou Vermit Application for a Permit to Construct( )Repair /)Upgrade( )Abandon( ) ❑Complete System TT vidual Components Location Address or Lot No. q Owner's Name,Address and Tel.bTo. Assessor'M a /Pazrel Installer's Name,Address,and Tel.No. �l Designer's Name,Address and Tel.No. '7 Type of Building: Dwelling No.of Bedrooms— � Lot Size sq.ft. Garbage Grinder( � Other Type of Building of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow �� gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank FWO/_ Dr, 13-OW Type of S.A.S. q' Description of Soil Z Nature of Repairs or Alterations(Answer when applicable) 7-b— e 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 b this o f th. — >�� /�� Signed Date l Application Approved b Date — l —4 Application Disapproved for the following reasons Permit No. Date Issued tl��e r. � -, . .. ...-. , r. t .... . r i'y' .... .rery.y. ... . ., .. T.y 11 • ,.. ,; .. ... k No.6. _ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for Mi-4pozal bpztem Construction Permit Application for a Permit to Construct( )Repair( /upgrade( )Abandon( ) El Complete System Ekl5dividual Components Location Address or Lot No. f Owner's Name,Address and Tel.No. Assessor's Map/Parcelin Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( � Other Type of Building feNo. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow /Z4 gallons per day. Calculated daily flow 4"'5D gallons. Plan Date Number of sheets Revision Date Title 1 Size of Septic Tank OZ-Z)s r%_ f�� Type of S.A.S. — SGV 94�®� G A-11' �jrc / i r Description of Soil /D�Y'LJD�t'� r Nature of Repairs or Alterations(Answer when applicable) .7/ 22 g�_ Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b this Boar f H -th. � Signed Date Application Approved bye Date Z Application Disapprovfor the following reasons � el ed" fJ Permit No. - bate Issued — 4�i THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHU.SETTS �t1 Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( W<Upgraded( ) Abandoned( )by 9,4 r Z4,e�f .dEs 74-. at /�? .1i1� ei J�i/' O. �/�,[ fo`.9.�S fir`//S has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. , dated .- 4, !f. h' Installer Designer. The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date � _ s �� Inspector `\ ----------------------- ---------------_-- No. THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS Migogaf *pgtem Construction permit Permission is hereby granted to Construct( )Repair(Xupgrade( )Abandon( ) System located at 60 and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date: A _Approved by // TOWN OF BARNSTABLE LOCATION e/', SEWAGE # VII.LAGEf� ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. s7' 1171-1 � SEPTIC TANK CAPACITYX%9j LEACHING FACII.TTY: (size) zO,Y�D ' NO.OF BEDROOMS I BUILDER OR 0 PERMTTDATE: 1 -f 1 IV—FT COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Sf Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Jy Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by Feet 03 1 i i >z' O �g S� r(/SCr i + CJ H ' a olx Q�c J� i I AAA- - ...�� Y-' .... �i•--,. 'r>: r ":G# a .�._k rxr....a _ _. '€v._._.. ..1...:� _. ,{.. ,e...c,,: .,�..�.-r:' �.-a��p'k - TOWN OF BARNSTABLE LQCATION L—.-.)7(,( r SEWAGE # .� VILLAGE_ cr�i2C ASSESSOR'S MAP Sk LOT iNSTALLER'S NAME & PHONE NO. —� ,�,� �, SEPTIC TANK CAPACITY S LEACHING FACILITY:(type), 19 / (sue) � NO. OF BEDROOMS _PRIVATE'WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COLIPLIANCE ISSUED: VARIANCE GRANTED: :'es No . . , 1 No... Fss......,7: .. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH - - 7061W..........OF.........I i �t/STig l ......... .................. Appliration for Ui4pu,iaal Workii Towitrurtivit permit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at: r!c... . 2.!-� ra. s ,c .� c s. .... - o ation-Address VILLAor Lot No. ._._._ � ............................................... O ner Address w o7.� ,�RGSCO%� � yvIILLS _ Ins talIer Address y.� a®Q Type of Building Size Lot.___......_i.......:.......Sq. feet U Dwelling—No. of Bedrooms................./__........................Expansion Attic (ND) Garbage Grinder ki/d) a Other—T e yp of Buildin �_4_�D•FRfl g m4-- No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ............................ Design Flow...............116......................gallons per person per day. Total dai flow..............!_ .............................gallons. Septic Tank—Liquid'capacityl ..gallons Length....P....... Width....6--------- Diameter................ Depth... ........... W Disposal Trench—INTo. --•----------------- Width............ Total Length.................... Total leaching area....................sq. ft. x Seepage Pit No------------------- Diameter.___..fQ'_._._. Depth below inlet_��. I...... Total leaching area..3.49.......sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by............................................... _..._.......... Date------------.--------------------- --. Test Pit No. 1.___�'.X___minutes per inch Depth of Test Pit___�_ ��_.__ Depth to ground water..N�,`-' ---------- (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.------ . ......... •-------•---=----------------------•--•-••---------•---......................_.......-----•-•--••-----......----...---•--------...._.-- O Description of Soil---0""`-=3 6 „ Zp PS 4I L.`,1- 5616,50/( .- -----. .................................P9N/� .......... ....................................................•-------...-•---------...--•--•------------..._...-•----•----------••--------------.... .-...----•---- W -----•-----•----------------------------------------------------------------------------------••-------•--------------•--••--•... ---------•-•---•--•-••-••--•••---------•----------•• ................ UNature of Repairs or Alterations—Answer when applicable................................................................................................ --------•------------------------------------------•-------•-----------------------..........---.....---........---------------------------------------•--------------------------------------..._..•--- Agreement: The undersigned agrees to install the afor edescribed Individual Sewage Disposal System in accordance with the provisions of'TIT 5 of the State Sanitary Codegth gned furtl: es not to place the system in operation until a Certificate of Compliance as een iss of heaSi ne Dgate Application Approved By----- --------------------- -----------// :2%1- -9 Date Application Disapproved for the following reasons---------------••-----•-•------------------------•.............................................................. -••----•----------------------------------•------------------...-•---•----•-----••--------------•-----------------------....__._....•--•---•-•-----•-•---------••---•--...----•-----•------------------- Date PermitNo.......f ....................... Issued....................................................... Date No.-- - ° FizE...... ...... ........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF 1HEALTH ............ '� .. .....OF....... .5`/M tO App iration for Bispnattl Works Tontitrurtiun 1hrmit Application is.hereby made for a Permit to Construct O or Repair ( ) an Individual Sewage Disposal System at ,p¢si Location Address �7� p� } or Lot No. .................................................... .... f sra "`` FG�-4..`Ga,........................................................ O ner Address ---.....-•------------•---------------•--- Installer IAddress Type of Building Size Lot....Y 5'_0----Sq. feet Dwelling—No. of Bedrooms................. `.......................Expansion Attic (A/0) Garbage Grinder (d'd Other—Type of Building , No. of persons............................ Showers — Cafeteria Otherfixtures --------............................................................................................................................................. WDesign Flow............... 1 ....... ._...gallons per person per day. Total daily flow....... w.....................gallons. WSeptic Tank—Liquid capacity ea?�{, ..gallons Length...../�L':____ Width... _........ Diameter__.-_-__-____- Depth.._,, �....... x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area______.-.-----------sq. ft. Seepage Pit No_ ______I_________ Diameter......,,0........ Depth below inlet.: ...... Total leaching area..q , j..__...sq. ft. Z Other Distribution box ( ) Dosing tank ( ) `" Percolation Test Results Performed by...................................... ............................... Date........................................ 1.4 Test Pit No. I.... ____minutes per inch Depth of Test Pit--- Depth to ground water..I^ltA+ :----- fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ---------------------------------------------------•--..............----.......--•-••------•-•------........................................................ O Description of Soil �� ` f rf cat` 't a '--------•--- U - 5 'f_lrl .. t- - -C'=i'-------- ------ W ---------------------------------------------------------------------......................................--------------------•------------•----•------------------------------------------•-.------ U Nature of Repairs or Alterations—Answer when applicable._.............................................................................................. -----•--•-------------------•--•------------------------------------------------............-------•---•----...---------------------•-•------------------------------------------------......_....-•---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T p of the State.-Sanitary Code— e un ,igned furtl:e es not to place the system in operation until a Certificate of Compliance as een issue b th ,o rd of heal Signe ------•--•------------------- Date Application Approved By........... ,,.._. ._ ,. ..... Date Application Disapproved for the f ollowin` reasons---------------•-•---•...........----•------------------------....--••-------------------------•------......_..._ ..................................•-------•-•-----...----•--------------••---------............---........_.......---........----.....-----------•-----•------------------------------------•-----------. Date Permit No....... .:._ _ - Date THE COMMONWEALTH OF MASSACHUSETTS ! BOARD OF HEALTH .............t ? ` .........oF........ ' 1,a / r .................................. Trrtifiratp laf TautpliFana THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( } by------.._. .:.. ; :, :�!-.---•------•---------------•-•--••-------------.........---------•-•-------------•--•----•-•--•---•-----••----------....-----._....._......._ _ Installer at t t : /Lj 1 , f: .a1' ............................................................� has been installed in accordance with the provisions of Ti 5 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 YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ In spector ector.............. f ---------------------------------------------THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH / ( :':.:err,........OF..........f t E° �" ............................... No.... FEE.......7......... iou1 nrkii Tunstrttrtilan rrutit Permission is hereby granted.------- �_7L.__ ;rt' ' _�....--------••--•---....--••----•---•-------------------•--.........----.........:.......... to Construct ( Y.) or Repair ( ) an Individual Sewage Disposal System at NO --f7 _ = ° .............................. Street as shown on the application for Disposal Works Construction P it No.._ Dated.......................................... . --•--•.----- ......................................_ ,�' ,� Board of Hea DATE...............-------------•---. ............................................... 1 FORM 1255 HOBBS & WARREN, INC., PUBLISHERS S YS TEM PROFILE NOT TO SCALE TOP FON. FINISH GRADE OVER FINISH GRADE ' EL . FINISH GRADE OVER DIST. BOX 5(2o- � FINISH GRADE OVER � ° SEPTIC TANKj� LEACHING PIT BCo. P Z e0.2 VARIES ^� , 'o';° t.•e.... ...�• .•.;..:, °: °. . . .•,. 3" OF 1/8" — 1/2" t2' MAX °" "°' '"` • " ' ' ' PRECAST CONC, OR y. .• o;:b :�:. . e. ASHED PEA STONE p,_:e_., ....:_ ..;.o..•� :d o. .. . e,o BRICK 6 MORTAR °: °•� 3" OUTLET PIPE LEVEL TO 12" BELOW GRADE e FOR 2 FT. MIN. •:°:b.QO: e:S:e e.,•.o:e: .o ..�p D. O• �• O d...p;. Q -14, p• a [l c• a : . ,T,:•.:: •�p`. :d: 8�' 8Z. iv 'o �O' �j2.CJ" � :e ;..•.s .•o..: o o•.o a o'.o: 'd ..e,.Q.°•,. o, o.o o . ::.:° o C. I. OR PVC TEES �• 2;10 ° °' ° o.p°° ° :o. .e'• o as o q 81Z BSMT. FLR. ::'o,•'o': GALLON I EL . 79.0• •. . . ° DIS TRIBUTION BOX f INSTALL ON LEVEL BASE 3/4 " TO 1-1/2" a° 3 '-7" PRECAST CONCRETE PRECAST °..o..•.• ..o. o: ° •. WA Si' D CRUSHED CONCRETE H— l 0 REINFORCE 't a STOVE t D�e;•o�b'•o'.'0° o:e p o•o''e.°o,.q. e4b' •° a o;o e•.• :e. . o . e o b a•' H— 1 0 REINF• b t. °• 0 0' SEPTIC TANK INSTALL ON LEVEL BASE °•'° °•• a• .: p'p.o.°. o:b NO TE: EXCAVATE TO EL V. 74.4 OR :°o:°' . ' '° °�� ° �• �L. �8.4 L OWEP TO REMOVE ALL IMPERVIOUS '— MA TERIAL BENEA TH THE LEACHING ,AREA 2 '-0 " 2 '-0 Is V REPL A CE EXCA VA TED MA TEPIA L WI TH 6 '-0 '' Y CL EAN, CL A Y FREE SAND gg . 10 '-0 " i EFFECTI VE DIAMETER GENERAL NO TES LEACHING PIT J. A L L EL EVA TIONS SHOWN ARE BA SED ON FIEL D SUR VEY INSTALL ON LEVEL BASE 2. A L L PIPES IN THE S YS TEM MUS T BE CAS T IRON - OR SCHEDULE 40 PVC, OBSER VA TION PIT 3. - THE BOA RD OF HEA L TH MUS T BE NO TIFIED WHEN CONSTRUCT ION IS COMPLETE PRIOR - 5683 TO BA CKFIL L IN6 PERCOL A TION RA TE: 4. ANY CHANGES IN THIS PLAN MUST BE APPROVED 2 MIN. /IN. ` I BY THE BOARD OF HEALTH AND CAPE 6 ISLANDS WI TNESSED B Y.' 8Z SURVEYING CO., 'INC. _ T. MCKEAN 5. MATERIALS AND INSTALLATION SHALL BE IN t � BAR S. BRD. OF HEALTH DESIGN DA TA COMPLIANCE WITH THE STA TE SA NI TARY �. CODE — TITLE V — AND LOCAL APPLICABLE DA TE.' �JL/L �,� 1986 RULES AND REGULATIONS NUMBER OF BEDROOMS 4 s 6. NORTH APRON IS FROM RECORD PLANS AND 0 " i �o, GA RBA GE DISPOSAL NO I -1 4 ,� vo 8 8 IS NO T TO BE USED FOR SOLAR PUPPOSES TOPSOIL 6 7. FL OOD HA ZARD ZONE C DA I L Y FLOW 440 GAL . ! B. WA TER SUPPL Y, , TOWN WA TER a " SUBSOIL SEPTIC TA NK REO 'D. 1250 GAL . R�\ o SEPTIC TA NK' PRO VIDED 1250 G,A L . LEACHING REOUIRED 440 GPD. F• V N Z Z' PRECAS r NCRETE Clp> LEACHING P'IrS MEDIUM ►�; 0_`�2 REG'D.1 SAND SIDEWALL APEA 225 S. F. 0� 225S. F.X 2. 5GIs. F. = 562GPD BOTTOM AREA 157S. F.cc H 0� PRECAST CONCHES � LEGEND 1575. F. X 1. 0 G/S. F. = 157GPD O N'j SEPTIC TANK \ 9O L EA CHING PRO VIDED = 719GPD LOT 64 VOPOSED EL EVA TION 144" NO GROUNDWA TEP ��•�g, 5' 47 200 S. F.SF '! , . o ti o —-- �o—— Exls rING CONTOUR SINGLE FA MIL Y RESIDENCE 6 H � OBSERVA TION PI T _ O DISTRIBUTION BOX - of M� • q P�`ICHARD ss9�\ - PROPOSED SEW GE DISPOSA L . S YS TEM AMES LEACHING PIT � BER RAND PREPARED FOR 2 No. 19894 260• 0 _ e �; 79 20' ex / 65 0 o SEPTIC TANK °��SF-ISTER� ,```��, CAMMET T CONS TRUC TION s B2 eA ions �' I (RP RESERVE of LOT 64 MIS TIC DRIVE 76 BoDAV M+r 74 CHARIDES s9�yU' SARNSTASLE — MARS TONS M.TLLS — MASS PIPE INVERT ELEVATION SANICKI �F 28085�� DA TE: 0 C T• Z-� 108� CAPE 6 ISLANDS SURVEYING, INC. e , PLOT PLAN oc�S7�� -�o SCALE AS NOTED SCA L E.' J "_ �O �9 �o�o w 4 s J/ P. O. BOX 334 TEA TICKET, MASS. MAP SFC PCL. LOT f 1sr- PLAN NO. S 3'�7 8 Co z�