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0500 MARSTONS LANE - Health
500 Marstons Lane Barnstable A= 348-026 r ' a. t Commonwealth of Massachusetts OcZ. Title 5 Official Inspecti®h Form Subsurface Sewage Disposal System Form=Not for Voluntary Assessments 500 Marstons Lane, Barnstablr-Yarmouth Port, MA-02675. E Property Address Peter&Judith Semiak Owner Owner's Name u' information is / required for every Barnstable ✓ MA 02675 05/10/2018 page. Cityfrown s '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. ImpMing out forms A. General Information fil!lin out forms on the computer, , use only the tab a key to move your 1. (nSpeCtOr: , cursor-do not REID C. ELLIS. use the return " Name of Inspector ' 4 . key. ELLIS BROTHERS CONSTRUCTION Company Name 1 A 23 ENTERPRISE ROAD x `' Company Address YARMOUTH PORT,' MA 02675 y City/Town State Zip Code. 508-362-6237 S121891 Telephone Number License Number B. Certification 1 certify that I have personally inspected the sewage disposalisystem at this addres§and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved systeim inspector pursuant to Section 15.340 of Title 5( CMR 15.000).The system: T Passes ❑ Conditionally Passes ❑ Fails ❑J Needs Further Evaluation b Approving - y the Local pp owing Authority - E P r Inspe „rs Signature. Date G, The system inspector shall-submit.a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate w 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. r ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under. the same or different conditions of use. t5ins.doc•rev:6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 j I - Commonwealth of Massachusetts Title 5 Official -Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 500 Marstons Lane, Barnstabir-Yarmouth Port, MA-02675 Property Address v Peter&Judith Serniak ' Owner Owner's Name information required for isevery Barnstable MA 02675 05/10/2018 page. City/Town State Zip Code + Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E I always complete all of Section D A) System Passes: � ] I have not foun 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: . F 4 B) System Conditionally Passes: ❑ One or more system components as desc ribed 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 of *or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exf Itration 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 i structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. El Y ❑ N ❑ ND(Explain elow): • rf , t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspectiont Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 500 Marstons Lane, Barnstablr-Yarmouth Port, MA-02675 Property Address Peter&Judith Serniak Owner Owner's Name information is Barnstable MA 02675- 05/10/2018 required for every page. Cityrrown State Zip Code . Date of Inspection B. Certification (cont.) / El Pump Chamber pumps/alarms not operation stem will pass with Board of Health approval if pumps/alarms are repaired. v B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out 911 high static water level in the distribution box due to broken or obstructed pipe(s)or due to a bro en, settled or uneven distribution box. System will pass inspection if(with approval of Board of H alth): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ .ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveledor replaced ❑ Y .❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 tir ies a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval c f 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 oard of Health: ❑ Conditions exist which require further eval ation by the Board of Health in order to determine if the system is failing to protect public healt , safety or the environment. 1. System will pass unless Board of He ilth determines in accordance with 310 CMR 15.303(1)(b)that the system is not func oning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet I a surface water ❑ Cesspool or privy is within 50 feet i f a bordering vegetated wetland or a salt marsh t5i ns.doc.rev:6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 500 Marstons Lane, Barnstabe-Yarmouth Port, MA-02675 Property Address Peter&Judith Semiak Owner Owner's Name information is required for every Barnstable MA 02675 05/10/2018 page. Cityrrown State Zip Code Date of Inspection B. Certification (cone.) f 2. System will fail unless the Board o al h(and Public Water Supplier, if any) determines that the system is function ng 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 tribu tary 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 SA and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS ar d 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 analys s, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the pre ence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other f Rilure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each.of the following for all inspections: Yes No El Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent.to the surface of the ground or surface waters ❑ due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded p or clogged SAS or cesspool ❑ A Liquid depth in cesspool is less than 6"below invert or available volume is less rer/ than Y2 day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts• . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . 500 Marstons Lane, Barnstabe-Yarmouth Port, MA-02675 ' Property Address Peter&Judith Serniak Owner Owner's Name information is required for every Barnstable MA ,02675 05/10/2018 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ' Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Any portion,of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ , Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well wateranalysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided)that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving.a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system'fails. The system owner should contact the Bo d of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large syste he 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 b . ❑ ❑ the system is within 400 feet o .a surface drinking water supply ❑ ` ❑ the system is within 206 feet o a tributary to a surface drinking water supply El Area system is located in.a nitro en sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zoe II of a public water supply well If you have answered"yes"to any question in Secti n E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed_ The owner or operator of any large- system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc-rev.6/16 Me 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 M 500 Marstons Lane, Bamstablr-Yarmouth Port, MA-02675 Property Address Peter&Judith Semiak Owner Owner's Name information is Barnstable MA 02675 05/10/2018 required for every page. Cityrrown 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 a ❑ 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 available 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,4 cluding 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. El 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: y ' Number of bedrooms(design): Number of bedrooms(actual). DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins.doc-rev.6116 Tide 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 500 Marstons Lane, Barnstabe-Yarmouth Port, MA-02675 Property Address Peter&Judith Serniak Owner Owner's Name information is Barnstable MA 02675 05/10/2018 requiredd for every page. Citylrown State Zip Code $ Date of Inspection D. System Information Description: /V� s f� Number of current residents: Does residence have a garbage grinder? ❑ Yes (/No Is laundry on a separate sewage system? (Include laundry system inspection El Yes o information in this report.) N Laundry system inspected? ❑ Yes VN Seasonal use? ❑ Yes 8/No - Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? El Yes 4000'No Last date of occupancy: date' Commerciai/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑.Yes ❑ No Non-sanitary waste discharged to the Title 5 Sys t m? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form : Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 500 Marstons Lane, Barnstabir-Yarmouth Port, MA-02675 Property Address ; Peter&Judith Semiak Owner Owner's Name information is ,. 05/10/2018 required for every Barnstable MA 02675 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: �' Date Other(describe below): General.Information Pumping Records: Source of information: Was system pumped as part of the inspection? �es ❑ No 000 If yes, volume pumped: m gallons �'/ How was quantity pumped determined? Frd`< yy Reason for pumping: TYPe of yytem: r Septic tank, distribution box, soil absorption system El 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): t5ns.doc-rev.6116 Trtle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments b 500 Marstons Lane, Bamstablr-Yarmouth Port, MA-02675 Property Address Peter&Judith Serniak Owner Owner's Name information is Barnstable MA 02675 05/10/2018 required for every page. Cityrrown State Zip Code Date of Inspection. D. System Information (cont.) j Approximate age of all components, date installed (if known)and source of information: - Were sewage odors detected when arriving at the site? ❑ Yes /No Building Sewer(locate on site plan): Depth below grade: ��" � l- s�✓ i l � g feet Material of construction: El cast iron 40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): 4- Xv 1,o AIA Septic Tank(locate on site plan): /V Depth below grade: feet 'Mat al of construction: concrete ❑ metal ❑fiberglass ❑ polyethylene ' - ❑other(explain) JW- ° If tank is metal, 1' ag%Ce ye s Is age confi ed by aficate of Complian . (attach a copy of certificate) ❑ Yes No Dimensions: Sludge depth: t5ins.doc-rev.6116 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 9 of 17 , Commonwealth of Massachusetts F Title 5 Official Inspection Form =� a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 500 Marstons Lane, Barnstablr-Yarmouth Port, MA-02675 Property Address Peter&Judith Serniak Owner Owner's Name information is required for every Barnstable MA 02675 05/10/2018 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 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 How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): r WW Grease Trap(locate on site plan): /"� p Depth below grade: .feet Material of construction: ❑ concrete ❑ metal ❑fit rglass ❑ 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 outlE t tee or baffle Date of last pumping: Date t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts - W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .500 Marstons Lane, Barnstablr-Yarmouth Port, MA-02675 Property Address Peter&Judith Semiak Owner Owner's Name information is required for every Barnstable MA' 02675 05/10/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.. Comments(on pumping recommendations, inlet "nd outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence f leakage, etc.): Tight or Holding Tank(tank must be pumped at rr- of inspection)(locate on site plan): Depth below grade: Material of construction: , ❑ concrete ❑ metal ❑fibei glass ❑ 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, tc.): i *Attach copy of current pumping contract(require)_ Is copy attached? ❑ Yes ❑ No r S t5ins.doc•rev.6116 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 500 Marstons Lane, Barnstablr-Yarmouth Port, MA-02675 Property Address Peter&Judith Serniak Owner Owner's Name nformation is Barnstable MA 02675 05/10/2018 required for every page. City1rown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate o ite plan): Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of lids carryover, any evidence of leakage into or out of box, etc.): f? f / Pump Chamber(locate on site plan): . Pumpsin working p g order. ❑ Yes ❑ No ,Alarms in working order: ❑ Yes, ❑ No* , Comments(note condition of pump chamber, cc ndition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order,s stem is a conditional pass. Soil Absorption System'(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5irs.doc.rev.6116 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 i si - 500 Marstons Lane,Barnstablr-Yarmouth Port, MA-02675 Property Address ' Peter&Judith Serniak Owner Owner's Name information is required for every Barnstable MA 02675 05/10/2018 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: teaching pits ? T number: — ❑ leaching,chambers + number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil, signs°of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): t s Cesspools(cesspool must be pumped as part of Inspection)(locate on site plan): Number and configuration , Depth-top of liquid to inlet invert Depth of solids Gayer Depth of scum layer- i _Dimensions of cesspool ` Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-doc•rev.6/16 e 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts v Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 500 Marstons Lane, Barnstablr-Yarmouth'Port, MA-02675 Property Address Peter&Judith Serniak Owner Owner's Name information is Barnstable MA ` 02675 05/10/2018 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) �� Comments(note condition of soil, signs of by raulic 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.): f + F t5ins.doc•rev.6116. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 L Commonwealth of Massachusetts r Title 5 official Inspection Form _ Subsurface Sewage Disposal System Form-,Not for Voluntary Assessments 500 Marstons Lane, Bamstablr-Yarmouth Port, MA-02675 Property Address Peter&Judith Serniak Owner Owner's Name information is required for every Barnstable MA 02675 0'5/1.0/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Y Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to r at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate wh re public water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately r� e t ZI Y r PA � j' ag t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 it .. Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 500 Marstons Lane, Barnstablr-Yarmouth Port, MA-02675 Property Address Peter&Judith Semiak Owner Owners Name information is required for every Barnstable MA 02675 05/10/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope -�� ❑ Surface water71 ElCheck cellar �'- 4 ;;7?" " ❑ Shallow wells I Estimated depth to high ground water: c� 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 k ❑ Observed site(abutting propertylobservation 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: M ^ ®. ' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 500 Marstons Lane, Barnstablr-Yarmouth Port, MA-02675 Property Address Peter&Judith Semiak Owner Owner's Name information is required for every Barnstable MA 02675 05/10/2018 page. Cltyrrown 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 W- Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file a ' z r .• t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal P 9 System•Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 500 Marstons Lane, Cummaguid M-348 P-26 Property Address William & Marilyn Palle Owner Owner's Name information is 500 Marstons Lane Yarmouth Port MA required for every - 02675 January 30, 2014 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: CO key to move your I �J Y. cursor-do not Troy Williams - S use the return Name of Inspector key. Troy Williams Septic'lnspections �y Company Name - 19 Hummel Drive Company Address 1 South Dennis MA 02660 City/Town State., Zip Code (508) 385- 1300 S1682 Telephone Number License Number ' B. Certification ® a I certify that I have personally inspected the sewage disposal system atthis add e� and thaE;the information reported below is true, accurate and complete as of the time of the insp ction. The-Inspeation was performed based on my training and experience in the proper function and rn i tenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to ection 15.340 01 Title 5(310 CMR 15.000).The system: . ® Passes -❑ Conditionally Passes - ❑ Fail ❑ Needs Further Evaluation by the Local Approving Authority J � January 30 2014 rY 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. , I t5ins•3/13 Tide 5 Official Inspection Form:Sub a Sewage Disposal System•Page 1 of 17 4, r Commonwealth of Massachusetts Title 5 Official Inspection Form. o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 500 Marstons Lane, Cummaquid M-348 P-26 Property Address William &Marilyn Palle Owner Owner's Name information is required for every 500 Marstons Lane, Yarmouth Port MA 02675 January 30, 2014 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E I 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 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. r B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 4 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .•''t 500 Marstons Lane„ Cummaquid M-348 P-26 Property Address William & Marilyn Palle Owner Owner's Name information is 500 Marstons Lane, Yarmouth Port MA 02675 January 30, 2014 required for every rY page. City/Town State Zip Code` Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health):- ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑- ND (Explain below): ❑ obstruction is removed ❑ Y ❑ -N ❑ ND(Explain below): ❑ distribution box is leveled or replaced' ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N _ ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): , C) Further Evaluation is Required by the Board of Health: ❑ 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. t 1. SSystem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water , ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 r , Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 500 Marstons Lane, Cummaquid M-348 P-26 Property Address William & Marilyn Palle Owner Owners Name information is required for every 500 Marstons Lane, Yarmouth Port MA 02675 January 30, 2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins-3/13 Tide 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 500 Marstons Lane, Cummaquid M-348 P-26 Property Address William & Marilyn Palle Owner Owner's Name information is required for every 500 Marstons Lane Yarmouth Port MA 02675 January 30, 2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® -, ; Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of.a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence " of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑; the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts uv Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 500 Marstons Lane, Cummaquid M-348 P-26 Property Address William& Marilyn Palle Owner Owner's Name information is required for every 500 Marstons Lane Yarmouth Port MA 02675 January 30, 2014 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 IeN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 500 Marstons Lane, Cummaquid M -348 P-26 Property Address William &Marilyn Palle . Owner Owner's Name information is 500 Marstons Lane, Yarmouth Port MA 02675 January required for every 30, 2014 page. CitylTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? r ,, ❑ Yes ® No Water meter readings, if available last 2 ears usage d 13=52,000 gals. 9 ( Y 9 (gp )) 12=54,000 gals. Detail: Sump pump? ❑ Yes ® No Last date of occupancy: - occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: N/A p Design flow(based on 310 CMR 15:203): ' N/A Ganons 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 t5irs-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM ' 500 Marstons Lane, Cummaquid M -348 P-26 Property Address William & Marilyn Palle Owner Owner's Name information is required for every 500 Marstons Lane Yarmouth Port MA 02675 January 30, 2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: N/A Date Other(describe below): N/A General Information Pumping Records: Source of information: Last pumped in 2010 per info from owner. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form : Subsurface Sewage Disposal System Form -Not for Voluntary Assessments UVIS 500 Marstons Lane., Cummaguid M -348 P-26 Property Address William &Marilyn Palle ti .. Owner Owner's Name information is 500 Marstons Lane, Yarmouth Port MA 02675 January required for every 30, 2014 page. Cityrrown 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 leach pit#1 were installed on 7/7/86 per compliance. Leach pit#2 was installed on 5/17/95 per compliance. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 24'+ Depth below grade: ' _ feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Flushed lines and found clear at the time of inspection. Septic Tank(locate on site plan): 2'with riser to 6" Depth below grade: feet Material of construction: ®.concrete ❑metal ❑ fiberglass ❑'polyethylene,..,. ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 5'X9'X6' 1000 gallon Dimensions: 4" Sludge depth: t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 17 a Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 500 Marstons Lane Cummaq uid M -348 P-26 Property Address William &Marilyn Palle Owner Owner's Name information is required for every 500 Marstons Lane, Yarmouth Port MA 02675 January 30, 2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) 21 811 Distance from top of sludge to bottom of outlet tee or baffle 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.): Concrete 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/Afeet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 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/ADate t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 L Commonwealth of Massachusetts t Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 500 Marstons Lane, Cummaquid M -348 P-26 Property Address William & Marilyn Palle Owner Owner's Name information is required for every 500 Marstons Lane, Yarmouth Port MA 02675 January 30, 2014 page. Citylrown 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: N/A Material of construction: ❑ concrete ❑metal ❑ fiberglass ❑polyethylene ❑ other(explain): Dimensions: N/A 1 N/A Capacity: a gallons Design Flow: N/A gallons per day Alarm present: ❑ Yes ❑ No Alarm level: N/A Alarm in working order: ❑ Yes ❑ No Date of last pumping: N/A Date Comments(condition of alarm and float switches, etc.): N/A i Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13, Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17,. Commonwealth of Massachusetts u Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 500 Marstons Lane, Cummaquid M-348 P-26 Property Address William &Marilyn Palle Owner Owner's Name information is required for every 500 Marstons Lane Yarmouth Port MA 02675 January 30, 2014 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 level and 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 *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts JD Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 500 Marstons Lane, Cummaquid M-348 P-26 Property Address William & Marilyn Palle Owner Owner's Name information is required Marstons Lane, Yarmouth Port MA 02675 - Janua 30, 2014 requiredd for every rY page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: 1 -6'X6' pit with ® leaching pits number: 2' of stone , . ❑ leaching chambers number: 1 - pit with 2 off s stotone ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit#2 was found with water level approx. 18" below inlet invert with walls found clean above. No evidence of hydraulic failure or problems in the past were found at the time of inspection. Pit#1 originally failed in 1995 and Pit`#2 was added for repair. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A Depth—top of liquid to inlet invert N/A ` Depth of solids layer N/A Depth of scum layer N/A f Dimensions of cesspool N/A Materials of construction N/A Indication of groundwater inflow ❑ Yes ❑ No . t t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 500 Marstons Lane, Cummaguid M-348 P-26 Property Address William & Marilyn Palle Owner Owner's Name information is required for every 500 Marstons Lane Yarmouth Port MA 02675 January 30, 2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) I 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.): N/A t5ins•3/13 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 500 Marstons Lane, Cummaguid M-348 P-26 Property Address William & Marilyn Palle Owner Owner's Namev information is 500 Marstons Lane, Yarmouth Port MA 02675 -January 30, 2014 required for every �, page. Cityrrown State - Zip Code bate 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-sketchl in the area below ❑ drawing attached separately i aj � 2' 3 t5ins-3113- Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 500 Marstons Lane, Cummaguid M-348 P-26 Property Address William & Marilyn Palle Owner Owner's Name information is 500 Marstons Lane Yarmouth Port MA 02675 January 30, 2014 required for every page. City town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells 13.0'+ Estimated depth to high groundwater: 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. 1986 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 24.5' 5.1'adjustment You must describe how you established the high ground water elevation: Test hole recorded on plan showed no water found at 13.0'. Hand augered 5.5' below bottom of leaching at lower elevation with no water found at a depth of 15.5'. Groundwater adjustment at the time of inspection was 5.1'. Bottom of leaching at 10.0'was found not to be located in the high groundwater elevation at the time of inspection. USGS Maps show groundwater to be approx. 72.7' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ina•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 500 Marstons Lane, Cummaguid M'-348 P-26 Property Address , William&Marilyn Palle Owner Owner's Name information is required for every 500 Marstons Lane, Yarmouth Port MA 02675 January 30, 2014 page. Citylrown 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 a t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17. . C O EyLLIS . BR0S . C 0 N S T . TOWN CUMMAQUID SEWAGE :.PERMIT 'NO . ` 1, OWNER NAME MR. REILY 4 LOCATION 500 :MA'RSTONS LANE CUMMAQ.UID, MA PERMIT DATE ISSUED' a 4� COMPLIANCE ISSUEDS'�71 BUILDERS NAME WATER TABLE FINAL INSPECTION BY : d'��lzlely DATE T/1 j,<' NEW REPAIR, /6 c'00 DRAW SKETCH OF COMPLETED SYSTEM WITH DIMENSIONS ON BACK,. . i ` _.. a -- ��' � , 3 , , -,� � . ^� .. ' — � � , _ r o�� r TOWN OF BARNSTABLE O LOCATION 500 MARSTONS LN• SEWAGE # '/ VILLAGE CUMMAQUID ASSESSOR'S. MAP & LOT4FJ29 fJ94C r INSTALLER'S NAME & PHONE NO, ELLIS BROTHERS CONST. CO. r SEPTIC TANK CAPACITY /"��& LEACHING FACILITY:(type) ;- 16&zo ,qZ' (size) NO. OF BEDROOMS, PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER MR. REILY DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No 7� �� 1 � ���a ° �� � �^ �; ✓' / ��� ��� � � � / I / / ,�` (�? �!� t Y � ASSESSORS MAfi . . .. T �_ No.. =.......r_....... PARCELNO• ' _ Fig...�......... THE COMMONW _ STS BOAR® OF HEALTH TOWN OF BARNSTABLE Appliratiun for Ui"uual Morkii Tonutrttr 'ton Frrutit Application is hereby made for a Permit to Construct ( ) or Reppaiirp( an Individual Sewage Disposal Sys at: .P ......... .... .A ... ••• 0f"ner Address o. jV W - 'f.--....._: ... W r____.. �.. �i�/ wCAddres . � Installer �•+ Address UType of Building Size Lot...........................Sq. feet Dwelling—No. of Bedrooms___........ ..........................Expansion Attic ( ) Garbage Grinder �4 � `4 Other—T e of Building No. of persons............................ Showers a YP g -------------•-•--...------- P ( ) — Cafeteria ( ) Other fixtures W - Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. 1:4 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No_____________________ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) . " Percolation Test Results Performed by------•--------•--------------- Date........................................ . 0-7 Test Pit No. I................:ninutes per inch Depth of Test Pit.._.__._......____.. Depth to ground water........................ fT4 Test Pit No. 2................minutes per inch Depth of Test Pit---:................. Depth to ground water........................ P4 -•••---•-•--••---------------•-•--.......------------......-----.....------••... ----------- -------- ----------------- --------------------- -.......... O Description of Soil...............................................................................----------- A-:.. U W ----------- -- ------- -----------------------•---------------•-------- U Nature of Repairs or Alterations—Answer when applicable.-. � � -- ......... ...................................................... Agreem-e-nt-: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental CPde—The undersigned further agrees not to place the system in operation until a Certificate of Compliance 06been issued by the at e Signed - --- --------- -- -..-1 Application Approved --- ... -- ------------ --- ----- � ------------- '� "�e��G—� Ls �2 Dace Application Disapproved for the following reasons------ -------------- ----------------------------------- -......................................----------------------------------- - -- -- ------- ------------ --------------------. --........... --. ---.................. ... --...---...... ................... ----------------------------------- Permit No. ...... :..... . `— :r ''� � �'.� Issued .....................-�.......��...:' Dare + THE COMMONWEALTH OF MASSACHUSETTS BOARD—OF HEALTH TOWN OF BARNSTABLE ApplirFatinn for Disposal Works Tnnitrur inn Prrutit Application is hereby made fora Permit to Construct (� Qr„Re it (0 an Individual Sewage Disposal 'System at: /� '``SS 7R�(.' Loca' '-Address or Lot No. ----------------------------- .... �'t ..•. !'--------- .....---.... AIM �0wner i Address a 'r s ws 3 ..��,s-� 1. Installer Address Q Type of Building Size Lot...........................Sq. feet U Dwelling—No. of Bedrooms............•-�..........................Expansion Attic ( ) Garbage Grinder (,oV)P WP4 Other—Type of Building No. of persons............................ Showers YP g --------•------•--•-•------- P ( )..— Cafeteria ( ) dOther fixtures ----------------•---------------------------•---------.•----•-----•-•-••------•---•-----------•-----------•-------.- W a Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity....---.....gallons Length---------------- Width................ Diameter................ Depth................ x s� Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter...........----.---- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1------------....minutes per inch Depth of Test Pit.................... Depth to ground water........................ (X, Test Pit No. 2................minutes per inch Depth of Test Pit----------_-...._.- Depth to ground water...-----................ a •-•••-•----•------------------------------------••---•---------•---••-----------•-••--......._...---......................................................... Descriptionof Soil........................................................................................................................................................................ x W -----------------------------------------------------------------------•-----------------•------------------------------ -----------------------------------------..... ................. U Nature of Repairs or Alterations—Answer when applicable.-... - -----.. A.�_--_---••t-- Y ' ;Wa U P PP - ------- --------------------------------•---•----------------------•-------------------------.......----------------....---------------------------------------------------•--------..........•...--•--••••----- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Cede—The undersigned further agrees not to place the system in operation until a Certificate of Compliance Ole een issued by the ar f hea t _ Signed ... ... .... ? ......---- --------------- Application Approved ... ............. .........---...--------- //j-----...�.--------- ->.�� .. �el1�' Jc cj Eite Application Disapproved for the following reasons- -- -------------------------------------- ---------------------------------------------------------------------------------------- . .. .................. ....-- ---- --------.."-- Permit No. �'� � . Issued ----------------- .... ................... .�J ...... ...... Dale i THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C ertifirate of Compliance THIS IS TO CERTIFY, That the Indivi .al Sewage Disposal System constructed ( ) or Repaired by ..........--� f. ...5.. GAS ' .............7.... ---.... ------....--------......................-----.....----.....----------------................. ------------. ter.. Installer 00 at ---------- .............................................. ......:-W- w�., '' ''' .....-------------.->...-------------------------------------- has been installed in accordance with the provisions of TITLE of The Stat E"vironmental s d scri d ___--- the application for Disposal Works Construction Permit No. - �-. dated . ....... � -�--------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU D AS A GUARANTEE THAT THE SYSTEM WIL�NCTION SATISFACTORY. - DATE. Inspect --". " ... .. .. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No....................... FEE.. ` .......e-1 Eltopoo al Works Tonstrudion Vamit Permission is hereby granted.....--...-- C- 7._--Z� f�f'✓S.! .......................... to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo.................<.—...� .._. 1� .� �! ' .., -----------e�-w.- ............................................._ Street as shown on the application for Disposal Works Construction Pemit N�`�-...^����._'.. ed.. ----------------------------- Board � ,-,r of Health DATE..................... ................. ........................... FORM 36508 HOBBS 6 WARREN,INC.,PUBLISHERS P Town of Barnstable B� • Department of Health, Safety, and Environmental Services • wwsreSts, t M� Health Division 63¢ 367 Main Street, Hyannis MA 02601 Office: 508-790.6265 Thomas A.McKean FAX: 508-775-3344 Director of Public Health E dune 1, 1995 TO: Philip Reilly 500 Marstons Lane Cummaquid, MA 02637 ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE,TITLE 5. The septic system owned by you located at 500 Marstons Lane, Cummaquid was inspected on May 11, 1995 by David Munsell a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00)due to the following: • Liquid level observed above the top of the tank. You are directed to hire a licensed Town of Barnstable septic system installer to submit a sketch diagram of a proposed system to the Town of Barnstable Health Division Office (Town Hall, 367 Main Street, Hyannis) that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code, Title 5 within (14) fourteen days of receipt of this notice. You are also directed to bring the septic system into compliance within thirty (30) days of receipt of this order letter. You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings, onto the surface of the ground, or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BO OF HEALTH 6152 i �homTas-acKean, R.S., C.H.O. Agent of the Board of Health q ASSESSORS MAP N0. PARCEL NO: rr-) 26:;- r [Installer letter] J TO: 4c> 4e4 (Date) l� ' ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. (.11 The septic system owned by ou located at 5b0 M ns Lw V—Y4,G Zas inspected on Vmj 11 I99s by J MQ,\-5;ed a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00)due to the following: L.ta �e v-e( A E bbve eon `U--f IL You are directed to hire a licensed Town of Barnstable septic system installer to submit a sketch diagram of a proposed system to the Town of Barnstable Health Division Office (Town Hall, 367 main Street, Hyannis) that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code, Title 5 within (14) fourteen days of receipt of this notice. You are also directed to bring the septic system into compliance within thirty (30) days of receipt of this order letter. You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings, onto the surface of the ground, or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health Town of Barnstable 4 3{ { 4f r r MUNSELL ASSOCIATES , ` HOME INSPECTION SERVICES CO3�i79''MAIN STRE ET(RT. 6A) P:O BOX tl3'1 'BARNSTAB�LE, M'A"SS'ACH`US'ETTS 02�640 362-4043 FAX(508)362-2992 s . SUBSURT'ACE SEWAGE' D�ISsPOSAL SYSTEM INSIP'EtiCTION FORM' Address of prop'e>rty;` 500-- -Marstorf Lane Cumrm�quid, . MIS Owner' s Name': Mr. Phillip Reilley IRECEQ.VE Date of Inspection: May 9,, 1995, PART A MAY 18 1995 CHECKLIST,: HMTH DEFT. 7MOFOARNSDM Check if the fol 1 owing have been done X Informati'an was re` Isted of the owner; `idddupa'nt; and Board -of Health. X None of the -syst66 components have been `purr%`ed fo'r at least two weeks and th'e system has been re'c`evi ng 'normal flow rates during that period. Large vol`urries' of water. have not been introduced .Into the system rece'ntl`y or as. part of . this nsp"ec'ton 1 X As built::plans have` been obtained arid' 'e`kdr i`ne'd. Note if they are not available with N/A. X The facility or d'we11 •ng `eras nspe'c'te`d 'f`or 'S1 ms,,,of sewage, back-up: X The =site was- insp°ected for signs of bred 6! t . X All system cornpone'rits Includrn'g the .SAS'shave been located �{ on the site X The `wsept 1 c tank manholes were undovere'd, op°ene`d, and- the interior of the, s`ep't c tank. was ins'pec`t�0 .for co`nditi`on 'o'f ' baffles `or tees; material of ccan,structi'on, 'dimeri=sio'ns,, , depth of liquid; depth of sludge, degt'h of sc6iim.' X The 'zi:ze'''and location of the SAS on the site' has been determined` b`a_sed on !tHe existing information or apprcx- imated by non-intrusive methods . € X The .facility owner (and occupants, if diff'erent f:r`ovi owner) �Ej were provided w'i"th information on the' proper ma 'nten'ance,- 'of. SSDS r. Page 1 �. SUBSURFACE, SEWAGE DISPOSAL" SYSTEM eIN'SPE{CTI, Nr FORM z' :PAR T -B SYSTEM I�NF'ORMATIOI�T°"' r FLOW CONDITIONS ' If residential 3 number of be°droorns H 2 numb"er, of current residents`= NO garbage gr n"de"r, yes or";no t ti YES laundry donne`c'ted to systems yes' are zro X NO s,eas,onal u.sfe, yes or no If nonresidential; cal.cualated''= flgw: N/A >, Water meter' readin'gjs,, sf, avaa fable 3t80"0© qa 11la. t 06 months • t v4 CURRENT` Last date of- 'occupancy GENERAL IN'FORMAT T QI Pumping records and �s#o rr6e 'of information ° .HAS NOT BEEN PUMPED' SINGE NEW' PER ..OWNER � k + NO _System pumped as p"art `of rispe'ctlon, ye's or no' If yes, volume pumip'ed Ga11ons Reason far pumping n F Type of System r \ X Septic+ tank-/disaribut on box/s'ozl 'abEsorpst $on sr stern S i ng l-,e c'e sspd l Overf low` c'e �spdol . i¢ Privy . v. Shared system (yes or noT (if yes,,`, atftac'h_ in previous{ g specti:or- records; if f, a-ny)`. " Other (Ekpl'ain)` x y Approximate age of all 'c-omponents . D'a'te iistal ed, `4f known Source of information DULY 1986 RECQRD OF k. NO Sewage' o°do'rs° det'e`cted : heri arriving #at sa to to yes or no " c 4 � 53r- , # � t i 4 of tr t, d r t Page 2 F t \ } SUB-,S,URFACE S'E AGE" DISPOSAL INsSPE{CT I.`OI� 'F!QIRM =t { 'PART aB SY STEM TN'F`ORMAT.I"ON' ";contnd' } SEPTIC TANK: YES 186 GALLON` (locate on site` 'plan)' depth below 'grade` $ 32 TITCHES material of con3s;truc'tiion. Xr concrete: metal {k FRP other (exp?iasn) R s 4 q dimensions :- 0. 2 INCHES sludge depth 30 inches distance .from `top of sludge to -66t o outlet ytee or baffle 6" inch scum th kknesrs 10 inch di's'tance` f rom top o`f acum' to `'topx bbaf 8 inch ' di;sta'nce" from' "b'o'tt"o of scum to 1�ott=dm,. c� outlet '-`tee or baffle 1 `� - _ A 'HTN PITF . . 4 Comments. tTANK SHOULD BE`}PUT�I'P'ED� AT THE, T-I�ME Q�F' ICE TAT LE C G (recommendation 'fror pumip" ng, cozditio'n `of inlet angel out>1"et "tees`> or baffles; depth of lfq''uid level- 'in relat-lon to o� tle't iriv"ert, structural" i•nteg'rity, evrdenc`e of leaka'ge;, reconmimmendrat.%ons°,for repairs, etc k. .. ' ' ✓ � it X.M� "� n � S .T SNwf _ *.rd x DISTRI.BUTI=ON BO�X` "" 'CION'CRETE "22X16 i' INCHES :. (locate on t sie glaze) A ze, R # 0 ' deptth `o`f ,l qui"d,. level aboveb:outl-et Comments,— (note . t C f=' if °level. and" elistrbution is equal, ev2depnc�e;;opf s3olids carryover, evifde'o' , of lea'kag`e r to ��dr `&d 6f k gokf,: rec`o`men'e`rrdati'or� for repairs, etc'' ) { PUMP CHAMBER N/A (locate on sitie 'plan') F. N/A pumps rn working order,, yes.for nc M Comment a: p' p condition of :pumpfs and appurte' .. (note condition of. um chamber, nances, recommendat"ions`; f"dr maintenance otr rep?a x,7d, e't6' } > a r Page 3 g u J k S p 'SN4 .11 _ - ,.- - - - .. - .. •Fay' i SUBSUR°FACE ZEWAGE DIS�,P'OSAL SYSTEM °I1�7rSP`ECT TON F`JFRI I ' .E PART B'. SYST`E'M. INFORMATION.`continuseici SOIL ABSORPTIONF SYSTEM '(,SAS) CONCRETE LEACHxIN{G EIT 'TiTIT THREE FEET OF STONE AR,OUI+TD' P'E+RTMET`E?R ::(locate ;an _•s"itex plan=;''i`f '`pos$si- ble, excavation ,not required, but may be approximated by neon-intrusive ime�thf66s) „u; b If not determin'eU, to; ,bje' p're'sent exp°lain Type . leaching pits �an'd nudmbie�r l _ leaching chambers -sand riurm'ble'r 0" leaching gallldrie-s and numb,`er leaching trenches, number, ed ;mensIoris overflow cesspool nu+mble'r comments: (note conditions:- of soil., signs of hydraul=i�c faa lure, �-le,�,e,1 of,. ponding, condition ''of `v�dgetat,ion, reddmimieWd+at rm"a•irit"enance or repairs, etac. ) LIQUID LEVEL 'WAS ,AB'O'VE� 'THE' TOP :OF THE TANIfi• N'D _T1�T'P`0 T'HE' EXTEN SION COLLARS'. THI^S IS A FAILED ,SYSTEM. RE'COIu!'M�E1�TD` THAT --A& NEW LEACHING PIT &E INiST'AL'LEjD' IN' THE EXPANSI�O'N AREA ?AS,,D'ETF'INED IN THE ORIGINAL PLAN *ONFILE AT THE LOCAL BOARD OF 'F*IEALT=�rI OF 'BARNSTABIE. CESSPOOLS (lcv,cat'e on- sit`e plan)' N/A number and cdnf igur,,a'tfc'n' depth-top of liruid` to`, inlet invert depth of solids layer d'epth,of scum layer dimensions of 'ce�sspb6l materials of c'on',s'�tr'uct `dri t indication of groundwater t inflow ('c`esspdoT must bV p mp6d as part of inspection) _, .. Comments : (note condition :of soid, signs of hyd:raizla c f-`a' bevel of ponding, condition 'of ve'g'etatio'n, recor�irn'e 'datio'n"s :far r 'a•iri`tenar%ce or repairs, etc.,) ti Privy: N/A (locate on .site ,pla',n) materials of const•r=uct 'o`n dimensions depth of solids Comments (note condition ' o'f' soil, signs of hydrau•li.c fa'iluxe, ponding, ,conditio'n `of ve'g'etationp recomrri"e'ndat =ons: 'for rml&''n na tde. or repairs, etc ) Page 4 T. SUB SURFACE DISPOSAL SYSTEM INS'PECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to., at least two permanent references landmarks or benchmarks, locate all wells within 100 ' 0 0 f�nUS� 0 0 DEPTH OF GROUNDWATER NO WATER ENCOUNTERED AT A DEPTH OF 156 INCHES :depth to ground- water method of determination or approximation: OBSERVATION PIT DUG AT TIME OF ORIGINAL PERCOLATION TEST IN 19185 ON RECORD AT. THE ,BARNSTABLE BOARD OF HEALTH. Page 5 y r SUBSURFACE SEWAGE DISPOSAL SYSTEM IN'SPt&ION FORM PART C FAILURE CRITERIA Indicate yes, no, or ndt determined (Y,N, or ND)' . Describe basis of determination in all instances . If "not d'e'termined" , explain why not) NO Backup of sewage into facility? NO Discharge or pbn'ding of effluent to the surface of the ground or surface waters? NO Static liquid level in the distribiit do box above the outlet invert? N/A Liquid depth in cesspool <'6" below invert or available volume< 1/2 day flow? NO Required pumping 4 times or more in the last year? number of times pumped 0 NO Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: NO below the high groundwater elevation? NO within 50 feet of a surface water? . NO within 100 feet of a surface water supply or tributary to a surface water supply? NO within a Zone 1 of a public well? NO within 50 feet of a bordering ve'g'etated wetland or salt marsh (ces's'po-ols and privies only, not the SAS) ? NO within 50 feet of a private water supply well? NO less than 100 feet but greater than -50' fele't 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 coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. Page 6 SUBBURFACIE SEWAGE DISPOSAL SYSTEM INSPECTION FORM' .' PART D CERTIFICATION Name of Inspector: David P. Munsell Company Name: Munsell Associates Company Address: 3179 Main Street Barnstable, MA 02630 Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and. complete as of 'the time of inspection. . The inspection was performed and any recommendations regarding up- grade, maintenance and repair are consistent with my training and . experience in the proper function and maintenance of on-site sewage disposal systems. Check one: I have riot found any information which indicates that the system fails to ade'giiately protect public Health or the environment as defined in 310; CMR 15`. 303 . Any failure criteria not evaluated are as stated in the FAILURE" IG CRITERIA section of this form. X . I have determined that the system fails to protect public health and the envircihm'e'nt as defined in 3`10 CMR 15 . 303. The basis' for this determination is provided in the FA-ILURE CRITERIA section of this form. SEE COMMENTS UNDER SAS. THE OVERFLOW PIT HAS FAILED. Inspector' s signature Davi �P�Munsell Date: May 11, 1995 Original to system owner: Yes Copies toc Buyer (if applicable) Approving authority. Barnstable. Healt"h Department Page 7 = SESSOR'S MAP NO. -3 PARCEL L � 'TION SEWAGE PERMIT NO. � VILLAGE s� INSTA LLER'S NAME i ADDRESS DgiA".3 c. V.1-ss'L-dG B U I L D E R 0R OWNER J DATE PERMIT ISSUED DATE COMPLIANCE ISSUED P ,�s L�tel�._ _ ��� ��� 4. { ,> o�5 C a � °�+ a� ,. • �. fr .. _-� No. . .. �-- Fs$... .._ THE COMMONWEALTH OF MASSACHUSETTS BOARD' Olt ' HEALTH ...........................................OF.............OF...... .... ,17 ................................... Appliration for Biopolq'ttl Works Tonotrnrtion rprutit Application is hereby made for a Permit.to Construct (X) or Repair ( ) an Individual Sewage Disposal System at: 4 500 .-. L�.. a - o1�... ...._ : .. -----........----------... ...--- - ------.........------..._._.......... Loc ion-Address uLt No.ow Address ............................................... Installer Address Type of Building Size Lot..... ..Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building _..___..... No. of persons............................ Showers — Cafeteria W YP g ---------------=- P ( ) ( ) a' Other fixtures ................................... W Design Flow...._.... ........................gallons per person er day. Total daily flow..._...... ......................gallons. • I / WSeptic Tank—Liquid capacity.:0W.-gallons Length-_-_ _-•._...._ Width._. f_.._.___ Diameter______________ Depth_=,::........_. x Disposal Trench—No. .................... Width.................... Total Length...... _._._.... Total leaching area.______.............. ._.._...I.sq. ft. Seepage Pit No.........I........... Diameter.....1.2.�.... Depth below inlet.......`��_�._-----. Total leaching area-�fk -sq-#t.6 2� Z Other Distribution box (u ) Dosing tank ( ) '-' Percolation Test Results Performed by.....000_4 &L, �.��� �._.-� ........... Date Date.. -_z�•-�3••._�._S 3 �3 .Wa minutes per inch Depth of Test Pit-__._r:3Z...... Depth to ground water.._. Test Pit No. 1_..__l.A._._._. .- (i, Test Pit No. 2_.....&......minutes per inch Depth of Test Pit._,.fS' ....... Depth to ground water_.C,!!" O Description of Soil..................... ......... .... x �.-� �' - ---------------•-------•••.......-•••-•• -•-••-.••--• ---......-.... ----.----...----- V --.---.----- •---- -... ----- ----------- .-------------------------------------------- ---------------- •------------------- -------------•------- -----------------------•-------------------- ---------- W VNature 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 iI'U 5 of the State Sanitary Code—The undersi ned further agrees not to place the system in o eration until a Ce ficate of Compliance has bee ssued by he bo of lth. JtA-4-) C' Signed. -- ----•------ - ----------------- -••��...----- . --------•-- Application Approved Bgs ••--• --•---•-�------ --•-•-•---•----••- =1_' at ........ Date Application Disapproved for the f l wing reasons-------------------------------------------------•---•---------•--------.........----------••......---........... --.......---•-••.................................•--••-••-•-•-----••••--....•-•---------•...-•••-...•••---•-•-•-•----••-----•••-•-•••-•-----••-••-••--•-•------•..._.................•--•-•.........---- Date Permit No.......5.-:.CIA............................ Issued....................................................... a w ASSESSOR'S MAP NO.�PARCEL- 7 LOCATION SEWAGE PERMIT No. VILLAGE I N S T A LLER'S NAME i ADDRESS /SA A A 6 U I L D E R OR OWNER Cow Co , S ., DATE PERMIT ISSUED DATE COMPLIANCE ISSUED p �� ► Or c No._. ' 7 `'��'1' Y a Fsa v .` 1 THE COMMONWEALTH OF MASSACHUSETTS - BOARD OF HEALTH .. ,>U.............OF...........�/Rc.'.,U�1�1QL ..........-.............. ppliraftniffor Dispoiial Works Tnnitrnrtiun pamit Application is hereby made for a Permit to Construct (K) or Repair ( ) an Individual Sewage Disposal System at: A'56co ........... ., �-( 7 ,tJ,S C_............................................... _..-••---•---•-----------•----•-• ........`�=.....-........-.... ............. L( ion-Address or Lot No. .......... LL�.�..5...__... ar?S� 7' - /------------------------- � � /�.U.U.%f. r ?.�....�G/�1 •t!!..!!_.j- Owner— Address Installer '"y Address t Type of Building Size Lot....4� ± ..Sq. feet aDwelling ;1 No. of Bedrooms.......a..............................Expansion Attic ( ) Garbage Grinder ( ) p, Other—Type of Building .................:.......... No. of persons............................ Showers ( ) = Cafeteria ( ) Other fixtures ............. W Design Flow......... ........................gallons per person per day. Total daily flow............. ._? .......................gallons. c ! WSeptic Tank—Liquid capacity L,-Ca.gallons Length----- Width..:4 r.....-_ Diameter................ Depth............... x Disposal Trench No -------------------- Width................... Total Length........ .... Total leaching area.............�..._sq. ft. .. Diameter, ages�Pit Nisi..........�.. f2:. .... Depth below inlet.................... Total leaching area.:��....... .-sq-ft:G •P a 4istriittlon box (q ) Dosing tank ( ) _ Percolation Test Results Performed by....�.. �+�_` .(. Z_L,N K j �Ll(.:........_._ Date.._=2G- {� a J_,3 a .. ` est`Pit No. 1.... _re......minutes per inch Depth of Test Pit.....+`_?.. Depth to ground water..- G4 ' Test Pit No. 2.....44......minutes per inch Depth ,of Test Pit----- Depth "to ground O j•.................................................................--•-------......------........................... Description of Soil----.....---••------ ,tii. ............ `'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 TLITIE 5 of the State Sanitary Code—The iuidersi ned further agrees not to place the system in o eration until UCe , ficate of Compliance has bee ssued by he bo of Ith. t�Stgt�ed4 C --..............................- ----- ............ Date Application Approved B -- - . ------. 5 Date Application Disapproved for the f l wing reasons: - .......................................-----•------------- ;w---------------•------ ------=------------------------------------------------------------------------------- ------- Date Permit No...... 5 idq. Issued-..................................................... Y., Date THE COMMONWEALTH OF WASSACHUSETTS BOARD--OF HEALTH ./ r .ae e I .. O.F...... eft'............ ... Trrtifiratr of T-am rliaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired .( ) a by. ..... , ,....... ............................................................. �.} 4 Installer at---••-------------------•-La-{-----L- -•---=•=-•..�..AfK&N-----------L:W-1.....................................................--------------------••••-_..... has;been installed in accordance with the provisions of TITI j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No....G_S_-__774............... dated..................:.........------------------ . THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT XNE SYSTEM WI FU CTIOQI SATISFACTORY DATE.......7, C............................................ Inspector...-- i tne•'CQr.TMONWEALTH OF 'MASSACHUSETTS - BOARD OF HEALTH 1 � - �, ..:.:....:..........................OF:_.......... FEE.....1J .......... RSVOsal Works lvtlunotrud!i n Varnit Permission is hereby granted_.......`'( -�-`f:-_ p�ryt �R i�+ or Repair to Construct p ) an Individual Sewage Disposal System �"� .,..: ( ) at No..- -------Lcz. .......... strect as shown on the application for Disposal Works Construction Permit No. ? ��q¢ Datctl .............................. ---------------------------- DATE.——= . ara or e:ath i I I I I i 'DECK e ( I I I I ►N I I I I 4r6 A I b - -V x 46" I I collar, skyllglut I I I ties ' i I I I I I I I i III A I IAMM Y NOO111 I I I I E k i I I I I . L., - - -- �. - - -- -- - - - - - u ---- - - - - - - - - - - - _ 200 PT joisus @ 16'o.c. iv/3VJ' \ I ply sub-floor v c4. Dbljoists w/ DhIjo&s w,l \12'pkrdt 12"pier& 4r4 post 4r4 post \ -12'dia:rant:sons-tube piers /' \to 48'belowpude w/4r4 2-2.r81'7'girt/ lq posts&metal anchors 6'-4" 6'-4" 6-4" (OP) Floor Plan & Floor o c a Frame 1 /4" = V-0" Home Improvement Specialists' William & Maralyn Palle Page: 1 25 lyannough Road 500 Marstons Lane Hyannis, Ma. 02601 Cummaquid, MA. Date: 7/6/2006 508-775-2815 . CO O O N CO N cv ca D..I I I I I t -11101111111 11 1111 1 1 1 1 1 1 1 1 1 Q G1 CIO $ cc O CU LO WT� Grade V CL N _ U) c O N U') O O j O N O LO uj Q Ca � End Elevation 1 /4" = 1 '- EN = ' 0 0„ CO O C N M � N M C77- - � N C Q aJ N L c IT I O cu ® E LO Ell, I I I I i I i I I H L -.1—YM N Grade U cn m O CO N � C � Left Side Elevation > o In Ri ht Side Elevation � _Cb g � T � o E C4 o 2 co 0 - o J N ti N a cU 2r10 rafters @ 16'o.c. ►y/1/2" OSB sheathiq,asphalt mof shingles,ndgc&cave-vents& R—V FG insulation 4x6 collar lies set 113 up tmm plate c C Q �,J cc N 1 0 �. cu E Cc 2r4 KD studs @ I e o.c w/1/2'OSB LO V i sheathing,w-c.shingles&R-13 FG / insulation 2ri0PTjoists @ leo.c. wj 314' CDX ply sub-floor,R-30 FG 'rr insulation&PT ply soffit below 2-2,8 PT girt on 44 PT posts on 12"din cone.sonaiube preys F Ll cc Z N Q-p U) 0 Extend wall sheathing&siding24'belowfloor +�+ W N LO fume&enclose remainder to grade w/11'Z N cement board incbrdit{g air vents N = ' 00 � � N e i 0 � QCU tt') T LO Cross Section 1 /4°' 1 '-o" N cfl O dew O N —- - Cn Co ti N N t� r � t0 0- BATH KITCHEN DINING 91 DEN Stroke - BEDROO.V ° Detector. t BATH Smoke Detecto_r in basement a> s =,gv s cc CU Smoke S Detector cc cLa cn Cc:Ca NCr - � ccCis m E M MC:) O Co LIVING ROOM BEDROOM BEDROOM GARAGE I I • I � i I i Cn cc o Co 4 p N t� N 10 n' > O L C Q.. � C ~ , 2 A to E N = O 2 Existing house plan with -smoke detectors (no scale) .. _ F F 4 f IN r .. w.aLFIX t AJ©TE M E3CTE-!VDNHL C' G AOE c�V ERS To WIT/-l/A./ --o— o—o--n - propoScd round pr-ofrl� HOQ/z. 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L:) 0)= HE,QL TH NI > : ,... ._,.,v. r..v ,rd-.b+xww:rama. a::.wec.s�i..a:..::.�.,mr•x:ar r:-zvrsadw�.•.�nrlahlsiafcr=- 'N' .r +yd�t�hW;khl+ra��MCtI!�',"� .,: .: .. ''9-