HomeMy WebLinkAbout0489 MARSTONS LANE - Health c'.09 Marstons Lane
Barnstable
J I I : ' I ..
M
No. .( €71 — 11 Fee
BOARD OF HEALTH
TOWN OF BARNSTABLE
zIppYicattou jfor Yell cougtructiou Permit
Application is hereby made for a permit to Construct( Alter( ), or Repair( ) an individual well at:
Location-Address Assessors ap and Parcel
Owner Address
Installer-Driller Address
Type of Building /
Dwelling
Other-Type of Building No. of Persons
Type of Well `�'r�(L� `1�►� Capacity
Purpose of Well 41 W el"
Agreement:
The undersigned agrees to install the afore described individual well in accordance with the provisions of the
Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the
well in operation until a Certificate of Co liance has been issued by the Board of Health.
Signed "T
ate
Application Approved By /� 000r — V rr
Vare
Application Disapproved for the following reasons:
Date
Permit No. n 1( Issued t<
Date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate of Compliance
.THIS IS TO CERTIFY,that the individual well Constructed( Altered( ), or Repaired(
by N 14^-).S 6L)egZL iQJ 1.j C=,
Installer
at 7"g
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private We l P tection
Regulation as described in the application for Well Construction Permit No.f,-)2011 O N Dated I Zpl
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORILY.
Date Inspector
No. 1�( a 11 Fee
BOARD OF HEALTH
TOWN OF BARNSTABLE
ZtppYtcattou _for Vern Cou,5tructtou Permit
Application is hereby made for a permit to Construct(�� Alter( ), or Repair( ) an individual well at:
34
Location-Address y Y Assessors MAP and Parcel
Owner Address
c,t�Fe\-A— -Q
Installer-Driller Address
Type of Building
Dwelling
Other-Type of Building No. of Persons -*
Type of Well 12 V 6F3rr117 0 Capacity 1,19 /-Lh'n
Purpose of Well 411 W , V
Agreement:
The undersigned agrees to install the afore described individual well in accordance with the provisions of the
Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the
well in operation until a Certificate of Compliance has been issued by the Board of Health.
Signedt4
a ss ate (
Application Approved By
PP rove
. PP 7
r / t Date
Application Disapproved for the following reasons:
Date
Permit No.
bo �-V1q 0)( Issued
t Date
—e — -------------------------------------------------- m-----------------------------------------
I
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate of Compliance
THIS IS TO CERTIFY,that the individual well Constructe Altered( ), or Repaired( )
by
Installer
at (s9 tA.,Z c,
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit No.t-)20(1- O 11 Dated t/A! 2-oily
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORILY.
Date Inspector
---------_ ________________________________ ---------------------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
Veil Con5tructtou Permit
Fee ( 7
Permission is hereby granted to Iy QS WC� i L4,l ty
Installer
to , I Construct( Alter( ), or Repair( an individual well at:
No. �! Oq /A�1?-S_TnA) <- / A-iJr TzP,- -t\,L �1'I(�l_k�
• -� ` °'ems � Street t /
as shown on the application for a Well Construction Permit No. ( �( I I Dated 'i ( �'7� q
Date (.,rf I i 1 I -210 (q Approved By
Commonwealth of Massachusetts °
Title 5 Official Inspection Form; -
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments R
489 Marstons Lane, Cummaquid }, M =348 P. =34
Property Address
Joseph Donahue
Owner Owner's Name
information is '
infor edorevery P.O. Box 102,Cummaquid'£• MA 02637 April�5,2012
page.requi City/Town State Zip Code Date of Inspection .
Inspection results must be submitted on this form. Inspection forms may�not1be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer, • l��"") \�v/
use only the tab 1'. Inspector: ,' '' -
key to move your
cursor-do not Troy Williams
use the return key. Name of Inspector
Troy Williams Septic Inspections
ICI Company Name
19 Hummel Drive '
'
Company Address w `
South Dennis _ 'MA •02660
Cityrrown State Zip Code
(508) 385 71300 S1682 -a
Telephone Number License NumbercD
. • ,
B. Certification ;
I certify that I have personally inspected the sewage disposal system at this address apd that the _.�
information reported below is true, accurate and complete as of the time of the inspection. The inspec0on
was performed based on my training and experience in the proper function and maintenance of ors site=
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15340 of
Title 5(310 CMR 15.000).The system:. - -
'-® Passes ' [a.Conditionally,Passes ❑ Fails,r•
❑ Needs Further Evaluation by the Local Approving Authority
2, Aril 5, 2012 <
Inspector's Signaturd 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•11I10 , Title 5 Officialbsurface SewagIMSpoVystem Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
489 Marstons Lane, Cummaguid M-348 P-34
Property Address
Joseph Donahue
Owner Owner's Name
information is P.O. Box 102, Cumma uid MA 02637 April 5, 2012
required for every 4 p
page. Cityfrown 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:
w
® 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 meets minimum standards set by Massachusetts DEP at the time of inspection only.This
inspection is not a guarantee or warranty on the future working conditions of leaching, pipes,
components or the future structural integrity of said components and only represents conditions found
at the time of inspection only.
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):
N/A
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Y -
Commonwealth of Massachusetts
Title 5 Official Inspection Form ,
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments{
489 Marstons Lane, Cummaquid M -348 P=34 -
Property AddressA
Joseph Donahue 4 .
Owner Owners Name Y
information is b {
required for every P.O. Box 102, Cummaquid.' MA - 02637 ' April 5, 2012 ,
page. Cityffown ' r-• State Zip Code Date of Inspection
B. Certification (cont.)- `°
B) System Conditionally Passes(cont.): r t`
❑ 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):
Elbroken pipe(s)are,replaced # ❑i.Y .-❑1N ❑ ND(Explain below):l
❑ obstruction is removed`` 0 Y' ❑ N ❑,,ND(Explain below):
❑ distribution box is leveled or'replaced.. ❑ Y° ❑;'N ❑ ND�(Explain below):
* - PT .
N/A ,.
❑ 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): s
❑ 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:,
4, ❑ 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)(bj that the system is not functioning'in a manner which will protect public health,
safety and the environment:' .R ;
❑• Cesspool or privy is within 50 feet of a surface water t .. .
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh k.
Pins•11110 _ 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
489 Marstons Lane, Cummaquid M-348 P-34
Property Address
Joseph Donahue `
Owner Owner's Name
information is required for every P.O. Box 102 Cummaquid MA 02637 April 5, 2012
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: ,
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 s, ,
❑ ® 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 Y2 day flow
t5ins•11/10 Title 5 Official Inspection Forth: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 y ,.
°l 489 Marstons Lane, Cummaquid l M=348 P-34 ,
Property Address 1 '
Joseph Donahue
Owner Owner's Name +
information is
required for every P.O. Box 102, Cummaquid ; . MA:' 02637 .April 5; 2012. 1-7
page. Cityrrown ;',,• State', Zip Code Date of Inspection
B. Certification.(cont.)
Yes No 14+4 '
Required pumping more than 4 times in the last year NOT.due toclogged or
❑• ® obstructed pipe(s). Number of times pumped:
"
❑ ® 'An portion of the SAS,'cess ool or privy is below high ground water-elevation..
YP P .
Any portion of cesspool or privy is within 100 feet of a`surface water supply or
0 ' -® `` tributary to a surface water supply. f .. .; -
❑ ®' Any portion of a cesspool or privy is within a Zone 1,.of a public well.
❑ 19 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.
` El ® 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
❑ ❑ .E •the system is within 406 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
❑" t 0' 'Area-IWPA)or a mapped Zone'll of a public water supply well ,
If you have answered"yes"to any question in Sectioh'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 316 CMR 15.304. The system owner should contact the appropriate
regional office of the Department. '
t5ins:11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts ,
-UTTitle 5 Official Inspection -Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
489 Marstons Lane, Cummaquid M -348 P-34
Property Address
Joseph Donahue
Owner Owner's Name
information is p O: Box 102, Cummaquid MA 02637. A 5 required for every April , 2012
page, City/Town State Zip Code Date of Inspection
C. Checklist ,
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ •,Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 1.5.302(5)]
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 gpd
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
"Y 489 Marstons Lane, Cummaquid M-348 P-34
Property Address µ
Joseph Donahue
Owner Owner's Name
information is P.O. Box 102, Cummaquid. ` MA 02637 A nl 5, 2012
required for every P
page. City/Town State Zip Code bate of Inspection'
D. System Information a
Description: -
x .
Number of current residents: , 2'
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?. ® Yes ❑ No .
Seasonal use? _ ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 11=115,000 gals.
9 ( y g (gP ))' 10=110,000 gals.
Detail:
Sump pump? ❑ Yes ® No.
Last date of occupancy: occupied ,
Date
Commercial/Industrial Flow Conditions:.
Type of Establishment: N/A ."
Design flow(based on 310 CMR 15.203): N/A
Gallons per day(gpd)
- Basis of design flow(seats/persons/sq.ft., etc.): N/A
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: N/A
t5ins•11110 Title 5 Official Inspection Forth: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
yt 489 Marstons Lane, Cummaquid M -348 P-34
Property Address
Joseph Donahue
Owner Owner's Name
information is required for every P.O. Box 102 Cummaquid MA 02637 April 5, 2012
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: N/A
Date
Other(describe below):
General Information
Pumping Records:
Source of information: No pumping info was available.
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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form T
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
489 Marstons Lane, Cummaquid M -348 .P=34
Property Address t
Joseph Donahue '
Owner Owner's Name
information is
required for every P.O. Box 102, Cummaquid MA 02637 . April 5, 2012'
page. Cityfrown State Zip Code Date of Inspection,
D. System Information (cont.)
Approximate age of all components,.date installed (if known)and source of information:
Tank, d-box and leaching were installed on 4/11/83 per compliance.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan): ?
_ 18„
Depth below grade: ' feet
Material of construction:' ,.� • �: }
{ .
❑cast iron ®40 PVC ❑other(explain):
Distance.from private water-supply well or suctiodline: N/A
feet
Comments(on condition'of joints, venting, evidence of leakage, etc.):
Lines were found clear at the time of inspection.
Septic Tank(locate on site plan):,
2.5'with riser to 6"-
Depth below grade:
feet
Material of construction; Via.
®concrete ❑ metal ❑ fiberglass ❑`polyethylene - ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach'a copy of certificate) y. ❑ Yes ❑ No
Dimensions:
6'X10.5'X6''1500 gallon
A11:
Sludge depth: Y
t5ins•11/10 Title 5 official Inspection Forth: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 ,
489 Marstons Lane, Cummaquid M -348 P-34
Property Address
Joseph Donahue
Owner Owner's Name
information is P.O. Box 102, Cumma uid MA 02637
required for every q April 5, 2012
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
21811
Scum thickness Thin layer
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 14"
How were dimensions determined? probe/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.):
Pvc inlet and outlet tees were found present and in working order. No evidence of leakage or damage
was found. Tank was not in need of pumping at this time.
Grease Trap(locate on site plan):
Depth below grade: N/A
feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
N/A
Dimensions: N/A
Scum thickness N/A
Distance from top of scum to top of outlet tee or baffle N/A
Distance from bottom of scum to bottom of outlet tee or baffle N/A
Date of last pumping: N/A
Date
t5ins-11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection' Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
489 Marstons Lane, Cummaquid M.=348' P-34
Property Address
Joseph Donahue
Owner Owner's Name
information is p O:Box 102, Cummaquid' 'MA• 02637 Aril 5 2012
required for every P � -
page. Cityrrown 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.):
N/A _
t
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on.site plan):
Depth below grade: N/A '
Material of construction:
Y
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
N/A
Dimensions:
Capacity: N/A '
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.):
N/A
{
*Attach copy of current pumping contract(required). Is copy attached? `❑ Yes ❑ No
y
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
489 Marstons'Lane, Cummaquid M -348 P-34
Property Address
Joseph Donahue
Owner Owner's Name
information is required for every P.O. Box 102, Cummaquid MA 02637 April 5, 2012
page. Cityfrown 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 level
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 was found in working order.
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.):
N/A
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts .• .� � >,
Title 5 Official Inspection Form `- t
ai Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r Y
a
6
489 Marstons Lane, Cumma uid.
Property Address
Joseph Donahue
Owner Owner's Name
information is P.O. ox 102, Cummaquid MA a 02637 April 5, 2012 _-
required for every _ C1. State, Zip Code ` Date of Inspection
page, City/Town
D. System Information (cont:) _ • r : '~ _t
�a
Type.
2-4'X6' pit with
® ' leaching pits` "�' h^ number: 2'of stone
❑' - leaching chambers . number: .
*..
leachin alleries x'.� + number:'
El „9 9 ,
number;len the
❑ leaching•trenches ,{ g
❑ leaching felds� 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.): •` `
Leach pit#1 was found with'little water present on inspection with a visible stain`line approx. 2"from
bottom. No evidence of hydraulic failure was found present in pit#2. No evidence of hydraulic failure
or problems in the past were found at the time of inspection.
j
n
Cesspools (cesspool'must be pumped'as part of.inspection) (locate on site plan):
N/A
Number and configuration
-N/A
Depth=top of liquid to inlet invert• ;y
r + Y MA. '
y. Depth of solids layer
i N/A
Depth of scum'layer,i ~
N/A ~
Dimensions of cesspool
N/A
Materials of construction 4 '
Indication of groundwater inflow ❑ Yes ❑ No
15ins•11110 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
r
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments,
489 Marstons Lane, Cummaquid M-348 P-34 `
Property Address
Joseph Donahue
Owner Owner's Name
information is p O. Box 102, Cummaquid MA 02637 A 5 required for every April , 2012
page. Cityrrown 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.):
N/A
}
Privy(locate on site plan):
Materials of construction: N/A
Dimensions N/A
Depth of solids N/A
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
j
N/A,
t5ins•11/10 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,'t
489 Marstons Lane, Cummaquid. 6� ' 3 `� _ M:348 P-'34
Property Address
Joseph Donahue
Owner Owner's Name '
information is g April 5, 2012
required for every P.O. Box 102, Cummaquid MA 02637 .
page. City/Town .• State Zip Code . Date of Inspection.
D. System Information(cont:)
Sketch Of Sewage Disposal System: Provide a view of the-sewage disposalrsystem, 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: S
® hand-sketch in the area below
El drawing attached separately
S.
t31 - ►76
L.
, . •,,. �y c -� ,� • ,� g Y • _ .• . R.F. •• _ •
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 s
Commonwealth of Massachusetts
Title 5 Official Inspection- Form .
Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments
489 Marstons Lane, Cummaquid M -348 P-34
Property Address
Joseph Donahue
Owner Owner's Name
information is required for every P.O. Box 102 Cummaquid MA 02637 April 5, 2012
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°0'+
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:
AIW 247 Zone C 23.4' 3.6'adjustment
You must describe how you established the high ground water elevation:
Hand augered 4' below bottom of leaching with no water found at a depth of 10.5'. Groundwater
adjustment at the time of inspection was 3.6'. Bottom of leaching at 6.5'was found not to be located
in the high groundwater elevation at the time of inspection. USGS groundwater map for Barnstable
estimated groundwater at 78.8'. '
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 OfficialInspektion Form y
Subsurface Sewage Disposal System Form'-Not for Voluntary Assessments
489 Marstons Lane, Cummaquid M -348 P 34
Property Address -^
Joseph Donahue
Owner Owner's Name
information is required for every P.O. Box 102, Cummaquid MAI. 02637 April 5, 2012
page. Cityrrown , State Zip Code Date of Inspection
E. Report Completeness Checklist.` ;
® Inspection Summary:A,B, C,b;'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-11/10 Title 5 official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17
• I
TOWN OF BARNSTABLE
LO�ATION~'y�°I M&MAS f AAe SEWAGE#
VILLAGE CUMMAui 8 ASSESSOR'S MAP &LOT 3y$ 03
INSTALLER'S NAME&PHONE NO. Soe MAh
SEPTIC TANK CAPACITY 2560 GA
� o n
LEACHING FACILITY: (type) o� ' y X r ITS (size)
NO.OF BEDROOMS
BUILDER OR OWNER f O
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the: -{-
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility -30 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 f leaching fhcility) Feet
Furnished by /i � /q q�
a
AJ
36
�9 6
y 99
.® C A Tl1QM SEWAGE PERMIT NO.
2e, 2--
'VI L LAG.t
INSTA LLER'S NAME ADDRESS
BUILDER OR OWNER
Y
® ATE PERMIT ISSUED n�
DATE COMPII.ANCE ISSUED r�
114
/3 R GF1 vl�,ysC
F,
t
t�
eIJo. z..7[�7.... Fps.. _...............
�
THE COMMONV EALTH OF MASSACHUSETTS
3 BOAR® OF HEALTH
�4CdOoJ--------------OF....19.9 �.. s � :.
3 Appliration for, Uiipniiai Morks Tomitrurtiun ramit
Application is hereby made for a Permit to Construct ( �r Repair ( )(an Individual Sewage Disposal
-
System at: _
Loca'on•Ad ess i I or Lo No.
. .5_... �'� ........:................... .... i®l_..�--��94..1d
Owner Address
Installer Address
Q Type of Building Size Lot.__�)�7.�, .Sq. feet
U Dwelling—No. of Bedrooms............. -------.._ -Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtures .............. . j�
Design Flow.......... gall ns er person per flay. Total daily .................7_-__._._.._....___..gal ons.
W ..... �,�p f /
WSeptic Tank—Liqu' dcAt�.. tons Length.,lr2_..X' Width____-____ Diameter................ Depth_._ �.. _.
x Disposal Trench—No- ---------------- --- Width.................... Total Length.................... Total leaching area.:.....--..... ..sq. ft.
Seepage Pit No...__.`Z......... Diameter.... 1.4v00'_... Depth below inlet... P...:.. Total leaching area../,/&?sq. ft.
Z Other Distribution box Dosing tank '
'-' Percolation Test Results Performed by. l �fo�------•---------- Date--,1'G� ��/ff!Z.�-.
Test Pit No. 1_...�71-Priinutes per inch Depth of Test Pit.../� ..2,Depth to ground water... f- _._..
„G Test Pit No.S_� rminutes per inch Depth of Test Pit...,lt.; Depth to ground water---- ✓.......
----------------------- ------------------------------------------------•.'--.....---------.---•••--..............--•--•----------......------------....--
O Description of
S--o-i�l. .....I..... --�G����G ---l.....�_ ��tif--f-.�{'Yf^, �S�-%�$s�e�---.l�.,.f���ll,��'..2�p•--®�.
! 4`
6 -1 .
UNature of Repairs or Alterations—Answer when applicable----------------------_____
-•-----•---•-•---------------•-•-------------••--•------------•-•-•-----------------------------------.....--------------------------------------------------------------------•--_..._........._...----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITX 12 5 of the State Sanitar — The undersigned further agrees not to place the system in
operation until a Certificate of Compliance as b en issue by hoard health.
- c
'gned_ . ---.• .•-• � ��.... .....'•-'l.�
Application Approved .....: ....... . ji 1
..------•----------
Date
Application Di ov f the following reasons:. ...........................................-.....................................
...................... ----- . -----------------------.....--•----•--•----------........_............---
Date
PermitNo......................................................... Issued_.......................................................
Date
A
No. %. �..... F i z i .................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR®._Off' HEALTH
_ti .
Applirtation for Disposal Works Tnntrnrtiun Prrmit
Application is hereby made for a Permit to Construct ( �r Repair ( ) an Individual Sewage Disposal
System at:
.. -=`': 1`==.-`........................... ................. . .... 7 � . ...................
Location-Address �,� ' or Lot,No. y..
�) .�. .----, '` d ..... try; r ' f=-.�.> >. ...._ . ......
Owner _ Address
Installer Address
......
_Sq. feet
Q Type of BuildingSize Lot._._ r '�_r
U Dwelling—No. of Bedrooms..............�Y......_........__.._..Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building ............................ No. of persons............................ Showers — Cafeteria
QOther fixtures --- ----- •--- • -- --- ...•------•--------------•.----•-... ---------•-------- ----...........................
- - - .. . Width..: � Ions.
W g ��� g � P P P !.i daily flow............................................�
Desi n Flow.......___ ,_�____r___._...�4� allons er person e, a . Total d�
WSeptic Tank—Liquid capacity ,.�.__ga� ons Length_h ...._.. Diameter................ Depth.. ' .... `
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No......:a-------- Diameter...� V...... Depth below inlet....f-Z r...... Total leaching area../X.tc'�'2'sq. ft.
Z Other Distribution box ( -""' Dosing tank ( )
'-' Percolation Test Results Performed ......................... Date..-K:' )-----.�".-`t-'
Test Pit No. I....::�..`:minutes per inch Depth of Test Plt'f f_'r-_._ Depth to ground water..__A !'--_ .
rs, Test Pit No. --____._.I-minutes per inch Depth of Test Pit__................... Depth to ground water----- ......
i ---•----------------------------•-----•-----------•-.------•-------------- _
DDescription of Soil - = ` _��•�' ..............................< `""°�'------ ` -y - .. pM..........
..:. f/'L•A� ...................................-J f� /�F•f'f re f.. Vr.......�,y ......... ,_��_1 C��I.r...ti �''_�________________
.............................cA/< ? ..... ` ....... ��fef i`,�.r^ `.. CLJ• /tJ���....�._G7CC G... c ( :J...
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
-------------------------------•---••--------•--•--•----••-•------•----•-•----------•-••--•-•---------------•----------------------------------•--------------------•-----•--••••....._..--------------•
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT11- 5 of the State Sanitary-Code The undersigned further agrees not to place the system in
operation until a Certificate of Compliance as been isssu�ued%by,th'board,of,health.
Signed_.,/..:�------' ....................................."" ' ' L-''
f. - ;: �
e .
Application Approved B,:! .!.� .....el
------------
Date
Application Dr a .p weo d or the following reasons:... --------•-------------------------------
, '
Date
PermitNo......................................................... Issued.......................................................
Date '
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
el
.............OF....f- r.z < ..ate: `� :.........................
Trdif iratr of Tout rliFanrr
THIS IS TO CERTIFY, That the Individ al Sewage Disposal System constructed ( 4)--tr Repaired ( )
�-
bY =` -...14, .-r ' ------------------•-----....-----•-•-•--•---•--•----...--•-•-------------......---------•-----._......._
_Installer
- ..................
has been installed in accordance with the provisions of TITLE _ r The State Sanitary Cod as scribed in the
application for Disposal Works-Construction Permit No � 4. ................ dated.��''
PP P , r7. --- -------------------------
THE ISSIJA. OF THIS CERTIFICATE SHALL NOT BE CONSTRII A GUARANTEE THAT THE
SYSTEM Wl = CTION SATISFACTORY.
DATE...... l = d Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
f
r.
.:-r OF ._ ...........................
No........................ FEE
72
ipoaal Works �nnrnr#inn rrmi
Permission is hereby granted.. ..........It` .......... '_ � ��
to Construct ( r r Repair ( ) ,fin•,Individual Sewage Disposal System
at No.•- �'---� ....-• - --- !` -" =`1 ` ` �'r '` �� 16' r� it �J 1
Street
as shown o/t /a tion for Disposal Works Construction Permit-bo.. ,! __ ated. .. ...............
Board of Health
DATE_: .- ----------------•-•-----------------------:-.._..---
1 FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
6
p,
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617)292-5500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI �" DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL-SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 489 Marston Lane, Cummaquid, MA Name of Owner: Bob Munro
Address of Owner: same
Date of Inspection: March S, 1999
Name of Inspector: (Please Print) James M. Ford
system
I am a DEP approved inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: James M. Ford
Mailing Address: P.O.Box 49, Osterville, MA 02655-0049 - Map: 348 '
Telephone Number: 1508)862-9400 Parcel. 034
Lot: 28
CERTIFICATION STATEMENT -
I certify that I have personally inspected the sewage disposal system at this address"and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was perforn ed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
t
✓ Passes
Conditionally Passes
Needs Further Evalua ion y the Local Approving Authority
Fails
Inspector's Signature: Date: March 9, 1999
The System Inspector shall sub copy of this inspection report to the Approving Authority(Board of Health or DEP) within thirty(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 Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS, -
P
999
to
r,
4*
revised 9/208 F Page I of lI
Primed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 489 Marston Lane, Cummaquid, MA
Owner: Bob Munro
Date of Inspection: March 5, 1999
INSPECTION SUMMARY: Check A, B, C, or D:.
A. SYSTEM PASSES:
✓ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes,no, or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not.
The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or
the septic tank, whether or not metal,is cracked, structurally unsound, shows substantial infiltration or exfiltration,or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health)
_ broken pipe(s)are replaced
_ obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
revised 9/2/98 Page 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
-� PART A
CERTIFICATION (continued)
Property Address: 489 Marston Lane,'Cununaquid, MA
Owner: Bob Munro
Date of Inspection: March 5, 1999
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)
THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND
THE ENVIRONMENT:
The system has a septic tank and soil absorption system(SAS)and the SAS is within100 feet to a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet.but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
revised 9/2/98 Page 3ofIII
F
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 489 Marston Lane, Cummaquid, AM
Owner: Bob Munro
Date of Inspection: March 5, 1999
D. SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due to an 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.
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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
colifotm bacteria, volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either "Yes" or"No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
Yes No
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
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 Page 4of11
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
F CHECKLIST
Property Address: 489 Marston Lane, Cunvnaquid, MA ,
Owner: Bob Munro
Date of Inspection: March S, 1999
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
✓ _ Pumping information was provided by the'owner, occupant,or Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
✓ _ As built plans have been obtained and examined. Note if they are not available with N/A.-
✓ _ The facility or,dwelling`was inspected for signs of sewage back-up:
✓ _ The system does not receive non-sanitary or.industrial waste flow.
✓ _ The site was inspected for signs of breakout.
✓ _ All system components,excluding the Soil Absorption System,have been located on the site.
✓ _ The septic tank manholes were-uncovered,opened, and the interior of the septic tank was inspected for conditions of baffles
or tees,material of construction,dimensions,depth of liquid,depth of sludge, depth of scum. "
The size and location of the Soil Absorption System on the site has been determined based on:
✓ _ Existing information. For example, Plan at B.O.H.
✓ _ Determined in the field(if any of the,failure criteria related•to Part C is at issue, approximation of distance is unacceptable)
[15.302(3)(b)l
✓ _ The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of f
SubSurface Disposal Systems.
T, revised 9/2/98 Pages ofll
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 489 Marston Lane, Cwwnaquid, MA
Owner: Bob Munro
Date of Inspection: March 5, 1999
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 110 g.p.d./bedroorn.
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
Total DESIGN flow 440
Number of current residents: 2
Garbage grinder(yes or no): Yes
Laundry(separate system) (yes or no): No ; If yes, separate inspection required
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last two yeargs usage(gpd): 1998- 75,000 gals.: 1997-80,000 gals.
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied.
COMMERCIALANDUSTRIAL:
Type of establishment:
Design flow: god(Based on 15.203)
Basis of design flow
Grease trap present: (yes or no) _
Industrial Waste Holding Tank present: (yes or no)
Non-sanitary waste discharged to the Title 5 system (yes or no) _
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
Pumped two years ago-per owner.
System pumped as part of inspection(yes or no): No
If yes, volume pumped: gallons
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)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed(if known)and source of information: April 1983-per as built card.
Sewage odors detected when arriving at the site: (yes or no) No
revised 9/2/98 Page 6ofII
I
SUBSURFACE SEWAGE DISPOSAL' SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 489 Marston Lane, Cwnrnaquid, MA
Owner: Bob Munro
Date of Inspection: March 5, 1999
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction: _cast iron _40 PVC other(explain) t
Distance from private water supply well or suction line
Diameter
Comrnents: (condition of joints, venting, evidence of leakage, etc.) ,
SEPTIC TANK ✓
(locate on site plan) s
Depth below grade: 15" "
Material of construction: ✓concrete _metal Fiberglass Polyethylene other(explain)
If tank is metal, list age® Is age confirmed by Certificate of Compliance_(Yes/No)
Dimensions: 10'6" x 5'8" x 5'8" (1500gal.)
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or baffle: 29"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: 12"
How dimensions were determined: Measuring stick
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.) The tees were present. The liquid level was even with the outlet invert. There were no sign of leakage.
GREASE TRAP: None
(locate on site plan)
Depth below grade:
Material of construction: concrete _metal _Fiberglass ,_Polyethylene _other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
'Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping: _
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.) -
'revised 9/2/98 Page 7ofII .. ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 489 Marstons Lane, Cummaquid, MA
Owner: Bob Munro
Date of Inspection: March S, 1999
TIGHT OR HOLDING TANK: None (Tank must be pumped prior to,or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
:Ca acit gallons
Capacity:
Design flow: gallons/day
Alarm present:
Alarm level: Alarm in working order: Yes T No_
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX: ✓
(locate on site plan)
Depth of liquid level above outlet invert: 0" (even)
Comments:
(note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box,etc.) The box was level and there
were no signs of solids or leakage.
PUMP CHAMBER: None
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms in working order: (Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,etc.)
revised 9/2/98 Page 8of II
f
SUBSURFACE SEWAGE DISPOSAL` SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 489 Marstons Lane, Cummaquid, MA
Owner: Bob Munro
Date of Inspection: March S, 1999
SOIL ABSORPTION SYSTEM(SAS): ✓
(locate on site plan, if possible;excavation not required, location may be approximated by non-intrusive methods)
If not located,explain:
.Type:
leaching pits,number: 2- 4'x 6' with 4'stone-per design plans
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number: -
Alternative system
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,etc.)
The pits were not dug up. Pit#1 was under a nine tree and unaccessible Pit#2 bottom to grade was approximately 6'6
CESSPOOLS: None 11
(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(cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
PRIVY: None
(locate on site plan)
Materials of construction: Dimensions: -
Depth of solids:
Comments:
(note condition of soil;'signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
revised 9/2/98 Page 9ofII
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 489 Marston Lane, Curnmaquid, MA
Owner: Bob Munro
Date of Inspection: March S, 1999
Map: 348
Parcel: 034
Lot. 28
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
MgcS'r/1S �f1�
-1
bcc,K — —
A
_O
69
3b
� 1
49.6 45
11
99'
revised 9/2/98 Page 10of I
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM_
PART C
SYSTEM INFORMATION (continued)
Property Address: 489 Marston Lane, Cummaquid, MA
Owner: Bob Munro .
Date of Inspection: March S, 1999
NRCS Report name
Soil Type
Typical depth to groundwater
{
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater .Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site(Abutting property, observation hole,basement sump etc.)
Determined from local conditions
✓ Checked with local Board of Health f
Checked FEMA Maps
Checked pumping records
Check local excavators,installers '
✓ Used USGS Data
Describe how you established the High Groundwater Elevation. Must be completed)
Using the Barnstable water contours and topographic maps, the maps were showing approximately 80'to groundwater at
this site.
This report has been prepared and the system inspected and passed as of the date of inspection.. This.report is not a warranty
or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,
written or implied, relating to the system, the inspection and/or this report.
r
`revised 9/2/98 W Page 11of11
•
r
NOTES
1. 0,,TUM IS NAVD 88 0
LEGEND 2. MUNICIPAL WATER IS EXISTING oDennis
� Pond
99 — EXISTING CONTOUR S77 65 3. THIS PLAN IS FOR PROPOSED WORK ONLY
P 7 •00' ( ORDAN� OTHERT TO E USED PURPOS OR LOT LINE STAKING
X 99•1 EXIST. SPOT ELEV. 1 Q
W
—[99]— PROPOSED CONTOUR / 4. CONTRACTOR SHALL BE RESPONSIBLE FOR
/ co
CALLING DIGSAFE (1-888-344-7233) AND --
g NEO
C 8.4] PROPOSED SPOT EL. LOT AREA VERIFYING THE LOCATION OF ALL
UNDERGROUND & OVERHEAD UTILITIES PRIOR Exit 7
TH1 44,549t S.F. TO COMMENCEMENT OF WORK. Route 6
TEST HOLE X [84] X_
FENCE \ _ _``1 5. EXISTING SEPTIC LOCATION PER TIE—CARD Locus
ON FILE WITH THE TOWN.
2� SLOPE OF GROUND v Yarmouth
LO x PATIO ' Compground
J: 6. POOL FENCE SHALL HAVE SELF—CLOSING
71) UTILITY POLE s.
\\�� � SELF—LATCHING GATES, SIZE AND MATERIALS TO � ��� a =.
MEET LOCAL AND STATE BUILDING CODE, ALL �N
FIRE HYDRANT A
DWELLING DOORS OPENING TO POOL SHALL BE
NOTE: NOT ALL SYMBOLS MAY APPEAR IN DRAWING x PO,L BU LDI G \ ALARMED TO CODE. �\o� 91
POOL 1`
/ R PIG -
14, CO LOCUS MAP
lj Q SCALE 1"=2000't
N � [83] ..
` 82 ASSESSORS MAP 348 PARCEL 34
N
\
i CP LOCUS IS WITHIN FEMA FLOOD ZONE X(AREA OF MINIMAL FLOOD HAZARD) AS
SHOWN ON COMMUNITY PANEL #25001 CO559J
DATED 7/16/2014
PARCEL IS WITHIN ZONE II
ZONING SUMMARY
TON ET ,'(SAL \ v5 ZONING DISTRICT: RF-1 RESIDENTIAL DISTRICT
—
�-
8� \QP� MIN. LOT SIZE 43,560 S.F.
` �� MIN. LOT FRONTAGE 20'
Z `v V9O\ ��� ' MIN. LOT WIDTH 125'
MIN. FRONT SETBACK 30'
MIN. SIDE SETBACK 15'
MIN. REAR SETBACK 15'
9 . MAX.', BUILDING HEIGHT
0 Cv 30'
N
9 DECK le, OWNER OF RECORD
ol `- CHRISTIE A. NAKACHI
489 MARSTONS LANE
BARNSTABLE (CUMMAQUID), MA 02637
46.4,,
i EXISTING DWELLING REFERENCES
j FFLR=96.6
�- DECK DEED BOOK 26373 PAGE 246
c PLAN BOOK 361 PAGE 73
39 9
0
j5 —� °
93
13 n
2 / 192Co
SITE PLAN
90 �\ A OF
�"`- g9, _ 489 MARSTONS LANE
METER lC Zr �, O ��- CUMMAQUID BARNSTABLE MA
`� � �`p � ��� ✓�� PREPARED FOR
NE E WAL
(�- T.- NATE REINHART
N88'38'28"W 178.61`' -
-8�- DATE: JANUARY 29, 2019
qs off 508-362-4541
\V;6of Massgcti �`DAtvIELs�cy�� fax 508-362-9880
�� DANIELA. A R� downcope.com
MARSTONS LANE ��A�� �l .
6502 o No.40930 ' down cape en fi7eeri# inc.
-?E� ;DES civil engineers
Scale: 1 - 20 i _qp),..-k� Sio„ . - b / 1C7I7 Ur Surveyors
939 Main Street '( Rte 6A)
r�or DATE DANIEL A. OJALA, P.E., P.L.S.
� ��=� YARMOUTHPORT_ MA 02675
LICE # 18-471 0 10 20 30 40 50 FEET
`` 18-471 BASE-DWG
NOTES
LEGEND \ 1. DATUM IS NAVD 88 V
2. MUNICIPAL WATER IS EXISTING o Dennis
,
99— EXISTING CONTOUR 05 Pond
'41 'E 3. THIS PLAN IS FOR PROPOSED WORK ONLY fie' ° ono I
1;75 AND NOT TO BE USED FOR LOT LINE STAKING �Q c
X 99- EXIST. SPOT ELEV. 00 OR ANY OTHER PURPOSE. �j Q° I
-- c1
[99] PROPOSED CONTOUR 4. CONTRACTOR SHALL BE RESPONSIBLE FOR
E� CALLING DIGSAFE (1-888-344-7233) AND
198.41 PROPOSED SPOT EL. SN
LOT AREA � VERIFYING THE LOCATION OF ALL Exit 7
TH1 UNDERGROUND & OVERHEAD UTILITIES PRIOR Route 6
44,549f S.F.
TO COMMENCEMENT OF WORK.
TEST HOLE [84] Locus
Y X X FENCE _ 5. EXISTING SEPTIC LOCATION PER TIE-CARD
2Z� SLOPE OF GROUND X ON FILE WITH THE TOWN. Yarmouth
'n G k P�ATIO 't Campground
CT I) UTILITY POLE 6. POOL FENCE SHALL HAVE SELF-CLOSING
SELF-LATCHING GATES, SIZE AND MATERIALS TO
MEET LOCAL AND STATE BUILDING CODE, ALL
FIRE HYDRANT DWELLING DOORS OPENING TO POOL SHALL BE
NOTE: NOT ALL SYMBOLS MAY APPEAR IN DRAWING PO L BU LDI G ALARMED TO CODE. �\o�' L o�
POOL
FIRE
x. �=X
PIT LOCUS MAP
N [83] SCALE 1"=2000'f
82 ASSESSORS MAP 348 PARCEL 34
N
CP' d LOCUS IS WITHIN FEMA FLOOD ZONE X
(AREA OF MINIMAL FLOOD HAZARD) AS
SHOWN ON COMMUNITY PANEL #25001 CO559J
�.\ DATED 7/16/2014
8s C* .\
PARCEL IS WITHIN ZONE it
g� ZONING SUMMARY
_u TON ET.,-, AL \ a5 ZONING DISTRICT: RF-1 RESIDENTIAL DISTRICT
89 �._P� `\ �6 �� MIN. LOT SIZE 43,560 S.F.
N 90 MIN. LOT FRONTAGE 20'
z41MIN. LOT WIDTH 125'
9j �� oti w MIN. FRONT SETBACK 30'
MIN. SIDE SETBACK 15'
MIN. REAR SETBACK 15'
Xgo MAX. BUILDING HEIGHT 30'
9� DECK
--- N N 9S�
< OWNER OF RECORD
`9 �- J �"I
I CHRISTIE A. NAKACHI
489 MARSTONS LANE
98 46,4,
93 BARNSTABLE (CUMMAQUID), MA 02637
EXISTING DWELLING REFERENCES
j FFLR=96.6
DECK DEED BOOK 26373 PAGE 246
o C� �,� PLAN BOOK 361 PAGE 73
94- 39 9,
a
a.
15
34 93
3 93
7 92 fl
- �p
9' SITE PLAN
90 9 OF
ELECTRIC /
89 92 489 MARSTONS LANE
METER Sg ���� Ax o� (CUMMAQUID) BARNSTABLE, MA
Q a� �9
/ �E ET PREPARED FOR
wAL NATE REINHART
N88°38'28"W _ 178.61 ' - -
88 DATE: JANUARY 29, 2019
MA,sc c s off 508-362-4541
"1 -_, Dr i�iELfax 508-362-9880
D�MAR downcape.comOSTONS LANE ,Lv,
�s5o2 down cape ea4fiaeering, Inc.
1 No ru ,a0
0,
��� y civil engineers
Scale: 1 = 20 _ � �s
-Z°1 1� s `° `' . , I land surveyors
939 Main Street ( Rte 6A)
'
0 10 20 30 40 50 FEET DATE DANIEL A. OJALA, P.E., P.L.S. 'KARMOUTHPORT MA 02675
DCE # 18-471 1
t 18-471 BASE.DWG
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