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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
"< 516 Marstons Lane, Cummaguid OAVVs M 6L-6— M -348 _ P-028 .
Property Address
Steven & Kathleen Titus h;
Owner Owner's Name
information is a
required for every 516 Marstons Lane, Yarmouth Port MA 02675August 11, 2016
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:
key to move your '
cursor-do not Troy Williams
use the return Name of Inspector
key.
&*---h Troy Williams Septic Inspections
ICI Company Name
19 Hummel Drive ;
Company Address
South Dennis ' MA 02660
City/Town State Zip Code
(508)385- 1300 S1682
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
August 11, 2016
Inspector's Signature 'Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
516 Marstons Lane, Cummaguid M -348 P-028
A Property Address
Steven & Kathleen Titus
Owner '^" owner's Name
information is`required for every 516 Marstons Lane Yarmouth Port MA 02675 August 11, 2016
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary:Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
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):
t5ins•3/13 Title 5 official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17
1
L_
Commonwealth of Massachusetts
Title 5 Official Inspection Form .
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
"< 516 Marstons Lane, Cummaquid M-348 P-028
Property Address
Steven & Kathleen Titus,
Owner Owner's Name
information is required for every 516 Marstons Lane, Yarmouth Port MA 02675 August 11, 2016
page. Cityrrown 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):
• s
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet'of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-3113 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
"t 516 Marstons Lane, Cummaquid M-348 P-028
Property Address
Steven & Kathleen Titus
Owner Owner's Name
information is required for every 516 Marstons Lane Yarmouth Port MA 02675 August 11, 2016
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic.tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® 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•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts v
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�< 516 Marstons Lane, Cummaquid M -348 P-028
Property Address
Steven & Kathleen Titus
Owner Owner's Name
information is required for every 516 Marstons Lane, Yarmouth Port MA 02675 August 11, 2016
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cunt.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® 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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
516 Marstons Lane, Cummaquid M-348 P-028
Property Address
Steven & Kathleen Titus
Owner Owner's Name
information is 516 Marstons Lane, Yarmouth Port MA 02675 August 11 2016
required for every g ,
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
[D ❑ 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
I ,
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
516 Marstons Lane, Cummaquid M -348 P-028
Property Address
Steven & Kathleen Titus
Owner Owner's Name
information is 516 Marstons Lane Yarmouth Port MA 02675 August 11, 2016
required for every � 9
page. Ciijr own State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage 15=81,000 gals.
g y g (9pd))' 14=75,000 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): NIA
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 •
15ins•3/13 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
516 Marstons Lane Cumma uid
q M -348 P-
028
Property Address
Steven & Kathleen Titus
Owner Owner's Name
information is 516 Marstons Lane, Yarmouth Port MA 02675 August 11 2016
required for every 9 ,
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: N/A
Date
Other(describe below):
NIA
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•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
516 Marstons Lane, Cummaguid M -348 P-028
Property Address
Steven & Kathleen Titus
Owner Owner's Name
information is 516 Marstons Lane, Yarmouth Port MA 02675 August 11, 2016
required for every g
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 leaching were installed on 4/28/98 per compliance.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 18"+
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.):
Lines were found clear at the time of inspection.
Septic Tank(locate on site plan):
Depth below grade: 1
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
Dimensions: 6'X10.5'X6' 1500 gallon
Sludge depth: 41'
t5ins-3/13 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
516 Marstons Lane, Cummaquid M -348 P-028
Property Address
Steven & Kathleen Titus
Owner Owner's Name
information is 516 Marstons Lane Yarmouth Port MA 02675 August 11 2016
required for every � ,
page. CitylTown 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
2'8"
Scum thickness thin layer
611
Distance from top of scum to top of outlet tee or baffle
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):
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•3/13 Title 5 Official Inspection Form: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
'( 516 Marstons Lane, Cummaquid M -348 P-028
Property Address I -
Steven & Kathleen Titus
Owner Owner's Name
information is 516 Marstons Lane, Yarmouth Port MA 02675 August 11, 2016
required for every 9
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.):
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
Capacity: N/A
p tY" 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.): g
N/A
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-3113 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
"< 516 Marstons Lane, Cummaquid M-348 P-028
Property Address
Steven & Kathleen Titus
Owner Owner's Name
information is 516 Marstons Lane Yarmouth Port MA 02675 August 11 2016
required for every � 9 ,
page. Cityrrown 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. No evidence of backup in the past was found at the time of
inspection.
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°( 516 Marstons Lane, Cummaquid M -348 P-028
Property Address
Steven & Kathleen Titus
Owner Owner's Name
information is required for every 516 Marstons Lane Yarmouth Port MA 02675 August 11, 2016
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ Teaching pits number:
® leaching chambers number: 4 infiltrators with
4' of stone
34
Elleaching galleries number: 'X 11'X 10"
❑ 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.):
Soil was sandy. Checked stone and found dry and clean. No evidence of hydraulic failure or problems
in the past were found at the time of inspection.
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
Dimensions of cesspool
N/A
Materials of construction
N/A
Indication of groundwater inflow ❑ Yes ❑. No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
516 Marstons Lane, Cummaguid M-348 P-028
Property Address
Steven & Kathleen Titus
Owner Owner's Name
information is 516 Marstons Lane, Yarmouth Port MA 02675 August 11 2016
required for every 9
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.):
N/A
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
i
Commonwealth of Massachusetts '
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'< 516 Marstons Lane, Curnmaguid M -348 P-028
Property Address
Steven & Kathleen Titus
Owner Owner's Name
reformation is required for every 516 Marstons Lane Yarmouth Port MA 02675 August 11, 2016
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
&A)w�4✓
x .
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
516 Marstons Lane, Cummaguid M -348 P-028
Property Address
Steven & Kathleen Titus
Owner Owner's Name
information is 516 Marstons Lane Yarmouth Port MA 02675 August 11 2016
required for every � 9 ,
page. Citylrown 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: 13.0'+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. 12/9/97
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 23.3' 3.5'adjustment
You must describe how you established the high ground water elevation:
Test hole recorded on plan showed no water found at 10.0'. Hand augered 4' below bottom of
leaching with no water found at a depth of 10.0'. Groundwater adjustment at the time of inspection
was 35. Bottom of leaching at 6.0'was found not to be located in the high groundwater elevation at
the time of inspection.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
yt 516 Marstons Lane, Cummaguid M -348 P-028
Property Address
Steven & Kathleen Titus,
Owner Owner's Name
information is required for every 516 Marstons Lane, Yarmouth Port MA 02675 August 11, 2016
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Commonwealth of Massachusetts ;
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'( 516 Marstons Lane, Cummaguid M -348 P-028
Property Address -
James&Theresa Clark
Owner owner's Name
information is 516 Marstons Lane, Yarmouth Port MA 02675 August 6, 2013
required for every 9
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: COPY
key to move your �.
cursor-do not Troy Williams
use the return Name of Inspector
key.
Troy Williams Septic Inspections
ICI Company Name
19 Hummel Drive
Company Address
South Dennis MA 02660
Citylrown State Zip Code
(508) 385- 1300 S1682
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 16.000).The system: -
® Passes r ❑ Conditionally Passes ❑. Fails
❑ Needs Further Evaluation by the Local Approving Authority
August 6, 2013
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving.authority.
"""This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins-3/13 Title 5 Official Ins pectioffub urface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
"t 516 Marstons Lane, Cummaguid M -348 P-028
Property Address
James&Theresa Clark
Owner Owner's Name
information is required for every 516 Marstons Lane, Yarmouth Port MA 02675 August 6, 2013
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
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):
t ins•3113 Ttle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
516 Marstons Lane, Cummaquid M -348 P-028
Property Address
James&Theresa Clark
Owner Owner's Name
information is 516 Marstons Lane, Yarmouth Port MA 02675 August 6 required for every 9 , 2013
page. Cityrrown 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 (cunt.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will .
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced - • ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°f 516 Marstons Lane, Cummaquid M -348 P-028
Property Address
James&Theresa Clark
Owner Owner's Name
information is required for every 516 Marstons Lane, Yarmouth Port MA 02675 August 6, 2013
page. Cityrrown 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
E ® 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts b
Title 5 Official Inspection Form '
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y< 516 Marstons Lane, Cummaquid -M-348 P-028
Property Address
James&Theresa Clark
Owner Owners Name
information is 516 Marstons Lane Yarmouth Port MA 02675 August 6, 2013 r required for every �
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 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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
516 Marstons Lane, Cummaquid M-348 P-028
Property Address
James&Theresa Clark
Owner Owner's Name
information is required for every 516 Marstons Lane, Yarmouth Port MA 02675 August 6, 2013
page. Citylrown 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
❑ 0 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form,
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
yt 516 Marstons Lane, Cummaquid M -348 P-028
Property Address
James&Theresa Clark
Owner Owner's Name
information is required for every 516 Marstons Lane Yarmouth Port MA 02675 August 6, 2013
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
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
Seasonaluse?. ❑ Yes ® No
12=78,000 gals.
Water meter readings, if available(last 2 years usage(gpd)):, . 11=82,000 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
Gauons 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-3113. 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
.'t 516 Marstons Lane, Cummaquid M-348 P-028
Property Address
James&Theresa Clark
Owner Owner's Name
information is required for every 516 Marstons Lane, Yarmouth Port MA 02675 August 6, 2013
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: N/A
Date
Other(describe below):
N/A
4
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):
i
t5ins-3/13 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
Y
516 Marstons Lane, Cummaguid -M -348 P-028
Property Address
James&Theresa Clark
Owner Owner's Name
information is 516 Marstons Lane, Yarmouth Port MA 02675 August 6, 2013
required for every 9
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 4/28/98 per compliance.
Were sewage odors detected when arriving at the site? y ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: .18"+
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.):
Lines were found clear at the time of inspection.
Septic Tank(locate on site plan):
1,
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
Dimensions: 6'X10.5'X6' 1500 gallon
Sludge depth: 411
t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
516 Marstons Lane, Cummaquid M -348 P-028
Property Address
James&Theresa Clark
Owner Owner's Name
information is required for every 516 Marstons Lane, Yarmouth Port MA 02675 August 6, 2013
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cunt.)
Distance from top of sludge to bottom of outlet tee or baffle
2' 8
Scum thickness thin layer
6„
Distance from top of scum to top of outlet tee or baffle
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):
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-3113 Tice 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
I�
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
yf 516 Marstons Lane, Cummaquid M -348 P-028
Property Address
James&Theresa Clark
Owner Owner's Name
information is 516 Marstons Lane, Yarmouth Port MA 02675 August 6 required for every g , 2013
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: N/A-
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions: N/A
Capacity: N/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/ADate
Comments(condition of alarm and float switches, etc.):
N/A
"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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
516 Marstons Lane, Cummaquid M -348 P-028
Property Address
James&Theresa Clark
Owner Owner's Name
information is required for every 516 Marstons Lane, Yarmouth Port MA 02675 August 6, 2013
page. Cityrrown 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. No evidence of backup in the past was found at the time
of inspection. .
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•3/13 Title 5 Official Inspection Forth: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
'e 516 Marstons Lane, Cummaquid M -348 P-028
Property Address
James&Theresa Clark
Owner Owners Name
information is required for every 516 Marstons Lane Yarmouth Port MA 02675 August 6, 2013
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 4 infiltrators with
4 of stone
❑ leaching galleries number: 34'X 11'X 10"
❑ 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.):
Soil was sandy. Checked stone and found dry and clean. No evidence of hydraulic failure or problems
in the past were found at the time of inspection.
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
Dimensions of cesspool N/A
Materials of construction N/A
Indication of groundwater inflow ❑ Yes ❑ No
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
"< 516 Marstons Lane, Cummaguid M-348 P-028
Property Address
James&Theresa Clark
Owner Owner's Name
information is required for every 516 Marstons Lane, Yarmouth Port MA 02675 August 6, 2013
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.):
N/A
t5ins-3/13 Title 5 Official Inspection Forth: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
516 Marstons Lane, Cummaguid . M-348 P-028
Property Address
James&Theresa Clark
Owner Owners Name
information is 516 Marstons L Yarmouth Port . MA 02675 August 6, 2013
required for every Lane, armou y 9
page. Cityfrown State ' Zip Code Date of Inspection
D. System Information (cont.) ..
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
F
® hand-sketch in the area below.
❑ drawing attached separately
t
A i3w4�� t3
r w
4 1 " G • r
15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
ugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
516 Marstons Lane, Cummaguid M -348 P-028
Property Address
James&Theresa Clark
Owner Owner's Name
information is required for every 516 Marstons Lane, Yarmouth Port MA - 02675 August 6, 2013
page. Cityrown 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: ' 13.0'+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: 12/9/97
Date
® Observed site(abutting property/observation hole within 150 feet of SAS)
El Checked with local Board of Health—explain: -
-❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
AIW 247 Zone C 22.5' 2.4'adjustment
You must describe how you established the high ground water elevation:
Test hole recorded on plan showed no water found at 10.0'. Hand augered 4' below bottom of
leaching with no water found at a depth of 10.0'. Groundwater adjustment at the time of inspection
was 2.4'. Bottom of leaching at 6.0'was found not to be located in the high groundwater elevation at
the time of inspection.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3113 Title 5 Official Inspection Forth: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
516 Marstons Lane, Cummaguid M -348 P-028
Property Address
James&Theresa Clark
Owner Owners Name
information is required for every 516 Marstons Lane Yarmouth Port MA 02675 August 6, 2013
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
-
t5ins-3113 Title 5 Official Inspection Form:Subsurface• pecti Sewage Disposal System•Page 17 of 17
r
TOWN OF BARNSTABLE
LOCATION - SEWAGE # / �4
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) �/ ��r� , /)��� ~.,.,:i (size)
NO.OF BEDROOMS 7
BUILDER OR OWNER
PERMITDATE: "Z COMPLIANCE DATE: 1/
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of, aching faci ' ) Feet
Furnished by
3
f
L- -
y.
TOWN OF BARNSTABLE G ��
LOCATION v". "S '"�h SEWAGE# r
VILLAGE } r~ �`c ASSESSOR'S MAP & LOT 6
INSTALLER'S NAME&PHONE NO. ►,.Y I:✓�' a
SEPTIC TANK CAPACITY P Sed G
LEACHING FACILITY: L a J &e �.t'.e _ f 0
(type) � �� (sine)
NO.OF BEDROOMS `
BUILDER OR OWNER 4z
PERMTTDATE: f COMPLIANCE DATE: Z 2-,q
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of aching faci ' ) Feet
Furnished by iLQf
. a �/ 1
V.
� �n �
'� .,�a
�� � .
30
No. l V 1 Fee
r THE COMMONWEALTH OF 4ASSACHUSETTS Entered in computer:
Yes
PUBLIC 4ALT14 DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
01ppYicatiou for Wig ogaf gtem Cousstruction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) X'Complete System ❑Individual Components
Location Address or i:&No.s (- 4 t Ea•5
Owner's Name,Address and Tel.No.
13�3 Q+ �3u
Assessor's Map/Parcel .3 $ 0 0 r ;pe K y,;S �.G 2 6 t4
L.
InstallerAly
dress,and Te.No. Designer's Name,Address and Tel.No.
�16Korvo
9 r9 � 7
Type of Building:
Dwelling No.of Bedrooms 7�> Lot Size 114 K2_ sq. ft. Garbage Grinder(b )
Other Type of Building No. of Persons Showers Cafeteria( i )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued hu this of Health.
Signed• InA A Date
Application Approved by 2Date
_ -Application Disapproved for the following reasons
9
Permit No. '""' Date Issued
No. I COM ti Fee
e THE MONWEALTH OF 'ASSACHUSETTS Entered in computer:
" R :PUBLIC H�IALTA DIVISION —TOWN OF BARNSTABLE, MASSACHUSETTS Yes
i
Zipprication for Migonl *pgtem Construction Permit
'Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) X Complete System ❑Individual Components
Location Address or Lot No.S (._ c���,5 Z�/• Owner's Name,Address and Tel.No. 3 7 3 1
Assessor's Map/Parcel /I b c R� f oe H r,;S 0 n y, G�L�� �
-I 0 l� tih.N�, lQ Lr L, 7Drl4Jer T
Installer's Name,Address,and Tel'.No. Designer's Name,Address and Tel.No.
RAY C.06411VO
1 — Cf '-j7
Type of Building:
Dwelling No.of Bedrooms Lot Size��� (�Z sq.ft. Garbage Grinder(0 )
'• . Other Type of Building No. of Persons Showers(Z ) Cafeteria( ( )
Other Fixtures
Design Flow f gallons per day. Calculated daily flow gallons.
Plan Date f Number of sheets Revision Date
Titler =-
Size of Septic,Tank "4 Type of S:A:S.
' Description of Soil
Nature of Repairs or Alterations(Answer1 whet applicable).' f
Date laXt inspected: ? t 4
--,"Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance withthe provisions of Title 5 of the Environmental Code and not to place the system in
` opera tion until,a erti;f.-i-
f Comcat& pliance has been issued this - dof Health.
\Signed Date
Application AP roved-bY Date 9�Application Disapproved for-the following reasons
' •V
Permit No. Date Issued
—————— ———————————————————————————————
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CFR IFY,that trn-sit Se age Disposal System Constructed ( )Repaired( )Upgraded( )
Abandoned( )by
at __\" h s eif oc°�ras cted in accordance
with the provisions of Tie 5 and the for Disposal System Construction Permit No. dated"
Installer Designer
The issuance of this permit shall not be cons rued as a guarantee that the system will function as designed "
Date L,/ , ��` Inspector �y \� i
No.
_. - Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS ~F�
Migogar *paem Congtruction Permit
Permission is hereby granted to Construct( ), fair f )grade( )Abandon.
System located at `',
and as described in the above Application for Disposal System Construction Permit.-Me applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
Date: L/ -I ", t"d C j ..
Approved by a
L..
i
L L to 1 r
No................_....... Fmc..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
ApplirFatiun for DhipmFal urkii i n itrurtiun Truitt
Application is hereby made for a Permit to Construct (` or Repair ( ) an Individual Sewage Disposal
System at
... ...� � ........_ .. . -/------------------------- --------------------------------------------- ------------------------------.-----------
Location-Address or Lot No.
......................_.......................................................................... -•-------•--••--•._........--•-....__.........---------------------_........................------
Owner Address
W
Installer Address C� ''
Type of Building Size Lot___: , l-__`77�q. feet
1-4 Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( �'j�U
114 Other—T e of Building No. of persons____________________________ Showers — Cafeteria
P4 Other fixtures _________________________________ _
W Design Flow 1(( gallons per ref®Ay. Total dailowlP r
WSeptic Tank—Liquid capacity/—.5_ O.gallons Length................ Width_. _____ Diameter................ Depth...�.........
x Disposal Trench—No. ......Z............ Width........>'_(_.......Total Length....... _____ Total leaching area...... l....sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( Cj Dosing to ( )
4 Percolation Test Results Z Performed by_____________________________________________________,I __ bate.....
14 Test Pit No. I... per inch Depth of Test Pit..../.________..... Depth to ground water....7f.___..��.
4 Test Pit No. 2_._.._-_7-._minutes per inch Depth of.Test Pit.... �_u._ Depth to ground water_27/ZO _._
-----------------------------------•---------•------•----------•-- ------_............................................................
0 Description of Soil.__. —��:'�``^J �._ _
x ---
U
w
------------------- -----------------------------------------------------------------------------------------------------------------•----------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
r
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance s been issued y the b a of health.
Signed ..........I
..--------- .........------. ----------------
ApplicationApproved By --------------------------------------------------- -------------- ------------------------------------ - --------------------------- -------------------------------- ----
Date
Application Disapproved for the following reasons- ---------------------------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------------------- ---- --------- ----- -- -- ---------------------------------------- ......................-----------------
Date
PermitNo. ....................................... .......... ... ........ Issued ............. -----------......----------- -- ..................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
(frdifirate of C�oxaylinurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by.......................................................................................................................... .. ....... ..........................
Installer
at .. ------------------------------------------------- -----------....................---- -- -- ------------------------------.....................-------------------------------------------------------
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ................................................ dated ........--......................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE------------------------------------------------------------------------------------------------------- Inspector ........... ------.---------------------.....--------.....------ ............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No......................... FEE.........................
MaposFal Vorkg T11mitrurtion firrmit
Permissionis hereby granted----------------- ------------------------••.-------.-.-.-.-.---------------••--•-----------------------............----.....__..........---
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
atNo...............................................................................................................................................................................................
Street
as shown on the application for Disposal Works Construction Permit No_____________________ Dated..........................................
•------------------------•-•-•-•-----•---------------------------------------.........................
Board of Health
DATE................................................................................
FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS
J
No......................... Fzs.............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Applirat ion for BiupuualWork-s Tongtrnrtiun ramit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System�f•
..... ............................................... `�` ;� -----........w!` .........----••-••...•--••-••---•••_•-----•-•••---_-•-----•----........
Location-Address or Lot No.
Owner Address
W
Installer Address
Type of Building Size Lot--- _ -Z-Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder
a`4 Other—Type of Building No. of persons............................ Showers
YP g ---------------------------- P ( ) — Cafeteria ( )
Other fixtures .....................................
// O> �- 72an�-1------------------------------------------------------_----•----------------------•--
W Design Flow...........................................gallons per ersc )ef day. Total daily flow__.________.___._.._..__ _. _._._._gallons
WSeptic Tank—Liquid capacitye5..' Ions Length__!�-._ _._ Width.4.O..... Diameter................ Depth................
x Disposal Trench—No. ......1_f......... Width........�:�....... Total Length___.... `'1._.... Total leaching area___-: :_._sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet......_............. Total leaching area..............!---sq.'ft.
Z Other Distribution box ( (�'� Dosing to ( ) -•67
W Percolation Test Results Performed bY---------�-------=--------------------.......---------------------------- hate.....
,a Test Pit No. 1___G____--..minutes per inch Depth of Test Pit.....//Z j� .T.. Depth to ground water....2:.Y ..r.rf.
f� Test Pit No. 2.... Z...minutes per inch Depth of Test Pit___.t:.%_C_'l_. Depth to ground water.. ... .4...�.
P4 •-•----•-•--•----------------------•---••---------•--•-•-- ----•-..... --•---...........__._...----••••••••--•--•-----••...•-•-••......•....••••.........--
x . Description of Soil f ter..=f , � ---------------------•--------------.....
V ............................. ................-•---•-•---------•----•••-----•--•-----•••-•••••-----.•-------•---------•----••-------••-----•----.....................................................
W
x ----------------------------------------------------------------------------------------------------------------------------------- --------------•-------•-------------------•--•---•-------•-.....--
'�� 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 TITLE 5 of the,State Environmental Code—The undersigned further agrees not,to place"the
system in operation until a Certificate of Compliance has been issued by the board of health.i,
Signed
him . p -.................... -... ...............................
Date
ApplicationApproved By ...................... .... .... ..... .../ -- ---...........�.�-- -' .............- .e"------...--- ..
Application Disapproved'for the following reasons: .................... .-
....------------.....---............ ----------------------I..------.............................
.......---...........................-----------...... .--...........---.............---------......------......---------------..--..........................................------------ .............--- ---------Date
PermitNo- .................-------------------------------------------------- Issued .................................----------=--------------- ----
Dace
THE COMMONWEALTH OF'MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
C�Er#i�ictt#e o� C�um�It�xn�E
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by .......................................................-------------------------------------------------------------------------------------
Installer
at ................ -
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ------------------------------ dated ...............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........ . .............. ........................................ ... ....... ... Inspector ---------------...................................... -----------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No......................... FEE........................
�iu�uu�1 Turku �unu�riun rrnti� ,.�
Permissionis hereby granted............................................................................................................................................
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
atNo...............................................................................................................................................................................................
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
------------•------------------------•------ -----= ------------------------------------•------
Board of Health
DATE...............................................:................................
FORM 36508 HOBBS&WARREN.INC.,PUBLISHERS
G::i :^ Nome—.. mA '..'ems.4r,'iN=394' .'.w-VommmonwramomSOIL T 7-
'NA"r OF
O!L TEST
SOIL TESTS
SDONE �` N
WITNESSED BY
C'Jv , , , :: �' _�� may,- ll�' 3 OBSERVATION MOLE 2 ELEV.- D
�, _ OBSERVATION HOLE 1
- rrltN. Pl;:ri b c 2 F`. , PERCOLATION RATE '� MIN./INCH AT 6D INCHES PERCOLATION RATE 2- _ MIN./INCH AeW
r F5EPTH HORIZ TEXTURE COLOR MOTT. OTHER DEPTH ' HORIZ TEXTURE COLOR MOTT. OTHER
_
1�J i
/ "•- t0 �D!; PIPE �� ON k2QU1RED 5�,��y �/ 'OX
,,,N 4UM y..s_ _� .� r -_,. N O /O�� ' I O D t YLr
,�y-- __ _ - �A 3 -0
DER FT. r 1 ! �` \ "�� 1 . OF �� �- /Z ao
l C
'-ic. +_mil �."_i ANCIAOR i I
, r�3 o I —L1�•` - -- _y Lo fi•n y
MIN y IQ- k ` 10-3rVELZ
V. ■. ✓ rim .11a�._� J �- r, w �i Y,- SF cs' ' �t i"^q) 9�°"� / i t /4N�
t ! . V. a i ✓! _,.,,' �/ GA; ( LuEV. - GuG7 �- U�P L8.1.V. •f w:.L..Y.
I t
BAFFs utST�= i 3U��0i I Lai.,-) y toy ` o % Lo��r ✓ �!°11k�,�
aU'J OUT HIGH C. Y -ILT^ATOR:', =, ? i Y-t'?.O
Cu�' uiu Y (�,�/ �T ,-he f
j T._ , _ - JO BE PACED GN FIRM BASE) , 2 f S
T
i �' a ' �E M' ,TEFL 4 tEu t� r "'�L X G^�'v a r0 pk A- ,N ,, +
� -EE 7 ! r' 1 IF MORE. TH 01 ONE OUTLET --- � � yy 9L
6 !`.T 2 C t J1",3 vALL-0t\ 'J ` r (iV ,0 ! ,/ I W I6 0
7 -' v t SE PiAC:D ON FIRM E S, J I "" t > t; VEu /" /vo WATER ENCOUNTERED AT t ELEV. - /`�0 WATER ENCOUNTERED AT ELEV. -
8 Fi 34 1NC,.cS S`.I�T'Ci i At\:� (� ) J �Jv;L t�:.i )iJ`\i 1LJ �t i LONE
-- ,�- _- SYS E (SAS; ;!+DEX_
WASHED S ONE ADJUST , .r
LEGEND: DESIGN CALCULA 1 ONS3
A' n -V. - EXISTING SPOT ELEVATION OOXO
c�� - U��e Nay tic ._ NUMBER OF BEDROOMS
_ N R
S W AG� L�t..r. S YS I -E M `'R 0 I LE OLSERVED WATI;'' :� . ( / � F�'-V. - � EXISTING CONTOUR ----00---- GARBAGE DISPOSAL UNIT �Q_
I NOT i.i SCk.-- �•� 13C`i k OF MZ i I HC.. ELEV. - _ FINAL SPOT ELEVATION TOTAL ESTIMATED FLOW 33
A FINAL CONTOUR ( 110 GAL/BR./DAY X BR.) GAL/DAY
SOIL TEST LOCATION_ ® REQUIRED
SIZE SEPTIC
SEPTIC TANK CAPACITY Go GAL
U11UTY POLE 7- TOWN WATER —W-����N�� SOIL CLASSIFICATION 1 I GAL
i
CATCH BASIN ` iN DESIGN PERCOLATION RATE < -5 -- MIN./IN.
GASH B \ EFFLUENT LOADING RATE 0.74 GAL/DAY/S.F.
CLE.kN OUT X >Z0 SQ. FT.
C. ACHIN' Al}EA /l
CESSPOOL C.P. ACHIN g; CAPACITY (AREA X RATE) 33Z�L GAL/DAY
RESERVE LEACHING CAPACITY 3 GAL/DAY
r- NOTES:
ES:
1. ALL WORKMANSHIP AND MA TF�IALS SHAL-. CONFORM TO D.E.P.
TITti 5 AND THE TOWN OF 1f 9ie"'S�4% RULES AND
".i2 ��' } `� \ \ REGULA"'ONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE.
/ 2. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO
` � t7-- rr; �-'' �� ✓ 1 ,�ty�v WITHIN 6" OF FINISHED GRADE.
3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF
WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN
10 FT. 07 DRIVES OR PARKING AREAS. H-20 LOADING SHALL BE
I ---- / USED UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS.
4. ANY MASONARY UNITS USED TO BRING COVERS TO GRADE SHALL
BE MORTARED ;N PLA v
i..J DE SIN 0M MA eEEN: 14AnF AS TO COMPUANCE WITH
PA
DEEDED '•2 �C"`IEN�= R�atlPTI�?i•�C /J�r°•IrR � r.i'iuO.nivi is 'iJ
OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY.
\ ` - �� - _T _.� )�_ ,1=- C3��' •� ! t ` 6. UTILITIES' SHOWN ARE APPROXIMATE ONLY, EXCAVATION CONTRACTOR
l,'\ �/. IS TO CALL 'DIC-SAFE' AT 1-E00-322-4844 AT LEAST 72 HOURS
� � I ! �.., • ) + ti1� /-_ _ � PRIOR '70 COMMENCING WORK 01•i SITE.
f ! 7. CONTRACTOR IS TO VERIFY GRADES AND ELEVATIONS AS WELL AS
J J / P M, S17E CONDITIONS PRIORZONE TO COMMENCING WORK ON SITE.
\ 7 I 8. PARCEL IS IN FLOOD
9. LOT IS SHOWN ON ASSESSORS MAP AS PARCEL 2 g
ILX I�
t ' 1 v
1 T v
1 ;
wY ! 1 APPROVED: BOARD OF HEALTH
Lo7-/
DATE AGENT
(4 t PROPOSED SEPTIC DESIGN
FOR
JT1S pf MgSr *+ fu'A PROJECT LOCATION LoT 16
T. A. G���� �/�STa�✓S L�9.-+��� .�.7.9 c�ui r�
DUMAS
.r, N0. 81�J r
SWEETSER LNGINEERING
�•��' 235 GREAT WESTERN ROAD
iN1T F,c•;% I + 506_ P. 0. BOX 713
i � oar<•�o�r 398-:,922 SOUTH DENNIS, MASS. 02660
L6 C US P�Jc
LLX -1 �' A U v T-K 6 � REVISED B NO.
wl : �
F /
r°, - � �� LOCATION MAP f l REVISED i SHEET / 0
01997 SWEETSER ENGINEERING