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HomeMy WebLinkAbout0794 MISTIC DRIVE - Health r.4*-794 Mistic-Drive A,= 079 069,` a 'Marstons Mills e F,7 e � � / Town of Barnstable P# Department of Regulatory Services awartar,�� Public Health Division Date r Mess. 200 Main Street,Hyannis MA 02601 i prFr1 htA't A 17 Date Scheduled t! ! ime Fee Pd, Sol Suit ility Assessment for sew Performed By: � �y,�`��6�/��� Witnessed By: C� LOCATION& {GENERAL INFORMATION Location Address Owner's Name Address 7V 8*4 OCT Assessor's Map/Parcel: ' � Engineer's Name i NEW CONSTRUCTION REPAIR Telephone# Land Use 5%-;p . Slopes Surface Stones n Distances from: Open Water Body > t!<Q' ft- Possible Wet Area�5 0' ft Drinking Water Well �Q�ft Drainage Way >!j�a ft Property line - )!%c' ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) $ur.i.grf L—A-,4 r�, Ta e% • (r1 � 1 e7? F-7z7 ov �► 43i G'E4 st= I V Parent material(geologic) Depth to Bedroelt _' Depth to Groundwater. Standing Water in Hole: 4 .. Weeping ftin PI Face Estimated Seasonal High Groundwater _ /n DETERMINATION FOR SEASONAL-HIGH WATER TABLE Method Used: �r�z�12Aapv �-T--7 Depth Observed standing in obs,hole: In, Depth to soil mottles. Depth to weeping from side of obs,hole: In, Groundwater Adjustment ft. Index Well# Reading Date: Index Well level A�;factor Adj.Oroundwater'Ixvel PERCOLATION TEST Dole 8 'z. Time Observation Hole# _ Time at 9" . ._ ,... Depth of Pere i Time at 6" Start Pro-soak Time @ Time(9"•6" End Pre-soak Rate Min./Inch . �-Z. L Site Suitability Assessment: Site Passed ✓ Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation testis to be conducted within 100' of wetland,you must first notify the, Barnstable Conseirvation Division at least one (1) week prior to beginning. Q:IS EPTIC\PERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# — Depth from Soli Horizon Soil Texture Sdi1 Color Soil. Other Surface(in.) (USDA) (Munsell) Mottling (Stnucture,.Stonea;Boulders. �slstency.4b't3raven 114 �✓y.ri.c,r� 5�ri-r- G a�. L. w c Cs�v�ns�.n`S DEEP 013SERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil thrir Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. � . .� `'L. \e tG.�� 1�1o1-�ttri ti K (e K. 3 1 L 5//7"6o DQLCSS- at.s SOH Z 71-7 L t.. ]DEEP OBSERVATION HOLE LOG Hole# 3 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure;Stones,Boulders. onsistency. • Tt7 — r. Q St:... l n �.y�Z �t lf' t_h -T= _.-« ' C—— 3� �--�i LD 1G 5u-T.SAA-.z7 z,f�{���,__ l'i G- Z o C— rFcs�-12f, G z DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,5lones;Boulders, o ' 360 -IZD G'i o 3 L GoSFrI�.�� rs iA.%4 X, JFlood Insurance Rate Map_ Above 500 year florid boundary No_- Yes (� Within 500 year boundary No-l- Yes _ Within 100 year flood boundary No. Yes Depth of Naturally Occurrine Pervious Material Does at least four feet of naturally occurring perviis material exist in all areas observed throughout the area proposed for the soil absorption system? If not, what is the depth of naturally occurring peiklous material? . Certif cation I certify that on _ -1/ft (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the required training,exper 'se and experience described in�10 CUR 15.017. Signature Date oB- zZ-�� Q:\S,1?PT1CTF-RCF0R.M.DOC Commonwealth of Massachusetts -= Title 5 Official Inspection Form . -rl, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 794 Mist,c Drive Property Andress Bill Sparrow Owner Owner's Na,re information,is required for every Marston Nfi!ifs Ma. 02648 03/09/2013 ;:age City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When fling out forms A. Genera! information on the computer ::se only the tab key tc move your 1 Inspector cursor-do not Mike Bisienere use the return key. Name of inspec cr Cape Septic Inspecnons Company Name 624 OId Barnstarle Road Company Address : Mashcee Ma. 9 CityfTown State - : Zip, de 508-280-3356 S13938 Q) '"' '� Telephone NumCcr License Number "ri *;-du B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the rn 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 by the Local Approving Authority 03/17/2013 Inspectors 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 desion 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. • t. - Tq.e 5 Dklc:a!Inspect,,.i-,Frnn Sacswface Sawage D:.sposa.Systerr:•Page t of)? A Commonwealth of Massachusetts INUMN :- Title 5 Official Ins pection ection Fora Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 794 Mistic Drive Property AoIress Bill Sparrow Owner Owners Name in,ormat;on is required for every Mlarston Mills Ma. 02648 03/09/2013 page City,'Town. 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: Z 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 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 nr 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): „ s - - :,•T;tlz�Of�ci&:insGe.:iur For:: S❑ts,03.-a Sewage D,sGo=a Systar. •Page 2 ct t' f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 794 Mistic Drive Property Address Bill Sparrow Owre; Ovrrer's Name �r.�ormatio�is requ red for every Marston Mills Ma. 02648 03i09/2013 page Ctty,Town State Zip Code Date of Inspection. B. Certification (cont.) 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 Healthy L broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): El oostruc~on is removed ❑ Y ❑ N ❑ ND (Explain below): distribution box is leveled or replacea ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system wiil pass inspection if(with approval of the Board of Health) nroi<en pipes) 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 . rd!a 5 6riaal;rSpea:cr.Form S:,b"rfaoe Sewa:a�:D,sposal Systel^.Page 3 of 17 . . Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 794 Mistic Drive r Property Address Bil Sparrow Owner Owners Name information is required for every Marston Mills Ma 02648 03/09/2013 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: I 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. ❑ h: system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply Tine system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. J The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more frorn a private water supply well" Method used to determine distance: " This syste-^� passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria ind;cates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than: 5. cpm,. 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 u 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 C or clogged SAS or cesspool Liquid depth in cesspool is less than 6° below invert or available volume is less than Y2 day flow Tice 5 On:aal ^.soec..,,,Form. S�w..race Sewage D:sresa.System•Page 4 c. .7 Commonwealths of Massachusetts Title 5 Official Inspection Form =. A Subsurface Sewage Disposal System Form Not for Voluntary Assessments J 794 M stic Drive Property Address Bill Sparrow Uwncr owner s Name - . ,nforrnat:on is Marston Mils Ma 02648 03/09/2013 required fcr every page CitylTow State Zip Code Cate of Inspection B. Certification (cont.) Yes No `�— ter,; Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped, r Any portion of the SAS, cesspool or privy is below high ground water elevation. ,— h;1 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. i< Any portion of a cesspool or privy is within a Zone 1 of a public well. I— Any portion of a cesspool or privy is within 50 feet of a private water supply well ❑ l 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 I the system is within 400 feet of a surface drinking water supply LD J the system is within 200 feet of a tributary to a surface drinking water supply E 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. T:ua;UMe;aj L^-specnon Form. 5u_•s.;rtec2 Sewage U:>„c,a!Sys,em•Page e!+.7 Commonwealth of Massachusetts Title 5 Official Inspection Form ;t �~ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments AD 9 P Y Y 794 Mistic Drive Property Address Bill Sparrow Owrer Owner's Name information is required for every 1�larston Mills Ma 02648 03/09/2013 page CitylTown State Zip Code Date of Inspection C. Checklist----- i---��- --_,-~ Check if the following have been done You must indicate"yes' or"no" as to each of the following Yes No El L Pumping information was provided by the owner, occupant, or Board of Health 17 2 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 G this inspection? Z 07 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? Z [I Was the site inspected for signs of break out? u 1 Were all system components, excluding the SAS, located on site? Z El Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, deptn of sludge and depth of scum-? Z 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: L7 Existing information. For example, a plan at the Board of Health Z 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 Suns::rfaca Saw•ace Cusp osa:Systar.^.•Pare 6 at 17 tr. . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' -194 Mistic Drive Property Addres-s Bill Sparrow Owner Bill Name nforrnat!on is requ!rec for every Marston Mills Ma. 02648 03/09/2013 o3ge City;Town State Zip Code Date of Inspect!en D. System information Description. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes .❑ No Is laundry on a separate sewage system? (if yes separate inspection required] ❑ Yes ❑ No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes © No Last date of occupancy occupied Date Commercial/industrial Flow Conditions: Type of Establishment: - Design flow(based on 310 CM 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: 'hie-5 Oeicaa;!rspen w Fcrm.Suosurfaca sewa42 osspo;a!Sys12m,Page_of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form = _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 794 Mistic Drive Property Address Bill Spa_rrow Owner Owner's Name information is required for every Marston Mills Ma. 02648 03/09/2013 page CltyrTowr, 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.- Was system pumped as part of the inspection? ❑ Yes 0 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): ca=Ot?:c,al Inspact,on form S�bsur?aca Sewage o.sresa'Sysfen;•page a of 2. Commonwealth of Massachusetts Title 5 official Inspection Form j Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 794 Mistic Criv Property Adaress Bill Scarroh Owner Owne,s Name equnforr or,ievery s requiredd for Marston Mills Ma. 02648 03/09/2013 --- .. . page C{ryrTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes Z No Building Sewer(locate on site plan): 22 Depth below grade. feet Material of construction: cast iron [l 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feel Comments (on condition of joints. venting, evidence of leakage, etc.): Septic Tank (;ocate on site plan): 18 Depth below grade: — feet Material of construction: ®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank Is metal, list age: _-_.. years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: standard 1500 gallon < 1 Sludge depth: . «..., .., ?16e 5 OH:c:a!lnsoecaon Form S�osur'ace Sewage D�spcsa�Sysrsm-Page 9;;` „ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 794 Mistic Drive Property Add'ess Sill Sparrow Owner Owner's Name :nforr.at+on:s •equ:red for ever, Marston Mills Ma, 02648 03/09/2013 page City/Town _— State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance frorr top of sludge to bottom of outlet tee or baffle 38 Scum thickness Distance from top of scum to top of outlet tee or baffle 4 Distance from bottom of scum to bot om of outlet tee or baffle 12” How were dimensions determined? field instruments Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity: liquid levels as related to outlet invert, evidence of leakage, etc.): 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 5;.^s ?v?;; T::e 5 O`":rai ins ecucr.Fo;r. Sacsur`ace Sewage Disposal System•Page 13 of Commonwealth of (Massachusetts left. _. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments t94 Mistic Drive Property Address Bill Sparrow 0,xner Owners Name information is -ariu fed for every Marston, Mi!is Ma 02648 03/09/2013 page City/Town _ state Zip Code Date of Inspection D. System information (cont.) ---�- -- _-- Comments (on pumping recommendations. inlet and outlet tee or, baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage. etc.): Tight or Molding Tank (tank must be pumped at time of inspection) (locate on site plan). Depth below grade. Material of construction. concrete ❑ meta! ❑ 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 T.t!e 5 Offlc.a't-_„e..,�n form Surs.,riace Se.age D:sposai Systa;: .papa 1 1;,17 Commonwealth of Massachusetts Title 5 Official Inspection Form =_,A3 'Subsurface Sewage Disposal System Form - Not for.Voiuntary Assessments j u= 794 Mistic Dnve Property Adcress Bill S arrow Owner Owner's Name forrr,a:ion is required forever] Marston: Mills Ma. 02648 03/09/2013 cage City:Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of!Izakage into or out of box. etc.), Pump Chamber(ocate 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Ltia 5 0! ;al!r.sce--crt Fo;r.: SuOsurace Sewage D+syosal Systam•Page 12 Commonweal,. of Massachusetts Title 5 Official Inspection Form >.74 . w Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 794 Mist Drive Property Aduress Bill Sparrow Owner Owner's Name Information is required for every Marston Mills Ma. 02648 03/09/12013 page_ =ity/Towr:_ _State Zip Code _ Date of Inspection" D. System Information (cont.) Type: leaching pits number: two :eaching chambers number: leaching galleries number: El leaching trenches number, length: ❑ !eaching fields number, dimensions: El 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 ..,.-.� T:tie 5 OKt•a•(nspeci.cn Form Sucsurtace Sewage Dispasa!SysWn.•Page 13 of 17 Commonwealth of Massachusetts -M_ Title Official Inspection Form Subsurface Sev�age Disposal System Form - Not for Voluntary Assessments , 6 , 794 Mistic Dive Property Acdress Bill Sparrow Owner Owners Name information is Ma. 02048 03/09/2013 Marston Milis req��red :or every page City/Town State Zip Code Date of Inspection D. System Information (cont.) ---'- Comments (note condition of soil, signs of hydraulic failure, level of pond,ng. condition of vegetation, etc.): Privy (locate cn site plan). . Materiais of construction:. Dimensions Depth of solid,- Comments (note condition of soil, signs of hydraulic-failure, level of ponding, condition of vegetation, etc.): .,.._ ..,. Taie 5 Onc;ai inspact:o^Fcmi Subsurtaze Sewage Dspasai Systenn,•Page N Di!7 eN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Volintar;, 794 Misnc Drlv Blli Soar'•^' Owner Osv^er s tti _. n`or^-:aUon s Ma 02648 eGu net for every Marston %11 _G �''�-"r2013 — Page city': Towr Stage Zio"cce C�to Inspection. -D. System Information (cont.) Ske'cn Of Sev:- E-lisposai System: Provide a view of the sewac= dis.pGsai system. including ties to at least t.vc parMnacent reference landmarks or oenchmarks Loci:; ail v eiis within 100 feet. Locata where .:00C Wa er SJoDi`: enters the building, Check one of the D;.Xes, hand-ske c" :r. the area below ara-f1ing. separately f � � i 1 1 http:,'tiiw w.town.banlstable.ma.uS'asstssinellI Idisplay.asp?mappar=lt7�)Cl(,�c)ct y ; 6,;2013 ' . Commonwealth of Massachusetts Title 5 Official Inspection Form :y - Subsurface Sewage Disposal System Form Not for Voluntary Assessments ^-- 794 Mistic Dr ve Property Address Bill Sparrow, Owner Owner's Nam- !r:formauon is required for every Marston Mills Ma: 02648 03/09/2013 page. C ty;Town State Zip Code Date of Inspection: D. System Information (cunt.) Site Exam: E-j Check Slcpe Q Surface water h Chece,cellar Shallow Well.,; Estimated deoth to high ground water: 14 plus feet feet Pease Indicate a !methods used to determine the high ground water elevation: 11 Obtained from system design plans on record If cnecxed, date of design plan reviewed: pate Observed site (abutting property/observation hole within 150 feet of SAS) ❑ k Cnecked with local 36ard.of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) Q Accessed USGS database -explain: You must describe now you established the high ground water elevation. I aguared a hole at a lower elevation and shot elevations with a transit. Before filing this Inspection Report, please see Report Completeness Checklist on next page. T,:Ie;0^xie!Jnsoec::on Foam S:.as:rface Sesage D:saosa'Sys!e:•v•Page 15 of': f Commonwealth of Massachusetts ._ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I ROOF, 794 Mistic Drive_ Property Address Bill Sparrow Owrer Owner's Name information is Ma. 02648 03/09/2013 squired for every Marston Mills _ .. .._ _. page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Imo' Inspection Summary. A, B, C. D, or E checked Z Inspection Summary D (System Failure Criteria Applicable to Ali Systems) completed Z System Information — Estimated depth to high groundwater `= Sketch of Se.vage Disposal System either drawn on page 15 or attached in separate file .c.^s•t•:,tC Ua 5 off:c,at!nspancn corm Sunsi;rfa-e Sewage Disposai Systarn Pace 17o!•i . TOWN OF BARNSTABLE tip LOCATION SEWAGE # 9,3" -304 VILLAGE ILQ ASSESSOR'S MAP & LOT979f L169 INSTALLER'S NAME & PHONE NO. ��r�-z� �� GCb,(vST a SEPTIC TANK CAPACITY �LEACHING FACILITY:(type) /�1 T,5 ��J (size) f x �NO. OF BEDROOMS PRIVATE WELL OR UBLIC WATER BUILDER OR WNE DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No `+� 'I �� �. � e �` .��! �' � � II 3f ,� a .r. �� . k , s' .:,; ��I A --; 07, q --0 No Fitz... ... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH VI' - ,0W...�........._.......OF...... .Trz..1✓'`-� ----------------------------------- r: Appliratiou for 11isposal Works Tonstrurtion ramit Application is hereby made for a Permit to Construct (W) or Repair ( ) an Individual Sewage Disposal System at: �f r ''� _9...... _9......................................... Location-Address or Lot No. a .._......... .... ._........: ................. ....... l -•--...---• ----............... .............••.......••-•-.....•--...._...•---•-........--•--•---•--......._...._................ Address . ... ...................•-..............--. ® ....q:....._.0s Address Type of Building Size feet Dwelling—No. of Bedrooms.............!.;4---------------------.---Expansion Attic ( ) Garbage Grinder ( ) 04 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) W Other fixtures ------------------------•---- d - -------.------------------------------------------------------------•---•- Design Flow........................-`�-l.._.._.--gallons per person per day. Total daily flow.................. --............_.e7l*".a.........•..gallons. WSeptic Tank—Liquid capacity,!�; Dgallons Length.� �_e`Width:�v Diameter................ Depths 7`. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No.......z......... Diameterla-`-o. . Depth below inlet-%?..' Total leaching area.. 1�C.sq, ft. Z Other Distribution box (X) Dosing tank ( ) Percolation Test Results Performed 4;�e.................•........ Date,40re.. Test Pit No. 1.....�?n..._..minutes per inch Depth of Test Pit.. r��_...__ Depth to ground water..e! ......... fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ----••--•-•••-••••••-••-•-•------•-•----•................ •-•••-•••---.....------•..........•--•-•---•----•-••-•--•-.........---•----- 0 Description of Soil........15?n- e; ............ ........... .-ef.,00f.,.z-------------------••----•------------------------•--•-•-•--•. . .........................................•-•-•-------•---•--•-------- /llo._..-. rc�_l��s��rr!c.. ��.•.• !ter-�?t✓ r- 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 Compliant as een iss by t board f health. , ISigned . :--- ....... ............... D- ---...................... .................. .... ........ .---....--- Application Approved BY °------ -.-------- - .. Application Disapproved for the following reason • ..................... .. ........ .. ............................................. ........................................ ---------------------------------------------- ........................................................ ................... ............ ......... I?are Permit No. � ............... Issued ........ .. Dl .. .... .................. � a No................-....... �i` FEE............................. _ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....��.ww.................OF......... -.. - -------------------------------------- , pphration for Disposal Marks Tonstrurtion ramit Application is hereby made for a Permit to Construct (; ) or Repair ( ) an Individual Sewage Disposal System at: Zrr._!�L*Z, '._::u�= t_.c...` ..............i' '. --•--- ..Z ......;a® ?`J�............................. Location-Address or Lot No. Owntr , Address ? ..:r`...1--------------------------------------------•-•-- --•--•....------•---••.....-••••--•--••••-•.........-•-........................---......_......._. M Installer' Address Type of Building Size Lot_&• --- ?.�?..Sq. feet U ►-� Dwelling—No. of Bedrooms.............'____:_........___.._..........Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers a YP g -------------•-------------- P ( ) — Cafeteria ( ) dOther fixtures ------•-----------•- -----------•---------------------------------------•••••••................_......._.... W Design Flow.........................4�........gallons per person per day. Total daily flow..................-------------------------gallons. WSeptic Tank—Liquid capacity.::. allons Length_--/2..:n<'. Width..............-- Diameter................ Depth..-E 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 ( ) Percolation Test Results Performed ............................. Date.zrri° ......:x`/I:_.b Test Pit No. 1..... .......minutes per inch Depth of Test Pit---- Depth to ground water...............`........ f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -----------------------------------•----•--------------------------------------- ••---......... .•••------------ DDescription of Soil........: _:�._1 ............. e - h {..•......=,- A'..,,n '' -------- •---------...------------------....---.-.------- W ....='�..c� ��=`w°.__._.•=!;`-evt ......Ile.... ^........................................... U ......-•---•---------•-----••••••......• ....... .....................n..... .......... ✓--........ ._._... 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 the board of health. rN Signed ...................................... :....:�......... /...... l / �. / .............Dare-..I , Application Approved B /. i�: .........! 1.�. .�%..........................rJ ' J�. /% �� Application Disapproved for the following reasons: .................... ...................................................... ........... = ....... ................................................... /n r.'..!'...1/ j ........................................................................ /�/ / i Ir j 1'� C.,•+��� �� ,,."-^� Dare Permit No ------- ------------------- ............. Issued ............ THE COMMONWEALTH OF MASSACHUSETTS - r BOARD.OF/,HE~A Tk I . , �`t 1 (�e>r#ifirate of (gout Iinn're THIS,IS TO CT PY, That-the Individual Sewage Disposal System constructed ( � ) or Repaired ( ) y i ...............................................--------------------------------------- t �, /Installer A 1/1 at . r. ' : ............................... ."............----...--.... .............---.:..........--...................................................... has been installed in accordance with the provisions of TITLE 5.of The State.Er vi onmental Code as described in the application for Disposal Works Construction Permit No. ....... dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT.BE'CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. � DATE .... ... ... Inspector .............. ,... ..................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H-E LTH 5 No...�.:...... ...�.... i./( FEE........................ �i��u�ttt nxk� �nn��r�rtiun �.erutit Permission, is hereby granted.... .�......h`....._ i. . .................................... - to Construct.( f,) or Repair (. )_an,Individual-Sewage Disposal,System , �, / /1 �•/. / j' �, t _ at No.......... 1.......................................-•-••--•••••• i....................................... ...... -................................................. Streetr as shown on the application for Disposal Works Construction Permit No..._.............. _.- Da'ted.......................................... J ...........................................Board f Health DATE.................•-............................................................ Form 1255 (:H:&WD HOBBS&WARREN rnt Publishers • I _ , S YS TEM PROFILE NOT TO SCALE TOP FDN. FINISH GRADE n ,<'. '` FINISH GRADE OVER EL G."; a �:.° e: FINISH GRADE OVER DIST. BOX G� �. 1 FINISH GARDE D VER a D,• SEPTIC TANK.G</, c� LEACHING PIT 4 .-7 ,a .oIIAWTANWVARIES' ' '' ^ •.d•.. t . N u "' f �.• D•d. ,O. ..D.,O .e ,..e,...O b:'I'•O::p:..:o+,:d .s. .,..f. •o: •'e;•'/: '•e'0: j- OF 1/B y/2 12 MAX 0'.. :p. p'..• e: d.' o . a O.e• I PRECAST CONC. OR oa j SHED PEA o ,:Q:.: ;o• .:a.;.e. :a ( BRICK & MORTAR a 3" OUTLET PIPE LEVEL TO 12" BELOW GRADE 'e:,p•,'0 - - + O. D l•.•o a O.. o. . • a FOR 2 FT. MIN. ..e..e'..o: 'o':o:° ° : .4...b:.p,.e•.•-:-. o G 'o •s' D•. :: o'.p Q: 'o �i,�.,3� G/ Q ,y "d:.i�.:s.3..'0.. ' ••o:.e o .e o;p'.�. :O o� D .'O •O.� 'o0:•'e_ 'o C. I. OR PVC TEES •O' b• o: 0 BSMT. FLR. p .A.. LLON n DISTRIBUTION BOX DD e• EL . ° INSTALL ON LEVEL BASE - _ 4 2 a• 4 �'- 1 1 3 .� e' o P O. 0: 'Q o. . .e:•. . .: .p,.. .:., o: PREC/'7 S T CONCRETE a� Q[� PRE4./A S T o.. .o..o. �+ H- l O R '"INFORCEI? CONCRETE TE p• ° o:p; e:o-o':o;oo,:a;: o :o o',o.o,o•.'p•:o,p'p'.'o::.::.'d::o.•'o.: o:o.'o: STONE a 'I .b"o,•o. o..a.D, .o:O,A•,O,•p•o.,•n'•a.•.o•a•'.o.o• 0•;O•e•.• :O.. D:.•o•o:o• ', n ,' H— l O REINF. I :� O• f. . . o'. T TA N -a e'.p. INSTALL ON LEVEL BASE NOTE' EXCA VA TE TO ELEV. 5'2.a: 0 L OWER TO REMO VE A L L IMPER VIOUS �__. ENEA TH T, :._. LEACHING A R� r• �/ -U" Z -C� MA TERIA L B 2 REPLACE EXCA VA TED MA TERIA L WI TH CLEAN, CL A Y FREE SA NO EFFECTI VE DIAMETER NOTES LEA C�. "N� PIT ' -GENERAL 72 . ,. 4 .� INSTALL ON LEVEL EASE .n 4 1� p 2 1. ALL EL EVA TIONS 'SHOWN ARE BA SED ON A 5 S U M E D \ P IN THE SYSTEM MUST BE CAST IRON P� 2. ALL PIPES „ � \ OR SCHEDULE 40 PVc. 8�'� ::m, ' V�`� 3. ` THE BOARD OF HEAL TH MUST BE NOTIFIED TEST ;',' = ELf3��pCqE Ef�C�INi iZItiG PRECAST CONCRETE 3 WHEN CONSTRUCTION IS COMPLETE PRIOR cCACHING PITS 0 TO BA CKFIL L ING PERCOL A TION RATE: f `. (2 REo D.) d- 2 MIN. /IN. 0 I \, 4. ANY CHANGES IN THIS PLAN MUST BE APPROVED BY. THE BOARD OF HEALTH AND CAPE 6 .ISLANDS WITNESSED BY.• V \ , SURVEYING CO., INC. .J . C0�11LOQ �0 ,, ; cv 705. MA TERIALS AND INS TALLA TION SHALL BE IN F \ COMPLIANCE WI TH THE S TA TE SA NI TAR Y BRD. OF HEA L TH DESIGN DA TA o �z CODE - TITLE V - AND LOCAL APPLICABLE DATE: .C1A_LZ_�'JO. 5� RULES AND REGULATIONS NUMBER OF BEDROOMS 6. NORTH ARROW IS FROM RECORD PLANS AND IS NOT TO BE USED FOR SOLAR PURPOSES TOPSOIL GARBAGE DISPOSAL0 5UIJ501 L / ° Z7' 7. FLOOD HAZARD ZONE �� DA IL Y FLOW _._,, 8. WA TER SUPPL Y T rp W Q W AT E tZ f SEPTIC TANK PEQ 'D. 2I O SEPTIC TANK PROVIDED I Z 50 LEA CHING REQUIRED 4 4 o 0 -� �, /�� " r �A�coN MEDIUM 5AND �\ !� PRECAST GaONC ETE p� S ��_ O d , � � \!/ . b tip' ��SEPTIC TA�/l�', g / SIDEWALL AREA - 115_S. F. \� I13 S. F. X Z.5 G/S. F. a ��GPO Zi \ ` ` `lr„ n BOTTOM AREA = ��S. F. � `�,, LEGEND �9 S. F. X � . D G/S. F: - � g GPD 144 Na WATC-IZ E-L.52.0 LEACHING PROVIDED 5&0 GPD 3GO CIFO x Z PITS PROPOSED EL EVA TION ry . o Z — r.o— EXISTING CONTOUR SINGLE FAMILY RESIDENCE ZC . .- ,-::rfl O .� OBSERVATION PIT fO E N LOT 78 F �19 0 DISTRIBUTION BOX4 o0 5F �' L o T �Ps k PROPOSED SE 'AGE DISPOSAL SYSTEM \ RICHARD u;\ ;il JAMES � h, 1 rt I LEACHING PIT k sElzraA;vD �,� � PREPARED FOR No. 29894 _...- _ _.... 70 2�� a o SEPTIC TANK of �GISTER o � �� Bi � � h �2C7 s / 'p ' LOT 78 MI S TI C DPI VE Lo 7 7 o•, l R P� RESERVE ,,�''P�t N 0 F�y� —. _ T �� \ 5g �y� C°Ar°Ss�� I BAPNSTABLE M. MILLS MASS . & \ ; 1 r,2.00 PIPE IN EL EVA TION � SANICKI '-� �---�-- �z 1 28085 a y p TE.' MAY 14 1ebro p `C/ I 04 CAPE zC ISLANDS SURVEYING, INC. PLOT PLAN ��' fy �''��} �� �-� ��` � SCALE AS NOTED P. Q. BQX 334 SCALE.' 1 ,= 3a' IS 5� �wP ,�;�� .� TFAT�'CKE T MA,5S. - - _ _ L LOT HSE � >,�. ' PLAN NQ. 150F5G f MAP SEC PC .