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HomeMy WebLinkAbout0040 NEW LONDON AVENUE - Health 40 NEW LONDON �J2'�v�� �L`Cyrbn`� . -- - - - - - - A = 103 016 --- - - -- M���S - - -- - IFj i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 40 New London Avenue Property Address Marc and Breanna Powell Owner Owner's Name information is Marstons Mills MA 02648 May 26, 2013 required for every Y page. 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 filling out forms A. General Information on the computer, D use only the tab 1. Inspector: key to move your cursor-do not David D. Coughanowr, IRS use the return Name of Inspector key. Eco-Tech Environmental Company Name 43 Triangle Circle ILA Company Address Sandwich MA 02563 City/Town .State Zip Code 508 364-0894 1328 Telephone Number License Number B. Certification N ---1 I certify that I have personally inspected the sewage disposal system at this address and thatAhe information reported below is true, accurate and complete as of the time of the insp,"ection. The".inspet1lion was performed based on my training and experience in the proper function and maintenance of on s,e sewage disposal systems. I am a DEP approved system inspector pursuant totection 15:340 of�' Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails . ❑ Needs Further Evaluation by the Local Approving Authority May 26 2013 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 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-Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 40 New London Avenue Property Address Marc and Breanna Powell Owner Owner's Name information is required for every Marstons Mills MA 02648 May 26, 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: ® 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: Inspector's Note==> The septic system described herein is deemed to pass this Real Estate Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4-5. The scope of this inspection is limited to health and environmental compliance and the septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old" or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 40 New London Avenue Property Address Marc and Breanna Powell Owner Owner's Name information is Marstons Mills MA 02648 May 26, 2013 required for every Y 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: El 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 40 New London Avenue Property Address Marc and Breanna Powell Owner Owner's Name information is required for every Marstons Mills MA 02648 May 26, 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: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M .' 40 New London Avenue Property Address Marc and Breanna Powell Owner Owner's Name information is Marstons Mills MA 02648 May 26, 2013 required for every Y page. CityTrown State Zip Code Date of Inspection B. Certification (cont.) 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 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. ❑ ® 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 16,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 New London Avenue M Property Address Marc and Breanna Powell Owner Owner's Name information is required for every Marstons Mills MA 02648 May 26, 2013 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, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M55 40 New London Avenue Property Address Marc and Breanna Powell Owner Owner's Name information is Marstons Mills MA 02648 May 26 2013 required for every Y page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 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 ears usage d n/a-well in use 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments C�M , 40 New London Avenue Property Address Marc and Breanna Powell Owner Owner's Name information is Marstons Mills MA 02648 May 26, 2013 required for every y page. Citylrown 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: owner 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 40 New London Avenue Property Address Marc and Breanna Powell Owner Owner's Name information is Marstons Mills MA 02648 May 26, 2013 required for every Y 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: 13+ years. Certificate of Compliance for new system issued 12/16/99 (permit 99-504 at Health Dept). Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 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.): Sewer line appears structurally sound with no evidence of leakage or backup into dwelling. Septic Tank(locate on site plan): Depth below grade: 1 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: 10.5 x 5 x 6-1500 gallon Sludge depth: 6 in t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 9 p Y rY 9c ^M 40 New London Avenue Property Address p Y Marc and Breanna Powell Owner Owner's Name information is Marstons Mills MA 02648 May 26, 2013 required for every Y page. Cityrrown 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 28 in Scum thickness 2 in Distance from top of scum to top of outlet tee or baffle 9 In Distance from bottom of scum to bottom of outlet tee or baffle 13 in How were dimensions determined? Design plan Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping not required at this time, but maintenance pumping is recommended within and every 2-4 years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: concrete 0 metal El fiberglasspolyethylene other(explain): 9 Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 40 New London Avenue Property Address Marc and Breanna Powell Owner Owner's Name information is Marstons Mills MA 02648 May 26, 2013 required for every Y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No s t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �^M 40 New London Avenue Property Address Marc and Breanna Powell Owner Owner's Name information is required for every Marstons Mills MA 02648 May 26, 2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): q Depth of liquid level above outlet invert at outlet invert P Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-Box appears structurally sound and functioning as intended. No evidence of leakage in or out was observed. Some solids in sump. A bucket of water was poured into the distribution box and was observed to pass through in a rapid and unobstructed manner, and was heard splashing down into the concrete chamber. 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M10 40 New London Avenue Property Address Marc and Breanna Powell Owner Owner's Name information is Marstons Mills MA 02648 May 26 2013 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 1 ❑ 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.): Soils above leaching gallery appear unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. A bucket of water was poured into the distribution box and was observed to pass through in a rapid and unobstructed manner, and was heard splashing down into the concrete chamber. 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 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 40 New London Avenue Property Address Marc and Breanna Powell Owner Owner's Name information is required for every Marstons Mills MA 02648 May 26, 2013 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 I Commonwealth of Massachusetts =., f Title : - ffic� � 1� p c o"0" r S,ubsurface:-Sewage bisposaf'System"Form Not for Voluntary Assessments.. •''r 40 New, London Avenue Property,Address Marc and Breanna Powell` Owner -Owners-Name information is regwredfor,every Marstons Mills' MA 02648 May 26, 2013 page. C p nt Dl D. Sys#em. Inorimaion tcont:y Sketch Of Sewage Disposal System': Provides view of fhe sewage disposal system,including ties<to af.least two Permanent reference landmarks or benchmarks Locate a{I well's withrn:100 feet:,Locate "where public water,supp{y enters,.the�building. Check one;of the boxes below: hand.,sketch in the area'be'low 0 drawing attached;tseparately tt �. L F R CI-i v St1(.0 l ANk -ti- LAI " U. E 71 t5ins 3113, T01e'4.Otricial Inspection Form:Sutisuriace Sewage DisposaPSy tem Page 15 ct 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 40 New London Avenue Property Address Marc and Breanna Powell Owner Owner's Name information is Marstons Mills MA 02648 May 26 2013 required for every y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 25+ 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: 12/15/1999 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: Town of Barnstable GIS Department records You must describe how you established the high ground water elevation: Approved design plan on file with the Board of Health shows bottom of system to be 7.2 feet above the bottom of a witnessed test pit in which no water or groundwater mottling was encountered. Town of Barnstable GIS Department records indicate that the property is over 25 feet above groundwater table. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 New London Avenue Property Address Marc and Breanna Powell Owner Owner's Name information is Marstons Mills MA 02648 May 26, 2013 required for every Y page. Cityrrown 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-W13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 ulCOMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS - DEPARTMENT OF ENVIRONMENTAL PROTECTION -nl IVI TITLE 5 ; "m OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASS SSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 40 New London Avenue Marston Mills. MA 02648 Owner's Name: Linda Pinto Owner's Address: Date of Inspection: Selzteinber 15, 2005 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville.MA 02655-0049 Telephone Number: (508)862-9400 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 training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: September 18, 2005 The system inspector shall subm' 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 ti ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form . '6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 40 New London Avenue Marston Mills, MA Owner: Linda Pinto Date of Inspection: September 15, 2005 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: 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. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with 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. ND explain: Observation of.sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 40 New London Avenue Marstons Mills. MA Owner: Linda Pinto Date of Inspection: September 15, 2005 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 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 40 New London Avenue Marstons Mills. MA Owner: Linda Pinto Date of Inspection: September 15, 2005 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. _ ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public 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 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.] No (Yes/No)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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes" or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 40 New London Avenue Marstons Mills, MA Owner: Linda Pinto Date of Inspection: September 15, 2005 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? ✓ 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 detennined 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)]. 5 1 Page 6 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 40 New London Avenue Marstons Mills. MA Owner: Linda Pinto Date of Inspection: September 15, 2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents: 2 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203); gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Never pumped-per owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank, distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components, date installed(if known)and source of information: Installed on 12115199-per as built card Were sewage-odors detected when arriving at the site(yes or no): No 6 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 New London Avenue Marston Mills. MA Owner: Linda Pinto Date of Inspection: September 15, 2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 15" 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: 1506 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 6" 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: 10" How were dimensions determined: Measuring stick Conunents(on pumping reconunendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert There did not appear to be any si ns of leakage Recommend pumping. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7 µ 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 New London Avenue Marston Mills. MA Owner: Linda Pinto Date of Inspection: September 15, 2005 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) .Depth of liquid level above outlet invert: Even Coininents (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.): The D-box was level and clean. No solids were present. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): 8 Page 9 of I I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 40 New London Avenue Marstons Mills. MA Owner: Linda Pinto Date of Inspection: September 15, 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: 2-500 gal. chmnbers(21'L x 9'W x 2'D)-per as built card 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.): There did not appear to be any signs offailure CESSPOOLS: None (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 or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Conunents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 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 New London Avenue Marstons Mills. MA Owner: Linda Pinto Date of Inspection: September 15, 2005 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. 1 B a �a 3y � 10 i' 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 New London Avenue Marstons Mills. MA Owner: Linda Pinto Date of Inspection: September 15, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25+/- 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 local Board of Health-explain: topographic and water contours mas Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps the mans were showing approximately 25'+/ to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. . 11 Loty Tftw WN OF BA.RNSTA.BLE TI LOCAON L{,a lUeta1 SEWAGE # — ) VILLAGE- M A rStWil ftl t 1_ __ ASSESSOR'S MAP & LOT �C�l INSTALLER'S NAME&PHONE NO.90t'('DLo—tti Clot4l—, U081 gU492-6 SEPTIC TANK CAPACITY `S 6 0 Q &i 4 i LEACHING FACILITY: (type)Weed J4 (size) a 1 L X I?"W.A � �p NO.OF BEDROOMS r, BUILDER OR OWNER o }m• i PERMTTDATE: 9L ZI COMPLIANCE DATE:�>f/f I 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) 1 rtt Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �ooDr v� A' 14 2-q IL -2) 24' Jr 3 i - T WN))OF BARNSTABLE � LO('�.(I(ON ` ���1 GOi1 SEWAGE # C'1 Ct' PILLAGE ✓� ✓Y1�I S ASSESSOR'S MAP & LOT I O"-' OI(G INS I'ALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY SCUD LEACHING FACILITY: (type) 02 S� M�• C�AM�tarl(size) X WX .., NO.OF BEDROOMS �- BUILDER OR OWNER L' ►^�� PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom,of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leac ng facility)){ I Feet Furnished by Un 1 � a l aa� ay e a a� 33 p LoNoaT WN OF BARNSTABLE LOCA71ON 4ez eleiii� AAAe SEWAGE # VILLAGE ry►q t^STDNJ YVI 44 ( ASSESSOR'S MAP-&LOT n INSTALLER'S NAME&PHONE NO. Qa.-'n4,Tti COHSE. CE092 qlk-9'926 r� SEPTIC TANK CAPACITY Ig e o Q itu i VIACHIL`IG.FACITY: (type (?��'ea�jv I C)"n»�by-y (size) 1 [ X A"w.A NO.OF BEDROOMS B=ER OR OWNER i N PERMUDATE: COMPLIANCE DATE: 121J.t-, 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) - I ,ra Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i 8000� r P►2z.�.6�' Z i ¢ ?} 24 3 r No. UPI V Pv Fee THE COMM WEALTH OF MASSACHUSETTS ~"1 nteredincomputer: i Yes o�3� �P BLIC HEALTH DIVISION -TOWN OF BARNSTABLE} MASSACHUSETTS ZIppttcattort for ntopooat *potem Cottgtructtort Veruttt 7Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) []Complete System ❑Individual Components Location Address or Lot No. Td Ike LDlAofN Ne Owner's Name,Address and Tel.No. 2 yy '�yJ�J/'� pNaexcl q Cron:n C. oL Assessor's Map/Parcel �(�J/ ,f_ A4 C a 6.0 K d—t i N°Ga7AaM t J^A D;-Ce 57/ Installleer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size a Ot)o sq.ft. Garbage Grinder( ) Other Type of Building 0J3-2. No.of Persons e2-, Showers(°�) Cafeteria( ) Other Fixtures r Design Flow &-kO gallons per day. Calculated daily flow d�d'Z® gallons. Plan Date jJnC_ i 199`j Number of sheets Revision Date Title S-Oc- O f I..PrICA Size of Septic Tank 1500 Co,1l-a n S Type of S.A.S. Description of Soil CtS G�Gr C�1 jLC1 �(P� PaRS Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this and wealth. _ Signed Date �1i5 Application Approved by Date G? Application Disapproved for Re follo ing reasons Permit No. - s© Date Issued No {T��� ra-W � ,y -— Fee _ ______THE.COMM NWEALTH OF MASSACHUSETTS Iered in computer: �J Yes (.�P BLIC HEALTH DIVISION - TOWN OF BARNSTABLE3 MASSACHUSETTS ZippYtcation for ;Diooeal *raem Coug h truction ermit , r Application for aiPermit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 40 1'W ,Aan Ae Owner's Name,Address and Tel.No. Assessor's Map/Pazcel 103/11 A4 pa 6-D K o-f go, N-Gr s r`pm / -N A 0;-CS'/ Installer's Nazne,Address,and Tel.No. ! Designer's-Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms f 'Lot Sim' 1 000 sq.ft. Garbage Grinder( ) Other Type of Building t7JS 2 / No'. of Persons vL Showers(�.) Cafeteria( ) Other Fixtures Design Flow O gallons per day. Calculated daily flow 61;�e1 gallons. Plan Date joc- a 1999 Number of sheets Revision Date �t Title Sx-�r i �-, of Size of Septic Tank 1500 Type of S.A.S. Description of Soil x�. as C_.n!q llce relj n1ar�S Nature of Repairs or Alterations(Answer when applicable) a 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 issue by this ard ealth. / _ Signed Date Application Approved by Date & _ Application Disapproved for fKe follo ing reasons - Permit No. �� 6' Date Issued r THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed(�,�,)Repaired( )Upgraded( ) Abandoned( )by at /I 4 0 Ems- has been constructed in accordance - with the provisions of Title 5 and the for Disposal System Construction Permit No. dated 1 Installer Designer 4, /)The issuance of this permit sh 1notb�cons ed as a guarantee that the sy 11 function as de ign dDate Inspector �.'� /1 U1� v1fS r v � V ! No. Fee c�2 u THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS ;Digpogar 6pgtem Congtruction 30ermit Permission is hereby granted to Construct(,,,)Repair( )Upgrade( )Abandon( ) System located at_�r� ll/�.�am_j &.c AA 6% 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 c�o-m-�plleted within three years of the date of this 1109it. Date: Approved by ��, Department of Environmental Management/Division of Water Resources .j WELL COMPLETION REPORT WELL LOCATION GEOGRAPHIC DESCRIPTION Address � 40 A �AJb©n/ *V54 2� �+J S ci W of �A/� � /lreetl _(circle) City/Towri!=A/Z S r,94S MI,/S N&J L.00b 9J h'VA well owner�-I��g/'x �+r QAJ/A (road) Address r-I QX -7—02..- 0,1 _ N S En of A/l.&.m/ m k p n'; /ml.in tenths) lclrclel Board of.Healthpermitobtained: yesx no❑ btrersect. (road),� WELL USE WELL.-DATA ^7 Domestic*A Public.❑ Industrial 0 Total well depth ��+�� ft. Monitoring❑ Other Depth to bedrock-4/4 ft. Water-bearing rock/unconsolidated material: Method drilled 'J / fw ' e Date drilled td 5 �Vl�1L Description [a •-�'f1 Water-bearing zones: CAS.ING1n' 77t'4r� Type `tom w to 1) From To 2) From To Length at ft. Dia(.LD.► _in. �/� 3) From To Length into bedrock ft. 'Gravel pack well: dia. !✓r^�' Protective well seal: Screen: dia. 4 Grout-El Other tk-a As Slot I©1`� length __�) from'�, tOr_^•S STATIC WATER LEVEL(all wells) ' Static water level below land surface 35 ft. Date B"/6- WELL TEST(production wells) Drawdownft. aftor,pumping_T_hr. min,atgpm ` How measured� � Recovery VLL- ft. after hr. �a min. 0 LOG:of FORMATIONS " COMMENTS 55 Materials From To Q ' Driller IC 1�1+c%�U Go +i a ?, Firm l G L .L ?LL4A/er W S' 9 !Q Address ID,Q, 3 V eo lA Q/J City/Town Ali 4Zt 7 r Supervising Driller,Reg.>< rV /0"Alf f / L Signature of stipprvising registered well driller Pease Print drmry \ BOARD OF HEALTH COPY. Fee ------------------- BOARD OF HEALTH TOWN OF BARNSTABLE 0(pplication-*rVe[[ CongtructionVermit Ap lication i h reby made for a permit to Construct K Alter ( ), or Repair ( )an individual Well at: -�--�z---� - ����-- ------------- ------------------���-----------lam__----------- Location Address Assessors Map and P cel _C.2�/v rnJ---__ __-- o_, 3oc__2�2 _ �� s� srl � v26; 1CC_ Owner Address C- t Lc�n�G lJ �01C -� c� /1b,, s�Zl-_f-4--- Installer — Driller Address Type of Building Dwelling - ----------------------------------------------- Other - Type of Building —----------------- No. of Persons-------------------------------------_______ Type of Well J�" Cf/' —- Capacity----------- —_�7 /f — - ---— Purpose of Well ------------- Agreement: . The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board o rivate Well Protection Regulation — The undersigned further agrees not to place the well in operati until a i 1 t . f Com liance has been issued by the Board of Health. Signed ——------- e'r Uo, 786 --- +� ^date Application Approved B — -- --------- L a ae Application Disapproved for the following reasons:--------------- -------------------------------________ ------------ — - --- ----------------------------------------------------- date Permit No. ''s °- ----- - Issued---- '= -- ---- date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate ®f Compliance THIS IS T CERTIFY, That the I dividual Vell Constructed ( Altered ( ), or Repaired ( ) ^- r Ar In alter has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. -----_________Dated---- ------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE------ - -- Inspector--------------______— —_---__- ion No:-------------------- BOARD OF HEALTH TOWN OF!, BARNSTARLE '�' .­ :­ 11pplitatibnjorVelt Congtruct on.permit A lc p ation I hgreby made for'a permit to Construct Alfer ( ) or Repav ( )an individual Well at: /1J -�- a Location Address — ssessors Map andParcel j (^tD� CQv .��-- --- o , 3o�c `2�2 Owne Address C� � ��trt nfG t%OflK ,tf7ltil� �R 02 C•4 st" - - - ------ - ---?' r --- - - - G�' Installer'- Driller Address r TYPe',of,Building Dwelling-___a- -- - Oth • er -Type of Building No. of Persons---- ------- ------------ YP Capacity ---- -T e of Well`— `7" G, b l�Jc - -u --- --- -- Purpose of Well---- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board ofF-Health- rivate Well Protection Regulation —'The undersigned further agrees not to place the well'in operation:until a ifit t f Co' liance has been issued by the Board.of Health. Lt ,Uo. SSG �79/ Signed -------------=----- date Application Approved B — ✓% —�__ date ` Application Disapproved for the following reasons: ------ —=-- -- —- --- - ---——--- F , -- -------==--`-- -- ---==------—-------------------------- -- d — -- ---------- j ate ` — -- Issued--- - �r -- ----Permit No. date i BOARD OF HEALTH TOWN OF ,BARNSTAB.LE certificate Of Compliance THIS IS TO,CERTI- ,'That the Individual . ell Con tructed ( Altered ( ), or Repaired ( ) ;7 J by-- - - t I n aller u� I at has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the"application for Well Construction Permit.No- -------------- Dated----------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE---------- — Inspector-------- ----= —------ v1b!rsr pa?a`9:.eYetiassicCY.P/4na9Yariinbv!mwllaar.�iisisoYaiai'N.selieiaSaaIa!►s�ko.Tie«rite....e..................N+w:,►.ITaivanii�'iwry!.J!avegsS:.!a1J4eave.rckM34rf2:4rT.v��}�a!a+a TO�:e4ti'.:. BOARD OF HEALTH TOWN OF BARNSTABLE Yell Con5truet ion Permit No.f=°�'--- — Fee— �?> G i Fermis 1 sion,is hereby granted - =- --� �n- - - '` to o,nstr�(i�)� Alter or Re air (. ) an Individua ell at: No. f Street as shown.on Xhe application for a Well Construction Permit No.- .7 IF Dated.--1_' '�"" '_ !_--------------------- Board of Health DATE - 1 i TOWN OF BARNSTABLE I-ONCoN LOCATION ' "' SEWAGE # VILLAGE TaNJ '4 ( ASSESSOR'S MAP &LOT i INSTALLER'S NAME&PHONE NO. 90 eo e,.iT• rro —M2-6 SEPTIC TANK CAPACITY Q1 d �W j LEACHING FACILITY: (type) ^.���a I h nmb�--y (size) Q I A DUi� j NO.OF BEDROOMS BUILDER OR OWNERQ LLbQA i PERMITDATE: U47/V COMPLIANCE DATE: 1-7 �$f S Separation Distance Between the:. Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist V' Feet on site or within 20o feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �tC t� �)22' 6 3 ' 3 7 7, qs.,� v ACCESS-COVERS MUST.BE �.q AjIIMUM 'GEN ]MAX I MUM ORADE COVER D N fL EVA T I A '6*�OF FINISH JTER VERT 'ONS :,, ESI.GN , CR ER,A N : IRST, 2 TO W 0 TEIS 0.9.5 -'INVERT AT-BUILONG: 96,3 2 9 EDROOMS 'AT 10 G.P.'D'. PER, PEA$TOME �_PE LEVE MIN 2 OF INVERT IN SEPTIC TANA: 96 0 I THIS:PLAN. i'F`OR THE DESIGN AND CONSTRUCT-ION BEDROOM EQUALS 220 O.P.D. I NVER T.OUT i,SEP TI C TANK., 95,75 W4"k, DISPOSAL SYSTEM ONLY.' '4* DIAM Ptp� OF THE ��J14* 1 ' 112*� DIA. INVERT ,IN DIST BOX 04 0 T2' ASHED STONE 94.'0 VERTICAL DA TVM_,I S A NVER T OUT DIST.' BOX: SSUMED. ,FOR BENCH MARKS NO GARBAGE , ,2. GAS 91.0 0 96.0 ' — I I I� 94 1 SEE $17'E 'PtAN. T SET. INVERT IN LEACH CHAMBER: '9 -0 SEPTIC, TANK RFQUI�RED: -2-50016AL,LEAC CHAMBERS BOTTOM OF 'LEACH CtAMBER: 220 G.P.D. X 2OOX 440 0AL.- X D-BOX J ALL CONSTRUCTION 14ETHOD$'AND HATERIALS� AND W12*. :STONE AROUND.' -8.8' 21*X 2* NIA ADJUSTED GROUND WA TER. ' SEPTIC tANK PROVIDED: 1506 GAL. MIN. MA INTENANCE� OF THE.SEPTIC ,SYSTEW SHALL TANK 6 CRUSHED 'STONE. BASE' OBSERVED GROUND WATER: NIA CONFORM TO NAS$. D.E.P. % 71 TLE5 AND LOCAL SOIL ABSORPTION S YS TE REQUIRED: BOTTOM OF TEST HOLE #1 BOARD OF HEALTH REGULATIONS. PR OF LE : NO'T.' TO �SC'ALE DESIGN PERC RATE 5 INIINCH '$OIL TEXTURAL CtASS I TS L OCA TED UNDER ,4.- - ALL--SEPTIC:SYSTEM COMPONtN EFFLUENT LOADING RATE 0.74 ,GPDISF, , �AREAS T IC OR .GREATER -,SUBJECT, 0 EHICULAR TRAFF REQUIRED 297 S. THAN 3' N DEPTH $HALL BE CAPABLE OF WITH WHEEL LOAD$. TOWN WA TER LEACHING CHAMBERS W12* STONE AROUND.' A-304 S.F. .5., ;ALL SEFEW PIPE $HALL BE SCHEDULE 40 OR 304 S.F. x 0.74 225 6.P.D. APPROVED EQUAL. SO, / L DA TA 6. 1 SEPTIC.-TANK AND DBOX SHALL-RE .REINFORCED TES T P 1, T PRECAST CONCRETEND WATERTIGHT. INDICATES IND/CA TES PERCOLATION OBSERVED 7.'- --BEFORE CONSTRUCTION C,4LL,*DIG- AFE', S TES 7 ORO UND WATER WA TER D EP T. 'LOCAL D THE 10-$AFE AND TOWN WATER FOR _LOCATION 'OF UNDERGROUND UTILITIES..'. TP *2 SOIL,REMOVAL THORIZONS. cl LAYER) HOR I ZOM TEXTURE' COL OR ORIZON TEXTURE COLOR ALL UNSUITABLE MATERIAL IkA 8 Ol 96.3 0* 95,7 . IOYR --LOAkY I O?R ENCOUNTERED BELOW THE INVERT. 'OF, THElEACHIN6 . A SAND, $AND FACIL ITY-I'd 'RE REMOVED FOR A D I STANCE .OF,-.5 314 J14 + ........................... AR&UN6A&D REPLACED W1 TH-SAND IN ACCORDANCE 7. . ........................................... 95.7 SEPTIC LOMY IOYR IOYR LOAMY WITH TITLE 5,- '416 B B SAND $AND � 416 02, J6-— -------......... ............. .......... 93.3 24.. .............. ......... .......... NO.DLeTERMINATION HAS BEEN MADE AS TO OAL -c WITH DEED RESTRICTIONS:& ZONING L&CHINO CHAAMEWS I NPACT COMPA CT 6UL bN$, I T SHALL 17HE' eL I ENTS. V12' $TONE AROUM Co . .RE ATI REMAIN. LOAMY F NE RESPON.$1 1 BILITY 'TO ORTA I IN ALL. PERMITS. SPECIAL ;2 LOAMY FINE Y514 SAND 2.5YS14 $AND 2.5 91.7 FOR PERMITS. VAR IANCES ETC THIS.PROJECT. 46 67.8 60 102 IT $HALL REMA'IN THE'CLIENT'S 'RESPONSIBILITY 10. ISO*,a4L EPTIC 7Aw K To HA vE -rHE PROPOSED BUILDING FOUNDATION' COARSE COARSE IOYR IOYR THE EXISTING GRADE C2 SAND AND DESIGNED TO ACCOUNT FOR C2� SAND AND 516 516 &RA VEL GRA VEL AND $OIL' CONDITIONS AT THE LOCAT16N OFTHE +97.5 PROPOSED BUILDING. ol 4b NO WA TER 85.7 NO WATER 5 83.8� 120* 1 DATE: MAY 6. 1999 TEST BY: STEPHEN HAAS TOWN WA TER -DONNA .UtORANDI WITNESSED BY: IP N1 I NCH'. PER C RATE:.' ( 2 A41 20.996l'S'F. 16+ 5 % 4 -2 '7 e7 , A P L 0 L 7, E7 A VE7 "A P 00 IVE W, L 0 % 40 RA R OE IVI,��)ON' ( "A R S 7-0 N,5 I L' L A AIRPORT O-R 97. V A CANT ilk SIT SET 415 PROPI"D C, 0 HA 'L O�PA R 00 -BOV. 0�2�2 ITA S 7 EL-90.23 WELL � LO 1-9_c;? L'E s I N G 1 ,: N C c u> e�, 't MIA*r4a r-rnc> u t h r 0 2 6 508� 2 5,333 5 0 -CHECK. CFW' DRN:.',SAH_-�' I :CFWIEEK... B NO: MA A 99 �F tiD :'!�ALC 0 1 lq�CFV LOCUS . �� P' acr HI cl,