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HomeMy WebLinkAbout0204 MARSTONS LANE - Health (2) E204 Marstons v_. 0. r Commonwealth of Massachusetts ARI 3�9 _0q3 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r� 204 Marstons Ln. r` Property Address Lee Owner information Owner's Name is required for ✓ eve page. MA 02637 6/18/18 C? every p Barnstable g Cityrrown 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. A. General Information S/#r- 130 97 1. Inspector. Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 City/Town State Zip Code 508.272.6433 13010 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority. _ 4 6/18/18 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 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 204 Marstons Ln. Property Address Lee Owner information Owner's Name is required for every page. Barnstable MA 02637 6/18/18 Cityrrown 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: ® 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. F Comments: New system 2009 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): y , t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,. 204 Marstons Ln. Property Address Lee Owner information Owner's Name is required for every page. Barnstable MA 02637 6/18/18 Citylrown 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): A C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6116 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 204 Marstons Ln. Property Address Lee Owner information Owner's Name is required for every page. Barnstable MA 02637 6/18/18 Citylrown 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 El ® 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 '/2 day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° M 204 Marstons Ln. Property Address Lee Owner information Owner's Name is required for every page. Barnstable MA 02637 6/18/18 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) I 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. E] ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to,correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 204 Marstons Ln. Property Address Lee Owner information Owner's Name ' is required for every page. Barnstable MA 02637 6/18/18 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? 4 ® ❑ Has the system received normal flows in the previous two week period? El ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, 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): 41 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 204 Marstons Ln. ' Property Address Lee Owner information Owner's Name is required for every page. Barnstable MA 02637 6/18/18 Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents:: Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupied 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 204 Marstons Ln. Property Address Lee Owner information Owner's Name is required for every page. Barnstable MA 02637 6/18/18 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pumped 3 yrs ago per 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments' M 204 Marstons Ln. Property Address Lee Owner information Owner's Name is required for every page. Barnstable MA 02637 6/18/18 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: 2009 per BOH record Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10'feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 18"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) H-10 tank appears to be structurally sound, inlet and outlet covers raised If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500g Sludge depth: 3" t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 204 Marstons Ln. Property Address Lee Owner information Owner's Name is required for every page. Barnstable MA 02637 6/18/18 City(rown 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 >12" Scum thickness trace >2" . Distance from top of scum to top of outlet tee or baffle >2,i Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? measured 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 suggested every 3 years to prolong the life of the system Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete D metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 204 Marstons Ln. Property Address Lee Owner information Owner's Name is required for every page. Barnstable MA 02637 6/18/18 CityfTown 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 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts .z Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 204 Marstons Ln. Property Address Lee Owner information Owner's Name is required for every page. Barnstable MA 02637 6/18/18 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): 0.. 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.): D-box is 3' below grade, cover raised to 12", very good condition 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 204 Marstons Ln. Property Address Lee Owner information Owner's Name is required for every page. Barnstable MA 02637 6/18/18 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 5 infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields a 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.): Infiltrators were video inspected and are damp at this time, no indication of past hydraulic failure, top of chambers approximately 3'6" below grade s 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 204 Marstons Ln. Property Address Lee Owner information Owner's Name is required for every page. Barnstable MA 02637 6/18/18 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.): Soils are compact and dry Privy(locate on site plan): Materials of construction: Y Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): - • t5ins.doc"rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System"Page 14 of 17 " Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 204 Marstons Ln. Property Address Lee Owner information Owner's Name is required for every page. Barnstable MA 02637 6/18/18 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately v v C_ cl � a3 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 204 Marstons Ln. Property Address Lee Owner information Owner's Name is required for every page. Barnstable MA 02637' 6/18/18 ` - CityfTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high round water: P 9 9 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 Ian reviewed: 2009 NGW 132" p Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: 4' seperation per 2009 compliance ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: TOPO mapping, site is 55'msl and nearby surface water is 24'msl You must describe how you established the high ground water elevation: See above Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 204 Marstons Ln. Property Address Lee Owner information Owner's Name is required for every page. Barnstable MA 02637 6/18/18 City/Town 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 4 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LC!CATION U /I') :'r.lam+ - L� SEWAGE # 4:w:47a ASSESSOR'S MAP & LOT JYJ- y -1 u INSTALLER'S NAME&PHONE NO. ` SEPTIC TANK CAPACITY f LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: ' 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 leaching facility) Feet Furnished by tn3+fit>..,,; r �'L1 /0� 2 - 1 TOWN OF BARNSTABLE ®g LOCATION CPO y_ S SEWAGE# .� t� Vhf,LAGE C�Olp? /AQ(/a p ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /S-0O off/o LEACHING FACILITY.(type) JT to S-V (size) NO.OF BEDROOMS OWNER I'� 3 f PERMIT DATE: O 9 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 leaching facility). feet FURNISHED BY 17 leg, 23e io � i 4 No. 'gCJ'V Fee THE C04MONWEALTH OF MASSACHUSETTS Fntered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pplication for �Digogal &pgtemc Congtr ctfon Permit Application for a Permit to Construct( ) Repair V-4upgrade( ) Abandon( ) Complete System ❑Individual Components Location Address or Lot NoaO 7 ��5 � '(RH-C Owner's Name,Address,and Tel.No. 373 / w�fi n j Assessor's Map/Parcel Y - S`!J9'_775-7fj- A d Installer's Name,Address,and Tel.No. � ��T7� ��(� Designer's Name,Address and Tel.No.�`v 41, rj- Type of Building: 4 Dwelling No.of Bedrooms Lot Size (o// 0_7J--- sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided Z/4(17j_ gpd Plan Date Jam` 7-� /AG 17 �+ Number of sheets Revision Date Title �"�/c �J.�t P44 ©f— SOS/ /��i�fjdwJ `�IESC �dAyss Size of Septic Tank /sZa Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) rj f4/1 SJ 'R,—q Date last inspected: Agreement: The undersigned agrees to ensure the construcUuVand maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Ln rgrfinental Code and not to place the system in operation until a Certificate of Compliance has beZi this Bo eald Date Application Appro Date 0 Application Disapproved by: Date for the following reasons Permit No. .-:. w. Date Issued -- TTSANA s' No. n� ; f h i Fee THE;CO� "�IIONWEALTH OF MASSACHUSETT p Entered in com ufer 7 -- � PUBLIC 'HEALTHDIVISIONIN�- TOWN OF BARNSTABLE, MASSACHUSETTS; Yeg Rpprication for Migonl *p!tem Construction Permit Application for a Permit"to Construct O Repair(/i)' Upgradee( )''Abandon O U Complete System p❑Individual Components Location Address or Lot No p?lJ Owner's Name,Address,and Tel.No. )CZf-s41# .y Assessor's Map/Parcel �(f9 /.T 5V? 77e 7rf,fG /_��H" Nei. t Installer's,Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ,v6r1 "n J J rny.`/P 114Vl( ry!•�9,11 i7 f 3Gl- y1�// �.,nd.%6 l-es,11— Type of�Building: ,H / �/ / Dwel ng No.of Bedrooms L a Lot Size`7� G-7T sq. ft. Garbage Grinder (A;� Other ' Type of Building No.of Persons Showers( ) Cafeteria( ) Other E xtures Design Flow(min.required) gpd Design flow provided g`pd Plan Date —7,, j ��,�GG`� Number of sheets Revision Date Title T 1. Size of Septic Tank Type of S.A.S. S` ?0,Z,�,r Description of Soil Nature of Repairs or Alterations(Answer when applicable) J 4// ,;Jf e-7 ,� — ��7 s Date last inspected: Agreement: The undersigned agrees to ensure the constructio�j and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the nvirental Code and not to place the system in operation until a Certificate of Compliance has bee issuod_by this Boatd • ealths'' ; z` 5 Signed Date Application Appro by7 — Date Application Disapproved by: Date for the following reasons Permit No. co 9 Date Issued S1- 0101 THE COMMONWEALTH OF MASSACHUSETTS V BARNSTABLE, MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the /On-site Sewage Disposal System Constructed ( ) Repaired (4111/Upgraded ( ) Abandoned( )by at ��� �/ <yi,fury) l4 y y44 t e, ' has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. T dated Installer `jrlr 41,111" Designer / C #bedrooms Approved design fl'w` l r gpd The issuance of this permiJshall not be construed as a guarantee that the systeTwn�tion as designedDate �� J Inspector (n /. 8 S t—T—=— --�----- ——- _. =w z — t r s t--�? -z—T r zt——— -,--. — .. .— No. a, t �7 �J Fee �� — �r e THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS Mizpogal 4&pttem Con5trUction Permit Permission is hereby granted to Construct ( ) Repair ( � Upgrade ( ) Abandon ( ) System located at r2a /i/ab�fo zJ fe,s��r ���•�?�v'� i 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 co ,itions. Provided: Construction must bd completed within three years of the date of this pe tf. Date � Q ! APpr��by _ t Town of Barnstable regulatory Services Thomas F. Geiler,Director * BARNSTABLE, ' MASS. Publk Health Division 4J a639• ATFD Thomas McKean, Director 200 Main Street,Hyannis,A A 026011 Office: 508-862-4644 Fax: 508-790-6304 Installer & )lDesigper Certification Form Date: O ^2� sewage Permit#0,40 Assessor 9s map Warcefl Designer: D0 w4" cy installer:: Address: 9.3, Address: q On V—7-i�9? &rAple.100V (, ol" ; was issued a permit to install a (date) (installer) /4 A septic system at L.I 11A N-S)FUN S LA C based on a design drawn by (address) GLr_, p� 0 dated (designe 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. Flan revision or certified as-built by designer to follow: 30 '(InstafiVs Signature) CIVIC >R No.46502 - I S T e�`` Ss�ONAL (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO : BARNSTABLE PUBLIC HEALTH DMSION. CERTIFICATE OF C0Iy1 LIAI*TCE WML NOT BE ISSUED UNTM BOTH THIS FORM AND AS-BUILT CARD ARE � RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DI"SION. THANK YOU. Q:Health/Septic/Designer Certification Form 3-26-04.doc E • oF� Town of Barnstable P# I �3 Department of Regulatory Services R&MSTABt& : Public Health Division Date o q �A t639 ,6$ 200 Main Street,Hyannis MA 02601 rED MA'S� Date Scheduled a 10U� Time . Fee Pd. Soil Suatabil ty Assessment for Sewage is 0 al Performed By: Witnessed By: a�' �• //) LOCATION& GENERAL INFORMATION Location Address Owner's Name rwt lip F n► .�'/� � / Gu(g /�/). QG+�s� Q :Address o/U Assessor's Map/Parcel y y 3 Engineer's N me NEW CONSTRUCTION REPAIR Telephone# F01-- )-V(o— �7 t7 / .65 Land Use �Ff Slopes(go) 0--s Surface Stones Distances from: Open Water Body ft Possible Wet Area&��ft Drinking Water Well ft Drainage Way �'/— B ft Property (, Y o rt L' S P Y Line ft Other - ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) t . q b► . �� ' Parent material(geologic)MO Mt� Q 0TW M Depth t0 Bedrock s Depth to Groundwater Standing Water in Hole: Nd N C 'Wee from Pit PpCe N��( Estimated Seasonal High Groundwater G L DETER.MINATIONFOR SEASONAL HIGH WATER FABLE Method Used: Depth Observed standing in obs.hole: ln,: Depth to soil mottles: in. Depth to weeping from side of obs.bole: in. Groundwater Adjustment in Index Well# Reading Date: Index Well level , Adj,factor Adj.Groundwater Lavel PERCOLATION TESL' bate � Time Observation Hole# / Time ttt 9�/;/5 Depth of Perc _7,L " • time at 6" .. Start Pre-soak Time @ � i US Time(9"-6") -. End Pre-soak ` Rate Min./Inch 1 L zm�l l" - - Site Suitability.Assessment: Site Passed f Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back ---------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one (1) week prior to beginning. Q:4SEPTICVERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. on istenc vel 0 r�N �Ll✓ lt.mc�t-ed • I q -zd 46 ` a514 7Z 3Z— GZ MFS ' ` 4/6 l DEEP OBSERVATION HOLE LOG Hole# Z- Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) /Z ZO yam/ 72=13Z -7 Fb DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. I e Flood Insurance Rate-Map: ~ Above 500 year flood boundary No_ Yes _. Within 500 year boundary No Yes Within 100 year flood boundary No— Yes _ Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? --Vf If not,what is the depth of naturally occurring pervious material? Certification I certify that on J&4 (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the required training,expertise and experience described in 3 10 CMR 15.017. Signature — r L Date Z Q:\SEPr1C\PERCF0RM.D0C �4 q _ DIS 4 P oFt�T Town of Barnstable Barnstable SA$M Regulatory Services Department e;ca► q� MASS. , Public Health Division RFD M 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 f Thomas A.McKean,CHO. CERTIFIED MAIL# 70081830000205008833 5/18/2009 Irma Fairbanks Trust e/.o Richard Fairbanks Jr. 54 Scudder Road Osterville, MA 02655 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 r. The septic system located at 204 Martsons Lane,MA was last inspected on April 21 2009,by Troy Williams, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Backup of sewage into facility or system component due to an overloaded or clogged SAS. 0 Liquid depth in cesspool is less than 6"below invert or available volume is less than a % day flow. You are ordered to repair or replace the septic system within Sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE OARD OF HEALTH 0 as' cKean, R.S.;CHO ,ay Agent of the Board of Health r Commonwealth of Massachusetts Title 5- Official Inspection Form ' " 3 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments L p f M 204 Marstons Lane, Cummaquid Property Address Irma Fairbanks Trust c/o Richard Fairbanks Jr. Owner Owner's Name _ information is required for every 54 Scudder Road, Osterville }MA 02655 April 21, 2009 page.. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form.-lnspection forms may not be altered in any way. Important:When filling out forms A. General Information : on the computer, use only the tab Inspector:1. p : key to move your 3� cursor-do not Troy Williams use the return — key. -Name of Inspector - Troy Williams Septic Inspections _ rab Company Name — ---- —( — ----- 19 Hummel Drive Company Address -- �r� South Dennis _ MA 02660 Cityrrown State Zip Code (508) 385-1300 :S1682 " Telephone Number License Number B. Certification certify that 1 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; I:2. ❑ Passes. ❑ Conditionally Passes '., ® Fails - - ❑ Needs Further Evaluation by the Local Approving Authority A Aril 21, 2009 Inspector's Signature/— Date ? tt3 t1 The system'inspector shall submit a copy of this inspection,report to the Appr ring Authority (Board of Health or. DEP)within 30 days:of tompleting 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 and copies sent to the buyer,, alpplicable,tand he approving authority.'be sent to the system owner reportappropriate goriginal ****This report only describes conditions at the time of iiilspectioin and under the conditions of use at that time.This inspection does not address how the system will perform in the.future under s the same or different conditions of use. Lod" " 204 Marstons Lane,Cummaquid 03108 Title 5 Orricialanspection form:Subsurface Sewage isposal System-Page 1 of 15 Commonwealth of Massachusetts Title 5 Official +aInspection Form Subsurface Sewage Disposal System Form - Not,forVoluntary Assessments 204 Marstons Lane, Cumm_aguid _ Property Address --- r Irma Fairbanks Trust c/o Richard Fairbanks Jr. Owner - --_ ----------- -- -- Owner's Name information is 54 Scudder Road,Osterville MA 02655 April 21 .2009. required for every — - - page. Citylrown State Zip Code Date of Inspection B. Certification (cont.)'Y. Inspection.Summary: Check A,B,C,D;or E/;always complete all of Section D A) System Passes:. 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: N/A - - t B) System Conditionally Passes:: ❑ One or more system components asdescribed 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 over20,years old* or.the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiitration 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: N/A -- --- ❑ 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): El broken pipe(s) are replaced ❑ obstruction is removed 204 Marstons Lane,cummaquid•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System o Page 2 of 15 Commonwealth of Massachusetts • Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 204 Marstons Lane, Cummaquid Property Address ... Irma Fairbanks Trust c/o Richard Fairbanks Jr. Owner Owner's Name information i e 54 Scudder Road, Osterville MA 02655 April 21, 2009 required for every p � ' page. City/Town State Zip Code Date of Inspection B. Certification (cont:) B) System Conditionally.Passes(cont.): ❑ distribution box is:leveled or replaced ND Explain: N/A . El 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: N/A 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 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: Ej The system has a septic tank and SAS and the SAS is within a Zone 1 of:a public water supply.: h. El The system has a septic tank and SAS and.the SAS is within 50 feet of a private water supply well. 204 Marstons Lane,Cummaquid.03/08 Title 5.Official Inspection Form:Subsurface Sewage Disposal System-,Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 204 Marstons Lane, Cummaquid' Property Address Irma Fairbanks Trust c/o Richard Fairbanks Jr.' Owner Owner's Name information is 54 Scudder Road, Osterville MA 02655 April21,2009 required for every , page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health'(cont.): 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". i Method used to determine distance: N/A -. This system passes if the well water,analysis, performed at a DEP certified laboratory, for coliform' bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to.o.r.. 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' N/A . 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 sewa9einto 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 ® a Liquid depth in cesspoolis'less than 6".below invert or available volume is less than%day flow Required.!pumping more than 4 times in.the last year NOT due to clogged or El M obstructed pipe(s). Number of times pumped: ❑ H Any portion of the SAS, cesspool or privy is below high ground water elevation. El [A tributary portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 204 Marstons lane,Cummaquid•03108 Title 5 Official Inspection Form:Subsurface Sewage yDisposal System cPage 4.of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 204 Marstons Lane, Cu_mmaquid _ ` Property Address Irma Fairbanks Trust c/o Richard Fairbanks Jr. Owner Owner's Name information is . 54 Scudder Road,Osteryille' MA 02655 April 21 2009 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All.Systems'(cont:): " Yes No El M Any portion of.a cesspool or privy is within a Zone 1 of a public well. E] Any portion of a cesspool or privy is within 50 feet of a private water supply well. 0 ® 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 systen0ails. l'have determined that one or more of the above failure Ell criteria exist as described in 310 CM 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to.correct the failure. E) Large Systems: -To be considered a large system the system must serve a facility with_a, design flow,of 10,000 gpd to 15,000 gpd. For large "systems,you must indicate either"yes" or"no"to each.of the following, in addition to the questions in Section D. Yes No ❑ ® the system is,within 400 feet of a surface drinking water supply ® the system is within 200 feet.of a tributary to a surface drinking water supply El ® the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA) or a mapped Zone 11 of a public water supply well If,you have answered"yes" to any.question in Section E the system is considered a sign ificant'th reat, 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. 204 Marstons Lane,Cummaquid-03I08 - • _ Title 5 Official Inspection.Form:Subsurface Sewage Disposal System•Page 5 of15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System;For -Not for Voluntary Assessments 204 Marstons Lane, Cummaquid Property Address Irma Fairbanks Trust c/o Richard Fairbanks Jr. Owner Owners Name information is required for every 54.Scudder Road, Cisterville MA 02655 April 21, 2009 - 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 ® El 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? El ® Have large volumes of water been introduced to the system recently or as part of this inspection? El ®' 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? ❑ Z 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 ® 0 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: 0 M Existing information: For example, a plan at the Board of Health. ® ElDetermined 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)] a , z 204 Marstons Lane,Cummaquid•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal Sy tent d Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for.Voluntary Assessments : 204 Marstons Lane, Cummaquid Property Address Irma Fairbanks Trust c/o Richard Fairbanks Jr. Owner Owner's Name information is required for every 54 Scudder Road, Osterville MA 02655 Aril 21, 2009 _ page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design) 4 Number'of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 g pd Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes No Is laundry..on a separate sewage system? [if yes separate inspection required] ❑ Yes M `No Laundry system inspected? Yes ❑ No Seasonal use? ❑ Yes M No Water meter readings, if available last 2 ears usage (gpd)),. 07=116,000gals 9 ( Y 9 :.08=83,000gals- Sump pump? ❑ Yes ® ,No . Last date of occupancy: Vacant 3 mos. Date Commercial/Industrial Flow Conditions: Type of Establishment: N/A N/A Design flow(based on 3.10 CMR 15.203): Gallons perday(gpd) Basis of design flow (seats/persons/sq.ft., etc:): N/A Greasearap present? ❑' Yes M No Industrial waste holding tank present? ❑ Yes M, No Non-sanitary waste discharged to the Title 5 system? [-]..Yes No Water meter readings, if available: N/A Last date of occupancy/use: N/A Date Other(describe): N/A 204 Marston Lane,Cuiimmaquid•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Forrn Subsurface Sewage Disposal SystemForm-Not for Voluntary Assessments 204 Marstons Lane, Cummaquid ` Property Address Irma.Fairbanks Trust c/o Richard Fairbanks Jr. Owner Owner's Name information is required for every 54 Scudder Road, Osterville MA 02655 April 21, 2009 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General.Information` Pumping Records: Source of information: No pumping info available_ Was system pumped as part of the inspection? ❑' Yes ® No If yes, volume pumped: N/A` r gallons How was quantity pumped.determined? N/A Reason for pumping: ' N/A 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: Cesspools are original to home built approx. 40 +years ago; Were sewage odors detected when arriving at the site? ❑ _Yes ® No t; 204 Marstons Lane,Cummaquid•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal.System Page 8 of 15 47, I t Commonwealth of Massachusetts F Title 5 Official Inspection Farr Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 204 Marstons Lane, Cummaquid Property Address Irma Fairbanks Trust c/o,Richard Fairbanks Jr. _ Owner Owner's Name information is required for every 54 Scudder Road, Osterville MA 02655_ April 21, 2009 - page. CitylTown State Zip Code Date of Inspection D. System Information (Cont.) Building Sewer(locate'on site plan): ' Depth below grade: 18"+ feet Material of construction: El40 PVC Orangeburg ® cast iron ®other(explain): Distance from.private water supply well or suction line: feet ' .. Comments (on condition of joints, venting,evidence of leakage, etc.)-- Flushed lines and found clear at the time of inspection: j Septic Tank(locate on site plan): Depth below grade; N/A feet Material of construction: ❑ concrete ❑ metal ❑fiberglass E polyethylene 0 other(explain) N/A If tank is metal,list age NIA years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) „ ❑ Yes 0 No f L Dimensions: N/A Sludge depth: N/A Distance from top of sludge to bottom of outlet tee or baffle N/A Scum thickness N/A Distance from top.of scum to top of outlet teli or baffle N/A' Distance from bottom of scum to bottom of outlet tee or baffle N/A How were dimensions determined?. N/A 204 Marstons Lane,Cummaquid•03/00 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Fora o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 204 Marstons Lane, Cummaquid Property Address — = Irma Fairbanks Trust c/o.Richard Fairbanks Jr. Owner Owners Name -- information is required for every 54 Scudder Road, Osterville MA , 02655 April 21, 2009 - - page. City/Town State Zip Code Date of Inspection .s D. System Information (cont.) Comments(on pumping recommendation s,.inlet and:outlet tee or.baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,.etc.): N/A Grease Trap (locate on site plan): Depth below grade: N/A feet' Material of construction: ❑ concrete El -metal ❑ fiberglass. ❑ polyethylene ❑ other.(explain): N/A Dimensions:-. N/A Scum thickness N/A Distance from top of scum to top of outlet tee.or baffle' N/A , Distance from bottom of scum to bottom of outlet tee or baffle N/A Date of last pumping: N/A 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.): N/A Tight or Holding Tank(tank-must be pumped.at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other. (explain): N/A 204 Marslons Lane,Cummaquid•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form =Not for Voluntary Assessments °M 204 Marstons Lane Cumma uid Property Address P Irma Fairbanks Trust c/o Richard Fairbanks Jr. Owner Owner's Name information is required for every ARM 54 Scudder Road,Osterville MA 02655 21, 2009: page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: N/A Capacity: N/A gallons N/A Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level- N/A Alarm in working order: El Yes ,❑ No Date of last pumping: N/A Date:. Comments (condition of alarm and float switches, etc.): N/A a Attach copy of current pumping contract(required) Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert N/A 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.): N/A Pump Chamber(locate on site plan); Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 204 Marstons Lane,Cummaquid•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form = Not for Voluntary Assessments M °'c 204 Marstons Lane, Cummaquid { Property Address Irma Fairbanks Trust do Richard Fairbanks Jr. Owner Owner's Name information is required for every 54 Scudder Road, Clsterville MA 02655 April 21, 2009 page. City/Town State Zip Code, Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): N/A Soil Absorption System(SAS) (locate on site plan, excavation not required)`. If SAS not located, explain why: Due to conditions found and need for upgrade of system to Title V at this time-exact locations were not determined + Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number. ❑ leaching trenches, number, length: ❑ leaching fields number, dimensions ® overflow cesspool - number: 2.-5'X5' ❑ innovative/alternative system Type/name of technology: v Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Evidence of cesspools being full and in hydraulic failure when home was occupied was found.Cesspools had less than a minimum 1/2 day flow available at the time of inspection. _ v 204 Marstons Lane,Cummaquid•03/08 r Title 5 Official Inspection Form:Subsurface Sewage Disposal.System.Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection F.orrn Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °�M V•yr 204 Marstons Lane, Cummaquid Property Address Irma Fairbanks Trust c/o Richard Fairbanks Jr. Owner Owner's Name information is required for every 54 Scudder Road, Osterville MA 02655 April 21, 2009 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): • Number and configuration: 2.- Main cesspools Depth-top of liquid to inlet invert 3 Depth of solids layer 2„ Depth of scum layer thin.layer .Dimensions of cesspool• 5'X 5' Materials of construction Cesspool block Indication of groundwater inflow, ❑ Yes ®:No Comments(note condition of soil, signs of hydraulic failure,"level of ponding, condition of vegetation, etc.): Cesspool was found with walls and bottom of cover:stained and covered with scum above inlet and outlet lines. This is evedince of cesspools being full and in hydraulic failure when home was occupied. Privy(locate on site plan): Materials of construction: N/A Dimensions N/A Depth of solids N/A Comments (note condition of soil, signs of hydraulic failure, level of pondi.ng, condition of vegetation, etc.): N/A 204 Marstons Lane,Cummaquid•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 204 Marstons Lane, Cummaquid= Property Address Irma Fairbanks Trust c/o Richard Fairbanks Jr: Owner Owner's Name information is required for every 54 Scudder Road, Osterville MA . 02655 Ap0'21, 2009 page. Cityfrown State Zip Code Date of Inspection . D. System Information (cont.) 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: a (j 0 � C- � 2Z 204 Marstons Lane,Cummaquid•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 11 of 15 j, Commonwealth of Massachusetts + F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 204 Marstons Lane, Cummaquid Property Address Irma Fairbanks Trust c/o Richard Fairbanks Jr. Owner Owner's Name information is required for every 54 Scudder Road, Osterville MA 02655 April 21,2009 page. Citylrown State Zip Code Date of Inspection r D. System Information.(cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar Shallow wells Estimated depth to high ground water: 20+' feet Please indicate all methods used.to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked,date of design plan reviewed. Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database explain: k AIW 247 Zone B 22.9' 2.2' adjustment You must describe how you established the high ground water elevation: Soil was sandy. Hand augered 4' below bottom of leaching with no water found at 12.0'. Groundwater adjustment in area at the time of inspection was 2.2'..Bottom of leaching at 8.0 was found not to be Iodated in the high groundwater elevation at the time of inspection. 204 Marstons Lane,Cummaquid•03/08 Titles Official Inspection Form:Subsurface Sewage Disposal System r Page 15 of 15 LEGEND SYSTEM bESIGN; SYSTrEM PROFILE NOTES j Cb :NOT TO SCALE) 99 EXISTING CONTOUR ALL SYSTEM COMPONENTS SHALL BE x : PROVIDE MIN. 20" DIAM. WATERTIGHT MARKED WITH MAGNETIC TAPE OR 1. DATUM IS APPROX, NGVD (GIS SPOT EL.) `- GARBAGE DISPOSER. IS NOT ALLOWED � ACCESS COVERS TO WITHIN 6" OF FIN. GRADE COMPARABLE MEANS FOR FUTURE LOCATION. T' � �co -I` 99.1 EXIST. SPOT ELEV. + TOP FOUND, 5.4' PROVIDE INSPECTION PORT TO WITHIN 3" OF FINAL GRADE 2. MUNICIPAL WATER IS EXISTING a � Rte DESIGN FLOW: 4 BEDROOMS 0 110 GPD =440 GPD 1 s 99 PROPOSED CONTOUR - `-- \ 54.8 MINIMUM .75' OF COVER OVER PRECAST 296 SLOPE RE UIR O 54.3' 3. MINIMUM PIPE PITCH TO BE 1/8 " PER FOOT. USE A 440 GPD DESIGN FLOW Q E OVER SYSTEM r y MIN. 8" DIAM 4. DESIGN LOADING FOR ALL PROPOSED PRECAST UNITS 99 PROPOSED SPOT EL. COVER I I TO BE AASHO H-]Q TH1 SEPTIC TANK: 440 GPD (2) = 880 4~scs�4o Pvc 4"�scH4o Pvc f + - PIPES LE�L 1ST 2' 2 DOUBLE WASHED PEASTONE TEST HOLE `r * ' OR GEOTEXTII I FABRIC ' 5. PIPE JOINTS TO�BE MADE WATERTIGHT. v USEI1500 GAL H-10 SEPTIC TANK 1 53.06 51.5 �. ;, 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH L CUS 2% SLOPE OF GROUND F r. # , 53.06 51.75' TEE 1500 GAL H-10 TEE , LEACHING: sEPTrc TANK \51.50 _ 310 CMR 15.000 (TITLE V.) 00'- � O o o O o "o� 00 , 00 > 4' LIQ. LEVEL ° °O°° O 51.03 O 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO Q, u7iu7Y POLE SIDES:2 (41.5 + 10.25) 2 (.74) 153 GPD I cas BAFFLE ::' °°°o°°°° °° BE USED FOR LOT LINE STAKING OR ANY OTHER ACME OR EQUAL o 0 0 0 00 - c „o„o„o„o„o„o o„ 2 o FIRE HYDRANT TOM 41.5 x 10.25 (.74) 312 GPD! 1 51.22' 51.05' oo�o ? o 49.03' PURPOSE. NOTE: NOT ALL SYMBOLS MAY APPEAR iN DRAWING ::; < ' i : '•;• : o00 ,� TOTAL: 628 S.F. 465 GPD'' 00000000000 0 0 0 0 0 .o c 6" MIN. ;LIMP H-20 3050 INFILTRATORS 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4 PVC. } 000000o0000000000C 12" MINANT. DIM. o„o„o,o,o,o o„o„o„o�o„o, 3/4" TO 1 1 2" DOUBLE WASHED STONE 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED xit 7 USE (5) 3050 INFILTRATOR CHAMBERS 6" CRUSHED STONE OR MECHANICAL / WITHOUT INSPECTION BY BOARD OF HEALTH AND WITH 3' STONE AT ENDS AND 3' AT SIDES COMPACTION. (15.221 [21) PERMISSION OBTAINED FROM BOARD OF HEALTH. *THE INSTALLER SHALL VERIFY THE OVERALL DIMENSIONS TO OUTSIDE OF STONE: 41.25' X 10.25' LOCATIONS OF ALL UTILITIES AND ALL ' ( 2 2X SLOPE) ( 1 % SLOPE) ( 1 % SLOPE) 5.6' 31't 10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING DIGSAFE (1-888-344-7233) AND VERIFYING THE U M BUILDING SEWER OUTLETS AND s LOCATION OF ALL UNDERGROUND & OVERHEAD UTILITIES LOCUS MAP ELEVATIONS PRIOR TO INSTALLING ANY 1 PRIOR TO COMMENCEMENT of WORK. NOT TO SCALE PORTION OF SEPTIC SYSTEM ` } FOUNDATION 15 SEPTIC TANK 28 D BOX 4 LEACHING FACILITY 11, ANY UN!UITABLE MATERIAL ENCOUNTERED SHALL BE MA 60� ' 43.4' BOTTOM TH-1 REMOVED 5"BENEATH AND AROUND THE PROPOSED ASSESSORS MAP 349 PARCEL 43 APPROVED DATE BOARD OF HEALTH FOUNDATION ++ LEACHING FZclurY. I i NO GROUNDWATER FOUND NOTE: G-W EXPECTED EL. 18t PER G-W MAP SEPTIC UPGRADE ONLY NO CONSTRUCTION WORK 12. EXISTING LEACHING FACILITY SHALL BE PUMPED AND. (I I REMOVED OK PUMPED AND FILLED WITH CLEAN SAND. PROPOSED) 4. TEST HOLE LOGS / 53,2 z / 53.3 I ENGINEER: ARNE H. OJALA, PE, SE 5 .3 / � .5 53.6 WITNESS: DAVID W. STANTON, IRS I / DATE: JULY 23, 2009 / PERC. RATE = < 2 MIN/INCH F / \ CLASS I SOILS P# 12639 f�y ELEV. ELEV. tt,,- V �f /�� 54.4 1 , , � :• - 0" `�+/ 54.4' 0,• 54.5' / .< FILL FILL / E 54,5 14" UNSUIT.12„ UNSUIT. V r - - / 54.7: 7N -- ,�. A 8 / OIL,S _R ED G C}, - / 5 4,U LE 50 - O - r - J' .. ,.,.._ ., .m.. _ - yyyy' UNSUIT. ',. ti WITH CLEAN MED. BAN Ef . 10YR 2 OYR 4 2 i . O ! - r i I / 54,9 -- �/ C is ..: _- '�':... / ::.•.',_i•:,'�•. 77 +: -_..-..,y..- / L 3, SPECIFICATIONS OF 3;0-CMR;1a.255(3) w `` 20„ '20, / F / I 54.9 S4 n '• q BW BW LOT 10 �4,9 e ry /LS UNSUIT. /LS UNSUIT. 36075 SE ± I 55.8�, 54 i 10YR 5/6 10YR 5/6 32" 32„ / 55.0 5 9 / GARAGE \H 5�1'9 C1 61 / p UNSUIT. UNSUIT. I j (slab) i` 53. ,+ 5�,4 a �S LS 10YR 6/4 48.4' 72" 10YR 6/4 48.5' 72„ / 5 v, / Cn 4 4. / 55.0 ,54, 53 C2 C2 / S . ; !� + 54.b S4 PERc MFS MFS / o _ J BENCH MARK CORN. OF EXIST. DWELL. O 54.6 k „ 2.5Y 6/6 43.4' / 43.5' / c CONC. PAVER STOOP - 4, 132 132 2 5Y 6 6 55. 4.8 / �54 3 ELEV. 55 9 TOP FNDN L S4, S \ 5 NO GROUNDWATER ENCOUNTERED - 4 - - - .e' S / 5.3 6 52.i S� 4.8 52,2 c` J c 5 .9 52, �c, + 5419 + 7 �nrDER 4,2 4.7 59 �+ 59.7 TITLE SITE o TEL. AND CTV I ELECTRIC 60 N CTV 1N THIS3 ^47; - OF AREA LP 54,5 �� 61 �5 A C. 54,2 59 2 4 MARSTONS LANE GAS BBQ oo O AND LIGHTS + 64,2 CUMMAQUID 53.6 2000 PREPARED FOR o s S, 1 BORTOLOTTI CONSTRUCTION/ , �49.7� 4 FAIRBANKS 53,0 JULY 24, 2009 I Scale: 1"= 20' 0 10 20 30 40 50 FEET off 508-362-4541 DANIELk.�cyN o D OFMgss9cyG fax 508-362-9 80 ANIEL a o OJALA A. - downcape.com 0 CIVIL " r OJALA 1 • • G A 502 No:40980y down cape engineering, Inc• Fss�SST aL,� °��.s a civil engineers '"7«2`i.�q ° �SU. Ion surveyors 09- 1 s8 939 Main Street ( Rte 6A) DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675 09-168.DWG(SBO)