HomeMy WebLinkAbout0040 MOUNTWOOD ROAD - Health 40 '11n®tantw®®d`Roa.
. Marstons Mills P
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TOWN OF BARNSTABLE
LOCATIONS V ' � c�®c� �� SEWAGE #
VII.LAGE�m�a b�_S �`.L`5 ASSESSOR'S MAP & LOT`l *%--Or
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) L'sm�g.� p:"C' (size) e,
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:—�7—\�C.
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 facili ) Feet
y Furnished b `'�
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COMMONWEALTH OF MASSACHUSETTS -�-Z
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS 3
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DEPARTMENT OF ENVIRONMENTAL PROTECTION
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TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 40 Mountwood Road
Marstons Mills
Owner's Name: Rod Pelkey f
Owner's Address:
Date of Inspection: 11/23/2004
Name of Inspector: (please print) Patrick T. Sullivan s "
C,
Company Name: Ready Rooter ; }
Mailing Address: P.O.Box371 � r
Sandwich,MA 02563 rCD
Telephone Number: (508)888-6055 --_j M
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
trainingr and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The System:
_Passes
Conditionally Passes
Needs Further Evaluation by the Local Authority
Fails
Inspector's Signature: Date: !t 3
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.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 40 Mountwood Road
Marstons Mills
Owner: Rod Pelkey
Date of Inspection: 11/23/2004
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
C. System Passes:
-zi 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"secti n need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved b the Board of Health,will pass.
Answer yes,no or not determined (Y,N,ND)in the for the following atements. 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,liy 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. /
i'�
ND explain: ;
i
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 unev e ''distribution box. System will pass inspection if(with
approval of Board of Health): ;
broken ipe(s)are replaced
obstru tion is removed
distribution box is leveled or replaced
ND explain: !
The system required pumping mo than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the oard of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 40 Mountwood Road
Marstons Mills
Owner: Rod Pelkey
Date of Inspection: 11/23/2004
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the 13 d 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 Hea/determi accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a mannerect public health,safety and the environment:
Cesspool or privy is within 50 feet r
Cesspool or privy is within 50 feet getated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Waterupplier,if any)determines that the
system is functioning in a manner that protects the public health,sa ety and environment:
_The system has a septic tank and soil absorption system(S 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 i within a Zone 1 of a public water supply.
—The system has a septic tank and SAS and the S is within 50 feet of a private water supply well.
_The system has a septic tank and SAS and th AS is less than 100 feet but 50 feet or more from a
private water supply well**. Method used to de rmine distance
**This system passes if the well water anal s performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indica es that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate/ itrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of th��halysis must be attached to this form.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 40 Mountwood Road
Marstons Mills
Owner: Rod Pelkey
Date of Inspection: 11/23/2004
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
__jZ Static liquid level in the distribution box above outlet invert due to and overloaded or clogged SAS or
cesspool
__,Z' Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow
__jZ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
Any portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ __tZ Any portion of a cesspool or privy is 50 feet of a private water supply well.
_I_/-Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
(Yes/No)The system fails. I have determined that one or more of the above 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 sy/area
st serve a facility w' a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"tf the following:
(The following criteria apply to large syaddition to th criteria above)
yes no
_ the system is within 400 feet oe dri g water supply
the system is within 200 feet oary o a surface drinking water supply
_.the system is located in a nitrotive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone 1I of a public water supplIf you have answered"yes"to any questction E the system is considered a significant threat,or answered
"yes"in Section D above the large sys in has failed.The owner or operator of any large system considered a
significant threat under Section E o ailed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner shoul ontact the appropriate regional office of the Department.
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 40 Mountwood Road
Marston Mills
Owner: Rod Pelkey
Date of Inspection: 11/23/2004
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
_ Pumping information was provided by the owner,occupant,or Board of Health
Were any of the system components pumped out in the previous two weeks?
Has the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of this inspection?
/✓� Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_ Was the facility or dwelling inspected for signs of sewage back up?
_ Was the site inspected for signs of break out?
_ Were all system components,excluding the SAS, located on site?
_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
-44," Was the facility owner(and occupants if different than 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:
Yes No
Existing information.For example,a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)]
Page 6 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 40 Mountwood Road
Marstons Mills
Owner: Rod Pelkey
Date of Inspection: 11/23/2004
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual): _
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):32x0 i:P-.�
Number of current residents: Q
Does residence have a garbage grinder(yes or no):r'zC>
Is laundry on a separate sewage system(yes or no):.t�[if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use: (yes or no):,2c-,
Water meter readings,if available(last 2 years usage(gpd)): "K5,3.- a be ,r i
Sump Pump(yes or no): Y
C_5 — Q,s; c ,�, c
Last date of occupancy:
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(Xen /sgft c.):
Grease trap present(yIndustrial waste holdit(yes or no):
Non-sanitary waste dihe Title 5 system(yes or no):
Water meter readings,Last date of occupanc
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no):.rje--)
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
/Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank , Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Ak 1 Pv `C o'� ti T '12' a X
C� \ItSdi./`�a CS CcaSZ.r c9 w,MatiG.l'`�'
Were sewage odors detected when arriving at the site(yes or no):_A jC i
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 40 Mountwood Road
Marstons Mills
Owner: Rod Pelkey
Date of Inspection: 11/23/2004
BUILDING SEWER(locate on site plan)
Depth below grade: o <("
Materials of construction:_cast iron�PVC_other(explain):
Distance from private water supply well or suction line: 4//�
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: locate on site plan)
Depth below grade:
Material of construction: ;--*�Concrete_metal_fiberglass_polyethylene
_other(explain)
If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of
certificate)
Dimensions: n q• ,�r
Sludge depth:
Distance from the top of sludge to bottom of outlet tee or baffle: --ZQ't
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: i CC
How were dimensions determined. ♦.,,Q,� ��as,L,r,r-� �,.,� `�,����
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
�fw�C;
GREASE TRAP:_(locate on site plan)
Depth below grade:
Material of construction:_concrete meta fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum t/ceof
e or baffle:
Distance from bottom of scuoutlet tee or baffle:
Date of last pumping:
Comments(on pumping recinlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evge,etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 40 Mountwood Road
Marstons Mills
Owner: Rod Pelkey
Date of Inspection: 11/23/2004
TIGHT or HOLDING TANK: (tank must be pump at time of inspection)(locate on site plan)
Depth below grade: %j
Material of construction:_concrete_metal fiberglass_polyethylene_other(explain):
Dimensions:
Capacity: Qallons
Design Flow: gallons/ y
Alarm present(yes or no):
Alarm level: Alarm in work' g order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: (if present must bi opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(not if box is level and distrib on to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER: (locate on site plarif'
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump c}tamber,condition of pumps and appurtenances,etc.):
Page 9 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 40 Mountwood Road
Marstons Mills
Owner: Rod Pelkey
Date of Inspection: 11/23/2004
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
--Zleaching pits,number: -Q
leaching chambers,number:
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.): i
y�L�i�Y t rriv�se �i-1:��� w•a�.br— S�.+s`�`....a w�L,c�c���+�'"
[_-7!�V�
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 es or no):
Comments(note condition of s ' ,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,s' ns of hydraulic failure, level of ponding,condition of vegetation,etc.):
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 40 Mountwood Road
Marstons Mills
Owner: Rod Pelkey
Date of Inspection: 11/23/2004
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference'landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
I`
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53
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Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 40 Mountwood Road
Marstons Mills
Owner: Rod Pelkey
Date of Inspection: 11/23/2004
SITE EXAM
Slope
Surface water
Check cellar✓
Shallow wells
Estimated depth to ground water _feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record—If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with the local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain: � . `, r. `, , S,
You must describe how you established the high ground water elevation:
��✓c� r�� �.,A t .r- 'L.-.
Lav�G
COMMONWEALTH OF MASACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET BOSTON MA 02108(617)292-3500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI �; DAVID B.STRUHS
Govemor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 40 MOUNTWOOD RD MARSTONS MILLS, MA 02648 %.Jo 0�1
Name of Owner MARY ELLEN SKEHAN
Address of Owner: 108 LEE ST E.LONGMEADOW MA.01028
Date of Inspection: 8/18/00
Name of Inspector: JOHN GRACI
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O.BOX 2119 TEATICKET,MA.02636
Telephone Number: 608-664-6813 FAX 608-564-7270
CERTIFICATION STATEMENT �ay>
I certify that I have personally inspected the sewage,disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.The�system:
X Passes
_ Conditionally Passes
_ Needs Further Evalu tion By the Local Approving Authority
Fails is
<•r
Inspector's Signature: Date:8/19/00
The System Inspector shall su it a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
completing this inspection.If th system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
"The inspection is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.My
inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life"
THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL
LIFE.
00
revised 9/2198 Page 1 of I I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 40 MOUNTWOOD RD MARSTONS MILLS, MA 02648
Name of Owner MARY ELLEN SKEHAN
Date of Inspection: 8/18/00
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated
are indicated below.
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.
Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not.
Wa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance
attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether
or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system
will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health.
n/a Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due
to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health).
_broken pipe(s)are replaced
_obstruction is removed
_distribution box is levelled or replaced
n(a 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
t y
revised 9/2/98 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 40 MOUNTWOOD RD MARSTONS MILLS, MA 02648
Name of Owner MARY ELLEN SKEHAN
Date of Inspection: 8/18/00
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. 4,
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 ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
3 :
_ Cesspool or privy is within 50 feet of 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 ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a
surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well,
az
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm,Method used to determine distance ilia(approximation not valid).
3) OTHER
n/a S
r
revised 9/2/98 Page 3 of 11
,r
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 40 MOUNTWOOD RD MARSTONS MILLS, MA 02648
Name of Owner MARY ELLEN SKEHAN
Date of Inspection: 8/18/00
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is
identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
- X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
- X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.
- X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow,
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Q.
- X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
- X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone I of a public well.
X Any portion of a cesspool or privy.is within 50 feet of a private water supply well,
X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality
analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,
ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 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:
Yes No
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
- X 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)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the
Department for further information.
t,
• y,
revised 9/2/98 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 40 MOUNTWOOD RD MARSTONS MILLS, MA 02648
Name of Owner: MARY ELLEN SKEHAN
Date of Inspection: 8/18/00
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health.
X - None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.
Large volumes of water have not been introduced into the system recently or as part of this inspection.
X - As built plans have been obtained and examined.Note if they are not available with N/A.
X _ The facility or dwelling was inspected for signs of sewage back-up.
X _ The system does not receive non-sanitary or industrial waste flow.
X _ The site was inspected for signs of breakout.
X - All system components,excluding the Soil Absorption System,have been located on the site.
X _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of
construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been
determined based on:
X _ Existing information,For example,Plan at B4O,H,
X _ Determined in the field(if any of the failure criteria related to Part C is at Issue,approximation of distance is unacceptable)1 5.302(3)(b)J
X - The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal
Systems. .
E'l:4
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r revised 9/2198 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 40 MOUNTWOOD RD MARSTONS MILLS, MA 02648
Name of Owner MARY ELLEN SKEHAN
Date of Inspection: 8/18/00
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 110 g.p.d./bedroom
Number of bedrooms(design): 3 (Number of bedrooms(actual):
Total DESIGN flow: 330 gpd i
Number of current residents:0
Garbage grinder(yes or no):NO
Laundry(separate system)(yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no): NO
Seasonal use(yes or no): NO
Water meter readings,if available(last two year's usage): n/a gpd
Sump Pump(yes or no): NO
Last date of occupancy: 8/6/00
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow: n/a gpd(Based on 15.203)
Basis of design flow:n/a
Grease trap present:(yes or no): NO
Industrial Waste Holding Tank present:(yes or no): NO
Non-sanitary waste discharged to the Title 5 system:(yes or no):NO
Water meter readings.if available: n/a
Last date of occupancy:n/a
OTHER: (Describe)
n/a
GENERAL INFORMATION
PUMPING RECORDS and source of information:
n/a
System pumped as part of inspection:(yes or no):NO
If yes,volume pumped n/a gallons
Reason for pumping:n/a
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorption system
_ Single cesspool
_ Overflow cesspool
_ Privy
_ Shared system(yes or no)(if yes.attach previous inspection records,if any)
_ I/A Technology etc.Attach copy of up to date operation and maintenance contract
_ Tight Tank Copy of DEP Approval
Other:n/a
APPROXIMATE AGE of all components,date installed(if known)and source of information:
REPAIR IN 1996 '
Sewage odors detected when arriving at the site:(yes or no). NO
revised 9/2/98 Page 6 of 111
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 40 MOUNTWOOD RD MARSTONS MILLS, MA 02648
Name of Owner MARY ELLEN SKEHAN
Date of Inspection: 8118/00
BUILDING SEWER:X
(Locate on site plan)
Depth below grade: 12"
Material of construction: _ cast iron X 40 Pvc _ other(explain)
Distance from private water supply well or suction line: n/a
Diameter: n/a
Comments: (condition of joints,venting,evidence of leakage,etc.)
THERE IS TOWN WATER
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 6"
Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other
explain: n/a
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO
Age: n/a
Dimensions: 1000G L 8'6"H 6'7"W 4'10
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 32"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
How dimensions were determined: MEASURED
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFULL LIFE.
GREASE TRAP: _
(locate on site plan)
Depth below grade: n/a
Material of construction: _concrete_ metal_ Fiberglass _ Polyethylene_other
Explain: n/a
Dimensions:n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet"tee or baffle n/a
Date of last pumping: n/a
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
n/a
revised 9/2/98 Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 40 MOUNTWOOD RD MARSTONS MILLS, MA 02648
Name of Owner MARY ELLEN SKEHAN
Date of Inspection: 8/18/00
TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: n/a
Material of construction: _concrete_ metal_Fiberglass _Polyethylene _other
Explain: n/a
Dimensions: n/a
Capacity: n/a gallons
Design flow: n/a gallons/day
Alarm present: NO
Alarm level:N/A Alarm in working order:NO
Date of previous pumping: n/a
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
n/a
DISTRIBUTION BOX:_
(locate on site plan) .)
Depth of liquid level above outlet invert: n/a
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
n/a
PUMP CHAMBER: _
(locate on site plan)
Pumps in working order:(Yes or No): NO
Alarms in working order(Yes or No): NO
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
n/a
t,
a
revised 9/2/98 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 40 MOUNTWOOD RD MARSTONS MILLS, MA 02648
Name of Owner MARY ELLEN SKEHAN
Date of Inspection: 8/18/00
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
n/a
Type:
leaching pits,number:(2)1000 GAL 6'X 6'
leaching chambers,number: (n/a)n/a
leaching galleries,number: (n/a)n/a
leaching trenches,number,length: (n/a)n/a
leaching fields,number,dimensions: (n/a)n/a
overflow cesspool,number: (n/a)n/a
Alternative system: n/a
Name of Technology: n/a
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE LEACH PITS ARE STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY.THE NEW PIT HAD 1'OF WATER IN IT AT THE
TIME OF THE INSPECTION.THE PIT HAS NOT HAD MORE THAN 1'OF WATER IN IT.
CESSPOOLS: _
(locate on site plan) `
*,t
Number and configuration: n/a
Depth-top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer. n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection)NO
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
n/a
PRIVY:
(locate on site plan)
Materials of construction: n/a Dimensions: n/a
Depth of solids: n/a ""
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
n/a
. ,zy
:YS
revised 9/2/98 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 40 MOUNTWOOD RD MARSTONS MILLS, MA 02648
Name of Owner MARY ELLEN SKEHAN
Date of Inspection: 8/18/00
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100',(Locate where public water supply comes into house)
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revised 9/2198 Page 10 of 11
G 1
W
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 40 MOUNTWOOD RD MARSTONS MILLS, MA 02648
Name of Owner MARY ELLEN SKEHAN
Date of Inspection: 8/18100
NRCS Report name: n/a
Soil Type: n/a
Typical depth to groundwater: n/a
USGS Date website visited: n/a
Observation Wells checked: NO
Groundwater depth: Shallow_ Moderate_ Deep_
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
Shallow wells
Estimated Depth to Groundwater 12 Feet+
Please indicate all the methods used to determine High Groundwater Elevation:
_ Obtained from Design Plans on record
_ Observed Site(Abutting property,observation hole,basement sump etc.)
Determined from local conditions
Checked with local Board of health
_ Checked FEMA Maps
Checked pumping records
Checked local excavators,installers
X Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS-12+FEET
revised 9/2/98 Page 11 of 11
r
TOWN OF��M'
Sewer Permit No.
Name
Location
Installer's Name &Address a
o A 1 J�
r
Builder's Name &Addresses
Date Permit Issued
Date Compliance Issued '"
Jue-w
P
Fn$........ 4
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Diripo3ul Work,i Tontitr�anlndividual
ti n tfrrutit
Application is hereby made for a Permit to Construct (v ) or Repair ( Sewage Disposal
System at:
t4.0---------
i J a
.........A
�/ �� ...--_Location---\ddress- --'-------------------------or-Lot No. -
_ b1�! .+..L. -----------------•._._.....--•---- .-.•-----'--• ----•---.-...___^_•----..........-.....-.-.......__
0�ner Address
a ................. '.jcb----------------------------------------------------- -----------•-._._..••----------•-----...-----.._....._.
Installer Address
UType of Building Size Lot............................Sq. feet
,., Dwelling—No. of Bedrooms_____________ .........................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a' Other fixtures _______________________________ _ _
W
Design Flow.........................................___gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length________________ Width---------------- Diameter_............. Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------- ----------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
,.a Test Pit No. I----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
!? Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P' '--"-----------------------"-'-'-'------------•------•---•---•-•-•-•"'-'-'-••-••-------•---------..........................................................
ODescription of Soil........................................................................................................................................................................
x
U ._..._..••'••_.._....---••••"'-•---••-----••---•._....-•-'---'-"-••-•-•..........................................""•---••----'-----'----••-•-'•-•-•-••-•---•••-•---•..__..__._..._._....---.._..•---
W ..........................-------------------------------------------------------------------------------------------- -- --------- ---- _'-
UN �re of Repairs or Alterations— nswer wh n, licable_._ s5�" :.( _.-__._ - .�.�._...._.... Q._...�!+,�o� l
.... .._-..- �� ' ' ..................................................
Agreement: iae
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 be n issued lav the rd of health.
Signed ...........� ... . ._.. .... ................ ......... -d.`:. -,/
Application Approved By .... . ...... ... ............... ....0........ .. �-.
Dare
Application Disapproved for the following rear ...............................
..... ----------------------------------- - �
...................... .. Date..................
Issued -----------------
Permit No. .q,�„�. ..- ...........
Date
_') 00.
Fii. ............. ...........No...q
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Aopftratiott for. Diripaiial WorkB Tomitrurtion jJamit
Application is hereby made for a Permit to Construct (,, ) or Repair ( an Individual Sewage Disposal
System at: M()()V)i os ox A 0�ILL-S
................................01�......................................... ..............................................................................................
Location .Address or Lot No
......... ......... .. ........
0�sncr Address
................. ...................................................... ..................................................................................................
Installer Address
ell Type of Building � Size Lot............................Sq. feet
U — No. of Bedrooms............- -------------11 Dwelling ------------Expansion Attic Garbage Grinder
aOther—Type of Building ---------------------------- No. of persons.....................__.._.. Showers Cafeteria
Otherfixtures ------------------------------------------------------I---------------------------------I.............................................................
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
1:4 *0 Septic Tank—Liquid capacity------------gallons Length-_--_--__-.__-- Width---------------- Diameter................ Depth......_.........
Disposal Trench--No. .................... Width.................... Total Length......._............ Total leaching area....................sq. f t.
Seepage Pit No..................... Diameter.__--.----.-.-.--._. Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )!
$-_4 Pe'rizolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.-__-.--_-_-_------- Depth to ground water........_..._......._....
fi Test Pit No. 2................minutes per inch Depth of Test Pit._......_......._... Depth to ground water......_.................
P4 .............................................................................................................................................................
0 Description of Soil........................................................................................................................................................................
W .................................................................................I........................................................................................................................
U
---------------------------------------------------------------------------------------------------------------------------------- ...........I............ ..................................
Alterations—Answer when applicable._._ 4A — "t, P
U Nature of Repairs --- ------------t.............................
I- -en X--e t Ce L�
..k-IC11\1k _ Or ................................ ......................... ----- 2.......................................................
Agreement: _7
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 ben h, the be I ard of health.
----------- . . ..... ..... --------_---_ .........
Signed .........
Application Approved By
7",........................................
------ .. ...........y -y
t
...........................................
Application Disapproved for the following reas 7nsl ---------------------- - ........................................................
-
---------------------------------------------------------------
Da ce
Permit No. ----- ------------------------- Issued ................2)j........ -
30/ G
. . -------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
(gertifirate of Tomplianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
0. .. .....
-------------------...............................................................................................................
by ......................................................... ............
&<7 ......... . .....................................................................................
at ------ --------- .... .............
has been installed in accordance with the provisions of TITLE 5 of T e.State Environmental Code as described in
--------------------------
the application for Disposal Works Construction Permit No. I dated ......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUElb AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE ------ . .......... ----------- Inspe to-f.... .. ....................................................................
--------------------------- ----------I-------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
75 TOWN OF BARNSTABLE
No... FEE......�-36........
?it— ...
Bispofiat Works Tomitrudion "ermit
00 e
Permissionis hereby granted......�e�:-----------------------e_�_ ..............................................................................
I.-,
to Const ic orVRK pair_*,,,,, an In(jividual Sewage Disposal System
atNo.....4�4 00PA 'e"k -------_/71... ... . . ................... .........
Street
I ated;6..........
as shown on the )PplicatioYfor Disposal Works Construction Perm-*17
. ........
oar o H calth 7—
DATE.............. (2111-
----------------*----------------------
FORM 3650a HOBBS&WARREN.INC..PUBLISHERS 166,0
R.2 - -7,2
LOCATION � EWAGE PERMIT NO.
VI LLAG E
a
�• /�rG L S /'�dQ
INSTALLER'S NAME & ADDRESS
e U I L D E R OR OWNER
.mom d L�►►�5
r
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED _ � ��
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