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HomeMy WebLinkAbout0448 MARSTONS LANE - Health f . 348 i Barnstable 1 h p 2 y/ �023 Commonwealth of Massachusetts 1(c, d , _ - Title 5 Official Inspectn. Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 448 Marstons Ln Property Address r Anne Conway ; , Owner Owner's Name information is Bamstabie V required for every MA 02637 6-20-15 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. A. General 'Information ,ol. Inspector. 03 `) Sliawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address - E. Falmouth MA J1__ `nyrs S 5L+?t City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of ''Title 5 (310 CMR'15.000).The system: ® Passes— ,, ❑ Conditionally Passes „i ❑ Fails . ,, •,, ,❑ Needs,Further Evaluation by the,Local Approving Authority. ; 4 ' M. 6-20-15 ' ? Inspector's Signature` ' Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 448 Marstons Ln i Property Address Anne Conway Owner Owner's Name information is required for every Barnstable MA 02637 6-20-15 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: - ® I have not found any information which indicates that any of the failure'criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. 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. ti Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y, ❑ N ❑ ND (Explain below): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspecti®n Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 448 Marstons Ln Property Address Anne Conway Owner Owner's Name information is required for every Barnstable, MA 02637 6-20-.15, ^ page. City/Town t 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.): +. :F *a-I- a- ❑ Observation of sewage backup or breakout orkhigh 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❑ Y. f❑ N ❑ ND (Explain below): ❑ obstruction is removed El "Y x ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced' '❑ Y ` ❑'N ❑ ND (Explain below): a x � t,.' ',{ i ; YS.I."n. .`.F 'i}.7r # • a .'t -,t�. ,° •�1 M.a.ji •."'r . . � ti I. : .,'L 1 _ ❑ 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)rFurther,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, isafety and the environment: " ❑ Cesspool or privy is within 50 feet of a surface water El Cesspool or privy is within 50 feet'of a bordering vegetated wetland or a salt marsh bins•3/13: _ 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 448 Marstons Ln Property Address An ne Conway Owner Owner's Name information is required for every Barnstable MA 02637 6-20-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) _ 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less_ than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Y Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® 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 t5ins•3/13 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 448 Marstons Ln Property Address Anne Conway Owner Owner's Name information is required for every Barnstable MA 02637 6-20-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ,Yes . No-I Required pumping more than 4 times the last year NOT due to dogged or ❑ ® 4 p p 9 Y g9 i obstructed pipe(s). Number of times pumped: i,❑ Z. 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. ,:° ❑ ® . +t -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. ❑ ° ® r" tAny portion'ofil 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 ;.1� 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- ❑ t Z 10;000gpd- ' The system fails. l`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. ti,• Yes No El El the system is within 400 feet of a'surface do ing water supply' ❑ ❑ the system is within 200 feet of a.tributary to a'surface drinking water supply r _-El the system is located in a nitrogen sensitive area (Interim Wellhead.Protection Area— IWPA)or a mapped Zone II of a'public water supply well If you have answered "yes"to any question in Section"E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 448 Marstons Ln Property Address Anne Conway Owner Owner's Name information is required for every Barnstable' MA 02637 6-20-15 page. Cityfrown State Zip Code Date of Inspection C. Checklist a . ` - Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions,.depth of liquid,depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on:. ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (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: Number of bedrooms (design): - 3 Number of bedrooms (actual): 3 DESIGN flow based.on 310 CMR.15.203 (for example: 110 gp6x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts •i r', Title 5 Official Inspection Form _. Subsurface,Sewage Disposal.System Form -Not for Voluntary Assessments-`: r 448 Marstons Ln 5 Property Address Anne Conway Owner Owner's Name iinformation is required for every Barnstable +,•'' MA 02637 6-20-15- .§, 'f page. City/Town State Zip Code Date of Inspection D. System Information Description: OV, Number of current residents: 0 Does residence have a garbage grinder?z 0 Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection , Yes ® No information in this report.) s`' t"` Laundry system inspected? far N­04 3 ❑ Yes 2 No r Seasonal use? .� ►, n „ : • " t 9 :;t•. �` '► E Yes.® No Water meter readings, if available (last,2 years usage(gpd)) •x. e. Detail:. , . . Sump pump?rEl Yes ® No Last date of occupancy: t ,, 6-2015 - � �` Date r Commercial/Industrial Flow Conditions: i= f' r, ; xType-of Establishment: � ; •i i. Design-flow(based on 310 CMR 151203):%o *f Gallons per day(gpd)' d Basis,of design flow(seats/persons/sq.ft.,•etc.): Grease trap;present?t­-,%: El Yes ❑ No Industrial waste holding tank present? El Yes ❑ No Non-sanitary waste discharged to the Title 5 system?. Yes R No Water meter readings, if available: t5ins•3/13 a *. 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 Vol u ntaryAssessments . M 448 Marstons Ln Property Address ' Anne Conway Owner Owner's Name information is Barnstable MA 02637 6-20-15 required for every ' page. City/Town 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: N/A _ Was system pumped as part of the inspection? El 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 L Commonwealth of Massachusetts ., Title 5 Official -lnspectionform Subsurface Sewage Disposal System Form-Not for Voluntary Assessments LM 448 Marstons Ln , Property Address Anne Conway Owner Owner's Name information is , required for every Barnstable w. MA 02637 6-20-15 page. Cityfrown State Zip Code Date of Inspection e D. System Information (cont.) ', Approximate age of all components, date installed (if known) and source'of information: 1986 Were sewage odors detected when arriving at the site? p 0 Yes ® No Building Sewer(locate on site plan): . ' r, - Depth below grade:a'. .. 18"Meet •'- Material of construction: Elcast iron ® 40 PVC El'other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joinfs, venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): , 1211 Depth below grade: r -i feet Material of construction: -• .'3 ® concrete ❑ metal ❑ fiberglass t ❑ 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: 1 1000 gal Sludge depth:, 12" , t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts t . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form '-Not for Voluntary Assessments I M °r 448 Marstons Ln Property Address Anne Conway Owner Owner's Name information is required for every Barnstable MA 02637 6-20-15 page. City/Town 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 20" Scum thickness 1" 11 Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? 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.): Tank is in good condition with baffles installed and no sign of leakage. 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 t5ins 3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts •� _ - _ J Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G M 448 Marstons Ln Property Address Anne Conway r Owner Owner's Name information is required for every Barnstable t+ MA 02637 6-20-15 page. City/Town State Zip Code Date of Inspection , D. System Information (cont.) - f , :,,, Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage;'efc.): ' 1 - - �. -..-ll- • , 1.,a, +. •.:r.. .-+ ,# ,.•:{_ .. . � r�.+ y k;tti xt i•� •J r. 1.. 'r 1 •t. 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: t :;f '..3:, ; .. '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•3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts s Title 5 official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 448 Marstons Ln Property Address Anne Conway ' Owner Owner's Name information is Barnstable MA 02637 6-20-15 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) - Distribution Box(if.present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): Good condition with water at working level and no sign of back-up from pit. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in wonting 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System'Form-Not for Voluntary Assessments 448 Marstons Ln Property Address , Anne Conway Owner Owner's Name information is required for every Barnstable MA 02637 6-20-15 s page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type ® leaching pits number: 1-1000 gal ❑ leaching chambers - number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number;,dimensions: ❑ overflow cesspool number: r ❑ innovative/alternative system Type/name of technology: ° - -t _ ,< +;•r, Comments(note,condition,of soil, signs of hydraulic failure;level of ponding;damp soil, condition of vegetation, etc.): , Leach pit in good condition and empty at inspection with stain line at 36" below inlet invert. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System°Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 448 Marstons Ln Property Address Anne Conway Owner Owner's Name information is required for every Barnstable MA 02637 6-20-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.): a t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts q Title 5 Official Inspection ,dorm ` Subsurface Sewage Disposal System Form:-Not for Voluntary Assessments r �M 448 Marstons Ln Property Address 3 Anne Conway Owner Owner's Name information is Barnstable - MA 02637 6-20-15- required for every page. City/Town , 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 13 a 'W.l ... .. Eay a h[.-.I _ t5ins•3/13 a. Tide 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 448 Marstons Ln Property Address Anne Conway Owner Owner's Name information is required for every Barnstable' MA 02637 6-20-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope } ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 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: You must describe how you established the high ground water elevation: USGS and town,maps show groundwater at greater than 20'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 L_ Commonwealth of Massachusetts _ Title 5 Official Inspection Fora a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 448 Marstons Ln Property Address Anne Conway Owner Owner's Name information is required for every Barnstable MA 02637 6-20-15 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Commonwealth of Massachusetts . - • , Title 5 Official Inspection-Fiorrm Subsurface Sewage;Disposal System Form -Not for,Voluntary Assessments- M 448 Marstons Ln D Property Address ; Ann Conway Owner Owner's Name information is Barnstble MA •02637 11-24=12 T required for every page. City/Town' r - 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 =, 1. Inspector: Shawn Mcelroy - Name of Inspector Upper Cape'Septic.Services Company Name ~ 29 Atwater Dr Company Address E. Falmouth MA 02536 City/Town State Zip Code r . 1-508-495-6965 S13971 Telephone Numtier License Number B. Certification "- , R ry I certifyAhat l have personally inspected the sewage disposal system at'this address and that the -- 3 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 LrItsewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of, a- 'Title 5f(31.0 CMR 15.000).The system` M( Passes -, P , . 0 -Conditionally Passes. �~ ,• Fails _©5RIeeds Further Evaluation by the Local Approving Authority v _ Inspector's Signatur ", Date " The system inspector,shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the. report to the appropriate regional office of the DEP. The original should bment 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. mo .�� t5ins•J 1 t10 ,.. y * ' Title 5 Official Inspect F m:Subsurface Sewage Disposal System•Page 1 of 17 • ,. 3 Commonwealth of Massachusetts ; Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments, . M 448 Marstons Ln , Property Address Ann Conway Owner .Owner's Name information is required for every Barnstble Y MA 02637` ` 11-21-12 " page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ' ® 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: System is in good working order with no sign of failure. B) System Conditionally Passes: I El 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)forthe 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 ' i t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 i , a Commonwealth of Massachusetts - r' Title 5 Official, Inspection Form a Subsurface Sewage Disposal System,Form,='Not for Voluntary'Assessments ° 448 Marstons Ln• - " Property Address Ann Conway Owner Owner's Name information i e Bamstble MA 02637 11-21_12 rt required for every t' page. City/Town - ;. State Zip Code{ 'Date of Inspection B. Certification (cont.) B) System Conditionally,Passes (cont.): ❑ Observation of sewage backup or break out or high static water leveHh the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will t r pass inspection if(with approval of Board.of Health): ❑y -broken'pipe(s)_'are replaced ❑ 'Y ❑ :N'' ❑ ND (Explain below): ❑' 'obstruction is removed ❑ Y. '❑ N []' ND (Explain below): " ` ❑ distribution-box is leveled or replaced 04 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:: A. Iv El Conditions exist which require further evaluation by the Board Health in order to determine if the system-is failing to protect public health, safety or the environment.. x 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: y ❑ . k Cesspool or privy is within 50 feet of a surface"water ❑ Cesspool or privy is wlthin'50 feet of a bordering vegetated wetland or a salt marsh. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 L Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface°Sewage Disposal System Form -Not for Voluntary Assessments 448 Marstons Ln Property Address Ann Conway Owner Owner's Name information is required for every Barnstble MA 02637 11-21-12 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) - 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has'a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. tEl The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No } ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins•11J10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form m Subsurface Sewage Disposal System Form,-Not for Voluntary Assessments , 448 Marstons Ln Property Address Ann Conway Owner Owner's Name information is ^6 MA 0 tblarnse 237 11-21-12r required for every B "L:t page. City/Town, _ State Zip Code Date of Inspection B. Certification (cont.) w • Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pi,pe(s). Number of times pumped: ' ❑; ® Any portion of the SAS, cesspool or privy is below high'groundwater elevation." Any.portion of cesspool or privy is within 100 feet of a surface water supply or ' ❑' `'�.K " 'tributary. Co a surface water supply.- - •❑ -® ,i Any-portion of a cesspool or;privy,is within a Zone l'ofa•publicwell., ❑ ® ' Any portion of a cesspool or privy is within 50 feet of a private water supply-well. r ,. ❑ ® Any portion of a cesspool or privy is less than 100 feet butgreater 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 porn, provided that no other failure criteria are triggered.A copy of the analysis -and chain Iof custody must be attached to this form.] El. The system is cesspo ol•serving'a facility,with a design flow of 2000gpd- s The system fails. I have determined that one or more of the above failure,i ®" criteria oist'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.alarge system thersystem must serve a facility with a design flow,of10,000 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 surface drinking`water supply t ❑ ❑ 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•11/10 t - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts y Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i - 9 p Y rY M 448 Marstons Ln Property Address Ann Conway Owner Owner's Name information is required for every Barnstble . MA 02637 11-21-12 i page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of ® this inspection? 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? ® ❑ 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? _ ®' EJ 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:' 3 t 3 ' Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-:Not for Voluntary Assessments,P 448 Marstons Ln Property Address r Ann Conway Owner Owner's Name information is gamstble MA 02637. 11-21-12 - required for every page. Cityrrown State 'Zip Code bate of Inspection D. System Information Description: r r .-. Number of current residents: Does residence have a garbage grinder?. ❑ Yes ® No Is laundry on a separate sewage system?.[if-yes separate inspection required] ❑ Yes'®, No Laundry system inspected? r f_ {'❑ Yes Z No Seasonal use? .r , ,, _ .� ❑ Yes ® No Water meter readings, if available:(last 2 years usage.(god)):, Detail: ` rat Sump pump?, J =s. __ i ❑ Yes ® No Last date of occupancy: 11-2012 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on,310 CMR 15:203): - Gallons per day(gpd) 0-Basis.of design flow(seats/person s/sgft.,:etc.): Grease trap;present?, ❑ Yes ❑, No Industrial waste holding tank present?; , , , s#: 1 ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter.readings,.if available: t5ins-1 ill 0 . Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 17 v Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Vol untary'Assessments 448 Marstons Ln F Property Address Ann Conway Owner Owner's Name information is required for every gamstble' MA 02637 11-21-12 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General.Informatio n Pumping Records: Source of information: NIA ' 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): f - t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 E Commonwealth of Massachusetts h Title 5 Official Inspection'.Form I o Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments „t i M 448 Marstons Ln Property Address �` _ 4 ' Ann Conway r Owner Owner's Name information is Barnstble MA 020T 11-21-120 required for every - • page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1986 Were sewage'odors detected when arriving at the site? Yes ® No Building Sewer(locate on site plan):.c ,, n. • ; . 18" Depth below grade: ` , r +'�. feet'. { fi Material of construction: ' ❑ cast iron ` ®'40 PVC_ ❑r other(explain): s Distance from private water'supply well or suction line:' feet- Comments (on condition of joints, venting, evidence of leakage; etc.): Good condition. ' .. Septic Tank(locate on site plan): r Depth below grade: , .1' .,. _. 12" feet" Material of construction: _ s ® concrete ❑ metal ❑•fiberglass " El polyethylene t, ❑ other(explain) '. • or If tank is metal, list age: x. years Is age confirmed by a Certificate lof,Compliance? (attach�a copy of certificate) ❑ Yes ❑ No " Dimensions: 1000 gal Sludge pa de the 1211 t5ins•11110, Title 5 Official Inspection{ c p 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 448 Marstons Ln Property Address Ann Conway Owner Owner's Name information is required for every garnstble MA 02637 11-21-12 page. City/Town 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 20 1„ Scum thickness Distance from top of scum to top of outlet tee or baffle 611 Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? 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.): Tank is in good condition with baffles installed and no sign of leakage. 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I ; Commonwealth of:Massachusetts Title 5 Official Inspection form r r Subsurface Sewage Disposal System'Form -'Not for Voluntary Assessments , r 448 Marstons Ln Property Address Ann Conway Owner Owner's Name information is garnstble` MA - 02637 11-21-12 required for every - page. City/Town - State Zip Code., Date of Inspection' D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle•condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank'must be pumped at time of inspection) (locate on site plan): 'Depth below grade: q` 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-11/10 ' r' Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 448 Marstons Ln Property Address Ann Conway Owner Owner's Name information is required for every Barnstble MA 02637 11-21-12 page. City/Town State Zip Code Date of inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): Good condition with water at workinglevel and no sign of back-up. g P 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts-, ,! Title 5 Official Inspectionform Subsurface Sewage Disposal System Form,-Not for.VoluntaryAssessments ` y M 448 Marston s Ln 5+ A r Property Address 3 V Ann Conway Owner Owner's Name • information is Barnstble x a MA 02637 . 11-2.1-12`3 required for every r page. City/Town State Zip Code Date of Inspection D. System Information (cont.) a leaching pits number: 1-1000 gal ❑ leaching chambers - number: ❑ leaching,galleriesr_r number: - - ❑ leaching trenches number, length: p * ' . ❑ ` leaching fields number,dimensions: ❑ 1< overflow cesspool number: .•4 " ❑ innovative/altemative system Type/name of technology: Comments (note condition of soil.;signs of hydraulic failure, level of podding;damp soil, condition of vegetation, etc.): Y , Leach pit in good condtion and empty at inspection with stain line at 36"below inlet invert. r • • � r I Cesspools (cesspool must!be pumped as part of inspection) (locate on site plan): } Number and configuration r Depth—top'of liquid to inlet invert ,,='Depth*of solids layer Depth of scum layer u Dimensions of cesspool " Materials of construction ' Indication of groundwater` inflow ❑ Yes ❑ No t5ins•11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 , • Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 41 �M 448 Marstons Ln Property Address Ann Conway Owner Owner's Name information is garnstble MA 02637 11-21-12 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): g - Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11l10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection fb.r`m Subsurface Sewa ge e Disposal S stem Form -Not for Voluntary Assessment's ` 9 p Y rY 448 Marstons Ln Property Address 'k Ann Conway Owner Owner's Name + information is garnstble r• , required for every MA 02637 r 11-21-12 page. City/Town, ;, 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 R _, ❑ drawing attached separately Y ' Aq ot Y , + : .; t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of.17 Commonwealth of Massachusetts a Title 5 Official Inspection .Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 448 Marstons Ln ' Property Address Ann Conway Owner Owner's Name information is required for every Barnstble MA 02637 11-21-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: t ' ❑ Check Slope ❑ Surface water •y ❑ 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: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than20'. ` v Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection F-orm k . Subsurface Sewage Disposal System Form-Not for Voluntary Assessments - M 448 Marstons Ln Property Address < Ann Conway Owner Owner's Name information is: a required for every Barnstble MA 02637. 11-21-12' , page. CitylTown 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) completedw. ® System Information—Estimated depth to high groundwater - ® Sketch of Sewage Disposal System either drawn on page•,15 or attached in'separate file f s t5ins•11J10 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 17 of 17 • x ` LE lax LocaTiorr VILt, �lr �/1 :K A5SP,S4�It'S N1AP d'c 1.,0'�_.: ]N5TR�Ja1.EIt'S NAILA PtY(?ME hiC9 "S'AI'ZX CAPACTCY ------ L ►CivI11�iGSWUM (type) Bta— ER OR 1 kitVt;1T➢� .'XE• l►/Ct'"l;w-qd bAT i�...�. ._.: ..._...w` S�eprtr�eiaei 1!3)�f�►��.�eivl�£�tlae� :;t MaxlmumAdjusWdGtau►il.Watet' ,a taCatlwootM000,Lea Pals 4�:y 1 atcc 5ap�lj V1 it' i u.- hilt caGiy C t ty e1ls�xisti �rcr�a ata sl�,�acUil�lsn Epp feet,of 1�acEun�fttcillty) �,,,,-,�-„ ` Rim, f wo,c�aad aw I.�aatttniy ihaca�iey(CF r�uy w�tl�uycl5�xas4 � ivlthu,3QA font at 4f1C�li S Puty) jot r �✓r e Puri�st�rcl�t>y .:: T-1 C D 6"3c)` I TOWN OF BARNSTABLE L Cab 1ClON 7 �s -5 Z SEWAGE VIL:L'AGE 2GRIAs lb/e ASSESSOR'S MAP& LOT_ INSTAL, EWS NAME&PHONE NO. . - SEMC TANK CAPACITY _ZQ0 LEACHNG FACILI ff, (4r) (size) NO.OF'BSDR0OMS.,.r.,3 - WILDER OR OWNER. PERMIT®ATE:.-_ _COMPLIANCE DATE: Separation Distance Between the, Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feel Private Water Supply Well aid Leaching Facility (If any wells exist on site or within 200 feet of leashing facility) Feet Edge of Wedand and Leaching Facility(if any wetlands exis within 300 feet of l9sebing faciliry L � � �„�,,I Fee FurcVshed by .._. a Fro,, f y 1 11� A -0- 1S' /5S' C -F- 17' -f- 81 F-39' Q -6- ASSESSOR'S MAP N0.437 S�. PARCEL 6 0~ 0CA3IaN -5l4/ SEWAGE PERMIT NQ. 1 A Gam- �., 0.,?_1 INS-T:A LLER S NAME i AD'DRESS B U I L D E R OR OWNER DATE PERMIT ISSUED DATE C 0 M P L I A N C E ISSUED " 3 F i Q i l o�` No.� : 2 r Fxa ........... COMMONWIALTH'OF MASSACHUSETTS llv BOAR® OF HEALTH y' .. ... -.............-._..-.OF........ �1i`�S /f�L ration for Uiopoii al Vorkg Tonstrnrtinn rrrmit Application is hereby made for a Permit to Construct (LI"or Repair ( ) an Individual Sewage Disposal System at �K.1� . ' -... - .. ........ �• ocation-Address or.- t•No 1I /!/ O er / r Address W (' ..__.......SiJ _ ................. ...... L__7..__ �� 1 '11. t� '> ���i�}_�..1 ..1.. i �fy` �� Installer Address Type of Building Size LotS �__��______Sq. feet Dwelling—No. of Bedrooms......................_______________________Expansion Attic ( ) Garbage Grinder W'13 p`4 Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures ............................ j�� -------------------•--------............................................................ ---- W Design Flow..............___1. .................gallons per per �a,y. Total dail�flow--------------- - --------------gaup •e f _____04 Septic Tank—Liquid capacity/� gallons Length__ _________ Width__�e.l___ Diameter................ Depth_,-•_______-- Disposal Trench—No_ ____________________ Width.............._..... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.......... _________ Diameter......l_.Y..... Depth below inlet.... ..._.._..__. Total leaching area....39797sq. ft. Z Other Distribution box Dosing tank ( ) ' a Percolation Test Results rr// Performed by. �________.__ . ,_Y--___"IFY____�_:_��_______________ Date__.__...1._.t__._____ _______..__. Test Pit No. 1.:_._.__?`___.minutes per inch Depth of Test Pit..... Depth to ground water............... . Gz, Test Pit No. 2_G._.___._._minutes per inch Depth of Test Pit..... 5`,__ Depth to ground water aG vso�c w aterS_�__-_T/s.L.�x--..------- -----•----- ---------------•-••--7----- . ---- Fir✓ ��"A� e[ ¢YO Description of Soil '-- -- yy/f�-------- ------------ vx f0 Qortoe1c � ✓!�__8 �--� .. . f f .....3..... .................... ----s ---''-�---------------------------------- U Nature of Repairs or Alterations-Answer when applicable.__ _ 31601 Na �JF�iN�z;L . .-rr tT.v_ � l_ _ �1 C .--i5•--.--•1 ©�S Agreement: 12a�Q,t The undersigned agrees to install the aforeaescribed Individual Sewa e Disposal System in accordance with the provisions of iITI �, 5 of the State Sanitary Code—The under ' fur .er o place the system in operation until a Certificate of Compliance has a issued by t obi Signed - ----- ------------------ ---- ---------••-------• -- r� C atp Application Approved By.............. -� p--��=---=---•-- '-�.......................... `z_ _! -- Date Application Disapproved for the following reasons:...............................................................1.==............................................. -•-•-•------•-••-•-----•-------------------------•---•-•-•••••---•-----•--•-------•--------•-•--•-••...--•-•----------------•-•----------------------••••--•------••-•••-•----•--...-•--•---••---------- Date PermitNo...... ................................. Issued....................................................... Date i FE$ �......._. THE COMMONWEALTH 6F MASSACHUSETTS BOARD Of., HEALTH ..®`..............------...OF......... ! !�`�JsTr� C.. ................ Appliratiun for Disposal Works Tonstxnrtion Prrmit Application is hereby made for a Permit to Construct ( Ll"Or Repair ( ) an Individual Sewage Disposal System ................__- _.........._...... ............................................... ----••--•.....--•------••.................-•-•------------•---•----------•----•---..........---... .• .c,arti.o n-�Address G . 4U o � '�/ (�i� ¢o - 3/�... - .. ........... � _ _ Owner ddress ..... Installer ress / U ----%�Type of Building _j SAddize Lot......... - ............... feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( G aOther—Type of Building ............................ No. of persons............................ Showers t ) — Cafeteria ( ) Otherfixtures ------------------------------------ ------------------------------------------------------------------------------------------ Design Design Flow................ per persorrp�r da}�. Total �i)��flqw..--.---•--•-----•-.---------•---......-----gallgnA. WSeptic Tank—Liquid capacity.----•------gallons Length.- ... Width................ Diameter................ Depth...-.-- ........ x Disposal Trench—No. .................... Width ....-........... Total Length.................... Total leaching area.._........r �t ft. Seepage Pit No..................... Diameter.............�.... Depth below inlet.................. Total leaching area................... ft. z Other Distribution box Dosing tank �+ /may �'Cy2j l f2Z��Y a Percolation Test Results u Performed by....................................................-�-.�. ._....----- Date--------------- ..... Test Pit No. 1_..G.._..minutes per inch Depth of Test Pit...... Depth to ground water............... . 44 Test Pit No. 2.__G.-......minutes per inch Depth of Test Pit-------.. _y__«. Depth to ground water................. ..G'' --------•---•--------------•---------•--.---- O Description of Soil.. _-�C= ?o s�•�s��c - /V y /`?chi u.� �'f�w S�-!� f 1-i a 6 .... C r _ r._....--•------••--•-...--•--••••. --•- -- ��i ����L-`�(�/itJ� ✓i�" �1.� 1 / -�---------- -- 16 I O-----. 6i N 2 Moms i U Nature of Repairs or Alterations—Answer when applicable...___ Z-��................:......................................................... ..� �. SENT. C`a 1 � �nil �°Rc� f"I ury CEYz i f F �,-,I... .S I Vv,�------- y ' -------•---•� ---------------------- ---------------------------------- ------------ Agreement: y n e - �o� I!'�C�;I �� P 1 E The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITS E ;of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b issued b th d f health. Signed-• • ................. . ----_ y 13,�C Date 61 Application Approved By................z ��:� --------------�-...............--•-••------ ........ : _7 -Date Application Disapproved for the following reasons:---•----------•---------------------------------------•------•--.............................................. -•---••....---•----•••--•-•--•--•---••---•-•••-.....-••.......................••••-••---.......--------•••----------------•-••--•-••----•----•-•---------------•-•-•-•----•----•--•--•--•-•-••-•-----••- Date PermitNo........ -- .'D.2......... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH I ..........................................OF......................**.................. ........ (Irrfifiratr of. um l THI TO CERTIFY Tk "IC;aV the Individual Sewage Disposal System constructed ( �or Repaired ( } by �IL....1 n -......!`.. r --------------------------------------------------------------... Installer - at---_-------J.. -----1_'__.' ��� � ---...�=-n -rn-Mc c,v has been installed in accordance with the provisions of T I T I 5,of The State Sanitary Code as descrjbed in the application for Disposal Works Construction Permit No........ dated__.._-_.-�:_ ..�_ ... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE __S'YSTEM WILL FUNCTION SATISFACTORY. DATE............. ..-...)-K...-_.y.... Inspector........ �.... ... ............... THE COMMONWEALTH OF MASSACHUSETTS _VG i NsS r'z 4'�US j BOA D—G HEALTH (� P2 _VD q'N C_ �(p- 1-Z'Z �.�<f••�i��............OF............ ..................................._.................................. FEE iv'o.................. .... � Zl Disposal arks Tun #rnr$iun fermi# ° Permission Is hereby � granted}.. n..............g--...._ p ....y.-----..................................................................... to Construct or Repair an Individual Sewage Disposal S stem• at No......... .......,Y•`-cat } -�, L l'' Street as shown on the application for Disposal Works Construction Permit o.. -'_ ?� Dated.,.--z). 3__ ............. Board of Health DATE ............ FORM 1255 OBBS & WARREN. INC.. PUBLISHERS 5 i R.J. O'HEARN, INC. p REGISTERED LAND SURVEYORS eswan e,i iuEt q1nit 3 REGISTERED SANITARIANS J�.C�. Box 237 35 eRout- 134 eSout�i L1Dennls, ass. o266o 394-1265 May 20, 1987 . Town of Barnstable Main Street Hyannis, Ma. 02601 Attention: Board of Health Re: Lot 11 Marstons Lane Cummaquid Heights, Barnstable, Ma. Dear Board Members: This office has inspected the sanitary system at the above referenced project and it is our opinion that it has been installed as shown on the approved plans. `\ Very truly yoursgg R. J. rn- e ',hc. Oha ' Harn, President RJO/de ' i a Oe N NJ =i Q.To 107 �r .�00 JR I (ec�' i7 1 9 �cl`"„e co e tec4��C y - -- 20-- M IN TOP OF FOUND FT-- _ __ -------- - _ ------_ -------------_._ -_ -._---.'"� EL = /0 0 ' 10 FT MIN. .. ' CONCRETE —� COVERS 4 SCH 40 PVC -- CLEAN SAND 404, PIPE- M,N. PITCH CONCRETE 1/8�� PER FT COVER 4" CAST IRON - -- --------- - 1 2 LAYER OF ! ` -- MAX. -- -- �, �. y PIPE - MIN. PITCf' - -- -- 1/8 - 1/2 WASHED j --- -_ __ _ - 1` STONE 1/4" PER F T � _- � __ . 'LOW LINE-, 'v-I� E = Y MIN - - f l 6QS�t :l L. ��o.-- I�.. N E� t / AI U '`!'�� _ _.. S J _ E L. -- - ; DIST LOCATION MAP BOX n 4- - _--- --- / ! 3/4''- 1 1/2„ - - - _ -_ �'c' mw a o a my Gol'�tlC--�+ WASHED STONE c� y� w w n � ; �.J��t 1`V T•�" HOLE 1G r .i j' 4. „' i/.G0 ,4., Ep `i- ° Ujl� __.�n�._- _ GAL. PRECAST LEACHING �° --EI /-S I i roo BASIN OR EQUIV. I wrTrtE�a T SEPT I C 6.0, c / _ �ERC RJ�TE �{ jvi►N�Ih1 /oZ 9;;— ,� TANK I .. j _ 14 i If _ —/p ' M PROFILE OF BOTTOM OF TEST HOLE OR USGS PROBABLE WATER TABLE EL GROUND WATER TABLE( / / ) EL. _ - -'°8 SEWAGE DISPOSAL SYSTEM - 4 NOT TO SCALE , f N DESIGN CALCULATIONS SOIL TEST NUMBER OF BEDROOMS 3 -- DATE OF SOIL TEST TOT GARBAGE DISPOSAL UNIT ` WITNESSED BY -`�:'' * ' AL ESTIMATED FLOW �• __._ -/00 // If iC; z PERCOLATION RATE h? ^a ! N ;= ( GAL /BR./DAY x BR ) ,1.,iCa GAL./DAY Mt. REQUIRED SEPTIC TANK CAPACITY. 9s GAL OBSERVATION HOLE I OBSERVATION HOLE 2 179 ACTUAL SIZE OF SEPTIC TANK. . /OOL7 GAL ELEVATION = ✓00 Z ELEVATION sE 3 LEACHING AREA REQUIREMENTS SIDEWAIL AREA % BOTTOM AREA / , t GAL/S.F. TOPS SiJ£x�D/L ! 3b f .`cJc9S`�I:. N` LEACHING CAPACITY ( BOTTOM + SIDEWALL) . 479. GAL. JycO ►j'l", ';ET.F i ( RESERVE LEACHING CAPACITY _479.`'GAL /�f'4G'rfT �f i�"N✓f� „ •�cOC. - CFNSf i I \ � \ � t r9RGE .RUC iCS -,Dfir�',�' e�••.�+ �"�' ; t Ct 4Y NOTES I ALL WORKMANSHIP AND MATERIALS SHALL CONFORM f�r7 h<r�TERNCOfJ/i>~7'fKEp /'t'7 v+/ryTEn crc �Tt�",+]'Ec'3 ! TO D E.Q. E. TITLE 5 AND THE TOWN OF e'R.3'.r1.:`7" ter' r<T RULES AND REGULATIONS FOR SUBSURFACE DISPOSAL Ec . 94.6 OF SANITARY SE WAGE 2, ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO WITHIN 12'' OF FINISHED GRADE. 3. EXISTING AND FINAL GRADES SHALL REMAIN ESSENTIALLY MIN. FRONT SETBACK THE SAME. MIN REAR SETBACK _ ..�� 4. NO DETERMINATION HAS BEEN MADE BY THIS OFFICE AS TO MIN SIDE SETBACK — -- COMPLIANCE WITH TOWN ZONING REGULATIONS. OWNER/APPLICANT IS TO OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. APPROVED BOARD OF HEALTH O� +fir r !.1 u Y !u 1�n n 1 { ----- '� rJ j J /S r� !t. % i I�1�?:._.�' {2: fi '. i ti%'e�1C°leI DATE A G E N T 'O PROJECT LOCATION L� fi AAE APPLICANT - G � 1 � � .�A,; .Arcs?. �� Yr'(/ ,�. - ��:h''.' ��✓ t-/y.-B'(r ,t�c.e�e.� LEGEND SCALE: DR Q� DATE CA EXISTING SPOT ELEVATIONS 00 0 +� X EXISTING CONTOUR - - - - - - 00 - - - - °r 'jam = R1 I JOB NO APPD. 8� REV RiGHAP D , s z � FINAL SPOT ELEVATIONS 00.0 �ah�� / y FINAL CONTOUR - 00 O'N ARN R. J. O HEAR/V, INC. DRAWING SIT PLAN SOIL TEST LOCATION , \ T RE6- LAND SURVEYORS- REG. SANITAR/ANS -- - ----- - -- ,2,� � �� `/ /, r , rye' ROUTE /34 - UNIT 2 a SOUTH DENNIS MASS OF _J1