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HomeMy WebLinkAbout0534 MARSTONS LANE - Health - • - s - . ; 030 Y f J Commonwealth of Massachusetts NSW Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form Not for Voluntary Assessments ` — -- rN as 534 Marstons Lane ------ --------- ' ' Property Address ' Cheryl Fitzgerald-Britt ----------------- Owner Owner's Name r information is urns- ,b(,e MA 02675 `6/22/17 _ required for every --- — has page. 6ty/Town a State Zip Code Date of Inspection �v 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 A. General Information wd L{q9 filling cut forms on the computer; use only the tab 1. Inspector: key to move your cursor-do not Nicholas Geneseo --_--__ use the return Name of Inspector key. Wind River Environmental raa Company Name 46 Lizotte Drive Suite 1000 Company Address gum Marlborough MA 01752 ---------_. City/Town State Zip Code 800-499-1682 SI 13988 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 a ,a DEP approved'sys.em.inspector pursuant.to S m ection 15.340 of Title.5(31-0 GMR 15.000),The,sysiem - ` ®; Passes �' �C afly Poses t_ Faits. _kispectdes.Stnawre Irate The system inspector shall submit a copy of this inspeefion report to the Approving AutOriity(Board of Heath 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 arid 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 descrUm conditions at.the tuna of inspection and sender the of use at that tium This kapectiian dam not address how the system will perforim in the future under the same or differerd conditions of use. �s } o Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments . 534 Marstons Lane Property Address Cheryl Fitzgerald-Britt Owner Owner's Name information is required for every Yarmouth Port MA 02675 6/22/17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Recommend installing a filter and riser on outlet of tank. 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): t5 s doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 f - Commonwealth of Massachusetts ,w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments w 534 Marstons Lane Property Address Cheryl Fitzgerald-Britt Owner Owner's Name information is required for every Yarmouth Port MA 02675 6/22/17 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 breakout 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts w Title 5 Official 'inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments „ 534 Marstons Lane Property Address Cheryl Fitzgerald-Britt Owner Owner's Name information is required for every Yarmouth Port MA 02675 6/22/17 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 aseptic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used'to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No El ® Backup,of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the"surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool - ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments . 534 Marstons Lane Property Address Cheryl Fitzgerald-Britt Owner Owner's Name information is required for every Yarmouth Port MA 02675 6/22/17 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 determinedthat 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 10,00.0 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 El ❑ 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 11 of a public water supply well If you have answered"yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments° 3 534 Marstons Lane Property Address ' Cheryl Fitzgerald-Britt Owner Owner's Name information is required for every Yarmouth Port MA 02675 6/22/17 ' 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? ® 0 Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage'disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ 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): 4 Number of bedrooms (actual): 4 DESIGN'flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins.doc•rev.5/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts • , W Title 5 Official ,,Inspection Form. . i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ",M a 534 Marstons Lane Property Address Cheryl Fitzgerald-Britt Owner Owner's Name information is required Yarmouth Port MA 02675 6/22/17 page. CitylTown State Zip Code Date of Inspection D. System Information. Description: Number of current residents: Does residence have a garbage grinder? _ ❑ Yes Z 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 d 136 9 ( Y 9 (gP ))� Detail: 13300/730 Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? El Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary.Assessments 534 Marstons Lane Property Address Cheryl Fitzgerald-Britt Owner Owner's Name information is required for every Yarmouth Port MA 02675 6/22/17 page. City/Town State Zip Code' Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: The home owner and,Wind River Environmental are the sources of the information. Was system pumped as part of the inspection? ® Yes '❑ No If yes, volume pumped: 1500. , gallons How was quantity pumped determined? The quantity was determined by the pump truck and it was measured. Reason for pumping: To check the structural integrity of the septic tank. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of.latest inspection of the I/A system by,system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts- W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 534 Marstons Lane Property Address Cheryl Fitzgerald-Britt Owner Owner's Name information is Yarmouth Port MA 02675 6/22/17 required for every page. CitylTown State Zip Code Date of Inspection D. System Information (cont:) Approximate age of all components, date installed (if known)and source of information: 13 + years estimated from T5 done in 2014 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2 Depth below grade: � feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet . Comments (on condition of joints, venting, evidence of leakage, etc.): Joints are all clean with no signs of leakage. Septic Tank(locate on site plan): Depth below grade: 18" 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: 1500 Sludge depth: 3. t5ins.doc-rev.6,16 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 9 of 17 r Commonwealth of Massachusetts Title 5 OfficialInspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 534 Marstons Lane Property Address Cheryl Fitzgerald-Britt Owner Owner's Name information is Yarmouth Port MA 02675 6/22/17 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) h Distance from top of sludge to bottom of outlet tee or baffle . 33 3„ Scum thickness 7„ 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? The dimensions were determined by sludge judge, rod, and ruler. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level is at operating level, both baffles are in place, tank appears in good condition with no leaks or cracks observed. Recommend installing a riser and filter on outlet to prevent carryover, also recommend pumping annually. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal` ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc•rev.6/16 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 534 Marstons Lane Property Address Cheryl Fitzgerald-Britt Owner Owner's Name' information is required for every Yarmouth Port MA 02675 6/22/17 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: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑.polyethylene ❑ other'(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date' Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached': ❑ Yes ❑ No t5ins.doc•rev.6i16 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page.11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 534 Marstons Lane Property Address Cheryl Fitzgerald-Britt Owner Owner's Name information is required for every Yarmouth Port MA 02675 .6/22/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box•(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0„ Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box was replaced in 2014 and is on a riser to 3" below grade. Box has minimal carryover and no deterioration present. Both outlets are taking equal flow. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑. Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc-rev.6f16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts . W Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 534 Marstons Lane Property Address Cheryl Fitzgerald-Britt Owner Owner's Name information is required for every Yarmouth Port MA 02675 6/22/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits' number: 2 -6'x6' ❑ leaching chambers number: ❑ 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.): Pit#1 has 5' of available space with no staining on the walls. Pit#2 is dry, no staining present on the walls at all. Vegetation and soil is dry and sandy. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan)`. Number and configuration r- Depth—top of liquid to iinlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑.. No t t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form �m- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °.H 534 Marstons Lane Property Address Cheryl Fitzgerald-Britt Owner Owner's Name information is Yarmouth Port MA 02675 6/22/17 required for every - page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic.failure, level of ponding, condition of vegetation, etc.): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System.Form Not for Voluntary Assessments a' U r 534 Marstons Lane Property Address Cheryl Fitzgerald-Britt Owner Owner's Name -- ----- -------- --- information is required for every . Yarmouth Port MA 02675 -6/22/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) z 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 loublic water:supply,enters-the building.Check one of the boxes below: _ h44d aetch in the area below. Ll' dram—dn-g it6bhik separately IL 0. r - i 5ins.doc•rev:6 6 c . 50 a {- oecuonform:Subsurface Sewage Dispose;System-.Page's of 17 Commonwealth of'Massachusetts • w Title 5 Official. Inspection Form Subsurface Sewage Disposal.System Form - Not for Voluntary Assessments °.W 534 Marstons Lane Property Address Cheryl Fitzgerald-Britt Owner Owner's Name _ information is Yarmouth.Port MA 02675 6/22/17 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 Estimated depth to high ground water: t fee - 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: 2014, Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-`(attach documentation) ❑ Accessed USGS database'-explain: You must describe how you established the high ground water elevation: T5 done in 2014 used USGS maps.- Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts FD Title 5 Official Inspection Form = Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 534 Marstons Lane Property Address Cheryl Fitzgerald-Britt Owner Owner's Name information is required for every Yarmouth Port 'MA . 02675 6/22/17 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 No. u ' Fee UV THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ye PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01pplitation for NspoSaf 6pstem (Construction Permit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System X Individual Components LocaationffAddresss3s or Lot No. S 3 y � S ,� Owner's Name,Address,and Tel.rNo. Ass ss&Ns Ma7P6arce1 Installer's Name,Address,and Tel.No. Designer's Name,Addres ,and Tel.No. k U4 (2) -Sk (A' 4L-{ 3s� cam. s 773=9 Type of uilding: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil 'A q _ ZE Nature of Repairs or Alterations(Answer when applicable) f x� ?lv� Date last inspected: P V) 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 Certificate of Compliance has been issued by this Board of Hea Si d Date 's 1 Application Approved by Date Application Disapproved by Date for the following reasons Permit No. :?0 — I Date Issued z E}T^if f �, E No. Fee i S I - THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:--� Yl PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Rpplication for Misposal *pstent Construction Hermit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System A Individual Components Location Address or Lot No. L Owner's Name,Address,and Tel.No. `� (nr AssaessorsM pXcel Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. `),pe of Building: $� Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) ti Other Fixtures Design Flow(min.required) gpd Design flow provided i gpd Plan Date Number of sheets Revision Date j Title { Size of Septic Tank Type of S.A.S. { ` rs Description of Soil Nature of Repairs or Alterations(Answer when applicable) L / ) v )v a Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in� K accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Hea ct.Signed Date Application Approved by { Date I (/ Application Disapproved by V Date for the following reasons Permit No, Date Issued /a Y THE COMMONWEALTH OF MASSACHUSETTS t r' it-Qjk--tk BARNSTABLE,MASSACHUSETTS �X r (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage D'spos/al.syste1m Constructed( ) Repaired Upgraded Abandoned( )by ep e_k �� U ("/ at 3 )-'A'^0 , r I a ; �(M�h� has been constructed in accordance l with the provisions of Title 5 and the for Disposal System Construction Permit No. q IQ dated Installer Designer #bedrooms o1 A Approved design flow_ 'c/} gpd The issuance of this permit shall not /b/e'consconstrued�as a guarantee that the system will fw ction as designed. Date )/ 3)/ Inspector f --------------------------------------------------------------------------------------------------------------------------------------- No. . / l W Fee �U THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Disposal *pstem Construction permit Permission is hereby granted to Construct( ) )) Repair( )(J /Upggrade( ) Abandon( ) System located at7 and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construc ion 7//(/ st be completed within three years of the date of this permit. Date S�l 1 Approved by / l i i t-7 i \ ` a,/ P2.OPOS F-D k AC,-ru L i r W OOZ '-DN[Nq ."Owl Lor 1 t l l(a Mwvj-YJ1 =Maw `x hC V 1P, • w. HAUL DEDRoom ?)r=D0.QOM 4kL.L.. CL06ET MA6TEER LAurJDR4 akTN moon &"RooM $�pRr�oN1 a s1OgRA_tC-, W.G. WOMOUT P-WIK LIyINCG SPACE f I-► ING+ SPACE PW POSE IE4SE M S T , y Commonwealth of Massachusetts -- Title 5 Official Inspection Firm . Subsurface Sewage dal System form-Not for Voluntary Assessments 534 Marstons In Property Address Cheryl Fitzgerald Britt Owner Owner's Name information is Ct�rrraquid..kieights Barnstable MA 02637 " 4/24/2014 required for every _ page, Citylrown State Zip Code Date of Inspection Inspection results must be subr»itted on this form.Inspection form may not be altered in any way.Please see completeness check#st.at the end of the form. Important:When A. General Informationfilling out forms LL on the computer, I f use only the tab 1. Inspector _ 1 key to move.your cursor-do not Michael DiBuono use the return Name of Inspector -- --- �ey. NEIGHBORHOOD WASTE INATER SERVICES Company Name ------ —---— - 350 MAIN STREET company AddressW.YARMOUTH _-- _ - MA 02673 Cityrrown State Zip Code 508-775-2820 S13255 Telephone Number -------- t.icer Number B. Certification I certify that I have personalty 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 ins ction was performed bared on my training and experience in the proper function and;mairtante of onFs"ite sewage disposal systems. I am a DEP approved system inspector pursuant�� �1w5.34Q�af CD Title 5(310 CUR 15 ).The system. rD ❑ gasses Conditionally Passes ❑ Fall Needs Further Evaluation by the Loco�rQ- In Authority 03 4/24/2014 Inspector's Signature -- --- — ---�— Date The system inspector shall submit a copy of this inspec-ibn report to the Approving Authority(Board of Health or DEP)within 80 days ai"completing this inspection. If the system is a shared system or has a design flow of.'i0;0Q0 gpd or greater,the inspedor arld the system owner shall submit the report to the appropriate regional`office of the DER 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 inWctIoa and under the conditions of use at that fimee This insp6a6fi does riot add Efe6 w'tfW'syst�im will perform In the future under same e or dMemjift coadWorts of use. Ill, t5ins•3113 Tito 5 Form Ssthsafaca 5eaage Dispose!System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments. J . 534'Marstons In Property Address Cheryl Fitzgerald Britt Owner owner's Name requir required for Cummaquid Heights Barnstable MA 02637 4/24/2014 required for every page. Cdyrrown State Zip Code Date of Inspection B. Certification (cunt.) Inspection Summary: Check A,B,C,D or /ahvrays complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist Any failure criteria not evaluates are indicated below. Comments: The system consists of a 1500 Gallon septic tank. A concrete distribution box in need of replacement and two 6x6 Leaching pits. both-pits are dry and have stain lines visible with a mirror. Staining is approximately 30°A of pit in both pits Both are leaching properly. 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•W 3 Title 5 Official kispection Forth:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 534 Marston In Properly Address Cheryl Fitzgerald Britt Owner Owners Name information is required for every Cummaquid. Heights Barnstable MA 02637 4/24/2014 page. Citylrown r ' State Zip Code Date of lnspedion 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 Z: Y ❑ N ❑ ND(Explain below): Distribution box is rotted and in need of replacement. ❑ The system required pumping more than 4 tines 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 reply ❑ :Y ❑ N: ❑ ND(Explain below): . obstruction is removed: ❑ Y ❑ N ❑ ND(Explain below): C) Furth r Evaluation is Regtilred iby,the Board of Health: ❑ Conditions exist wliictii.r Haire further�valuatich by the Board of Health in order to determine if the system is failing to: rtotect.pgblic hea9th, safety or the environment 1. System will paw unless Board of Health determines in accordance with 310 CHAR 15.303(1)(b)UW the system is not functi ning 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 lr p on Form:Sibsefaoe Sewage DisPesal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 534 Marstons In Property Address Cheryl Fitzgerald Britt Owner Owner's Name information is required for every Cummaquid Heights Barnstable MA 02637 4/24/2014. page. city/rown Stake Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *"This system passes if the well water analysis,.performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other. D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or,clogged SAS or cesspool ❑ ® Static liquid level in the distribution box'above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow tsins,3113 Title 5 Offiad kopecbm Form:&ftutwe sewage DWxW System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 534 Marston In Property Address Cheryl Fitzgerald Britt Owner Owner's Name information is e required for every Cummaquid Heights Barnstable MA 02637 4/24/2014 page., Cityrrown State Zip Code. Date of Inspecfion B. Certification (cunt.) Yes No El ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Z Any portion of the SAS, cesspool or privy is below high ground water elevation. El ® 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 poliform bacteria indicates absent and the presence of aminenia nitivgen 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 eYmust be attached to this form.] 1 ® This sy'swrri is a cesspool servirig a facility with a design flow of 2000gpd- 1 0,000gpd. The system Bella.I have datOrmined 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 considemd a large system the system must serve a facility with a design flow of 110,000 gpd to„1s,0Q0 gpsi 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.sypfggj,..p Athin 400 fit of e:surface,drinking water supply ❑ ❑ the;system is w.#Nn 200-feat 4 a triputsry W a surface drinking water supply ❑ the cyst rn'is coca i in`e nitrogen sensitive area(interim Wellhead Protection Area-I A)or a mapped Zone 11 of a public water supply well If you have answered"yes" �any questJs:n in Section_Ir the systern 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 signif1pp t,:threat,under Sedionf or.failed under Section D shall upgrade the system in accordance with 310 CMR 15.3044. "rhe.system owner should contact the appropriate regional office of the Department. t5ins•3/13 r[Cs 5 Uffraslkmpacbm.Forrm SUbufffsM.Smvaga D408al System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 534 Marston In Property Address Cheryl Fitzgerald Britt owner owner's Name requon is required for every umm 9 Caquid Heights Barnstable MA 02637 4/24/2014 requir 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 tyceived 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)1 D. System Information Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): 4 DESIGN flow based.on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5ins•W13 Title 6 Offlow ForM Wtace sewage,wrage,Disposal System'Page 8 of 17 Commonwealth of Massachusetts Title 5. Of#icial Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 534 Marston In Property Address Cheryl Fitzgerald Britt Owner Owner's Name information Is. Cummaquid Heights Barnstable MA 02637 4/24/2014 required for every page Cityrrown State Zip Code Date of Inspection D. System Information Description: The system consists of a 1500 Gallon septic tank.A concrete distribution box in need of replacement and two 6x6 Leaching pits. both pits are dry and have stain lines visible,with a mirror. Staining is approximately 30%of pit in both pits.Both are leaching properly. 2 Number of current residents: Y Does residence have a garbage grinder? ❑ Yes ® No 1s laundry on a separate sewage system?(include laundry system inspection 0 Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No 2012 Water meter readings, if available(last 2 years usage(gpd)): Detail: 76 GPD water usage in.the,past two years Sump pump? ❑ Yes ® No occupied Last date of occupancy: Date Comaitercial lnadustrial Row Connditions:' Type of Establishment: Design.flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/pr<momisgft,etc.): — Grease Trap pre-sent'? .: [I Yes [I No Industrial waste holding tank pres�:t�'t'? ❑ Yes ❑ No Non-sanitary.waste discharged to the Title Yes ❑ No Water meter readings, if available: t5ins•3H3 Yids 3 Otr FA Wpedion Form:3ubaurfam sewage Disposd system•Page 7 of 17 Commonwealth of Massachusetts , Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 534 Marstons In Property Address Cheryl Fitzgerald Britt Owner owner's Name information is Cumrnaquid Heights Barnstable AAA 02637 4/24/2014 required for every Cityrrown State Zip Code Date of Inspection page. D. System Information (cont.) Occupied Last date of occupancy/use Date Other(describe below); The system consists of a 1500 Gallon septic tank.A concrete distribution box in need of replacement and two 6x6 Leaching pits..both pits are dry and have stain lines visible with a mirror.Staining is approximately 30%of pit in both pits Both are leaching property. General Information Pumping Records: - • Source of information: none Was system pumped as part of the inspection? ❑ Yes I 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 t ❑ Tight tank.Attach a copy of the DEP approval ❑ Other(describe): t5ins•3M 3 Title 5 0MdW kwpecbm Fow subsurface Sewage Disposal System•Page 8 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 534 Marstons In Property Address Cheryl Fitzgerald Britt owner owners Narne information, Cummaquid Heights Barnstable MA 02637 4/24/2014 required for every: paw Cityrrown state Zip Code Date of Inspection D. System Information (cent.) Approximate age of all components, date installed(if known)and source of information: 10+years is an estimate..The BOH has no record of this system. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): " Depth below grade: 24feet Material of construction: cast iron ®40 PVC ❑other(explain): 100+ Distance from private water supply well or suction line: feet Comments(on condition of joints, venting,evidence of leakage,etc.): Septic Tank(locate on site plan): 18N Depth below grade: Pert Material of construction: ®concrete ❑ metal 0 fiberglass ❑polyethylene ❑other(explain) If tank is metal, list age, yeaB Is age confiirrried by a Cert tote of Compliance?(afich a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gallon Sludge depth:. t5itu•W13 1 ide 5 Official kispeod vi Fort:S•.6sw1ace Sewage Disr System•Page 9 of 17 Commonwealth of Massachusetts j - , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 534 Marstons In Property Address Cheryl Fitzgerald Britt Owner Owner's Name information is Cummaquid Heights Barnstable MA 02637 4/24/2014 required for every state Zip Code Date of Inspection per. City/Town D. System Information (cont.) Septic Tank(cont.) 36"s Distance from top of sludge to bottom of outlet tee or baffle . 3"s Scum thickness 32"s Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 28"s Tape Measure 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.): The system consists of a 1500 Gallon septic tank. A concrete distribution box in need of replacement. and two 6x6 Leaching pits. both pits are dry and have stain lines visible with a minor. Staining is approximately 30%of pit in both pits Both are leaching properly. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete. 0 metal ❑fiberglass ❑polyethylene 0 other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle.- Date of last pumping: a Date t5im•3/13 TiNe 5 Offael ftpeMw Form:Subswface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title S .Official. Inspection Form Subsurface Sewage Disposal System Form=Not for Voluntary Assessments f 534 Marstons In Property Address Cheryl Fitzgerald Britt Owner Owner's Name information is required for Cummaquid Heights Barnstable MA 02637 4/24/2014 required for every � , 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.): No pumping records provided by BOH Tight or Holding Tank.(tank must be pyrnped at time of inspection)(locate on site plan): Depth below grade: — Material of construction:. ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present ❑ Yes ❑ No Alarm level: — Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date: Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contiact(reggdired). Is copy.attached? ❑ Yes ❑ No t5ins•3/13 YltJ 5 Ofi neat kisprachon Form:Subsurface Sswaga Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments W4 Marstons In Property Address Cheryl Fitzgerald Britt Owner Owner's Name i ton is Cummaquid Heights Barnstable MA 02637 4/24/2014 reequiredquired for every State �Code Daft of Inspection . page' Cdylrown D. System Information (cons.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert Rotted and in need of replacement 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.): Rotted and in need of replacement. Pump Chamber,(locate on site plan): Pumps in working order ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber,condition of pumps and,appurtenances, etc.): *If pumps or alarms are not in working order, system.is a conditional pass. Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 AffiaW hspechon 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 534 Marstons In Property Address Cheryl Fitzgerald Britt Owner Owner's Name information is Cummaquid Heights Barnstable MA 02637 4/24/2014 required for every page. City/Town State - Zip Code Date of Inspection D. System Information (cont.) V . Type: ® leaching pits number: 2 ❑ leaching chambers number: leaching galleries - number. ❑ leaching trenches number, length: ❑ leaching fields : number, dimensions: overf#ow 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.): No signs of hydrualic failure. Cesspools(cesspool must be,pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of.liquid to.inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Ti@e 5 Of dal lrapecbw Form:Sut;wtface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Torm Subsurface Sewage Digposal System Faros-Not for Voluntary Assessments 534 Marston In Property Address Cheryl Fitzgerald Britt Owner Owner's Name information is required for every Cummaquid.Heights Barnstable MA 02637 4/24/2014 - kv City/rown State Zip Code Date of Inspection page. D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): The system consists of a 1500 Gallon septic tank.A concrete distribution box in need of replacement. and two 6x6 Leaching pits. both pits are dry and have stain lines visible with a mirror. Staining is approximately 30%of pit in both pits.Both are leaching properly. Privy(locate on site plan,): Materials of construction: ,- Dimensions Depth of solids. - Comments(note condition of soil, signs of hydraulic failure,.level of pond ing, condition of vegetation, etc.): p. t5ins•3113 We 5 Official kispection Forth:Subsurface Sewage Disposal System•Page 14 or 17 . ardm CA, rr,0- �r Max 81�MohQt�rws imanifter �eetla��1e. .ftwVdAs.wdoraeft-- ate IPANYO fl hod did 11 *WWn Q R r . 50 Commonwealth of Massachusetts Title 5 Official Inspection,Form Subsurface Sewage Disposal System Fora-Not for Voluntary Assessments 534 Marston In Property Address Cheryl Fitzgerald Britt Owner Owner's Name information is Cummaguid Heights Barnstable MA 02637 4/24/2014 required for every — page Cityrrown State Zip Code Date of Inspection D. System Information (coat.) 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 t5ins•3H3 Title 5 Of Dal inspection Forth:Subsurface Sewage Disposal System•Page 15 of 17 a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal:System Form-Not for Voluntary Assessments 534 Marstons In Property press Cheryl FitzgeraW Britt Owner Owners Name information is required for every Cummaguid Heights Barnstable MA 02637 4/24/2014 page. CitYRown State Zip Code Date of Inspection M System Information (cunt.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water. 23+ FT feet Please indicate all methods used to determine the high ground water elevation: Obtained from system Cl Obta design plans on record Y 9 If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked.with local Board,of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: USGS map 1978 map You must describe how you established the high ground water elevation: USGS map 1978 shows Dennis pond at elevation 25 and Marston In at elevation 50 _ Before fills this Inspection.Report,please see Report Cornpleter�ess Checklist on next page. t5ins•3113 Me 5 MW hWedan Pam Subaafaw Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 534 Marston In Property Address — Cheryl Fitzgerald Britt Owner Owner's Name information is required for every Cummaquid Heights Barnstable MA 02637 4/24/2014 - - page. Cltyr town _- state Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, 0, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information•-Estimated depth to high groundwater 0 ® Sketch of Sewage Disposal System either drawn on page 15.or attached in separate file 3 T t5ins•3M 3 Title 5 ORicW hepeebon Farm&"urtace Sewage Disposal System-Page 17 of 17 •Marstons Lane •Barnstable, . •� mmaquid Golf Club . 4 -; L /�� T v �' 1?;a.:, it t':� �t�. ,lra?•? f 1 Ul:�i:�l'�1` }r \ .r; _v' I 13U "c �s `'?uF"� AQ•..11Tt, l V 1/�fr7i2'1 uTali Iy .fit+.. P ,p-" p ;, MAR 3 FEB 2 2 1980 ar .. s ,,,avtAQUID GOLF CLUB P. O. BOX 182 TOWN OF BARNSTABLE YARMOUTH PORT, MA 02675 UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS NAME C fii``n� c4 Q�� 'R ADDRESS'9t'�-6 ��s%o�v r /t�+s� VILLAGE,�'/?A/?/V j /14 I'/f-- LOCATION OF TANKS: CAPACITY: TYPE OF FUEL AGE: TYPE: OR CHEMICAL !�« �''/.��s%o �s L,�/✓� �M�/N%1S/✓RNCoe �/?N� do U C'i� _ (�i SaLi.,.� � Y�i�s ���°�,. . .. lip (Give same information for any additional tanks on reverse side of card) DATE OF PURCHASE OF EACH: 114122'L 19 76 2. '4i�R< /f 74 3. 4. DATE OF FIRE DEPARTMENT PERMIT: TESTING CERTIFICATION SUBMITTED: PASSED DID NOT PASS