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HomeMy WebLinkAbout0010 BAXTERS NECK ROAD - Health 10 Baxters Neck Road Marstons Mills P A = 056 054 ASSESSOR'S MAP NO. PARCEL LOCATION � S E W A G E P RMIT NO. VILLAGE �INSTA LIER'S NAME i DD III ESS Ids U i L D E R OR OWN ER c -DATE PERMIT I SUED DAT E COMPLIANCE ISSUED _ �;�. ` '*., �� o �,� . , _ _ � � � �'�� No —.-! Fps .................... THE COMMONWEALTH OF MASSACHUSETTS .t BOAR® OF HEALTH ----------- ....... ................OF.......:f..?..!!��. ..-----.------------......-----._.........._........ ApplirFatiun fur Mopug al Workii Tonstrurtivat Vantit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Syst a . ........ ..... .......... . Loca n- dd es`, J or Lot�N+o .s Owner Address I a .._. ...... ,�� : . ............................................................. Installer Address d Type of Building Size Lot............................Sq. feetZ. V Dwelling—No. of Bedrooms____.___. Expansion Attic ( ) Garbage Grinder ( ✓�s a aOther—Type of Building fir��! �1✓ No. of persons_______________________ Showers ( ) — Cafeteria Otherfixtures -----------------------------�------------------.--------------------------------------------------------------•---.....--------•...._......---- w Design Flow..........................................gallons per person per day. Total daily flow......................._....................gallons. WSeptic Tank—Liquid'capacity.l..1.0__agallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length......._.._ ...._. Total leaching area....................sq. ft. Seepage Pit No.................. Diameter.....�.Q.�.... Depth below inlet.....9_.�........ Total leaching area...;...0...sq. ft. Z Other Distribution box. ( ) Dosing tank ( ) Percolation Test Results. Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water...................... G4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -------------------------------------------------------------------------=-----------------•--------........................................................ 0 Description of Soil.........................................................................-............................................................................................... x c, w 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 TIIL LE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in eration u 1 Certificate of Co ance has b is ued b the o d of health. Signed.......... ... .. ... .� ... ......................... Date Pplication Approved By................................ G� z .8s Date Application Disapproved for the following reasons------------------------------•-----=--------------•-•---•-•-----•----•---------•-••--------------•---•--....._. .-•------------------------------•----.....-•-----•••-•••-•-•---•---••--•-•---------•-----•--•-•---------••-----•----.---•- Date PermitNo......................................................... Issued....................................................... Date No :.. FE& ............_ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ,Appliration for Disposal Works Tonstrurtion Vantit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Syst t Loc/i:3 Addre or Lot N •, Owner Address W .... . ............•----._...-- ......... �__�f ... --- -•._......---- Installer i Address UType of Building Size Lot____________________ _____Sq. feet Dwelling—No. of Bedrooms........ `F_____________________________Expansion Attic ( ) Garbage Grinder (t✓') Other-Type of Building.5irt� fi_ � No. of ersons_.____ a YP g •' P .3--------•--•••••• Showers ( ) — Cafeteria ( ) Otherfixtures --------•--------------_-- ---------------•-------------------------------------------•----------•-••-_-•-----------•--•••---•---- W Design Flow..........................._........ -----gallons per person per day. Total daily flow...................._.........._............gallons. WSeptic Tank—Liquid capacity1.3_Ad_gallons Length................ Width......_......... Diameter---------------- Depth................ x Disposal Trench No:... ________________ Width.................... Total Length._____.ff._.._..___. Total leaching area....................sq. ft, Seepage Pit No.____..,4---�:_.... Diameter._._,l.0—/..... Depth below inlet....fl-_�_...___. Total leaching area_,..P.___sq. t. Z Other Distribution box ( ) Dosing tank ( ) 'I Percolation Test Results Performed bY........................................................................... Date.................................... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Gi, Test Pit No. 2................minutes per inch.. Depth of Test Pit.................... Depth to ground water.......................... ^.. Descriptiono£Soil.................................................r...........................---------------------------------------------•-•----------------------------••••-•----------••- x V ------;----j--e------------•--------------= ........... ••------------V---- .... --------------------------------------------••--•••----••--••••-•-- W -- ,x :ror =---------------------------------------------------------••-••--------------_-••-• U Natur' of Repay or Alterations—Answer when applicable............................................................................................... -------=•------------------------------------------------------------------•........................................................---•------••••---•----------•---••--•--------------------•-------• Agreement: The, undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in eration u it Certificate of C fiance has b i ued the bo d of health. Signed_._....._ cx` _ - Date ' lication A roved B ..._... �_.�,,_. —[�• ---_------ �.�- ��-- �5.._..... PP PP Y /�� ----•--•----••---------••-•---------•-----•--••-----..Date Appliea.tion Disapproved for the following reasons_____________________________________ _ ._..._.._...._ •--------••----------•--......---•----------•------•-----•-------•---._..-•--------------•-•-------------•-----------••-------------•-••-•--•••-•------•---•••-•••••-------•----•••-----•---••.....-•--- Date PermitNo--------------------------------------------------------- Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................... ......................O F........................_........... ........ .................................... (9rdifiratr of Tontplittnrr THIS 1,5 TO CERTIFY, iZat the ndiv• Sew, e Disposal Sy,stem constructed) or Repaired ( ) Installer -has been installed in accordance with the provisions of TITLE 5 of The State,—Sanitary y Code as`-descr-bed in the application for Disposal Works Construction Permit No._._. _ l____.. -"-- dated �' ...Q'> THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FiJ O _ TISFACTORY. DATE = . ... ... Inspectorc. -----!.___ THE COMMONWEALTH OF MASSACHUSETTS \\ BOARD OF HEALTH ...........................................0 F...---. .)_.._._._._�:.....-..._.......--•--..._-..._......._._.. No.� �_P� _e✓L FEE._-5.i. Disposal Works T-PaInstrudion rrmft Permissionis hereby granted.........---------------- :_. ------_____----------------------------------------------------•--------•---•-••--------•_-------•---------- to Construct ( ) orx,Repair ( ) an Indivi Al­Sewage Disp Sy em at No. yh--`-•...'=-I...................... C as shown on the application for Disposal Works Construction Permi No.� __"_._�/ Dated.......�U_�____ ______________ _ &yq 44 .......... --- /,V.( Board of Health f ------------------------------- DATE............... ---�--- --.._..__.......---------........ FORM 1255 A. M. SULKIN, INC.. BOSTON ost LL G LE- IrAm 1 t_:I-e - ✓ 4 j` ""'-^-n�..__1_ ��a � ` '>i>•:�r`'s- C,e�.�.B�L� C�tr,•t�� l ¢ i.� 3\. t>%SPOSAL vtT V;E-- �- ri 1�E1NAt L AeFA BoTToAA s J f' r •_:I 4,�,� 5`,,,t._ F..,-,s� Tri 7•?. 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I VI LADE ^ r I �olt,\ � MSTA LER' � NAME i D �RRESS i '} �S UILDE R OR GWNER %DAT PERIAIT 1 SUED � DATE COMPLIANC I S S U t D I 1 1 I 1 1 I I \ I I i :r Loy"io -- � I I rA 60 2a8. 37 BAXTF i.Li40 I. � 111.. 1 CENT%�/ 7?-L47- 77/� Ell/-�%ir�v CE 2 T/�/EO OL�T FG4�c/ •rG���/D,4TJc�/ �Ud.�l.�/ �E�E�/ Cow J I zEq�UI,eE�fE�!l� G� 7�-EE -TC��,c�,�/ C� SCE,L E- �•��� � O.�IT� r / - t I _ I I I 1914 XT,E,E?E 7"///S �,L'9�//S .(/aT BASEO aiv Apt/ AEG/STE.eElJ L�/!� SU.eY6ybr�� ���5'E'TS Sh!o�/•Y Ss�vt� IVoT' B- j AOP4/C.4N7 -------------- --- - - - - - �- --7--------------- ---J MOVE EXIST. i CASEMENTS FROM BREAKFAST AREA TO NEW LOCATION I i BREAKFASTN co REPLACE 3"-0"C.O. r WITH 4'-0"C.O.)INING I I rL— -- ---------------- MOVE EXIST. c CASEMENTS FROMiI i iv ®� N KITCHEN AREA i J TO NEW LOCATION i NEW KITCHEN CABINETS KITCHEN N INSTALLED IN NEW LOCATION MOVE PLUMBING AND ELEC.' i 3'-2 3/4" 9'-91/4" 1 '- 1 7/8" o)l 3'- 11 5/8' 17'-3 1/2" --- O O -- O O -- - ------ DN c CV N 9 POWDER o F YER HALL o M M I 711 a � C° LAUNDRY r�-C� COAT ROOM i 12'- 101/4" 10'-6" 10 N DEN COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS . DEPARTMENT.OF ENVIRONMENTAL PROTECTION MAP PARCEL ..� - LOT TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A S CERTIFICATION Property Address: 10 Baxtej Neck Road Marstnns Mi , , RECEIVED. . Owner's Name: Pm i 1)4 F.1 i 7. Tnhin — (POA John Tobin) Owner's Address: FEB 17 2004. Date of Inspection: .. TOW N OF NSTABLE FHj--ALTH DEPT. Name of Inspector.(please print) W 111 i am _ .Robinson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville, MA TelephoneNumber: (508) 775-8776 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 Sect n 15340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: �,y yG y Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heatthir 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 seat to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued). Property Address:__ 10 Baxter Neck Road Marstons Mills Owner. F.mi liz E1 i z_ Tobin Date of Inspection: . Inspectio Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. S tem Passes: 1 have not found an information which'h h indicates s that an of the failure criteria described- Y in 310 CIvIR. 15.303 or in 310 Chin-15:309 eicist.An failure criteria. y not evaluated are indicated below. Comments: ' 77 System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repair d.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass Answer es,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. Th septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,a ibits substantial infiltration n or exfiltration or tank failure is imminent.System will pass inspection if the existing is replaced with a coin i ' septic tank as P Ying eP approved by the Board of Health. •A metal s ptic tank will pass inspection if it is structural) sound of leaking and ' Y g if a Certificate of Compliance indicating at the tank is less than 20 years old is available. ND cxpla' O ervation of sewage backup or break out or high static water level in the distribution box due to-broken or obstruct pipe(s)or due to a broken,settled or uneven distribution box..System will pass inspection if(with approval f Board of Health): broken pipe(s)are replaced obstruction is removed distribution trtion box is leveled or ' laced r'�P ND explain: The sy em required pumping more than 4 tunes a year due to broken or obstructed pipe(s).The system will pass inspectio if(with approval of the Board of Health): broken pipe(s).arc replaced obstruction is lzmotrod ND explain: f Page 3 of l l OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 10 Baxter Neck Road Marstons Mills Owner: Emily Date of Inspection: C Further Evaluation is Required by the Board of Health: nditions:exist which require further evaluation by the Board of Health in order to determine if the system is failing t protect public health,safety or the environment. 1. Sys( m will pass unless Board of Health determines in accordance with.310 CMR 15.303(l)(b)that the syste is not functioning in a manner which will protect public health,safety,and the environment:: esspool or privy is within 50 feet of a surface water sspool or-privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. Systen will fail unless the Board of Health(and Public Water Supplier,if any)determines that the . system is fi inctioning in a manner that protects the public health,safety and environment'. _ T1 e system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surfac water supply or tributary to a surface water supply. e system has a septic.tank and SAS and the SAS is within a Zone 1 of a public water supply. e system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more frond a pr' ate water supply well- Method used to determine distance "T is system passes if the well water analysis,performed at a DEP certified laboratory,for coliform -bact 'a and volatile organic compounds indicates that the well is Gee from pollution from that facility and the pr sence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failur criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: in RaXter Neck Road Margfnncz Mi11S Owner:Em• Date of Inspection D. System Failure Criteria applicable to all systems: You must indicate"ycs".or"no"to each of the following for all inspections: Yes o _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspools Discharge or pondirig 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 I00.feet of a surface water supply or tributary to a surface Hater supply. Any portion of.a cesspool orprivy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 56 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 fect from a private uatrr 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 (lie 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.) (Yes/No)The system fails.I have determined that one or more ofthe 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. Lar a Systems: To be co sidered a large system the system must serve a NOR*with a'design now of 10,000 gpd to 15,000 gpd• You must dicate either"yes"or"no"to each of the following: (The folio ' g criteria apply to large systems in addition to the criteria above) yes no th 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 Zo a 11 of a public water supply well If you have swere.d"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Sec ion D above the large system has fatted.The mArner or operator of any large system considered a significant t eat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The ystem owner should contact the appropriate.regional office of the Department. 4 Page 5 of l 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST. Property Address: 10 Baxter Neck Road Marstons Mills Owner: Emily F.1 i z_ Tobin Date of Inspection: 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?... v Were as built plans of the system obtained and examined?(If they were not available note as WA) !� 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: 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)J 5 Page 6 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 10 Baxter Neck Road Marstons Mills Owner: Emily El i Date of Inspection: FLOW CONDITIONS RESIDENTIAL. Number of bedrooms(design):. Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): ., Number of current residents: AIIA Does residence have a garbage der(yes or no): ' Is laundry on a separate sewage system(yes or no).k O (if yes separate inspection required) Laundry system inspected(yes or no):/1,G Seasonal use:(yes or no):A-0 Water meter readings,if available(last 2 years usage(god)):-2 0 0 3-�-- 1 7 6,�00 Sump pump(yes or no): 0 .2002 - Last date of occupancy: COMME IAIANDUSTRIAL Type of es lishment: Design flo (based on 310 CMR 15.203): avd Basis of de gn flow(seats/personslsgft,etc.): Grease trap resent(yes or no):_ Industrial ante holding tank present(yes or no):_ Non-sane waste discharged to the Title 5 system(yes or no): Water met r readings,.if available: Last date f occupancy/use: OTNE (describe): GENERAL INFORMATION Pumping Records Source of information: 1t1 � Was system_pumped as part 96he inspection(yes or no): U If yes,volume pumped:__gallons-=How was quantity pumped determined? Reason for umping: TYP F 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) _InnovativelAlternative 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 co pon is ate installlgd(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): D 6 i Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART_C SYSTEM INFORMATION(continued) Property Address: 1 o Baxter Neck Road Marsttons -mills Owner: Emil y E1 i 7._ Tobin Date of Inspection: BUILDIN EWER(locate on site plan) Depth below ade: Materials of onstruction:_cast iron 40 PVC_other(explain): Distance Go private water supply well or suction line: Comments( n condition of jousts,venting,evidence of leakage,etc.): SEPTIC TANK:_ locate on site plan) Depth below grade: Material of construction: ✓concrete metal fiberglass _polyethylene other explain) _ —' certificate is metal list age:_ Is age`confymed•by a Certificate of Compliance(yes or no):_(attach a copy of Dimensions: � Sludge depth: Z/-S " I Distance from top of sludge io bottom of outlet tee or baffle: � toy Scum thickness: ,S Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom f outlet tee or baffle: �O How were dimensions determined: Q r&.-,— GduLr'A-S Comments(on pumping recommendations,inlet and outlet tee or baffle conditicn,structural integrity,liquid levels as related too tiet invert,evidence oflcakage,etc.): n GREASE T (locate on site plan) Depth below gra c:_ Material of cons ction:_,concrete._metal fiberglass_polyethylene_other (explain): —. Dimensions: Scum thickness: Distance from to of scum to top of outlet tee or.baffle: Distance from bo tom of scum to bottom of outlet tee or baffle: Dale of last purr ing: Comments(on p ntping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to out t invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 o Baxter Ng-rX Road Maretnnc Mi11 � Owner: 'PlizTobin Date of Inspection: TIGHT or OLDING TANK: (tank must be pumped at time of inspection)(locate on site.plan) Depth below ade: Material of co struction: concrete metal fiberglass_ A-1yethylene other(explain): Dimensions Capacity. gallons Design Flow: allons/day Alarm presen (yes or no): Alarm level: Alarm in working order(yes or no): Date of last mping: Comments( ondition of alarm and float switches,.etc.): DISTRIBUTION BOX: " (if present must be o ened locate on site plan) P )( P ) 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.): PUMP CHAIIIBE (locate on site plan) Pumps in working rder(yes or no): Alarms in work-in order(yes or no): Comments(note ndition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 Baxter Neck Road Marston-; Mi11s Owner: F.mi l Y F.1 i 7.� Tobin Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): t/ (locate on site plan,excavation not required) If SAS not located explain why: Type/ ,.. leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow,cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): G� 6Z- 660 L� f / CESSPOOLS: (cess of must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet in ert: Depth of solids layer. Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflo (yes or no): Comments(note condition of soi 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.): 9 Page l0 of l 1 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 Baxter Neck Road Marstons Mills Owner: Emily Eliz . Tobin Date of Inspection: 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.)00 feet.Locate where public water supply enters the building. S _ 1-0 1 G-4 fJ 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 Baxter Neck Road Marstons Mills Owner. Rmi 1 y Rl i z _ Tobin Date:of Inspection: IV--0 �J SITE EXAM Slope Surface water Check cellar Shallow wells 7 Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed.- Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Ssfiecked with local excavators,installers-(attach documentation) ✓Accessed USGS database-explain: You must describe how you established the high ground water elevation: 11 60"MEDIA ; LIVING BEDROOMBEDROOMROOM ; rROOM I , I I I I t REMOVE WALL 1 a INSTALL FLUSH FRAMED BEAM ABOVE ALL HALL r- -------- ------------�------ ---------- B I _ - = MASTER r. i-- --T-------------- I B --- I nil, 4'-3 3/4" '9 T 3 1/4"3'- 11 1/4" BREAKFAST N FOYER I I HALL - - _ - - - - _ _ WH REPLACE"c O.)INING rl-- ---I-------------r O O _4 9 BEDROOM I 5'-4 3/4" 8'-2 1/4" TUB T. I ° S FROMREA i L I I N CATION _ _ _ c EN CABINETS ° KITCHEN N IN NEW LOCATION 3'-2 3/4" 9'-91/4" 4'- 3 7/8" 3'-7 1/8" 9'-9 1/4" 3'-7 1/4" gBING AND ELEC.V r l N -� 1 '- 1 7/8" 01 a'I 3'- 11 5/8' 17'-3 1/2" 8'-3 1/2" '-4 1 d' 1 V- 7 1/2" 2'- 11 5/ ' I .- I --- O O -- I N M O o I BEDROOM Ln -- --- ------- DN POWDER N - - \t� FNIDYER CV HALL o _ M Ile M # 5'- 10 1/4" 5'-7 1/2" 5'- 10 1/4" I 18'-2 1/2" LAUNDRY �41 COAT ROOM MI -W �I _-D- - -