HomeMy WebLinkAbout0152 LAURIES LANE - Health 152_Lwaries Lane
Cotuit
A= 027— 121
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 152 Lauries Lane
Property Address
Anderson
Owner's N me
— (1 i� MA, 02648 3/23/12
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.
A. General Information
3I f
1. Inspector: I
Frank Nunes III
Name of Inspector
saa
Company Name
Box 841
Company Address
East Falmouth MA 02536
City/Town State Zip Code
508.272.6433
Telephone 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 Fair
,-� Z
F1 Needs Further Evaluation by the Local Approving Authority '
3/23/12
Inspe is 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 s
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under,
the same or different conditions of use.
. i l
152 Lauries Lane.doc-03108 Title 5 Official InspectioWr.m: bsurfffa.ce ewage Disposal System-Page 1 of 15
L
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,•''� 152 Lauries Lane
Property Address
Anderson
Owner's Name
Barnstable MA 02648 3/23/12
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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:
Pumping suggested every 3 yrs to prolong the life of the system
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:
n/a
❑ 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
152 Lauries Lane:doc•03/08 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
152 Lauries Lane
Property Address
Anderson
Owners Name
Barnstable MA 02648 3/23/12
Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
n/a
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
ND Explain: r
n/a
F
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.
152 Lauries Lane.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 152 Lauries Lane
Property Address
Anderson
Owner's Name
Barnstable MA 02648 3/23/12
Cityrrown 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 n_o other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
n/a
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
El ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ®. Static liquid level in the distribution"box above outlet invert.due to an overloaded
or clogged SAS or cesspool
❑ ® liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
Required pumping more than 4 times in the last year NOT due to clogged or•
El' ® obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑• Z Any portion of cesspool or privy is within 100 feet of a surface water supply or .
tributary to a surface water supply.
152 Lauties Lane.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form'
Subsurface Sewage Disposal ! Form =Not for Voluntary Assessments
152 Lauries Lane
Property Address
Anderson
Owner's Name
Barnstable MA 02648 3/23/12
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. ;
152 Lauries Lane.doc•03/08 Title 5 Official Inspection Form: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
152 Lauries Lane
Property Address
Anderson
Owner's Name
Barnstable MA 02648 3/23/12
Citylrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® 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® El Have as Y Y or 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)]
152 Lauries Lane.doc•03108 Title 5 Official Inspection Forth: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
yy� 152 Lauries Lane
Property Address
Anderson
Owner's Name
Barnstable MA 02648 3/23/12
City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): unk Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220
Number of current residents: 1
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: Occupied
Date
Commercial/Industrial Flow Conditions:
Type of Establishment: n/a
Design flow(based on 310 CMR 15.203): canons 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): n/a t
152 Lauriesiane.doc•03/08 Title 5 Official Inspection Form: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
M ' 152 Lauries Lane
Property Address
Anderson
Owner's Name
Barnstable MA 02648 3/23/12
Citylfown State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: No recent pumping
Was system pumped as part of the inspection? ❑; Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes,attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed(if known)and source of information:
3/30/87 per BOH file
Were sewage odors detected when arriving at the site? ❑ Yes ® No
152 Lauries Lane.doc•03/08 Title 5 Official Inspection 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
,M 152 Lauries Lane
Property Address
Anderson
Owner`s Name
Barnstable MA 02648 3/23/12
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
18"
Depth below grade: feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: >100'
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
1'
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate'of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000g
4„
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle >12
2,.
Scum thickness
>201
Distance from top of scum to top of outlet tee or baffle
>2,,
Distance from bottom of scum to`bottom of outlet tee or baffle
How were dimensions determined? measured
152 Lauries Lane.cloc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M ' 152 Lauries Lane
Property Address
Anderson
Owners Name
Barnstable MA 02648 3/23/12
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping suggested every 3 yrs to prolong the life of the system
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
n/a
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.):
n/a
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):
n/a
152 Lauries Lane.doc•03/08 Title 5 Official Inspection Form: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
,. 152 Lauries Lane
Property Address
Anderson
Owner's Name
Barnstable MA 02648 3123/12
Cityfrown 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.):
n/a
*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 level w/the bottom of the pipe
.Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-Box is 2'6" below grade and in average condition for its age. No indication of backup
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
152 Lauries Lane.cloc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 152 Lauries Lane
Property Address
Anderson
Owner's Name
Barnstable MA 02648 3/23/12
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.) .
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
n/a
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
Type
® leaching pits number: 1`
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
}
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments.(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach Chamber is 3' below grade, it has 6"of effluent in it at this time, no stain line above this level,
no indication of backup
152 Lauries Lane.doc•03108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 15
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 152 Lauries Lane
Property Address
Anderson
Owner's Name
Barnstable MA 02648 3/23/12
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):.
r
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 poriding, condition of vegetation,
etc.):
n/a
152 Lauries Lane.doc•03/08 Titles Official Inspection Form: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
152 Lauries Lane -
Property Address
Anderson
Owner's Name
Barnstable MA 02648 3/23/12
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.
LJA '
152 Lauries Lane.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 4f 15
Y
Commonwealth of Massachusetts.
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
152 Lauries Lane
Property Address
Anderson
Owner's Name
Barnstable MA 02648 . 3/23/12
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: >12
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 and surveys
152 Lauries Lane.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 15,
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r
f
Commonwealth of Massachusetts
rA
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 152 Lauries Lane
Property Address
David Dennison YO
Owner Owner's Name
information is required for - Ma. 02648 3/24/2008
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: A. General Information
When filling out
forms on the
computer,use 1. Inspector:
only the tab key
to move your Robert Paolini
cursor-do not Name of Inspector
use the return
key. Capewide Enterprises,LLC
Company Name
r� P.O.Box 763
Company Address
}
Centerville Ma. 02632
eN" City/Town State Zip Code ;
(508)428-4028 S.14454 "
Telephone Number- License Number
r
B. Certification 1 �
I certify that I have personally inspected the sewage disposal system at this addre s and that the
information reported below is true, accurate and complete as of the time of the ins ection.c.. e inspection
was performed based on my training and experience in the proper function and m interiance 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 Eval ation by the Local Approving Authority
3/24/2008
In ctor's Signatur 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: '
l
****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.
152 Lauries Lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
t
r
s
Commonwealth of Massachusetts,
W 'Title 5 Official Inspection Form
Subsurface Sewage Disposal System.Form - Not for Voluntary Assessments
ac°,M 152 Lauries Lane
Property Address
David Dennison
Owner Owner's Name
information is
required for Marstons Mills Ma. 02648 3/24/2008
every page. City/Town . State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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:
The septic system is in proper working order at the present time.
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
152 Lauries Lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
a
• Commonwealth of Massachusetts
W 'Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
152 Lauries Lane
Property Address
David Dennison
Owner Owner's Name
information is
required for Marstons Mills Ma. 02648 3/24/2008
every page. City/Town 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.
152 Lauries Lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
T
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
152 Lauries Lane
Property Address
David Dennison
Owner Owner's Name
information is Marstons Mills Ma. 02648 3/24/2008
required for
every page. City/Town 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 1/2 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.
152 Lauries Lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
W ' Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
152 Lauries Lane
Property Address
David Dennison
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 3/24/2008
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.
El ® 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 4
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
b and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10j000gpd.
❑ ® 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 li 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.
152 Lauries Lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
w • Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
152 Lauries'Lane
Property Address
David Dennison
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 3/24/2008
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done.You must indicate "yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
❑ ® Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is.unacceptable) [310 CMR 15.302(5)]
152 Lauries Lane-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
I ;
Commonwealth of Massachusetts
W " Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
152 Lauries Lane .
Property Address
David Dennison
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 3/24/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330.
Number of current residents: 1
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 0 No
Water meter readings, if available last 2 ears usage d Well Water
9 ( Y 9 (gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: 3/24/2008
Date
Commercial'/Industrial Flow Conditions:
f 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):
152 Lauries Lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
• Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
152 Lauries Lane
Property Address
David Dennison
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 3/24/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: Capewide Enterprises,LLC
Was system pumped.as part of the inspection? ® Yes ❑ - No
If yes, volume pumped: 1000
gallons
How was quantity pumped determined? Measured
_
Reason for pumping: Maintenance ,
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
System installed 1987
Were sewage odors detected when arriving at the site? ❑ Yes ® No
152 Lauries Lane•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
CAmmonwealth of Massachusetts _
W ' Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
152 Lauries Lane
Property Address
David Dennison
Owner Owner's Name
information is required for Marstons Mills • Ma. 02648 3/24/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
1'
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
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: 1000 gallon
Sludge depth:
15"
Distance from top of sludge to bottom of outlet tee or baffle
17"
2"
Scum thickness
6"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle 12
How were dimensions determined? Measured
152 Lauries Lane-03/08 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
152 Lauries Lane
Property Address
David Dennison
Owner Owner's Name
information is Marstons Mills Ma. 02648 3/24/2008
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on.pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pump septic tank every 2 years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank
appears to be structurally sound.
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):
152 Lauries Lane•03/08 Title 5 Official Inspection Form:.Subsurface Sewage Disposal System-Page 10 of 15
f
. Commonwealth of Massachusetts
F Title 5 Official InspectionForm
Subsurface Sewage Disposal System Form -,Not for Voluntary Assessments
° 152 Lauries Lane
Property Address
David Dennison
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 3/24/2008
every page. City/Town _ State Zip Code Date of Inspection
J
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 No
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.):
Box is Ievel.Box has one outlet Iateral.No evidence_of solids carryover.No evidence of leakage into or
out of box.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
` Alarms in working order: ❑ Yes ❑ No
152 Lauries Lane•03/08 Title 5 Official Inspection Fomm:Subsurface Sewage Disposal System•Page 11 of 15
• Commonwealth of Massachusetts
W 'Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
c� 152 Lauries Lane
Property Address
David Dennison
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 3/24/2008
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 Ian excavation not required):
p Y ( ) ( P
If SAS not located, explain why:
Type:
® leaching pits number: 1-600 gallon
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:_
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Sandy dry soil.No signs of hydraulic failure.Water was 36" below invert pipe with no stain line above
that point.
152 Lauries Lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
I
. Commonwealth of Massachusetts
W `Title 5 Official Inspection Form .
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4M
152 Lauries Lane
Property Address
P Y
David Dennison
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 3/24/2008
every page. City/Town 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 sollids 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.):
152 Lauries Lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15
Map Page 1 of 2
Town of Barnstable Geographic Information System
Parcel Viewer Custom Map Abutters Map Size lam Zoom Out J I M.91, J M In
y r R r l
V7` f
a ` f
Y
x
20 Feet
L
Set Scale 1" = 20 I Aerial Photos
(nnr,rinhf )onr-,)nn7 T—sn of Rometohln KAA All rinhrc recon„
i
http://www.town.bamstable.ma.us/arcims/appgeoapp/map.aspx.?propertyID=027121&map... 3/24/2008
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
152 Lauries.Lane
Property Address
David Dennison
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 3/24/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: Bottom of LP 50'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:
As-Built Card
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database- explain:
You must describe how you established the high ground water elevation:
USED:USGS Observation Well Data.USED:Technical Bulletin 92-000-01 plate#2 Annual ranges of
groundwater elevations.
152 Lauries Lane-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
I
ENVIROTECH I.ARORATORIE.S, INC
MA CERT. NO.: RI-MA 063 r
8 Jan Sebastian Drive Unit 12
Santhnich.ALL 02S63
(508)888-6460 1-800-339-6460
FAX(508)888-6446
1_
Client Name Meehan Well Drilling Location #152 Lauries Lane
Address PO Box 616 Marston Mills MA
Forestdale MA
02644 Sample Date 02f26/08
Collected lay Ed Meehan Sample Time 9:30
Sample Type Existing Well Date Received o21 ww
Lab Order Number DW-80389 Well Specs NA
Location Source _ Date Collected Time Collected Cotnneents
A 2128108 8:30
Analytic Requested _ Units Recommended Linritc Analysis Result I Aldhod DateAnahze Analyzed 41,
Total Coliform /100ml 0 0 9222 B 2j26/2008 IRS
pH pH units 6.5-8.5 6.32 4500-H-B 2/26/2008 LL
........_..- ._._... .. ..... - .... . .---- .. ...—... .- -- --.._. ..__.
Specific Conductance umhoslcm 500 157 120.1 2QT92008 LL
Nitrite-N mg/.L 1.00 <0.004 300.0 2/2612008 LL
Nitrate-N mg/L 10.0 3.83 300.0 2t26/2008 - LL
Sodium mg/L 20.0 18.1 200.7 2/27/2008 MC
Total Iron ' mg/L 0.3 0.37 200.7 2/27/2008 MC
Manganese mg/L 0.05 0.057 200.7. 2/27/2008 MC
.Comments:
pH is below recommended limit,and may have corrosive characteristics.
Iron level Is not a health hazard. .
Manganese is not a health hazard.
Water meets EPA standards and is suit ble for drinking for parameters tested.
c
Date (,/_Z.�.�a.a-.. .._.....-... _..
Ronald.1. Saa i
t
Lahoraton,1) ector
A
BRL=Below Reportable Limits Page 1,of 1
*See Attached
f
yoF ram,
Town of Barnstable
t
y�P ti� Regulatory Services
B,R,,SrAB Thomas F. Geiler,Director
MASS:
9$ 1639. Public Health .Division
PIED NIAy p
Thomas McKean, Director
200 Main Street, Hyannis, MA.02601
Office: 508-862-4644 Fax: 508-790-6304
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system in the future
not does this Division agree with any technical observation s and interpretations
contained within this report.
In addition,by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on the"Disposal
Work Construction Permit".
If you should have any questions regarding this report,please contact the certified Septic
System Inspector who conducted the inspection.
No................ ` .� Fss...........L�.......•_....
�( THE COMMONWEALTH OF MASSACHUSETTS
152,� BOARD OF HEALTH
1.1f... l .......................OF.... .........................................
Appliratiun for Disposal Works un�ivin Prruttt
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at:
....SCOT Ju..ZAz i�.e2 ....��.................. ........................................... ------------.......-----........--••-----
_.... 9cation-Address ........................................Lot No.
Owner Address
Installer Address
Type of Building Size Lot. ...f. ?.....Sq. feet
aDwelling—No. of Bedrooms_.. ........-...............................Expansion Attic (�'U Garbage Grinder
p-, Other—Type of Building ________ ._.K....... No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures .__......
d ---•---•••----••••••----......•--
W Design Flow................���...............gallons per person per day. Total daill}' flow....��_ 0_..__...__.__._.._.__._....gallons.
WSeptic Tank—Liquid*capacity. .gallons Lengthke .��_..... WidtO. ....... Diameter................ Depth---`j_/._........
x Disposal Trench—No:.................... Width.................... Total Length................ Total leaching area...................sq. ft.
Seepage'Pit No..,O fJ�cc:'__/diameter-_-._.0......... Depth below inlet.P.7..�.... Total leaching area._a�. ......sq. ft.
Z Other Distribution box- (✓) Dosing tank (
) r
~' Percolation Test Result Performed by.. "/C.n ,c........................................... Date...l.l_._ ...��......_......._.
a -
a Test Pit No. 1.�_._.__.. ..minutes per inch Depth of Test Pit__ _ __.. Depth to ground water.................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ------••----•••---------•..................•------••---.........--•-•----•-----......-••••-••---••......--••--•••-••-•-•---••--•-•...---••••-•._.._._..._-•--
ODescription of Soil........................................................................................................................................................................
x
V -------------- ------------------------------------------
•--- --•
_.......--•---------•----------------------------------- -----------
-._----------------------••.............
W
----•••• ----------------------------------•-• •-•-•------••--•----.............--
�xj Nature of Repairs or Alterations—Answer when applicable ............. gip*: .........
Agreement:
TO PLAN. .
...................................•-----------••---._....................._...__...---... ��;� �Y: ..
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—T hhe.4ndersigned rther agrees not to place the system in
operation until a Certificate of Compliance has n ' su board ealth.
��
............ ... .•-
A Application Approved B ..
PP PP y-----------•-- ------- --------- __---- - ...... ---.......
Date
Application Disapproved for the owing real :••----------------------------------------•------•------------•--•------...........-•----•.....•-----•••_----•-
•--•........................••----........._.._...----•--•--•-----._.....-----•--._..._._.....•••------•--------------------•---..._._........--•------•-•------••----•----------••..........---•-------
��yy Date
PermitNo.... .` _`.._..__l.- __._.. Issued......................------••••----------------------•-
Date
................... .............................................................................. .......................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
l! ....................OF..../ ? X .............................
C�rr�f�cu#r u$ �una�ltttnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
by....................... ...- ..I......................................................................................................................................
Installer
oe
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Cod. as degribed in the
application for Disposal Works Construction Permit No------ ____.��-------- dated___.___$_��e7 :........................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE......:......................................................................... Inspector....................................................................................
�P�OFTHE Tp�♦ TOWN OF BARNSTABLE
i DAH!liABLt OFFICE OF�M/�l BOARD OF HEALTH
1639.
�
367 MAIN STREET
HYANNIS, MASS. o26ot
Sewage Permit # : _ C-7y
Applicant
Proposed Installer: —Jh� s a off,
The plan for the on-site sewage �
at b�
stem disposal system
i
L.G.N;-- L r, m m �L<,-
has been approved with the condition that the design engineer must be on-site
and supervise installation as well as certify in writing that the system was
installed in strict accordance to the approved plan.
Approved B Dake
PP Y
4.
No'�S- Fizz
...........I......... -4............-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....................OF....eAe.Z?� ...........................................
Appliration" for Disposal Works Tonstrurtion ramie
Application is hereby made for a Permit to Construct (L,1��®r Repair an Individual Sewage Disposal
System at:
119 Z�Z................... .................................................................................................
Location-Address or Lot No.
....................... ................................................................................................
-7�7 Owner Addr6ss
............................................... ................................................ ...*"....... ....................Installer Address
P2
Type of Building 3 Size Lot.Z�_=......Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic (t/) Garbage Grinder (41r',)
Other—Type of Building ...�& ............ No. of persons............................ Showers -7Cafeteria
Otherfixtures .....................................................................................................................................................
Design Flow...............Cry-----................gallons.per person per day. Total daily ...........................gallons.
1:4 Septic Tank—Liquid'capacity,.' gallons Lengt4k... ...... Width.Z:.6...... Diameter................ Depth...�/---------
Disposal Trench—No..................... Width_................... Total Length........._......._.. Total leaching area....................sq. ft.
Seepage Pit No.-O.Ab-'_,,I)iameter....�D......... Depth below inlet?Lr:..,S ... Total leaching area..Zc......sq. f t.
Z Other Distribution box (v/) . Dosing tank ( )
Percolation Test Results Performed ..... Date._iLA...y.' '...*------------------------ .... ......................
as
Test Pit No. I ...minutes per inch Depth of Test Pit../-.��..... Depth to ground water...6&..............
Test Pit No. 2................minutes per inch Depth of Test Pit..........._......_. Depth to ground water............._..........
------------------------------------**.............------------------------*------***-*----------*......---------*----------*---------*----------
0 Description of Soil........................................................................................................................................................................ .
.....................
...................**----------------------------------------------------*......... ....................*------------------- ------------ --------
........................................................................................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable................:..............................................................................
..............._......................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIE 5 of the State Sanitary Code—Th nderSignedkrther agrees not to place the system in
operation until a Certificate of Compliance has SU e boar ealth.
rr,S ... ......... .......... ................................................ ..... ............... ....
Date.
)"C
Application Approved By....... ........i.. -
--------------------------- --o-, - -......D lie 7
Application Disapproved for th wing eas . ...............................................................................................................
.........................................................................................................................................................................................................
Date
PermitNo........4_�=.......... .............. Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..7. ....................OF.... .. ..............................
... . ...........
(9rdifiratr of Toutphatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (14--or Repaired
by................ .I
.......................................................................................................................................
Installer
............. ...............I...............................................................................................
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.... 1'.y.......... dated..... J., .7..................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.............................................................................. Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
- BOARD OF HEALTH
....................................
..
......................................OF...0................... FEE.. .......
......................................................................................................
.... I k Permission is hereby granted...
to Construct or Repair an Individual Sewage Disposal System
atNo.. ................................................... . . ..................................................................................................................
Street
as shown on the application for Disposal Works Construction Permi't-_ I Dated.._.. . -7...........
.................. ...................................
Boards
of Health
DATE. _1Z. .......................
—.—
FORM 1255 A. M. SULKIN,'INC,, BOSTON
t
- Department of Environmental Management/Division of Water Resources
4; WATER WELL COMPLETION REPORT
WELL LOCATION
Address ��� 9S .CCiur.PS �Q
City/Townh-)QrSir.m_S
G.S.Quadrangle Map
Grid Location \
Owner -JZrXriP u HOM f S
Address Dn !�) (?a ''9 57` / /1/I rS e!2 W
WELL USE CONSOLIDATED WELL
Domestic Eir Public ❑ Industrial ❑
Type of Water-bearing Rock
Other
Water-bearing Zones
Method Drilled AL(qR r 1 From To
2) From To
Date Drilled 7' 3) From Tc
4) From To
CASING Depth to Bedrock
Length 9 O Diameter CR
b
Type 1 )05 TI C UNCONSOLIDATED WELL
STATIC WATER LEVEL Water-bearing Materials
Feet below land surface :3 8 Sand:, fige�211'medium coarse❑
Date measured /-"y- 87 Gravel: fine❑ "medium❑ coarse❑
Screen:
GRAVEL PACK WELL /
Slot#length.3 from to
Yes ❑ No Q�
Split Screen (or 2nd screen)
WATER QUALITY TESTS MADE 'Slot# lenqth from to
Chemical Biological ❑ Depth To Bedrock
PUMP TEST
Drawdown feet after pumping days hours at_�GPM.
How measured Of)h!(?rm//) Recovery feet after hours.
r
LOG of FORMATIONS COMMENTS: (On well or water)
Materials C From To
o
Me d
m
O DRILL/ERCb
/ e Firm mpAan hhll, ti ��/I1CL .
"50 nato Address Pe).5X R06 `
City ' t�1 4?,S-"a(e.
Registration No.
perato�s ignature
ease Print firmly BOARD OF HEALTH COPY 25M-10-85-807101
J� OWN OF BARNSTABLE
PS�1
LOCATION 101- �.� /-,s to R.t�S 14 SEWAGE # F 7 7
VILLAGE,A tQA/ / I-,( ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. � �/ /R
* SEPTIC TANK CAPACITY_
LEACHING FACILITY:(type) #T,t a PO-9 90- (size) �d
NO. OF BEDROOMS _PRIVATE WELL OR PUBLIC WATER P/PI I/A?'T
BUILDER OR OWNER P-[5ilq I.—PS
DATE PERMIT ISSUED:
DATE .COUPLIANCE ISSUED: 3— 3 ooSs 2
VARIANCE GRANTED: Yes No f�
,o
o '
.4s i
ssstn s•s:asssmr.::::rs^ts,,,, ssfssr.:s;:ss;�s:::snsst:s:rss;st:=sr;•�;:s:;sr�:ssr:�:ssss
ENVIROTECH LABORATORIES
66 Lewis Bay Road • Massachusetts 02601 (617)•,771-7265
CLIENT: Dacey Homes LOCATION Lot 95 Lauries Lane
ADDRESS:
100 W. Main Street Marstons Mills, MA
Hyannis,MA 02601
COLLECTED BY: Ed Meehan SAMPLE DATE:1/7/87 TIME: 4PM
DATE RECEIVED:1/8/87 SAMPLE ID: 334
JOB #: We]] WELL DEPTH:
.•" RESULTS OF ANALYSIS:
Parameter Units Recommended limit Result
. Coliform bacteria/100 ml (MF Method) 0 0
Ei PH pH units 6.0-8.5 5.72
Conductance umhos/cm 500 57
Sodium mg/L 20.0 6.5
Nitrate-N mg/L 10.0 .80
Iron
mg/L 0.3 .04
Manganese mg/L 0.05
EE Hardness mg/L as CaCO 3 500
Sulfate mg/L 250
Potassium mg/L 20.0
Alkalinity mg/L 200
;- Chloride mg/L 250
y
COMMENT: �T -.UpER,"SE
J
Water is suitable for drinkingipurposesufoar`;,alPlRp�arameters tested.
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EL.
TOP OF FOUNDATION '
CONCRETE COVER
•.. 'CONCRETE COVERS
4' CAST. IROf >>nsrr,•T "12"MAX. inr 77nrr. `
OR SCHEDULE 40
i .•. P.V.C. PIPE 4"5CHEDULE 40 PV.C.(ONLY) !�2�"-MAX,
• PITCH 1/4"PER.FT PIPE - MIN:' I
LEACIi
PITCH 1/4'PER.FT
e.• PIT
�—INVERT io'' �y PRECAS
ELY.Bxo . -� LEACNif,
SEPTIC TANK INVERT INVERT i� Q.; PIT OR
.•e INVERT EL,Y.7.XE.y DIST. EL.. >_ EQUIV
EL.S!7.X8 /.�a .. .... GAL i •
INVERT BOX
ELM Y. INVERT ww �: ;.' 3/4"TO 11
o• o ELy6A'. is w.0 �: WASNEf
•, . /o W. STONE
�..•.o �`— to ' DIA.----.-� y
PROF!LE OF E� z�
ND GROUND WATER TABLE
SEWAGE DISPOSAL SYSTEM
NO SCALE
• SOIL LOG .
WITNESSED BY
DATE�./y7 TIME..
130ARD OF HEALTH
TEST HOLE _I TEST HOLE 2
ELEV. :S"oXQ pt? ENGINEER
0 3 � . _ • . . . . . DESIGN • • DATA-:
.. •
NUMBER OF BEDROOMS 3
sfla� TOTAL ESTIMATED FLOW . 3,3
ft5 . . . : GALLONS/DAY
BOTTOM LEACHING AREA 7 Fl SQ.FL /PIT
SIDE LEACHING AREA . . . /0.�. SO.FT./ PIT .
GARBAGE DISPOSAL .,n�O. . .•(50% AREA INCREASE)
TOTAL 'LEACHING AREA �, SQ.FT
PERCOLATION RATE . !. .2_. .6 MIN/INCH -
•—
/!�� ,WATER ENCOUNTERED LEACHING AREA PER PERCOLATION RATE .. . SQ.FT.
! NUMDER OF LEACHIN PITS Q��i �.1
APPROVED . .. . . . . . BOARD OF HEALTHR
DATE
` , 7-07,1,1 3SZ 6I'D
AGENT ,OR. INSPECTOR ,
%ALCL
Sq
' 0.814
OBI
PETITIONER
lDo W_ 174IAI 67 ✓.
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NAoM� A. c�ovR�i�
i
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iI
\L o T c1 S I
91 �!
i
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7�t I T -
i
60
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h
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CERTIFY THAT THE
Fov N DA-r i o rJ �' Sfor��fy S r-,,,,•-�„j•�'
SHOWN ON THIS PLAN IS
LOCIAT D pTHE GROUND �Q��� OF
_ X �
o.31341
4Rc�J,��c�
DNA[ LA��
DATE R G ISTE R D S EYOR
LEVY 81 ELDREDGE ASSOCIATES,INC. SAMA15,04eti CERTI
CLIENTN04� FLED ' PLOT PLAN
ENGINEERS - LANDSCAPE ARCHITECTS J08 -Na V&
PLANNERS-- LAND SURVEYORS ' _ T 5 L� ries Lane
AR. BY AN
889 WE� MAIN STREET CHO BY��
CENTERYI LLE MA. 02632 I 1 ��_ �.
SHEET��'�,,. SCALES nATFt