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HomeMy WebLinkAbout0544 MARSTONS LANE - Health 544 MAI2STOlS LAI�TE, Bi`RNSAB .E' A=349.103 i a I u � u 3 . n • <' ,..�`- ..w., �, ,�. y d ,.y.y°,, a 41 ,� '°., ,�... �T• 'd �:FH.. V r: @::,- -'t�'� ��,�,+' ,,<..'� ,Q �k.o .'� -w... I , . r V 3: n y _ LEACHING AREA: ` --—108 USE 2-500 GALLON CHAMBI N 4'OF STONE ALL AROUND __ \ SIDE AREA: (25'+12.8')x 2 1 BOTTOM AREA: 25'x 12.8'= ——106 1 POot- \I 1 104 , 1 \\ 1 11 � � 1 102— DECK \ 1 1 F3 6E��1G gg \ Dw vd,102 1 1 1 \ top f 1 1 102 \ 1 i.p. \ 1 0- 108 S1 102 _ G 1 1 N Ct� th-3 i rem \ 1 w a o, existing th-1 1500 gallon / 106 t septic tank 102, i \��_� i each l Larea, th-2 T Paved l } Parking . 104 J Area I J 1 � J 1 � \ 1 BENCHMARK ATMAG NAIL 1 \ ELEVATION=102.48lyr 1 \ �°s�'�� 11 108 / 11 Q \ / 102 \104-' LOCUS r �`/L�- �`'— �102-- Z r �00—// 98P��.2 LOT LOCATION SF) ASSESSORS MAP:349 PARCEL:103 98 n. A^,-.1.70� nA/ =.77 . 150,Z Town of Barnstable P a y� $ Department of Regulatory Services 4 /J i 4 .�e,8,: Public Health Division Date (/! p yy 200 Main Street,Hyannis MA 02601 Nlld Date Scheduled Time Fee Pd. /D0 . Soil /ySuitability Assesssment for Sew a Dil posal Performed By:J1-1(/t t}t M c Lt�N . I Witnessed By: /���r(�Il ✓I JCS &GENERAL INFORMATION ' Location Address - LOCATION, Owner's Name ANV-aJ MAKEQ 544 MARZ-(alS LN Address 5'Jq MAPSWN (/�• Gvm�IQv1rJ Assessor's Map/Parcel: 34g/♦'03 Engineer's Name?t-r�,,A(AnC�'•ELIN/J - NEW CONSTRUCTION REPAIR V1 Telephone#' O3' 315. 341X Land Use Slopes(%) . Surface Stones 50�� Distances from: Open Water Body /V d .ft Possible Wet Area NU ft Drinking Water Well /V V It Drainage Way ft Property Line (�, ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&Pere tests,locate wetlands in proximity to holes) J S.00 of �..t,, ,t .y,; ♦ rr t. .. �00, Parent material(geologic) t Depth to Bedrock r - 'Depth to Groundwater: Standing Water in Hole: A/0 h Weeping from Pit Face /"QA ' _Estimated Seasonal High Groundwater a :3 O' y DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: ... . . Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment - I ft. Index Well# Reading Date: Index Well level 'Adj.factor. - Adj.Groundwater Level' '- PERCOLATION TEST Date 4•7_7.14rime JIA) Observation Hole# - PP�V�ou3. 1 (,/IN Time at 9" Depth of Pere Time at 6" , Start Pre-soak Time @ Time(9"-6') End Pre-soak Rate Min./Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original:Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100'of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:\SEPTIC�PERUORM.DOC �o Vs i JePY H TE1 uk 60LV /poll �6 S �b ` 13 N� 6d 138 �' r • Town of Barnstable Barnstable Regulatory Services Department MASS Public Health Division .39.#1 200 Main Street, Hyannis MA 02601 2007 Office: 5 - 2- 44 3 08 86 4 6 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7015 1520-0001 2273 3326 May 3, 2016 Andrew Maker 544 Marstons Lane Yarmouth Port, MA 02675 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 544 Marstons Lane, Barnstable MA was last inspected on 4117/2016, by Joseph M. Martins, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: • Backup of sewage into the house due town overloaded or clogged SAS or cesspool. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Th ma McKean, R.S. CHO (° Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\544 Marstons Ln Barnstable Apr2016.doe r- r Health Master Detail Page 1 of 1 Heith` Master h Logged In As: TOWN\Flynnj Health Master Detail Monday,May 2 2016 Application Center Parcel Lookup Selection Items Reports Parcel Septic Perc Well Fuel Tank Parcel: 349-103 Location: 544 MARSTONS LANE,BARNSTABLE Owner: MAKER,ANDREW P&ERIN Business name: � Business phone:��� T> Rental property: El Deed restricted:❑ Number of bedrooms - 0 Contaminant released: 0 Fuel-storage tank permit: ❑ Save Parcel Changes Return to Lookup Parcel Info Parcel ID: 349-103 Developer lot:LOT 19 Location:544 MARSTONS LANE Primary frontage:76 Secondary road: Secondary frontage: Village:BARNSTABLE Fire district:BARNSTABLE Town sewer exists at this address: No Road index:0989 Asbuilt Septic Scan: 349103_1. Interactive map r Town zone of contribution:AP(Aquifer Protection Overlay District) State zone of contribution:OUT Owner Info Owner: MAKER,ANDREW P&ERIN Co-Owner. Streetl:544 MARSTONS LANE Street2: City:YARMOUTH PORT State:MA Zip: 02675 Country: Deed date:4/5/2010 Deed reference:24464/189 Land Info Acres: 1.00 Use: Single Fam MDL-01 Zoning:RF-1 Neighborhood:'.0106 Topography:Level Road:Paved Utilities:Public Water,Gas,Septic Location: Construction Info Building No ear Buil Gross Area Living Area Bedrooms Bath rooms 1 1999 6538- 2296 3 Bedrooms Full-1 Half - Buildings value:$205,800.00, Extra features: $33,200.00 Land valuer $156,300.00 http://issgl2/intranct/healthMaster/HealthMasterDetail.aspx?ID=349103 5/2/2016 U.S.POSTAGE>>PITNEY BOWES f ypFIKE*�wti Town of Barnstable.- I Public Health Division 5 RARNSTARLE.g• 200 Main Street - r,. • 0 a; . ZIP 02601 �+ :n N1F+°` •, ,Hyannis,MA 02601 ��;� 02 4" $ 006.73 00003.36455AP.R. 21. 2016. _ 7018 1520 0001 2273`-2718 - � �. - sy Andrew Maker cal ' a Iv 544 Marstons Lane i 'Si s n s ON Barnstable, MA 02630 !I FI 11 slli} rfi 3•si f; , If lii i �i !i s�fi, I! i ' - : :1 ii i i G= i i f SENDER: DELIVERY, i nature Si9 � j ■ Complete items 1,2,and 3. A. ■ Print your name and address on the reverse X 0 Agent❑Addressee i } so that we can return the card.to you. - , t Attach this card to the back of the mailpiece, B. Received by(Printed Name) C. Date of Delivery I j or on the front if space permits. 1. Article-Addressed to:_- — D. Is delivery address different from item 1? 0 Yes. I I If YES,enter delivery address below: p No I � - ! Andrew Maker = ! 544 Marstons Mills Lane ! Barnstable I i - 3. Service Type ❑Priority Mail Express® I ll I'III'I I'll I'I I I I I I IIIII IIIII II I I'll I I II I III ❑Adult Signature ❑Registered Mail I ❑Adult Signature Restricted Delivery ❑Registered Mail R Restricted! F ! ❑Certified Mail® Delivery - I I" 9590 9403 0923 5223 2894 39 ❑Certified Mal Restricted Delivery ❑Return Receipt for / ❑Collect on Delivery Merchandise ! \� ❑Collect on Delivery Restricted Delivery ❑Signature ConfirmationTM! , 2.Article Number(Transfer from service label) ❑Signature confirmation I ❑Insured Mail g Restricted Delivery , 1520 ,R7 015_15 2 0 0 0 01. 2 2 7 3 2 718 ( t t Insured $500j it Restricted Delivery IHS orm ,July 2015 PSN 7530-02 000-9053 Domestic Return Receipt �. Town of Barnstable Barnstable Regulatory Services Department "" " s r - - � r i "MM ' Public Health Division Q D 639 1� 200 Main Street; Hyannis MA:02601 2007 Office: 508-862-4644 g `, Thomas F.Geiler,Director FAX: 508-790-6304 - - Thomas A.McKean;CHO 4t CERTIFIED MAIL # 7015:1520 0001 2273 2718,. April 20,_2016,_ „ • , Andrew Maker 544 Marstons Lane Barnstable, MA 02630 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system locafed at 544 Marstons Lane, Barnstable, MA was last: ; inspected on 4/17/2016, by.Joseph M: Martins, a certified septic inspector for the State of Massachusetts: The nspe'tlori+of fhe septic system showed that the system `,`Fails" under the guidelines of the 1995 TITLE 5 (310;CMR 15.00) due to the following'-,. . • Backup of sewage into the-house due to an overloaded,or clogged SAS or cesspool. You are ordered to'.repair,or,,replace the septic°system within Sixty•.(60) days" from the date.you,receive this.notificatiori: Failure to repair/replace the septic system-within the deadline period will result in .future enforcement action. PER ORDER OF.TH OARD.;OF,HEALTH, 7 cKean, R-S =CHO Agent of the Board of Health E . L Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\544 Marstons Ln Barnstable Apr2016.doc �©y,CO o . ■ p fi3 4 C- Certified Mail Fee ruru '$ t4 rn Extra Services&Fees(check has aqd fed as appro ) � ❑ O P Return Receipt(hardx»py) r ❑Return Receipt(eleeftnic) t Postmark O ❑Certified Mail Restricted Delivery $ Here Q ❑Adutt Signature Required $ ❑Adult Signature Restricted Delivery$ 0 Postage rr) $ r �-1 Total Postage and Fees ter$-_. <. . i 'Andrew Maker 544 Marstons Mills Lane Barnstable . Certified Mail service provides the following benefits: ■A receipt(this portion of the Certified Mail label). for an electronic return receipt,see a retail ■A unique identifier for your mailpiece. assoc*.for assistance.To receive a duplicate ■Electronic verification of delivery or attempted return receipt for n`additional fee,present this: delivery. USPS®-postmarked Certified Mail receipt to the ■A record of delivery(including the recipient's retail associate. signature)that is retained by the Postal Service- Restricted delivery service,which provides for a specified period. delivery to the addressee specified by name,or to the addressee's authorized agent. importantRemindeii- Adult signature service,which requires the ■You may purchase Certified Mail service with signee to be at least 21 years of age(not Rrst-Class Mail®,First-Class Package Service®," available at retail. or Priority Mail®service. , r; I Adult signature restricted delivery service,which ■Certified Mail service is notavailable for requires the signee to be at least 21 years of age International mail. and provides delivery to the addressee specified ■Insurance coverage Is not.availabie for purchase by name,or to the addressee's authorized agent with Certified Mail service.However,the purchase (not available at retail). of Certified Mail service does not change the ■To ensure that your Certified Mail receipt is insurance coverage automatically included with accepted as legal proof of mailing,R should bear a certain Priority Mail items. USPS postmark.If you would like a postmark on ■For an additional fee,and with a proper this Certified Mall receipt,please present your endorsement on the mailpiece,you may request Certified Mail Item at a Post Office'for the following services: postmarking.it you don't need a postmark on this Return receipt service,which provides a record Certified Mail receipt,detach the barooded portion of delivery(including the recipient's signature). of this label,affix it to the mailpiece,apply ' You can request a hardcopy return receipt or an--appropriate postage,and deposit the mailpiece. electronic version.For a hardcopy return receipt, r complete PS Form 3811,Domestic Return —. Receipt attach PS Form 3811 to your mailpiece; IMPORTWP Save this receipt for your records. h• PS Forrn 3800,April 2015(Reverse)PSN 7530-02-000-9047 �. Commonwealth of Massachusetts 3�9-I Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 544 Marstons Lane Cummaquid MA Property Address 70 Andrew Maker 544 Marstons Lane W Owner Owner's Name ~information is required for every Yarnwuth-Bert F��/'�/1� 8�� MA 02675 4/7/2016 page. City/Town State Zip Code Date of Inspection CA Inspection results must be submitted on this form. Inspection forms may not be altered in anyGco way. Please see completeness checklist at the end of the form. Important:when A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Joseph M Martins use the return Name of Inspector key. Accu Sepcheck Comp � Company Name 17 Northside Dr Company Address South Dennis 4 MA 02660 Cityrrown State Zip Code 508-385-5891 SI 147 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 4/7/2016 In Actors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same.or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 544 Marstons Lane Cummaguid MA Property Address Andrew Maker 544 Marstons Lane Owner Owner's Name information is required for every Yarmouth Port MA 02675 4/7/2016 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: ❑ I have not found any information which indicates that any of the f ure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure cr' ria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system compo ents as described in the"Conditional Pass" section need to be replaced or repaired. The stem, upon completion of the replacement or repair, as approved by the Board of Health, will ass. Check the box for"yes", " o"or"not determined" (Y, N, ND)for the following statements. If"not determined," please ex in. The septic tank is m al and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits s bstantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the a isting tank is replaced with a complying septic tank as approved by the Board of Health. r *A metal se c tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance ndicating that the tank is less than 20 years old is available. ❑ Y ❑ ND(Explain below). t5ins•3113 Title 5 Official Inspection Form: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 544 Marstons Lane Cummaquid MA Property Address Andrew Maker 544 Marstons Lane Owner Owner's Name information is required for every Yarmouth Port MA 02675 4/7/2016 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health ap oval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in t distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven i ribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ ❑ 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 pum ng more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspec i n if(with approval of,the Board of Health): ❑ broken pipe are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstructi 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 wM 544 Marstons Lane Cummaquid MA Property Address Andrew Maker 544 Marstons Lane Owner Owners Name information is required for every Yarmouth Port MA 02675 4/7/2016 � 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 S 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 ne 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is w In 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS i ess 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 anal is, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and th resence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no ther failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ® ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ® ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 41M , 544 Marstons Lane Cummaquid MA Property Address Andrew Maker 544 Marstons Lane Owner Owner's Name information is required for every Yarmouth Port MA 02675 4/7/2016 page. Cityfrown 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 I ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 544 Marstons Lane Cummaquid MA Property Address Andrew Maker 544 Marstons Lane Owner Owner's Name information is required for every Yarmouth Port MA 02675 4/7/2016 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ 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)] t 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M s•'" 544 Marstons Lane Cummaquid MA Property Address Andrew Maker 544 Marstons Lane Owner Owner's Name information is required for every Yarmouth Port MA 02675 4/7/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 1500 GALLON SEPTIC TANK, DISTRIBUTION BOX, 6 INFILTRATORS IN 40'X2'X10' STONE FORMATION Number of current residents: 3 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 years usage(gpd)): Detail: NOT OBTAINED Sump pump? ❑ Yes ® No ' Last date of occupancy: 4/7/15Date Commercial/Industrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Tide 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 �M 544 Marstons Lane Cummaquid MA Property Address Andrew Maker 544 Marstons Lane Owner Owner's Name information is Yarmouth Port MA 02675 4/7/2016 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: PUMPED IN JAN 2016, PUMPED 2011 PER OWNER Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and . maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. I ❑ Other(describe): 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 4M , 544 Marstons Lane Cummaguid MA Property Address Andrew Maker 544 Marstons Lane Owner Owner's Name information is required for every Yarmouth Port MA 02675 4/7/2016 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: 18 YEARS. INSTALLED IN 1998. Were sewage odors detected when arriving at the site? ❑ Yes ®' No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ®40 PVC . ❑ other(explain): Distance from private water supply well or suction line: >10'feet Comments (on condition of joints, venting, evidence of leakage, etc.): OK. NO LEAKS Septic Tank(locate on site plan): 8 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: 5.6'X5.6X10.2' 1500 GALLON Sludge depth: 3" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 544 Marstons Lane Cummaquid MA Property Address Andrew Maker 544 Marstons Lane Owner Owner's Name information is required for every Yarmouth Port MA 02675 4/7/2016 page. Cityrrown 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 31" Scum thickness 0 Distance from top of scum to top,of outlet tee or baffle 1" Distance from bottom of scum to bottom of outlet tee or baffle 23" How were dimensions determined? CORETAKER 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 57"AND BACKING UP INTO HOUSE SEWER PIPE. SIGNS OF SCUM AND BLACK RING AROUND BOTH COVERS Grease Trap(locate on site plan): Depth below grade: N/A 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•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 M 544 Marstons Lane Currimaquid MA Property Address Andrew Maker 544 Marstons Lane Owner Owner's Name information is required for every Yarmouth Port MA 02675 4/7/2016 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: 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•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 wM 544 Marstons Lane Cummaquid MA Property Address Andrew Maker 544 Marstons Lane Owner Owner's Name information is required for every Yarmouth Port MA 02675 4/7/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): 611 Depth of liquid level above outlet invert 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.): LIQUID LEVEL WAS OVER OUTLET INVERT BY 6". SNAKED LINE 35'TO VERIFIY NO BLOCKAGE. HYDRAULIC FAILURE 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 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 544 Marstons Lane Cummaquid MA Property Address Andrew Maker 544 Marstons Lane Owner Owner's Name information is required for every Yarmouth Port MA 02675 4/7/2016 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 6 IN 42'X10'X2' STONE VOL. ❑ 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.): NOT EXPOSED, NO INSPECTION PORT 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 Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins r3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 v Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 544 Marstons Lane Cummaguid MA Property Address Andrew Maker 544 Marstons Lane Owner Owner's Name information is required for every Yarmouth Port MA 02675 4/7/2016 page. Cityfrown 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.): i Privy (locate on site plan): Materials of construction: N/A Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I 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 �M 544 Marstons Lane Cummaguid MA Property Address Andrew Maker 544 Marstons Lane Owner Owner's Name information is required for every Yarmouth Port MA 02675 4/7/2016 page. Cityrrown 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 1 i F(2, N T ----W i 3 a O t D 151 AoOCZ: (' Al t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 544 Marstons Lane Cummaquid MA Property Address Andrew Maker 544 Marstons Lane Owner Owner's Name information is required for every Yarmouth Port MA 02675 4/7/2016 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: >5' FROM SAS BOTTOM PER PLAN.feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: REVIEWED PLANS - ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: PER PLAN THERE WAS A LEAST 5'SEPARATION. 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 • W Commonwealth of Massachusetts Mm Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 544 Marstons Lane Cummaguid MA Property Address Andrew Maker 544 Marstons Lane Owner Owner's Name information is required for every Yarmouth Port MA 02675 4/7/2016 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 117 of 17 TOWN OF BARNSTABLE L ION Sq4 n SEWAGE# O/�-/ VILL GE H(/` ASSESSOR'S MAP&PARCEL'J`['� D INSTALLER'S NAME&PHONE NO. 0, FA SOT-3�P --7ZCV SEPTIC TANK CAPACITY LEACHING FACILITY: (type) tZJ)&J Chl hheCS(size) P,S� I1.8' 4' SJa-c_ NO.OF BEDROOMS 3 OWNER i4gd,cw /4,,,a,-- PERMIT DATE: COMPLIANCE DATE: 5-613-/6 Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 leaching facility) Feet FURNISHED BY Aa as� s �- as A! aq' A4 3713 J! s� / AA IA I��� No.C7 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2ppliLation for -Misposal *pstrm Construction Permit Application for a Permit to Construct(g) Repair()Q Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. SLILI A.M a-rc)tjS G"E- Owner's Name,Address,and Tel.No. 508- 3&9 -3L J Z6 Assessor's Map/Parcel 3 Li ci l03 ,, OQ Aft�. �N4 J7Q0c1 Vy\jf, Innsttalller's Name,Address,and Tel.No. Z (g E Hasitav, Designer's Name,Address,and Tel.No. cH,0V0%-►-tb"n S µ C LE o N1 —B S tV&f C&fo I Nf-" Type of Building: Dwelling.,No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures 2 Design Flow(min.required) 3 3O gpd Design flow provided ;tfC1 gpd 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 n .t to place the system in operation until a Certificate of /- Compliance has been issued by this Board of Health. 6, �� Cf� gne Date Application Approved by Date 'J 3 /, Application Disapproved by. Date for the following reasons Permit No. f lt7 l s` Date Issued � ���O/C9 16 Fee 190 THE COMMONWEALTH„_ F MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OBA°RNSTABLE, MASSACHUSETTS Yes application for Misposal *PBtem Construction 3pPrmit j Application for a Permit to Construct W Repair%) Upgrade,,.(-)NL Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Name,Address,and Tel.No. SOCR- Assessor's Map/Parcel 3 q Ci /03 P 1/1�" ftQ (-w MAJUK - SAIL) A[5-TON)3 CAJQE Installer's Name,Address,and Tel.No. 2 he UrfAf r-0 91MV- Designer's Name,Address,and Tel.No. �a�J - tir�aw�cK,UZ(oy� ��-►bMr+S n,�C����a� r3�55 ?1VC-y f,( CdM SC-S i to C cl zr ()LIP j Type of Building: sos �qq`?-,260 Dwelling No.of Bedrooms Lot Size, sq.ft. Garbage Grinder( ) Other Type of Building . No.of Persons Showers( ) Cafeteria( ) Other Fixtures" 2 <, Design Flow(min.required) 3 gpd Design flow provided 7`f Cl gpd Plan Date Number of sheets Revision Date Title 1 Size of Septic Tank r Type of S.A.S. Z - S00 6A(.(o k) CN R MT"S Description of Soil d I Nature of Repairs or Alterations(Answer when applicable) it Date last inspected: f `� " Agreement: v' The undersigned agrees to ensure the construction and maintenance of the afore described on-site sew e.disposal system in accordance with the provisions of Title 5 of the Environmental Code and n t to place the system in operation u�t�a Certificate of Compliance.has been issued by this Board of Health. 5• �� /� Sign Date // Application Approved by Date 'S 3 1(" 1 Application Disapproved by Date for the following reasons Permit No. D"�''`� � 15 � Date Issued --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS } CPrtifitatejoaf Compliance THIS IS TO CERTIFY,that the On-site Sewage Dtsposaf system Constructed( ) Repaired(� Upgraded( ) Abandoned( )by fAl 9 M at ,� 1-11-) LA A'LS i p iU,S l /� n' has been constructed in accordance with the provisions of Title 5 and the for Disposal Sys m Construction Permit No�eJ(o /,5?dated S5 Jhz� Installer Designer #bedrooms W. Approvedrd i n fl�� (� gpd The issuance of'is pe it shall.not be construed as a guarantee that the systemll /ction as d si edg Date ,} �/ Inspector v No. C �0 _ O Fee X0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS disposal 6pstrm Construction permit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( ) s System located at K L(L4 "Fff-5 To til.S j tlj,)F 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:Construction mus be comp eted within three years of the date of this p it. Date 31514 Approved by r Town of Barnstable Regulatory Services Richard V. Scali,Interim Director • saxxsrnaM M^� Public Health Division 1659. Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: ' �i .J W Sewage Permit# Assessor's Map\Parcel 0 4� Designer: Tz*PI S MCLEWON PE� Installer: Address: �,� X )16 Address: e. bt Nti I S MA of -h dml c : M A ; Olt On was issued a permit to install a (date) (installer) septic system at 5`tN /V1AR_S-r0Iv 5 LAnNt based on a design drawn by (address) iHOMQ Cu£U-0/V dated' q Z? • 1, (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required)was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed in compliance with the terms of the IAA approval letters(if applicable) (Ins a 1 is Signature) CNL 4 � (Designer's Si ature) (Affix D�gnsS:tamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:\Septic\Designer Certification Form Rev 8-14-13.doc r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Marstons Lane Property Address Christopher Olsen Owner Owner's Name information is q required for Cumma uid MA 02637 10/15/09 every 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. Important:When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your Michael Kellett cursor-do not Name of Inspector use the return key. Aardvark Environmental Inspection Company Name - P.O. Boz 896 Company Address East Dennis MA 02641 fe0�' Cityrrown State Zip Code 508-385-7608 S13742 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 ins8ction was performed based on my training and experience in the proper function and+maintenance of onEsrte sewage disposal systems. I am a DEP approved system inspector pursuant to Section 1&340;df Title 5(310 CMR 15.000).The system: a' _ 01 ® Passes ❑ Conditionally Passes ❑ Fails U) ❑ Needs Further Evaluation by the Local Approving Authority 5 Go m 10/20/09 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. ' d USGS•12/07 Title 5 Official Inspection Form:Subsurface Sewage Dii System• 1 of 1 e Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 594 Marstons Lane Property Address Christopher Olsen Owner Owner's Name information is 4 required for Cumma uid MA 02637 10/15/09 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cost.) 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: 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. Answer yes, no or not determined (Y, N, ND) in the ❑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. ND Explain: ❑ 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 ❑ obstruction is removed USGS•12107 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M ' 594 Marstons Lane Property Address Christopher Olsen Owner Owner's Name information is q required for Cumma uid MA 02637 10/15/09 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ 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 ❑ obstruction is removed ND Explain: 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 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. USGS•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 594 Marstons Lane Property Address Christopher Olsen Owner Owner's Name information is q required for Cumma uid MA 02637 10/15/09 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 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 ❑ ® 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. USGS-12107 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 15 l_ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 594 Marstons Lane Property Address Christopher Olsen Owner Owner's Name information is q required for Cumma uid MA 02637. 10/15/09 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No ❑ ® 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. USGS-12J07 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 594 Marstons Lane Property Address Christopher Olsen Owner Owner's Name information fo is Cumma uid required for Q MA 02637 10/15/09 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ 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)] USGS•12107 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 594 Marstons Lane Property Address Christopher Olsen Owner Owner's Name information is Cumma uid required for q MA 02637 10/15/09 every page. Cityrrown State Zip Code Date of Inspection 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 Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: current Date CommerciaUlndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: • Last date of occupancy/use: Date Other(describe): USGS•12107 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 594 Marstons Lane Property Address Christopher Olsen Owner Owner's Name information is Cumma uid required for Q MA 02637 10/15/09 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed(if known)and source of information: 1998 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No USGS•12107 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 594 Marstons Lane Property Address Christopher Olsen Owner Owner's Name information is q required for Cumma uid MA 02637 10/15/09 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 1.5 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.): Septic Tank(locate on site plan): Depth below grade: 0.7 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 gal Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 4" Distance from top of scum to top of outlet tee or baffle 611 Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? measured USGS•12107 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 594 Marstons Lane Property Address Christopher Olsen Owner Owner's Name information is q required for Cumma uid MA 02637 10/15/09 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was sound and tight with tees in place and liquid at outlet invert. 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 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): USGS-12/07 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 594 Marstons Lane Property Address Christopher Olsen Owner Owners Name information is required for Cummaquid MA 02637 10/15/09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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 Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert even 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.): The box was level and tight with no sign of carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No USGS•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °r 594 Marstons Lane Property Address Christopher Olsen Owner Owner's Name information is Q required for Cumma uid MA 02637 10/15/09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 6 ❑ 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.): The system has 6 Infiltrators surrounded by three feet of stone. There was no sign of pond ing or failure in the stones. USGS-12/07 Title 5 official inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 594 Marstons Lane Property Address Christopher Olsen Owner Owner's Name information is required for Cummaguid MA 02637 10/15/09 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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 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.): USGS•12107 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G M , 594 Marstons Lane Property Address Christopher Olsen Owner Owner's Name information is Cumma uid required for q MA 02637 10/15/09 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch 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. a3 . V7 USGS•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,.' 594 Marstons Lane Property Address Christopher Olsen Owner Owner's Name information is Q required for Cumma uid MA 02637 10/15/09 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 20.0 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS maps show an elevation of over twenty feet. USGS•12107 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 15 COMMONWEALTH OF MASSACHUSETTS„, EXECUTIVE OFFICE OF ENVIRONMENTALCAFFAIRS" "`� ' � DEPARTMENT OF ENVIRONMENTAL P� TET1{fCT ON P r w"KISION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION �� 3 6 0(p r Property Address: 544 Marstons Lane j Cummaquid Heights Owner's Name: Jennifer Yuskaitis Owner's Address: Date of Inspection: 6/9/2005 Name of Inspector: (please print) Patrick T. Sullivan Company Name: Ready Rooter Mailing Address: P.O. Box 371 t Sandwich,MA 02563 Telephone Number: (508)888-6055 CERTIFICATION STATEMENT 1 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: asses 1 ' Conditionally Passes Needs Further Evaluation by the Local Authority l Fails Inspector's Signature: �i— 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. Notes and Comments i i '1 ****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. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 544 Marstons Lane Cummaquid Heights Owner: Jennifer Yuskaitis Date of Inspection: 6/9/2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D C. System Passes: 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: - B. System Conditionally Passes: One or more system components as described in the"C ditiona] Pass"section need to be replaced or repaired.The system,upon completion of the replacement o repair,.as approved by the Board of Health,will pass. Answer yes,no or not determined (Y,N,ND) /Id* or the following statements.If"not determined"please explain. i i The septic tank is metal and over 20 yee septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exnk failure is imminent. System will pass inspection if the existing tank is replaced with a complying seproved by the Board of Health. *A metal septic tank will pass inspection if it s structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: 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 broke ,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: i, The system requir pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with proval of the Board of Health): - broken pipe(s)are replaced obstruction is removed i ND explain: 1 a Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 544 Marstons Lane Cummaquid Heights Owner: Jennifer Yuskaitis Date of Inspection: 6/9/2005 C. Further Evaluation is Required by the Board of Hea Conditions exist which require further evaluation the Board of Health in order to determine if the system is failing to protect public health,safety or the enviro ent. 1. System will pass unless Board of Health etermines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner hich will protect public health,safety and the environment: _Cesspool or privy is within 50 et of a surface water —Cesspool or privy is within 5 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Su plier,if any)determines that the system is functioning in a manner that protects the public health,safe and environment: _The system has a septic tank and soil absorption system(S )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 ithin a Zone 1 of a,pub]ic 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 AS is less than 100 feet but 50 feet or more from a private water supply well". Method used to dete ine distance "This system passes if the well water analysis erformed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates at the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate ni gen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the anal sis must be attached to this forma r 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR'VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 544 Marstons Lane Cummaquid Heights Owner: Jennifer Yuskaitis Date of Inspection: 6/9/2005 ; D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _j," Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool __,Z' 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 and overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the 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 50 feet of a private water supply well. i/ 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] A-')O(Yes/No)The system fails. I have determined that one or more of the above 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 fa ility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the follo ing: (The following criteria apply to large systems in additio to the criteria above) yes no the system is within 400'feet of a surface rinking water supply the system is within 200 feet of a trib ary to a surface drinking water supply _ the system is located in a nitrogen ensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply`well If you have answered"yes"to any qu ton in Section E the system is considered a significant threat,or answered "yes" in Section D above the large stem has failed.The owner or operator of any large system considered a significant threat under Section E r failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner shou contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 544 Marstons Lane Cummaquid Heights Owner: Jennifer Yuskaitis Date of Inspection: 6/9/2005 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 owrier,occupant,or Board of Health —ZWere 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?. -Z- 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 than 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: Yes No _ 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(3)(b)] „ Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION , Property Address: 544 Marstons Lane Cummaquid Heights Owner: Jennifer Yuskaitis Date of Inspection: 6/9/2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: l 10 gpd x#'of bedrooms): Number of current residents: _ Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system.(yes or no)N [if yes separate inspection required] Laundry system inspected(yes or no):_ Seasonal use: (yes or no): n c 3 w 3� •#'�• cas�J Water meter readings, if available(last 2 years usage(gpd)):"Q�cxo+-1 `— Sump Pump(yes or no): A-2p Last date of occupancy: i COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on/R5.2 15.20 gpd ' Basis of design flow( ns/s . ft.etc.): Grease trap present(y Industrial waste holdient(yes or no): Non-sanitary waste di the Title 5 system(yes or no): Water meter readings, le:Last date of occupanc OTHER(describe): 1 GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): If yes,volume pumped: 5cgallons--How was quantity pumped determined? Reason for pumping: TYP,E OF SYSTEM eptic 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) Tight tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 544 Marstons Lane Cummaquid Heights Owner: Jennifer Yuskaitis Date of Inspection: 6/9/2005 BUILDING SEWER(locate on site plan) Depth below grade:` R� Materials of construction-_cast iron—V,�fo PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: (locate on site plan) Depth below grade: 9`^ Material of construction:_concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: \ k Sludge depth: Distance from the top of sludge to bottom of outlet tee or baffler" Scum thickness: Distance from top of scum to top of outlet tee or baffle: 4; Distance from bottom of scum to bottom of outlet tee or baffle: 10 How were dimensions determined: Y Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): =Acam (w. ; �.✓ _ GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or affle: Date of last pumping: Comments(on pumping recommendations, inlet and utlet tee or baffle condition,'structural integrity, liquid levels' ` as related to outlet invert,evidence of leakage,etc. . Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 544 Marston Lane Cummaquid Heights Owner: Jennifer Yuskaitis Date of Inspection: 6/9/2005 TIGHT or HOLDING TANK: (tank must be purr at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiber lass_polyethylene_other ex lain : � Dimensions: Capacity: gallons Design Flow: jAlarnmn gallo /day z Alarm present(yes or Alarm level: w king order(yes or no): Date of last pumping: Comments(condition d float'switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(not if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): cS�Jv� Gw��►�G- ..1�� Q.(:. .caw 7- PUMP CHAMBER: (locate on site pl/dition Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber, umps and appurtenances,etc.): 9 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 544 Marstons Lane Cummaquid Heights Owner: Jennifer Yuskaitis Date of Inspection: 6/9/2005 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: F , Type leaching pits,number:_ leaching chambers,number: ::Zleaching galleries,number: ra 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.): ((�� 5,�A `J L-a L-e�4-e-.�C � -N`'��, �(��',+e e�•A���:, ��v.�_p►-��e'eJ�,t� �d e.�,..c� J�� l.�,n e:SI,JWe�\.G. �•l`3].!^.e_� GSc��a.Q��� of �'�v-..ice CESSPOOLS: (cesspool must be pumped as pa yof 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(ye or no): 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 draulic failure, level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 544 Marstons Lane y Cummaquid Heights Owner: Jennifer Yuskaitis Date of Inspection: 6/9/2005 SKETCH OF SEWAGE DISPOSAL SYSTEM 4 Provide a sketch 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. cs4: vi dw� i 3.3 f 1 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 544 Marstons Lane Cummaguid Heights Owner: Jennifer Yuskaitis Date of Inspection: 6/9/2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water i� feet Please indicate(check)all methods used to determine the high ground water elevation: _V_Obtained from system design plans on record=if checked,date of design plan reviewed: q Observed site(abutting property/observation hole within 150 feet of SAS) Checked with the local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high groundwater elevation: Sr- <R . y' tOWN OF BARNSTABLE LOCATION ��� YY\moa�av-.s Lacy, SEWAGE # 7 5?---7 0 Vh,LAG ASSESSOR'S MAP & LOT I'NST LLER'S NAME&PHONE NO. 77/- 93.23 SEPTIC TANK CAPACITY1- LEACHING FACILITY: (type) :C,rZ�r (size) NO.OF BEDROOMS BUILDER OR QMMLER PERMITDATE: 1 - apt- ct - COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 leaching facility) Feet Furnished by ��- i� t� 'J • �3- 33 � Sk 3 3 ' B-3 ` TOWN OF BARNSTABLE LOCATION ,S yLl `/�Q/��O�s /a, SEWAGE # 'VE LACE ASSESSOR'S MAP&LOT33V y-163 a ,INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACTI'y LEACHING FACILITY: (type) �i �l`/p�`I�Q' S k (size) NO.OF BEDROOMS BUILDER OR PERMITDATE: e COMPLLANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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)ofj leaching facility) �''' Feet Furnishediby, 2vN vv 3� No. ' �j FEE COMMONWEALTH OF MASSACHUSETTS Board of Health, SkA Lr- , MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to ConstrucVR pair( ) Upgrade( ) Abandon( ) - ❑Complete System ❑Individual Components Location V-L< �1 A. LA: Owner's Name ON j ;+i S Map/Parcel# Z�.c �j 4 Address f?d, /3a 5-17 it)izr -Atuivor a 67? Lot# Telephone# L,,d .�.5-(P3 Installer's Name � Designer's Name STEPHEN J. DOYLE & ASSOC. 42 an er ury Lane Address tl/s �, �. Address East Falmouth , MA 02536 Telephone# -7 Telephone# Telephone: 508/540-2534 Type of Building S . Lot Size S, $i sq.ft. Dwelling-No.of Bedrooms Garbage grinder ( ) Other-Type of Building No.of persons Showers 4),Cafeteria( ) Other Fixtures Design Flow (min.required) 3 3® gpd Calculated design flow 373 0 Design flow provided 44 gpd Plan: Date 1'z -Z-57AI Number of sheets Revision Date / Title �.trr �u�,. ftr L&L- i wt �L1M c i�t� - � 'At3LF_ C-0tL �.y'� ,`(U SiLAIl'j.(,-- Description of Soil(s) `J5 Cc- S".11- Lai4&. Rt✓-, L-4d Soil Evaluator Form No. f Name of Soil Evaluator VNAli- Date of Evaluation 2— Z!(� �n1 DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees tp no)to lacpffie system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date Inspectio No ° C✓=' '/ FEE MASSACHUSETTS COMMONWEALTH Of., Board of Health, li= , MA. APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct�epairO Upgrade( ) Abandon( - ❑Complete System-❑Individual Components 1, 3 Location %< A Nr"1 To } 1„ly, Owner's Name O v j D f 5ZQ.AJ t�e r ' ✓u +i s Map/Parcel# e` 10 3 _"4 Address� �, /?e/r 5Y7 G✓ESA ]%l t?�l Gv f 11 U�Z 67 3 Lot# t Telephone# (�08) 5_6.3 Installer's Name API r0 C,00,5 7` Designer's Name S'TEPHEN J. DOYL Address--""'�.y 5- , J� Address 42 Canterbury Lane Telephone# 'i. `-7 1- Telephone# Telephone: 508/540-2534 71 • � 6 Type`of Building --•t_S f Lot Size ��� s�°� sq.ft. Dwelling-No.of Bedrooms ) Garbage grinder ( ) Other-Type.of Building No.of persons ol Showers (A,Cafeteria,( ) Other Fixtures" . ? Design Flow (min.required) '3�O gpd" Calculated design flow 33 O Design flow provided 44�' gpd Plan:'_Date iZ -Z-y'"( Number of sheets 'L. Revision Date `l Title .3 ..:Jtt-��i�awJ, er- Lr►wa,�,—Its 4M�`14pQt���. -�iyt�S'e' L�. TwtL �' y�� `IIaS1LAtl'l Description Tof Soil(s) •4, �t� ��o�t �aL -- StY '` Z 0(= Soil Evaluator Form No. Name of Soil Evaluator�jg_ -) A-LL Date of Evaluation ' t DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees t_q nolf to lace a system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed -Date Inspection r No. FEE G, Board of Health, MA. CERTIFICATE OF COM CE Descript��'on of Work: ❑Individual Component(s) ❑Complete System The undersign hereby certify that the Sewage Disposal System; Constructed (VRepaired ( ),Upgraded ( ),Abandoned ( ) by: GoZ' W`15.7' - at has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. dated ��'�7 1`^ff Approved Design Flow (gpd) Installer Dgne`r Inspector Date / 1 1 7 . The issuance of this permit shall not be construed as a guarantee that the system will function as designed. > No. — - FEE lel ' COMMONWEALTH OF MASSACIIUSE-TTS Board of Health, MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( �r Repair( ) Upgrade( ) Abandon`( ) an individual sewage disposal system at --6—4!� '0W�-r2�,S-7—g X-r � as described in the application for Disposal System Construction Permit No. dated s Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met. s ��� q q�y I Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date Board of Health�)- , TOWN OF BARNSTABLE � LOCATION �72-U RA125,Z"an� SEWAGE # VILLAGE ASSESSOR'S MAP & LOT ✓ INSTALLER'S NAME & PHONE NO. LGr NSEPTIC TANK CAPACITY 000 (h LEACHING FACILITY:(type) v,, (size) D NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER o BUILDER OR OWNER Z'4( U DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED VARIANCE GRANTED: Yes No� i .GQ a Q I ,0f✓/V7f F GA/, .......................... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Appliration for Uiopoottl Morki Toatotrur#ion Prrmit Application is hereby made for a Permit to Construct (r/) or Repair ( ) an Individual Sewage Disposal System at: !`9.�YlzSnls•--•�✓ !cam C�'`7�-1Aly L> - 407 ..--• - .................•----••---•-------••---- ....----......-•--....................._. Location-Address , - or Lot No. ..... � .z'fly: ...---z? -5z'...... "��'... __8 ............ r 'c '................................. Owner Address W CZL/S f3'2o S, v r.�TJY �?2— Installer Address 43 ,76 Type of Building Size Lot...__.__....................Sq. feet Dwelling—No. of Bedrooms___.......__3...........................Expansion Attic ( ) Garbage Grinder ( ) `•4 Other—Type T e of Building No. of ersons____________________________ Showers — W YP g -------••------•--•-------•- P ( ) Cafeteria ( ) a Other fixtures ----------------•••••-•••••-•••. - W Design Flow______________S-s__.___..______.__.__._gallons per person per day. Total daily flow_.__._.____��o_______.._....._._____gallons. WSeptic Tank—Liquid capacity_!�__gallons Length__E'._6".___ Width._!��."__. Diameter________________ Depth_:s_.8..`..- x Disposal Trench—No...:................. Width_____._____.______.. Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..___._�.-: �.__._._. Diameter____._.� ....... Depth below inlet...... �._..... Total leaching area...z� .....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '-' W Percolation Test Results Performed by-_ !�✓.._ .w .___ `� Date....� ,18 4 Test Pit No. 1__A;�_.Zt-----minutes per inch Depth of Test Pit....Z:68`....... Depth to ground water......._ ............. 0-4 44 Test Pit No. 2..G._ ___.minutes per inch Depth of Test Pit..... ?N.... Depth to ground water_____________________ •---•-•------------ ---......................................................... .................•-•- •--•-•---•----•---......--•----•---------••--•---•-------- -------- ------••-- 9 .._._. Description of Soil______-�_'_- �'" S"8 s©�(. 48°/--/e.6 x ---•-_..._ -••-•...-•------•------------------------------•---•-•--•-....--•-----•- U -----•-•-•---••---•••._...._...--•-•---------•--•--.......•--•-...---•---•--•-=---•--•-------...•--••---•----•-••-•-----•-•----------------------•-•................................................... W V Nature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________ •-•-•--------------- -------•------------...---------------•-•------...-=-----------------------.....----•---=------------------------•---•-•----------------.......................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System i(ace cordance with the provisions of TITL U 5 of the State Sanitary Code—The undersigned further agrees not top the system in oerarion until a Certlhca,te of Com Nance has been > sued b tp p y he board of health.Si ne� '. . �Date* toApedLBY a .....= ........_... ...... .....Aphca ---- .. ...... 11ate Application Disapproved for the following reasons:--------•------•---•--•--------•-----.....--•-------•------•--•--------------•----------•-••--•-•-•--.....---- -•-...•---------------------••--••----........_..----------...--•-----••------•--•-•-----•-...-----------•---...•-----•--•--------•-----•-•-----•----•--•-•••--------_._..•--•----•••-••-•-----•---•---- f Date PermitNo..___�tP.................`-••-----------•---------- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _---......._ tt/n/... ....OF....... a� , ppliration for Dhnp tsal Works Tonitrur#ion Prruat Application is hereby made for a Permit to Construct (r,,r) or Repair ( ) an Individual Sewage Disposal System at: i� pis l c:.....-�U��� , t>Cot.,, �> `�-- .... ........................... ....:...........�•_...............- ............................. ..---...--------•--.......---.......... Location-Address or Lot No. _ Owner Address LLB ✓T' .:,J/ .�.................. ........ .....----•...............•-•-•-••-•...........----•......_ Installer Address d Type of Building Size Lot...�3_.�".�"_..Sq. feet Dwelling—No. of Bedrooms.............................._.............Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building .___._.___._ No. of ersons____________________________ Showers a YP g ---------------• P ( ) — Cafeteria ( ) d Other fixtures . W Design Flow.............. ' ___.__.______.._..___gallons per person per day. Total daily flow..........................._................gallons. WSeptic Tank—Liquid capacity_6�et.gallons Length__.E' _ Width_.`l.'G Diameter________________ Depth___.8__-. x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter........ Depth below inlet.......m�........ Total leaching area....?_6-.%....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '-' Percolation Test Results Performed by.__4?1^!__V_.K! �ez � .__.__:T^! _________________ Date..... 23 ................ Test Pit No. 1...�_.z_.__.minutes per inch Depth of Test Pit..... ' ..... Depth to ground water........_" ............ f=. Test Pit No. 2... Z...minutes per inch Depth of Test Pit...... Depth to ground water-------__..___.._.. M ........-...............................................................................................--••-•-......-----....-•-•--••-•-••--••-••----...---- 0 Description of Soil......a '' 4e" �q'". e' s:.r• So.e— I Y "'-/6 6" /9�-�. sia i- --------------------- ••---••-•-•••-••-•-•-•--•--•----•-•••-•-...•-•---•---•••••-••••-•---•-•- U ••-•••••--••••--•••••-••-•-............................................................................................................................................................................. W VNature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________ ------------------------------------•-----------------•--------•------------•--•--------•---....-----•---•--------•-------------------------.._......................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIS 5 of the State Sanitary 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. -Z , SignedQ •,. .... ., J.................................................. Date Application Approved ......................a'-d2r�' '`-'-.»- � r / Date Application Disapproved for the following reasons:.......................................................................................................-......- •-•--•.....•-•••-----•--...•••-•-•-••••-•••-------•-••••-•-...-•-•----••--•-----•-•---••-••••--......_....------------------•----------•-..._••-----...•------••-•-•-••-•_._.--••-••--•••----....•---•-•- Permit No..._..� ..._... Date ...�_.....•. -•------- Issued..-•---•----------------------------------....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......OF.......... /3����✓ ............................. .............................. Trdifirat a of Tong hattrr THIS IS TO CEffIFY, That the Individual Sewage Disposal System constructed (rr•-)-'or Repaired ( ) by x2.-a._4---..................................................................................................................................... Installer 2'�- •r.�m .�<------------------------ has been installed in accordance with the provisions of TIT 5 of ��e tate Sanitary ode as escribed in the application for Disposal Works Construction Permit No...... ..... .............. _____. dated__--: �. _ �------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. _ DATE.................< .............................. Inspector--•--•. ---------------__------------•----------..... ........ A7 THE COMMONWEALTH OF MASSACHUSETTS —,�� BOARD OF HEALTH 1 r .�` 1' OF. f� ........ ..--.. /!-a�st%s7iGI/3 C .. No��••-._......... FEE................. Disposal IVo ko Tonitrnrtion rrrntit Permission is hereby granted , 1.1'.f_---- ?8_ --__-----•------------------- ....... to Construct ( or Repair,-( ) an Ind•vidual Sey�Tage Disposal System at No...... ............. ..�r - !!G. .._._. ate --�-..�-:�:-�:: .�_..----....-----------...--------------------........ Street / as shown on the application for Disposal Works Construction Permi o._el�.7 122 Dated____Z./,/...�..-_.... (� ) -----------------• ---- X h oard of ealt6 DATE.....................--•------- ........................_---....:-•••-•-•--- FORM 1255 A. M. SULKIN, INC., BOSTON si S/ Tze ,oG�tT/LDCATION ,r SCALE . "=40 . . DATE PLAN REFERENCE . . ' . . /. . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 901 rZ \41s, �-� L pT �r 14-1 �4 Sy r 1 r 47 id L_vT ,q EVA-no Ns !3gs eZ> eni t ,�.....•--"'/ i �.�/ i ..r--- i -�., lye P. v �v NO.26100 AL LA OP -tv 15 V,FIR .., sf1ezT z o F z 9�.4�1 L. .. . TOP OF FOUNDATION CONCRETE COVER CONCRETE COVERS 9.c, ''a 4"CAST IRON • ,°; OR SCHEDULE 402„MAX. 9 12"MAX. • P.V.C. PIPE 4„SCHEDULE 40 PVC.(ONLY) ' PITCH 1/4"PER. PIPE- MIN. LEACH PITCH 1/4"PER.FT PIT PRECAST INV5T a LEACHING ° EL••-.6: INVERT INVERT e . e•t PIT OR SEPTIC TANK EL 8S07 DIST. ELB¢�a j= : EQUIV. o INVERT /ooa BOX "'` - 0 o; EL.�SZ¢•• GAL. INVERT �� f F- 0. INVERT Wa.W :�: 3/4"TOIIlZ '�: �o °: LL .;. WASHED STONE • T _ I 3Z�----��-W DIA. PROR LE OF GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM NO SCALE sg SOIL LOG WITNESSED BY " DATE .^.?''M. .�� TIME. ./�/Gl BOARD OF HEALTH TEST HOLE I TEST HOLE 2 L�W6-`?o ENGINEER S� -so,e- 3°'! j so e- DESIGN DATA 3G" = Bz 90 ez'RX,00 NUMBER OF BEDROOMS 3 TOTAL ESTIMATED FLOW . . 33v . GALLONS/DAY 77, 7f,go BOTTOM LEACHING AREA .79 ,0. . . SO.FT. /PIT/�SCP, D. EZ. 7�,So SIDE LEACHING AREA . . SQ.FT./ PI 377C:P.D. GARBAGE DISPOSAL .N�'^!�'. .(50% AREA INCREASE) `xD TOTAL LEACHING AREA . . .247: Qe?. SQ.FT p.,oGres /.59" E'Z,72. Ioa /.5Z 70,5-0- PERCOLATION RATE MIN/INCH .No .WATER ENCOUNTERED LEACHING AREA PER PERCOLATION RATE 44Z.. SQ.FT/c,/?D, NUMBER OF LEACHING PITS oN� PiT li✓iTt/ APPROVED . .. . . . BOARD OF HEALTH DATE . . . . . . AGENT OR INSPECTOR tiAI`: OF 1' .LEY STi . G✓!"�<`?�1 C,{�(� i D. ��I�I;Ju/ GIS ��,�uR/ SAN(TAP1Pc� l PETITIONER �G ifllyR tL' - EXISTING o4oTING CONTOUR: ---- S71. 7 ��">7' „ s3 � SEPTIC SYSTEM DESIGN SEPTIC SYSTEM SECTION PROPOSED CONTOUR: ............. 2"PEASTONE OR FILTER FABRIC EXISTING SPOT ELEVATION: 25.5 FLOW ESTIMATE: FIRST FLOOR PROPOSED SPOT ELEVATION: P5.5 110 3 BEDROOMS AT 110 GAL/DAY= 330 GAL/DAY M 102.99 COVERS WITHIN 6" 3/4"-1 1/2" OF FINISHED GRADE WASHED STONE TEST HOLE: a 10 FOUNDATION \ FINISHED GRADE INSPECTION PORT UTILITY POLE: -0- SEPTIC TANK: ELEV.-_100,43 FENCE LINE: - -- - m HYDRANT: _GAL/DAY x 2 DAYS= 660 GAL RETAINING WALL: ® USE 1500 GALLON SEPTIC TANK(EXISTING) 100.4 COVER ' ELEV. a (V MIN) LEACHING AREA: 100.2 (EXISTING) ELEV.00.45 100 1 99 93 `--`�108 USE 2-500 GALLON CHAMBERS(8.5'x 4.8'x 2'EFF.DEPTH)WITH 1ELEV. ELEV. D-BOX ELEV. 97,6 N 4'OF STONE ALL AROUND (25'x 12.8'x 2'DEEP) ° �6"OF STONE UNDER OR V ' ELEV. \ SIDE AREA: (25'+12.8' x 2 x 2=151 SF 1500 GAL MECHANICALLY COMPACTED) SEPTIC TANK 25'x 12.8' -s ) (0.74),=112 GAL/DAY TEE SIZES:(TO BE CONFIRMED) 9.6 2-500 GALLON CHAMBERS WITH BOTTOM AREA: 25'x 12.8'=320 SF (0.74) 237 GAL/DAY INLET:6"UP,13"DOWN 4'OF STONE ALL AROUND v 1__106\ OUTLET:6"UP,14"DOWN ELEV. (25'x 12.8'x 2'DEEP) CAPACITY=349 GAL/DAY GAS BAFFLE AT OUTLET TEE� ry^ \ = P00- \ ' TH-1 TH-2 TH-3 102.0 103.0 103.0 104\ \ , 0 HORIZON ELEV. 0 HORIZON ELEV. 26,, FILL ELEV. \ \ 1 TEST HOLE LOGS 3" 10YR2/1 6" 1OYR2/1 TEST HOLE LOGS O/AHORIZON \ , \ ENGINEER STETSON HALL E HORIZON E HORIZON LOAMY SAND : 102- \ 5" 10YR 6/1 102.6 8" 10YR 6/1 102.3 ENGINEER: THOMAS McLELLAN,P.E. 36" 10YR 4/3 99,0 \, OECK \\ \\ WITNESS: J.DUNNING B1 HORIZON SANDY LOAM A HORINDY LOAM ZON WITNESS: DAVE STANTON,R.S. BOHORIZONSAND \ ` DATE: 2-27-97 36" 10YR 7/6 100.0 24" 10YR 7/6 101.0 DATE: 4-27-16 45" 10YR 518 98.3 G B2 HORIZON B HORIZON C HORIZON PERCOLATION RATE: <4 MIN/IN SANDY LOAM SANDY LOAM MEDIUM SAND EX�E ROOM 72" 10YR 7/4 97.0 60" 10YR 714 98.0 60" 2.5Y 7/4 97.0 \ DB OtAG 99 (n C1 HORIZON C1 HORIZON C2 HORIZON \ top fr`d MED-W m I 120" OYR 7/4E SAND 93.0 72" OYR 7/4FINE ND 97.0 126" 2.15Y 6/LT AM 91.5 \ ; w�\ C2 HORIZON C2 HORIZON C3 HORIZON FINE SAND MED-FINE SAND MEDIUM SAND \ \ I 132" 2.5Y 7/1 92.0 144" 2.5Y 7/1 91,0 138" 2.5Y 7/3 90.5 i 10\ \ ` NO GROUND WATER ENCOUNTERED NO GROUND WATER ENCOUNTERED 108 NOTES: 102 C9 _ ' rem II \ o bed bath 1.VERTICAL DATUM: ASSUMED �Q th-3 bath 2.MUNICAPAL WATER IS AVAILABLE. >> th-1 3.SCHEDULE 40-4"PVC PIPE TO BE USED THROUGHOUT SEPTIC SYSTEM. existing / t� bed bed 1500 gallon ` / 106 room room 4.ALL PRECAST UNITS SUBJECT TO TRAFFIC LOADS TO CONFORM WITH AASHTO H-20 SPECIFICATIONS. septic tank 102, 1 i 1 1 : I I \ 2nd floor 5.PIPE PITCH= 1/4" PER FOOT(UNLESS NOTED OTHERWISE). ~'/ leach! 1 ( \ 6.FIRST 21 OF PIPE OUT OF D-BOX TO BE SET LEVEL. urea J1 th-2 I \ \ 7.THE SEPTIC SYSTEM HAS NOT BEEN DESIGNED TO ACCOMODATE THE USE OF A GARBAGE DISPOSAL. T Paved I ) \ deck Parking 104 / \ 8.ALL CONSTRUCTION DETAILS ARE TO BE IN CONFORMANCE WITH THE STATE OF MASS.ENVIRONMENTAL AreaI / \ kitchen CODE(TITLE FIVE)AND LOCAL HEALTH REGULATIONS. / 9.CONTRACTOR TO VERIFY LOCATIONS OF ALL UTILITIES PRIOR TO CONSTRUCTION. bth Ind j1riving 10.GROUND COVER OVER ALL SEPTIC SYSTEM COMPONENTS NOT TO EXCEED 31. \\ \ \\ dining 11.FIELD SURVEY PROVIDED BY TERRY A.WARNER,P.L.S.,HARWICH,MA. \ Iroom 12.THIS PLAN REQUIRES THE REVIEW AND APPROVAL OF ONE OR MORE TOWN DEPARTMENTS AND \ \ 1st floor IS SUBJECT TO CHANGE UNTIL SUCH TIME. BENCHMARK AT � I � BAG NAIL I 13.EXISTING LEACH AREA(6 INFILTRATORS WITH STONE)IS TO BE PUMPED AND REMOVED ELEVATION=102.48 i �I \` \ EXISTING FLOOR PLAN WHEN WITHIN 5'OF PROPOSED LEACH AREA, ti \ 14.D-BOX TO BE WATER TESTED TO ENSURE LEVELNESS AND EQUAL FLOW. 108 15,IF UNSUITABLE SOIL(SILT LOAM,60"-126",TH-3)IS ENCOUNTERED WITHIN 5'OF PROPOSED LEACH AREA // ,, \ IS TO BE EN REMOVED REMOV D IIN 19 9 W E H N E OR G AND REPLACED I N INSTALLED.TH CLEAN MEDIUM SAND. UNSUITABLE HAVE AL SYSTEM WAS STALLED DESIGN TOENGINEER BEEN \ \ 4 VERIFY AT TIME OF CONSTRUCTION. \ 16.THIS DESIGN REQUIRES THE APPROVAL OF A VARIANCE FROM THE FOLLOWING TITLE V REGULATION: SECTION 15.211(1):PROPOSED LEACH AREA TO BE LESS THAN 20'FROM CELLAR WALL,(VAR.OF T). `106, i� 1 SITE PLAN 102 O�kMONT \\ // // § �� LOCATION: Ro --__ \ ,�R, 544 MARSTONS LN., CUMMAQUID,MA -+ 104/ TRANS a I` A ' ' "� � - 100 > z N r ) PREPARED FOR: LOCUS r \102 Z 4 .. �k ANDREW MAKER V p13� P•� `max ° DATE:4-29-16 SCALE: 1"=30' 00- LOLOCAg IO 59 AP \ �0 BASS RIVER ENGINEERING � �L � ASSESSORS MAP:349 PARCEL:103 98-' PLAN BOOK:361, PAGE:73 �P T OMAS J. MCLE LAN, P.E. P•O.BOX 1163, EAST DENNIS,MA 02641 M16-14 508-364-9048 k 1 tl !•s►•tf•. •� f 2 . �� I yz aw Ywimth :a. o • DOM Yaska WL 60 uUs 11•�9 1 Q P.O.Box 517 G .j Wat YmmoutA,MA 02973 10 • _.�,..:_. +..•-i FEMA DATA LOCUS DOES NOT LIE INA FLOOD HAZARD ZONE �; USCS LOCUS SCALE: 1:25.000 92 ASSESSORS DATA: 349-IO$ ZONING DISTRICT: RF-1 O • . BUILDING SETBACKS FRONT-301 SIDE- is REAR- 15' OVERLAY DIST: AP 1 A � MUNICIPAL WATER: YES PRIVATE TIELLS: NO ^�`�A, •�. NO WETLANDS49 EwsnNG -•• _ `. STORM _ ,_.�� �ti' s�' ,'. \ ht• �. DRAINS _� � „-:v/•-'`.f•IP Vim,' � ��'® � PROPOSED S.A.S MIRLTRATOR TRENCH (H-20 LOAD) __r :. �1• UNSURABLE SOILS T17LE 5 15.255(5) ob found / .,`r,:. ,:.•• sv^*.,�.,�.,�........................ !•P� / •p`opotb`woet 49,589 sq.ff. / �, ..�Y fl- �•� ------------�--�:' sw•' "• • � l / / 30' • ' e SAS EXPANSOI!'Z^ •.' -�- 9� GRAPHIC SCALE. 4 ° pp�/�p sb w ato a a CALLON TANK y W.. TOP CONC.BOUND EL 94.1' i. 1 ( TN l!!Z•f oAT1nu NCVD , ►�/I 1� •• 0Or 1 Inch � 20 ft �" ab found •'• CF 7 �Vllllal•i dm DOYLE o UfSERIAA V �e3r / �• 9IP SHEET 1 OF 2 $ S ITE AN O F LAND IN CUMMAQUID - BARNSTABLE, MASS. PREPARED FOR ib• 1DAVITD YUJis5 KAI'TI:E3 DEPICTING THE PROPOSED DWELLING ON LOT 19 MARSTONS LANE DECEMBER 2. 1097 SCALE: 1' : 20' PREPARED BY: STEPHEN I DOYLE AND ASSOCIATES 42 CANTERBURY LANE,EAST FALMOUTH.MA 02516 TELEPHONE 506/6 0-2534 GENERAL CONSTRUCTION NOTES 1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO O.E.P. TITLE 5 AND THE TOWN Of +=�c RULES AND REGULATIONS FOR PROFILE OF SEWAGE DISPOSAL SYSTEM THE SUBSURFACE DISPOSAL OfF SE SEWAGE. 2. AT LEAST ONE ACCESS PORT OVER TANK TEES SHALL BE ACCESSIBLE NOT To SCALE WHITHIN SIX INCHES OF FINISH GRADE WITH ANY REMAINING ACCESS PORTS BROUGHT TO WITHIN TWELVE INCHES OF FINISH GRADE. 3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN 10' TOP FOUND. EL 94.0 OF DRIVES OR PARKING. H-20 LOADING SHALL BE USED UNDER OR WITHIN 10' OF DRIVES OR PARKING UNLESS NOTED. 4. THE EXCAVATOR/CONTRACTOR SHALL VERIFY THE LOCATION OF ALL V SITE UTILITIES PRIOR TO ANY EXCAVATION. 5 SEWER PIPES SHALL BE 4 SCHEDULE EDULE 40 PVC LAID AT 0.02 SLOPE s 6. ANY MASONRY UNITS USED TO BRING COVERS TO GRADE SHALL BE INV, EL 85-3 MORTARED IN PLACE. °ArLr tlwr toc11 1 /�tm FLOW LINEtr 7, FINISH GRADE SHALL HAVE A MINIMUM SLOPE OF 0.02 FEET PER FOOT. INV. EL 8B.'T YtEva--, I 10' xIN. P LNX7 OFIIK i T%r .. -i�.-_..._ ..r Lt. •o,r. INV. 0. stir _ INV. EL INV. EL b5. 2'MIN. - I/6' TO 1/2' WASHED STONE 1500 GALLON PRECAST REINFORCED CONCRETE SEPTIC TANK N-Zb L.oq� MINIMUM CONSTRUCTION MATERIALS PER 310CMR 15.226(2) PRECAST REINFORCED CONCRETE INFILTRATOR DISTRIBUTION Box y TEES SHALL BE CONSTRUCTED OF SCHEDULE 40 PVC AND 3/4- - 1 1/2- WASHED STONE EFF. DEPTH SHALL EXTEND A MINIMUM OF 6' ABOVE THE FLOW LINE INSTALL ON A LEVEL BASE OF THE SEPTIC TANK AND BE ON THE CENTERLINE OF THE SEPTIC TANK LOCATED DIRECTLY UNDER THE CLEAN-OUT MINIMUM WALL THICKNESS - 2' LLSIr IA "="V1.t'Q.A�Ugs IM MANHOLE. MINIMUM INSIDE DIMENSION - 12' S.A,S, S.A.S. 40 LONG x� .. WOE x_ -EFF, DEPTH THE INLET PIPE ELEVATION SHALL BE NO LESS THAN 2' NOR INV. EL 9 H�9.:: WIT HIGH CAPACITY INFILTRATOR CHAMBERS MORE THAN 3' ABOVE THE INVERT ELEVATION OF THE CUTLET INVERTS SHALL BE EQUAL TO EACH N OUTLET PIPE. OTHER AND AT 2' MINIMUM BELOW INLET INVERT. i SEPTIC TANK SHALL BE INSTALLED LEVEL AND TRUE TO GRADE THE DISTRIBUTION LINES FROM THE DISTRIBUTION BOX '.. Qti A LEVEL STABLE BASE THAT HAS BEEN MECHANICALLY SMALL ALL HAVE EQUAL INVERTS AS DETERMINED BY FLOODING COMPACTED AND ON TO WHICH SIX INCHES OF CRUSHED STONE THE OWTRIBUTM BOX TO THE HEIGHT OF THE DISTP48UMONtWUSIt;YnrSt�. i HAS BEEN PLACED TO ENSURE STABILITY AND TO PREVENT LINE INVERT AFTER ALL LINES HAVE BEEN SEALED IN PLACE. TEt 9S,S TaQpuwouT S.A--S. C' liotc,.l-L, AU„SETTLING. - INVERT ADJUSTMENTS SHALL BE MADE BY FINING WITH DURABLE AstouUp S.4.S, T>6F� TZ"iL -IS.•LS�s) AND NON-DEFORMABLE MATERIAL PERMANENTLY FASTEND TO THE j SEPTIC TANK SHALL HAVE A MINIMUM COVER OF 9'. LINE OR RECONSTRUCTING THE LINES UNTIL ALL INVERTS ARE OF EQUAL ELEVATION. THREE 20' MANHOLES WITH READILY REMOVABLE IMPERMEABLE I COVERS OF DURABLE MATERIAL SHALL BE PROVIDED WITH ACCESS c VO AiF�L. PORTS BEING PLACED AT THE CENTER AND OVER THE INLET AND OUTLET TEES. '( 1 THE OUTLET TEE SHALL BE EQUIPPED MATH GAS BAFFLE. I I I f 1 REFERENCE MAP: SOIL OBSERVATION DATA: CAPE COO DESIGN DATA: i WATER TABLE CONTOURS `\ ' AND STRUCTURE k-.>=S _ 3 N0 �VlbtN of LEST DATE Z i''T-9't PUBLIC WATER SUPPLY - ...._ _ WELLHEAD PROTECTION AREAS TYPE 140. BEDROOMS GARBAGE DISPOSAL .,158 OF or =c SOIL EVALUATOR '�T"E-c�u... I�AtL ��i>'� DESIGN FLOW 3 r tto = •s-so r Yw,� yLGLtiEfF = v:auuA y STEPHEN $ LIEaLRMAv I B.O.H. AGENT S• �T7u�.... WAm ALSCUACES ORICL ..__ __..-_. 1 » I ...Li`' CAPE COD COMMMSO,I $ .DO YLE } �,•«..:•.40 WT 1 EXCAVATOR No.375" o a'IL o�rt PERC/RATE c 4 MIa wr i SEPTIC TANK -53o v. zoc�' s "o I usE l�uo G4, -ZO llA�so o• 1 1 1• L SHEET 2 4< 2 4L.�1 Y I. 6t.•Vt.T °" LEACHING FACILITY (.oA-AD k-It MIJ)k L c 2op o rIo Sl I '$o,. t°oYR'1 t b mil' `✓1 �\Y 1� -H S^ABo, ` 400 t-ZZO x 0,'j4 zL 4AA LPG 1»sic� i 1Z" 4o W 44A-330 = 114 GLl'D 11J 1�Q1.CW F Mrt0-C'nAe -+- C' IoYL 1L- Tz lNR SAND SCALE: AS SHOWN DATE: >�4V C., toliz'r/d 1At0-F44 SAWD io' STEPHEN k DOYLE AND ASSOCIATES I� �l+u w mot I�Z,• NOIAI ° \` 42 CANTERBURY LANL FALMOUTH MA. 02536 L A*�L V2 14� N ArlQ E1.11,� TELEPHONE 506/540-2534 i