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HomeMy WebLinkAbout0197 OLD FALMOUTH ROAD - Health 197 Old Falmouth Road -Marstons Mills A = 100 069 I I I TOWN OF BARNSTABLE r c LOCA'CION /97 Q//Q 604.26/7_1 SEWAGE #-° b0 Y-594 VII,LAGE `lil�h str> S MI/ls ASSESSOR'S MAP & LOT l INSTALLER'S NAME&PHONE NO. ,/0 5g,0L /70 y2N - 97.s? SEPTIC TANK CAPACITY /000 G,a �.EACHING FACILITY: (type) (size) NO. OF BEDROOMS 3 BUILDER OR OWNER PERMITDATE: 7 1CSS- 5' / COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and-Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachi g facility) Feet Furnished by �� - QLD �,���/ouT� f2� - L 7�,�'I �� H�' S� N5 c o _ CIS Ej/9 TOWN OF BARNSTABLE LOQATION L-r Z q pig ' SEWAGE # 3.. VILLAGE[, /VI ! �,(; -ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. L494 cCL ' ` Z Z05 MIEPTIC TANK CAPACITY �+ . .,..EACHING FACILITY:(type) 7 (size) f Cam% NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER y24 G�1 �- C71 DATE PERMIT ISSUED: ���f (p '' "_ DATE COMPLIANCE ISSUED: _ ��' 7. VARIANCE GRANTED: Yes No � :� ���� �� � r ��! � �� �p (�� f � j� 1 � . Asa a 1 I i 1 c � Commonwealth of Massachusetts �n Title 5 Official Inspection Form '- �I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 197 Old Falmouth Rd. Property Address Robert Wilson Owner Owner's Name information is required for every Marstons Mills Ma. 02648 1-5-21 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 A. Inspector Information filling out forms ��� t�� D 0%— on the computer, use only the tab Michael Sears key to move your Name of Inspector cursor-do not Robert B Our Co INC. use the return Company Name key. 363 Whites Path Company Address South Yarmouth Ma. 02664 City/Town State Zip Code 508-477-8877 S114430 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes .``\````� �jN OFtM�S`S9 2. ❑ Conditionally Passes go. MICHAEL •.N SEARS '�+= 3. ❑ Needs Further Evaluation by the Local Approving Authority *:. No.SI14430 *` 4. ❑ Fails %'r' FRTiF��• �o��c •,''''�F�5�N 1-5-21 Inspector's Si ure Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 ION, Commonwealth of Massachusetts Title 5 Official Inspection ' Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 197 Old Falmouth Rd. Property Address Robert Wilson Owner Owner's Name information is required for every Marstons Mills Ma. 02648 1-5-21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 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: 1000 gal tank D Box 2 drywells 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . u 197 Old Falmouth Rd. Property Address Robert Wilson Owner Owner's Name information is Ma. 02648 1-5-21 required for every Marstons Mills page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due' to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): t ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts �v _ Title 5 Official Inspection Form h Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 197 Old Falmouth Rd. Property Address Robert Wilson Owner Owner's Name information is required for every Marstons Mills Ma'. 02648 1-5-21 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *" This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. w c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ® Discharge or ponding of effluent to the surface of the ground or surface waters El due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 cam, Commonwealth of Massachusetts �v Title 5 Official Inspection Form �I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments A; 197 Old Falmouth Rd. V� Property Address Robert Wilson Owner Owner's Name information is required for every Marstons Mills Ma. 02648 1-5-21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/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. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. El ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the z questions in Section 0.4. J 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 l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form <I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 197 Old Falmouth Rd. u _ Property Address Robert Wilson Owner Owner's Name information is required for every Marstons Mills Ma. 02648 1-5-21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® 0 Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? _®, ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on. ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of.the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form }I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments C � 197 Old Falmouth Rd. u� Property Address Robert Wilson Owner Owner's Name information is required for every Marstons Mills Ma. 02648 1-5-21 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 2019- 28000 gal2020- 32000 gal Detail: . Sump pump? ❑ Yes ® No Last date of occupancy: Present Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 1 c Commonwealth of Massachusetts �m _ ,e Title 5 Official Inspection Form II Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 197 Old Falmouth Rd. u Property Address Robert Wilson Owner Owner's Name information is required for every Marstons Mills Ma. 02648 1-5-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank.present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: July 2017 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? i Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form lip Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �� 197 Old Falmouth Rd. u— Property Address Robert Wilson Owner Owner's Name information is Marstons Mills Ma. 02648 1-5-21 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 7-28-04 #20004-380 2-500 gal dry wells Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 32" Depth below grade: 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.): l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 c Commonwealth of Massachusetts �v Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form Not for Voluntary Assessments 197 Old Falmouth Rd. Property Address Robert Wilson Owner Owner's Name information is required for every Marstons Mills Ma 02648 1-5-21 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) 6. Septic Tank(locate on site plan): 22" Depth below grade: feet Material of construction: ® concrete El metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000 gal If tank is metal, list age: Years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal 1 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 29 - 0 Scum thickness Distance from top of scum.to top of outlet tee or baffle 8 Distance from bottom of scum to bottom of outlet tee or baffle 18„ How were dimensions determined? Sludge judge, tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1000 gal tank with tee in and baffle out, inlet cover at 6" outlet cover 22" below grade t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form - I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �. . 197 Old Falmouth Rd. Property Address Robert Wilson Owner Owner's Name information is required for every Marstons Mills Ma. 02648 1-5-21 page. City/Town State Zip Code Date of Inspection _ D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet r Material of construction: - ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): r � Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date ' Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8..- Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): 'Depth below grade: Material of construction: ❑:.concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: g r Capacity.= gallons Design Flow: gallons per day l5i6sp.doc-rev;7/26/2018 Y Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 s Commonwealth of Massachusetts . �� Title 5 Official Inspection Form �; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments' � 197 Old Falmouth Rd. u Property Address Robert Wilson .. , . Owner Owner's Name information is ` - required for every Marstons Mills Ma. 02648 . 1-5-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. . Tight or Holding Tank (cont.) 'Alarm present: ❑ Yes ❑ No Warm level: Alarm'in working order: ❑ Yes ❑ No' a Date of last pumping: Date Comments (condition of alarm and float switches, etc.): k Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑' No 4 9. Distribution Box (if present must be opened) (locate.on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D`Box is 16x16 with 2 outlet pipes cover at 17"below grade r r } t5insp.doc-rev.7/26/2018 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 16 k cam, Commonwealth of Massachusetts �� Title 5 Official Inspection Form Ilk ��; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �C V � 197 Old Falmouth Rd. Property Address Robert Wilson Owner Owner's Name information is required for every Marstons Mills Ma. 02648 1-5-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches. number, length: ❑ leaching fields number, dimensions: . ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments `C !% 197 Old Falmouth Rd. Property Address Robert Wilson Owner Owner's Name information is required for every Marstons Mills Ma. 02648 1-5-21 page. CityTTown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SAS is 2-500 gal drywells wells are clean with 6" of water and no sign of failure 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool ' Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form - III Subsurface Sewage Disposal System Form Not for Voluntary Assessments 197 Old Falmouth Rd. Property Address Robert Wilson Owner Owner's Name information is Marstons Mills Ma. 02648 1-5-21 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): a t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 u Commonwealth of Massachusetts �v Title 5 Official Inspection Form IIII Subsurface Sewage Disposal System Form - Not for Voluntary Assessments' { 197 Old Falmouth Rd. Property Address Robert Wilson Owner Owner's Name information is Ma. 02648 1-5-21' required for every Marstons Mills page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below', ® hand-sketch in the area below - ❑ drawing attached separately 0 • w MICHAEL9cyG�- � '36 1�� �• 'a; SEARS _ �sJ 3 *: No.SI14430 ;* -�15 fi l ��r�'FRTIF���'�o���. Page 16 of 18 t5insp doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System c Commonwealth of Massachusetts �v Title 5 Official Inspection Form iI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% 197 Old Falmouth Rd. u Property Address Robert Wilson Owner Owner's Name information is required for every Marstons Mills Ma. 02648 1-5-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high round water: p g g 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: 6-24-04 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: No ground water per plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. Y t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 197 Old Falmouth Rd. Property Address Robert Wilson Owner Owner's Name information is required for every Marstons Mills Ma. 02648 1-5-21 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included Gy,de _ 1/, A vvl A -C/,4,5 q" NO t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address�O vl✓I c�_��(^-��_.�_.._. t� ON ner ON ner's Name q informations ��l�� �j� ('a(� / required for every 45- �✓'S��✓/S page. Cky/Town - Gte Zip Code gate of 4risoettion 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. hn Ming out forms A. General Information fiping out forms on the computer, use only the tab 1. Inspector. key to move your Y/� a r � cursor-do not use the return Name of Inspector _ _ key. ����d --- L-C _ Company Name Company Address Eity/Tow n (So f J l C� so— /n 7/iq StateLl 0 SI J Zip Code Telephonemb Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 16.340 of Title 5(310 CMR 16.000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority a Inspecto'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 i0,000 god 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. Vs S �� t5s 3/13 Tile 50tfioalIrepectionFormSubsufae Sewage Diy •Page 1 of17 it Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disp saI System Form -Not for Voluntary Assessments Property Address 1t4 Ow ner Ow ner's Name information is �S required for every A, page. Citylrown State Zip Code Date of/Irispecton B. Certification (corn.) Inspection Summary: Check A,B,C,D or E 1 always complete all of Section D A) System saes: 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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. r Check the box br"yes", "no"or"not determined"(Y,N, ND) for the following statements. If"not determined,"please ex0ain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or.not)is structurally a unsound, exhibits sublantial 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): t� t8ns•3M 3 Title 5 Official Inspection Form Subaeace Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1,97 ©/d -/(•"*1O" 9 12d Property Address • —Z Inf ner ONner s Name ��� J H S / �� S A / V d 6 �© 1911 Information is required for every Ckyfrown State Zip Code Date of Inspectidn page. B. Certification (coat.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of health approval If pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR . 15.303(1)(b)that the system is not functioning in a mannerwhich 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 Title5 official lrtspac6cnFarm Subsuface Sewage Disposed Symm•Page3017 t5ins•3H 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments FropertyAddress u Owner Owner's Name �/J// s%�J� '!�, q information is di�l v�S /"// J 'v/ 01-L� '"�1 / y requ'Ired for every --- page. City/Town State Zip Code Date of Inipectidh 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 rJ 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 day flow tSns•3M 3 Title 50f5det Inspection f arm Su"am Sewage Disposal System•Page 4017 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 192 Property Address /)/� ON ner ON ner's Name / �/ /f/J information is //"" �/1 AU 00 C y-6 - required for every page. City/Town State Zip Code Date of kispectil5n B. Certification (cunt.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Ly' 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- � ElT The system The sysstem Uji-& I have determined that one or more of the above failure criteria exist as described in 310 CM 15.303, therefore the system flails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ 11 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. tOns,3f13 Tibe5Official InspectionFam Substsface Sewage Disposal System.Page Sot17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ! 9 7 0/� _ % l�o� A ►col Property Address ON ner Ow nees Name information is (�� q �f� �,r f /S {_C1 `tea- requQedforevery ---- page. City/Town State Zip Code Date of In pectic C. Checklist Check if the following have been done. You must indicate'yes'or"no"as to each of the following: Yes ❑ 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? ❑ H s 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? ElWere as built plans of the system obtained and examined?(If they were not / available note as NIA) Cd� 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? El Were the septic tank manholes uncovered, opened, and the Interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, 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 (f 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: 2 Number of bedrooms (design): Number of bedrooms (actual): 230 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Ons•3M3 Ti050ftel InspectlanForm SubsWace SevegeDisposal System-Page6017 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth -Not for Voluntary Assessments / 212 o/d F_� Property Address 1!:2/N ON her Owner's Name/ �i r f ✓1 S 1 1/( I� , $ information is required for every Page CStyfrown State Zip Code Date of Inspection D. System Information Description: 0 /00 o 6y/4_7 c Number of current residents: Does residence have a garbage grinder? ❑ YesO_ Is laundry on a separate sewage system?(include laundry system inspection ❑ Yes C-Wo information in this report.) Laundry system inspected? ❑ Yes �❑ No Seasonal use? ❑ Yes No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes N. GtA Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM R 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: Ore-Y13 Title 5official inapecan Form Subsulme Sewage Disposal System-Page 70f 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 9 � olJ Property Address 11910 In Om ner Infon aned on is every ON ner s Hama�/) �,'S�Opt� �/� /1 j D-6 4(4 � /�d / page. �yRown ( State Zip Code Date o nspecton D. System Information (corn.) Last date of occupancy/use: We Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ❑ H\ If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of Sy 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/Altemative 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 UA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. Other (describe): Ons-Y13 YiOe 5 olfidal Inspection F omc Substrface Sewage Dtsposd system•Pape s oW Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address lvI �ct ON ner Cw ner's Name Q reformation is required for every page. Q'tylfown State Zip Code Date of b4spectioh D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: c�� Were sewage odors detected when arriving at the site? ❑ Yes 0 Building Sewer(locate on site plan): ;2 Depth below grade: feet Material of construction: ❑ cast iron 40 PVC ❑ other(explain): f o r �- Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, e�Adence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material onstruction: 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: J Sludge depth: Oro-M 3 TI09 5 0MG161 lrapactian F wm Suboulaca Savage Dispos6l System•Pago 8 of 17 CommonweaM of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments / 97 Old Fv,low i -f4 led Property Address ON ner Ow ner's Name required for every � n Is 174 a'-s 4 vJf � 1, 4 M-C q'i �1�page. City/rown State Zip Code Date of Ipspectiofi D. System Information (corn.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle / Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle -- o/e How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t9ns•3M 3 Title 50lficial Irepectan F arm Subudwe Sewage Disposal System•Page 10 d W Commonwealth of Massachusetts ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Foam -Not for Voluntary Assessments Property Address /11 ON ner ON ner's Name information is 141 evr 41'fs l�j D Zf? required for every page CRylrown State Zip Code Date of In pectlon 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 woridng 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 tOns Y13 T105015ciel btspectionForm Subsu'feoe sewegeDisposal S)Olsm•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface.Sewage Disposal System Form -Not for Voluntary Assessments 9 _/d Fes, /►y ot, A �(, Property Address information is Ow oars Name 11411,,�S D✓!S /' �///l /�/� �o� �� required for every Page. Cityl1'rnnrn State Zip Code Date of InspdJction D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): 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: Sre-W3 Tice50ftcial InspectlmForm Sulsuface SewageDispasal System-Page 12 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property AddressON ner information is Qw ner's Name I �� ///�� U'o' 6 � ✓' required for every 64->r,5 page. Cky/rown Date of IrApection D. System Information (coat.) j / /Type. ( 'DO Cil/tU✓'rc7�lS / 5-' ❑ leaching pits number. ❑ leaching chambers number. ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovativetaltemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): �2- ��► � eg �2_G cam! �� p1r /✓i 4C ere_ s- r 1GS tl�1-1- � 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 terre•3/13 Me5Oftial Impeolm Form SubsWace Savage Disposal System•Page 13of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments p / 2 � o/P rG/17,017 4 Property Address / Ow ner Ow nets Name Information is l/_ I requiredforevery /V/Arf,�0�� y6"LY;p / l page. t:Frown State Zip Code Date of Ins tan 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.): t9ns•3M3 Title50f ial InspectionFome Subsurface SevfiqeDlsposal System-Page U of 17 Commonweafth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments / 9 7 Old 1-- 1Vt10- ft, /k1d Property Address / ON ner O v nets Wrie at is required for required for every S S page. CitylTown State Zip Code ❑ate of I pec D. System Information (coat.) Sketch Of Sewa Disposal System: Provide a view of the sewage disposal system, including ties to at least manent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where lic water supply enters the building. Check one of the boxes below. hend-sketch in the area below ❑ drawing attached separately �ACte"" P I � 3 � Yl 113 If r Wins•W 3 Title S OMdal I spec6an F am SubsWace Sewage Disposal System•Page 15 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form --Not for Voluntary Assessments �/ G/ Fe; f N'I 0 tom, Property Address / ON ner ON ner's Name InformaWn is required for every page. Otyfrown State Zip Code Date of Inspection' D. System Information (coat.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells a Estimated depth to high ground water. feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ /Observed site(abutting property/observation hole within 150 feet of SAS) L- Checked with loc Board of Health-explain: a V7, ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database-explain: You must d be how you tablished the high groundwater elevation: f �� 4!2 &I //J '_D_ XXV LO C ILI ©� �G d^'��-�o—f C 10 C, S k a14 Before filing this Inspection Report, please see Report Completeness Checklist on next page. f$m.3n3 T050f8cial Inspeatlen Fomc subowface sewage Disposal System-Pape 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Wi Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments 9 7 �L �� /���A Property Address ON ner / k infometion is Ow rter's Name requiredforevey // a��r S X/n} `/" !/�/t i�/� o `� ,� / l Code G W. Uy own State Zip ate of fnspectionn E. R.,,eppoor�t Completeness Checklist 3 Inspection Summary: A, B, C, D, or E checked M h pection Summary D(System Failure Criteria Applicable to All Systems)completed lam'System Information—Estimated depth to high groundvrater 0 Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file On-3M3 nme5omcw impmemForm wwwme.%wveowp*w Sulam•Pape v d v � �, �'\, 1 Town of Barnstable Regulatory Services Thomas F. Ceiler, Director • �tNb'9ABLE. MAMit Public Health Division._ sbyy. � Thomas McKean, Director 200!stain Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Forma Date: -7-le 09 Designer: Installer: jo '5 C SQL= Address: Address: On, 2 g- o y _ �L°—����/S*Av-e s_was issued a permit to install a (date) (installer) septic system at 197 Q/Q-zA Lrd- /2 based on a design drawn by (address) "CW-U S _ dated 7-30 --o y (designer) ry r 711 �94- I certify that the septic system .referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation-of the distribution box and/or septic tank. I certify that the septic system referenced above was installed "with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. ' �SH`OFMq AU PETER T. 1� �r (Installer's Signature) _ I o McENTEE I� CIVIL ; ,o No.351. / (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURIN T® BARNS'I ABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC .HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form �I TOWN OF BA�RNSTABLE i LOCATION /QI7 C l� ��I��yTti SEWAGE# Ad0 `1-39d VII,LAGE ASSESSOR'S MAP & LOT f9 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY IL G I -VIP LEACHING FACILITY: (type), `Sd0 /o-del •s (size) NO.OF BEDROOMS 3 BUILDER OR OWNER PERMIT DATE: .? :��i 0�/ COMPLIANCE DATE: Separation Distance Between the: Feet Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leachi g facility) Furnished by a i � 12 N1 c c No. �"'�� �l`� Fee G�✓f ' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes r PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01pplicatiou for Miopogar *patent Construction Permit Application for a Permit to Construct( pair( )Upgrade( )Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. 1117 0/ AX/W our' Owner's Name,Address and Tel.No. /y/;�rSr oys /",i/Y ✓ F�'/2 L y 5,w1 FT Assessor's Map/Parcel /00 G Installer's Name,Address,and Te.No. S"d$—l/Q�— q%3FS Designer's Name,Address and Tel.No. t)oScp4 U.c g)WW:5 �9i`!v'Fd'�y9 u rn;/c / s$v /I G(/:ST ice=/ �� �vr_STao.o1 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(An wer when applicable) 1w.5 l 2 ^s-0 o 6.0 Z Sr4a ck000y Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss b t d of Health. �7 Q Signe Date Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued . LYes No. - � nw % Fee HE COMMONWEALTHOF MASSACHUSETTS Entered-incompnter: PUBLIC HEALTH DIVISION -TOWN P BARNSTAB�L ,.!MASSACHUSETTS 01pprication f6r�"Mv5pozar *p6tem Construction 3permit Application fora Permit to Construct( Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Addressor Lot No./117 0/d ro/zal,aar%l Owner's Name,Address and Tel.No. s�v,Fr Assessor's Map/Parcel Installer's Name,Address,and Te.No. Designer's Name,Address and Tel.No., s p$- t/y9-.SY AV 1A, %/ Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other ,,Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title ` Size of Septic Tank Type of S.A.S. Description of Soil t 1 / Nature of Repairs or Alterations(Answer when applicable) /`!Sr�1! 2 -,5a0 6*1 Lid=101:�/ C1'!Wt4i_=,1, Y 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 y t ' d of Health Signe Date Application Approved by Date O Application Disapproved for the following reasons Permit No. C__ y' i Date Issued W a-V O -`—————————————————— 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 V®3G�®�i �� lfgf^ryS at /9/'? 4�7/Z) /' alj >'oclr4 )W has been const.j�jited/ini accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 90 '3 P dated /1°?�f V Installer VkPi as Designer The issuando this pe it s al not be construed as a guarantee that the sy to it function a esi ned. Date o Inspector s C7�/ 1 ....3�-------------------------- - No. Fee d _ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migogar *pgtem Congtruction 30ermit Permission is herebyranted to Construct g ( (,.)'Repair( )Upgrade( /)Abandon( ) System located at )/,g /ylpJ^s"TryNS !�//�s 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:Cons n ction must -completed within three years of the da e of this Date:_. /� Approved by Old Falmouth Rd OL.D .F'AYVOUTH ROAD LEGEND �0y 1 lb ���Edge of pavement � ��• q ' 99 PROPOSED CONTOUR Mugs pt 99 PROPOSED SPOT GRADE -- 40. EXISTING CONTOUR o 3 _y °52 � x 99.46 EXISTING SPOT GRADE o o LOCUS I �� A a 3 46'12'48" E �� �0 TEST PIT a \ 87.43' m + A=63.37'°Agti -- W— EXISTING WATER SERVICE F tio�' ,o °oog R=296.28' � EXISTING TREEtan_———_——^ <o �F vo�e o Map 100 ' i Parcel 69 a' St o�° 49,737 S.F.f + 1. 14 AC.f ` '•.. I '"'•`,•. o '�� Route 28 lop ------ to6,�,` `~ LOCUS MAP N.T.S. ~' �, �, GENERAL NOTES: +�' 1- ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL BOARD OF HEALTH AND THE DESIGN ENGINEER. + tt 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS 1� �,o• tto_ ��� �� �. I OF THE STATE ENVIRONMENTAL CODE, TITLE V. AND ANY APPLICABLE ¢yz + �. LOCAL RULES AND REGULATIONS. ~`k" �' 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR y TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE �0 titi z ti° ` DESIGN ENGINEER. P i 4. ANY CONDITIONS. ENCOUNTERED DURING CONSTRUCTION DIFFERING FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN ENGINEER BEFORE CONSTRUCTION CONTINUES. 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. • T I 1 11 "�' 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF Uu \ EXISTING ��`� THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF o\ 3 gEpROpM �,? HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. HOUSE �#12� o,� 7. WATER SUPPLY PROVIDED BY TOWN WATER. �,• � 8. THERE ARE NO PRIVATE WELLS LOCATED WITHIN 150' OF THE S.A.S. s 9. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED Z \` oo+ +ti,2°' m TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE Benchmark set __ \ ka ' THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING Left car. bulkhead \ n �ti°° ���`' �,�. .+`��41 a�° i CONSTRUCTION. • ' ' ' ' ' � '� 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS El,=114.20 Assumed 44' °° I +,� .-.--, ���'�_ Shed \`, °o�,� ° t- o , IN THE AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF THE S.A.S. EX/STING SEPTIC TANK + o 1 i ` AND REPLACE WITH CLEAN FILL AS SPECIFIED IN 310 CMR 255(3). A 10 - 69 �� �F MAS 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND TOP EL: 112.30 `� � i� �-'== ��� �P� s9�y IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY. INV.(OUT) EL: 110.95f _ 2 PETER T. GJ EXISTING SAS �!�° rn \� 115. `4��6 o McENTEE Q + � CIVIL SEPTIC SYSTEM REPAIR UPGRADE TO BE PUMPED & + m FILLED W/ SAND ft8-- A o _—_\ °o No. 35109 197 OLD FALMOUTH ROAD, MARSTONS MILLS, MA Si- m s r- FFSSIpNq FC1�\ Prepared for: Jeffrey Swift, 197 Old Falmouth Road, Marstons Mills, MA f �e 0 Engineering by: Surveying by: SCALE DRAWN JOB. NO. fv �► fv �laA- Engineering Works Terry A. Warner P.L.S. 1"=30' P.T.M. 64-04 12 West Crossfield Road 22 Long Road Forestdole; MA 02644 Harwich, MA 02645 DATE CHECKED SHEET NO. (508) 477-5313 (508) 432-8309 7/13/04 P.T.M. 1 Of 2 a y NOTE: TO PREVENT BREAKOUT, THE PROPOSED F.G. EL: 1 14.3t FINISH GRADE SHALL NOT BE < ELi 1 11.00 FOR A DISTANCE OF 15' AROUND THE EXISTING F.G. EL: 114.1 t(EXISTING) F.G. EL: 114t(EXISTING) PERIMETER OF THE S.A.S. MAINTAIN 2% MIN SLOPE OVER S, r INSTALL RISER OVER CHAMBER/S INSTALL RISERS OVER INLET & OUTLET INSTALL RISER OVER D—BOX TO 2-500 GALLON LEACHING CHAMBERS SHOWN ON PLAN AND SET COVER/S TO WITHIN 6" OF FINISH GRADE WITHIN 6" OF FINISH GRADE IN SERIES WITH STONE ALL SIDES WITHIN 6" OF FINISH GRADE L =.10' L 13'(MAX) 4" SCH 40 PVC 4" SCH 40 PVC r---_—2' LAYER OF 1 8" TO 1/2" i p., (EXISTING) • t 14" 0 S= 1% (MIN.) a S= 1% (MIN.) ®a®$aa� DOUBLE WASHEDSTONE EXISTING 2' EFF. DEPTH � �i eea d 1000 GALLON INV. ELEV.=111.47 INV. ELEV.=111.30 3/4"-1 1/2" SEPTIC TANK " ' (EXISTING) 4' 5.2' _ 4 DOUBLE WASHED EFFECTIVE WIDTH 13.2' STONE INSTALL INLET & OUTLET TEES NV:EL: 11 1.95t INV. ELEV.=110.50 GAS BAFFLE TO BE INSTALLED ON OUTLET TEE AS MANUFACTURED BY (EXISTING) . TUF-TITE, ZABEL, OR EQUAL TOP CONIC, ELEV.=11 1.3 •—BREAKOUT ELEV.=111.Ob D-BOX SHALL BE SET LEVEL AND TRUE TO GRADE INV: ELEV.=110.50 aaea� ON A MECHANICALLY COMPACTED SIX INCH CRUSHED 9933 STONE BASE, AS SPECIFIED IN 310 CMR 15.221(2). BOTTOM ELEV.=108.50 2 x 8.5' = 17.0' 3' 3' SEPTIC SYSTEM PROFILE MIN, ABOVE G.W. EFFECTIVE LENGTH = 23.0' N.T.S. NO G.W. ENCOUNTERED LEACHING SYSTEM SECTION BOTTOM OF TP EL: 103.5 ���� Of MgssgC (3) 5 DIA,OUTLET5 18" o PETER T. ,I- -i -- DESIGN CRITERIA M CIVILcEN SOIL LOG No. 35109 O r 6" NUMBER OF BEDROOMS: 2 BEDROOMS S(E�� 6' .. DATE: JUNE 24, 2004 SOIL TYPE: CLASS I Sl0 H-10 LOADING - 2" SOIL EVALUATOR: PETER T. McENTEE P.E., C.S.E. DESIGN PERCOLATION RATE: 2 MIN./IN. INSPECTOR: NOT REQ'D-CLASS 1 SOILS Q D-BOX DAILY FLOW: 220 G:P:D. µra DESIGN FLOW: 330 G.P.D Elev. TP— 1 Depth GARBAGE GRINDER: NO 115.0 0" LEACHING AREA REQUIRED: (330) = 445.9 S.F. EXISTING A SANDY LOAM .74 ®®®® ® ®®®® NOUSE q12) 10YR 3/3 PROPOSED SEPTIC TANK: 1000 GALLON CAPACITY ®®®E3®®E3®®®® 114.7 4" a E3®®®®®®®®®® 33 TOF=115.33 B N 3ha10®®®EREaE LOAMY SAND USE 2-500 GALLON LEACHING CHAMBERS IN SERIES - 10YR 5/8 �y°� 112.0 36" SIDEWALL AREA: 2(13.2' + 23.0') X 2 = 144.8 S.F. in � C BOTTOM AREA: 13.2' x 23.0' = 303.6 S.F: N 4 TOTAL AREA: • KNocxour .448.4 S.F. 20' 01A, COVER '_______---= MED. SAND DESIGN FLOW PROVIDED: 0.74(448.4) = 331.8 G.P.D. " KNOCKOUT Q/4' KNOCKOUT 62" i PROP. g•p,'S�� 2.5Y 5/6 W j 4" KNOCKOUT N ' 23'-=�, SEPTIC SYSTEM REPAIR UPGRADE 103.5 138" 197 OLD FALMOUTH ROAD, MARSTONS MILLS, MA 500 GALLON CAPACITY, H-10 LOADING PERC RATE <2 MIN/IN. ("C" HORIZON) Prepared for: Jeffrey Swift, 197 Old Falmouth Road, Morstons Mills, MA S.A.S. LAYOUT NO G.W. ENCOUNTERED Engineering by: Surveying by: SCALE DRAWN JOB. NO. CHAMBERS EngineetinaWorks Terry A. Warner P.L.S. NTS P.T.M. 64-04 NJA rar:a 12 West Crossfieid Road 22 Long Road Forestdole, MA 02644 Harwich, MA 02645 DATE CHECKED SHEET NO. (508) 477-5313 (508) 432-8309 7/13/04 P.T.M. 2 of 2