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Home My WebLink About0039 BLACK OAK ROAD - Health 39 BLACK OAK ROAD Marstons Mills - - - --- - - - - — - - - - -- - - - ---_ _. A= 101 -065 1x-3 T10 r SSEWAGE PERMIT N . 1 ;[ter'_ VILLAGE ` C INSTA JJ R'S b ADDRESS rt�J - - . A Ay G U I L D E R OR OWN ER ZE L/,4(/VIA " s DATE PERMIT IS 9 U E D Ei2� DATE COMPLIANCE ISSUED /2�ig—q f t,.,�± �'it F . Fxs......��... ...... p THE COMMONWEALTH OF MASSACHUSETTS * 'j 1 roBOARD OF HEALTH wnBarn. stable. . .. .--.. r-------------------------------•••------------- - D O F..................... ..... .. i Applirtt#ion for Disposal Works Cann #rnr#inn Permit Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal System at#3 - Black Oak Rd Wiarstons Mills I 111A .........ot-----•••--•--•......... .. .. .....••---•--....................... .................................................................................................. Capricorn ReldltyA` nSt 765 Falmouth Ro°aif;NoHyannis ......................-.......................................................................... ..................................................•-.............................................. W Steve Lebel Owner Address Installer Address dType of Building Size Lot............................Sq. feet U Dwelling-No. of Bedrooms..........................................Expansion Attic ( ) Garbage Grinder ( ) 04 Other—Type of Building ranch............... No. of persons............................ Showers (2 ) — Cafeteria ( ) aOther fixtures ...--------•------------------------------•----•---•--....-•--- W Design Flow.........5................�000 .gallons per person per day. Total dlaily��flow.._.....�5�____.._._..._....__........_�llons. WSeptic Tank—Liquid capacit.............gallons Lengt ............... Widt ._......_._...._ Diameter................ Depth____......... . x Disposal Trencl —No. .................... Wid j...._...._......... Total Length..___. �_......_._ Total leaching area . .. sq. ft. Seepage Pit N ..................... Diameter.._�......_..... Depth below inlet.................... Total leaching area.2bb.......sq. ft. Z Other Distribution box ( ) Dosi taannkk ►-� ldredg�e Engineering 11-25-81 Percolation Test Results Performed by---•-••--•••....................••...-- Date........................................ aTest Pit No. 12• _..._..minutes per inch Depth of Test Pit_12_�_.......... Depth to ground wateone erieounter— ..._ ....._minutes per inch Depth of Test Pi 1_/A............. Depth to ground water N_.ti..........._... e rX4 Test Pit No. Y / l � Description of Soil_....__.�_I_'--_•-•2-i---------loam_.&..tO�Sol.l-•-•-----•...-----•-•-=--•--•----...................................................•-••-- Pr ---_--- . .---- y ---------•----•-----•------------ x 1-C- -- Ivie ium ellow sand-------------•----•--------••-----•-•---• - ------------- me whi e san races o raveY no. wEE at 12 W -----------•--------------------------------------------------------- ------------------------•-•-•---••--•-•----------•------•-•---------•--•• •-----------------------.....-•------------••--••--- V Nature of Repairs or Alterations—Answer when applicable................................................................................•--............ -------------------------•--•--------------------•-----------•--------------------•-.....-•--•.••-•-----•.....•-•-•••-------------••---•-•-•-----••----•-•-• ........................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal Syste in a rda a with the provisions of TIli LE 5 of the State>mitary Code—The undersigned f ther agr es to p e t ystem in operation until a Certificate of Complia ce has n issu by t board o Ith. fined._ .. .. • ••--.. ..s..-- ...... ..1.8/.a.4....... Date Application Approved By-••-•...... ................... --•- ....... ••-•------?ey-I?Y........ \ Date Application Disapproved for the following reasons:............................................................................................................... ................•---•---.................................----............-•----.......---•......-•--..................---------•---•--•------•---••---•--•----•---------•••----••-•-----•-•--......._.... Date y- 6 y ........•-•-••......•--•--.. Issued------------------------------------... Permit No...........................1 ------•-•---.... Date FIzs........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town Barnstable ..................... ....................O F................................_............------............--------.................-- Appliration for Diiipoiittl Works Tontrnrtion nuti# glRAtion is hereby made for a Permit to Construct a► ) or Repair ( ) an Individual Sewage Disposal System at: ' Lot # _ Black Oak Rd.►__ .Yiarstons Mills it IfiA -3......................... ..._ .. _.._._._..__...._....---........---------------------.......-------.......---•---•.._.........-••- P Lo t' A ress o t Nq r Ca ricorn Rea` trust 765 Falmouth Ro$ � yannis ...................... --•------••-•-•------•---•-----........---.....__..........-••----------.......---------------_... W Steve L e b el Owner Address ----•---------•-----------••---------------•---••-----------.........-•-•---••-....._•-----_--••-- -•----...---•----•-••---....-•----•--•----.......---•-----......_..........-------------------••-- Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) H{ - p`4 Other—Type of Buildi:igz'a21Ch............... No. of persons.....__._..._.._.._.._...... Showers ) Cafeteria ( ) Q' Other fixtures ...................................................... W Design Flow....... ............................gallons per person per day. Total daily flow........33P...........................-gallons. W Septic Tank—Liquid capacit 000 ' __.gallons Lengt .6........._ Widtl'�:-'.10...... Diameter................ Deptl5_.____11....... x Disposal Trench—No. .................... Wide ................... Total Length_-_--b.V.......... Total leaching area•__Z g6........sq. ft. Seepage Pit N4.................... Diameter.................... Depth below inlet__.._._............ Total leaching area.__...............sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by -dredge Engineering Date._1.1-25-81 . . ...--•----•---- -- Test Pit No. 12*.0....___minutes per inch Depth of Test pit 12�_.___ Depth to ground wateni-One enCOunte — Test Pit No. Y A..._._•_.•minutes per inch Depth of Test PiW ... ....... : . Depth to ground waterN� ............... e a •-••----••••-•----------------•-••-••-•--•-•••-•--------•••........-•-------•-•-....••-------•------......................................................... 0 Description of Soil......... !_.__-__2. ____._.__loam & topsoil _. ---- x 2' - 10' Tvledium yellow sand -------------------------------------------- -------....._-•------•-••--- - - 10' - 12' med. white sand traces of ravel no wader at 12 ' ---------------------•---------------- --------------------•------- ---•-------....---------------•----•--------------------------------------- •-----------------------........-------------_------ 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 TITLI 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Pres. 71y Application Approved B ;7............... Date Application Disapproved for the following reasons---------------•-----._...-----••---•---•-••---•--•-----...----...---•-----------•---....._...-•--••--------_.... -•-• � -•-•-•---•---••-••--•-•----•---------•------'................................................................................. Date-•---------... lrf PermitNo....................------------------------------------ Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BPARD OF HEALTH �-"`Town Barnstable ....,...... .............................OF..................................................................................... Trr#ifiratr of Tontplittnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ) or Repaired ( ) --____--Steve Lebel by................................................ - •-.......---•----•----•---•••-••- -••--•-....._..-•------------------•---------•-•--•-.._.._...---------..........._-----------•- _ Install Lot 3 Black Oak k oad Marstons Mills , P-1A at -•-----•-•-�----- . . . •--------------•..-•-•--•--------._...........---•------........-----•-••-------- 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..__....��----�...................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............... �`" .f`--•••......---••---•---•••-.......---- Inspector--__------.'---......--------•---•----•--•--------•---•---•----------------•-----. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town.........................OF...Barnstabl e ... ...............................••---••................... No...................... FEE........................ �i��o�ttl ork� �on��rttr#ion �rrutit Permission is hereby granted................Steve Lebel to Construct J^, ) or Rep it ( ) a I ividual Sewa a Disposal System at No....1-'•°t--•,Z--- ..................ack Oa"k a. '-•.............arstons 1 i 1 `! --t+IA �` Street as shown on the app •cation r Disposal `'Works Construction Permit No..................... Dated.......................................... 2S ......------•--•-•------•-------•--...------•-----------------•-•--------•---...--••-•---•----.....--•--- Z vy --------_•-•------------------ Board of Health DATE--.....---------------- -----•-•--/------------•- FORM 1255 A. M. SULKIN, INC., BOSTON >z 0 A4 wp V/1 cp ( 411 ' ' . ICI r a =l �� A -RE J A s a SE Als S v M4zj l oi4 P NI Yw92�1to.) 4 / Alm �mr,6,E sS/pNA�� LEGEND j�OFM%�S CERTIFIED PLd�' EXtS.TINO 'SPOT' ON s,+cy V a'EX48TlN0 CONTOUR —" -- — c� �ROBERT, . G L0 7-3 / L/t-c-'< 0 ;FIS:HED SPOT ELEV TIONi Q g BRUCE IN Al S To//5 , 'FIN1-S:�tEQ CONTOUR 0 G ELORED y `> ` APP' IN R0VE1) BOARD 'OF/HEA{.TH y DATE AGENT SCALES /"_ 3 p ' DATE • / 6, tr¢ ;F 44-REDGE ENG/NEfRIAde CO. lM �RA�✓cO CLIE(�T.,__.__�_ i CERTIFY THAT THE PROPOSED E4ISTERE RE4ISTEREO _' JOB RIG. BUILDING SHOWN ON THIS PLAN ''CIVIL. 'LAND . ` CONFORMS TO THE ZONING LAWS DR.By 0 t?R OF BARNSTABLE , MASS 712 MAIN STREET. CH.,BYs 6 " 7 8 ,•�.� HYANN I S, 1d1A3S z �— _. f SHEET�L OF D TE REG LAND SURVEYOR SEPT/G`:TAm/< OR . 4 �. 2EACH/iYG,-Q�T :4RE /YORE : TNAN /2B.ELOW J . pT N/N rRAOEf.A,24"O/A/4'1 ETER, G'OyCRE T COVER a Sh�ALrC'_BE BROUGHT TO G/ -RA CONCRETE `4 PYC.:P/PE M/N. P/TCN /',IEAYy ;CAST /RO/Y CO(/ER Sf/ALL BE USEO CL :7 o_d COVERS /B /�'FR FT 2f'. MIN. CO/VCRLrTE' yt A :'d _ GRAOE CO✓ER CZ EA/V ,SANAO U(9t//O LEVEL - - - -••'. -.�,.�.• 2 LAYER IRONP/PE 0 0 000 OF �8 *"JAI.PITCW —�— GAL, D/ST, o' a • 0 • • • • • • 0 0 A., o4 WASHED 57VIVE �4 Pe�Rf7:: SEPTIC TANK 0 4 1 • • • • . • a � � i oa • `= BOX o o •� 80 • o • • � .°o • y o 3/ „ ., : x • o, s i � o DEPTf•/ • • � � ; v o 11645HEp STOiYE `tY .V /.o ?g e o � • o 0 0 • �• � p;o PRECASTSEE_PAG ~. IFC�S48. G,4L/�f*Y . a nrs• • •, o o • e •o P/7 OR MVI✓. I VVZAT.41L-EVAT/ON S �' T P Y e o A EL g z 3 IA?14*7'A77 AIMPING FT /NLET:.SEPTIC"T,4/VK !o FT, - IO FT VIA lw- C SEE TABUL�4TION> OUTLET SEPTIC TAAl.K Ar INLET BOX. 5 AFT :,t. .. S GRDuNO1TEft TABLE . OtJTLETD/STR/®t/7"/ON BQX�FT, :, INLET LEACN/IVG P/T 3-e,3. Fr .SEW 4GE OISROSA L SY.STj9M , TAXII-ATIDN LEACH//VG .PIT - 6 F'T DE5/6N CRITERIA p♦iy,�xS/ N 8 FT. NUMBER OF BEDROOMS 3 D/HENS/ON . C FT.MtAI GARe.4GE0/SPOSAL UN/T NO"/E So//- LOG TOTAL EJT/MATED Fzow GA4.14AY SO/L TEST #/ SOIL 7ES7702 SD/L TE$T NUMBER Of 40ACH/NG P/rs---L_ F'4Fy 6 0,3 I- AeXeY• DATE OP- SOIL TEST S/OB LEACH/NG PER P/7• S-Sr- 5V FT. 0 - 3 ' RESULTS v1rA,ESSEG BY 60TTOM 4G4CN/N0 PER P/T 79- so. &r. G �i¢M Pc PERCOLAT/ON RATE j '/ LDS S llJA /NCH TOTAL LEACHING AREA 2-6 6 SQ. FT. S4,`6.SO/Z- AERCOLAIrlON RATE 2 M1N�lNGH RESERVE LE4CNI/VG AREA S.P. AT. . 2, 0. 5-0 lL TcsT'; Z-7 S z L.D T _3 /3 L.4 C-k 0.4 XTH OF Mks S4 ✓p MA/Z S 7 0 445 AJ 1 L L-S. ROBERT B•RUCE o AL N (� EL ORE 'r �tSE y ELOREDGEENGINAER/NGCO,INC. ' No.109 p - 7I2 MAIN ST. 1 ri o pFC1V1 4. �Q EL 4-9.3 ., HYAiVN/9, MASS. Rp 5l1R �. 9°�SSION ��\�� Qd NO p GOO U0V Yti/�TER ATNEL gL!T1rR60 Cl-/ENT: �Y�✓c O DATE; / � JOB No. Z,-- t SHEET Z-OF �— i I:Ommonvveaitn of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , r< �3 39 BLACK OAK ROAD FREEDMAN ELEANOR TR w" Owner owner's Name -1 information is ,� MA 02648 2/9/18 ` required for every Marstons Mills page. City/Town State Zip Code Date of Inspection1 Inenarfinn racidta miief hp ciihmi"arl nn fhic fnrm Inenar+inn fnrmc mav_ nnf ha alfararl in anv_ way. Please see completeness checklist at the end of the form. Important:when A. General Information filling out forms on the computer, use only the tab 1: Inspector: key to move your cursor-do not Robert Paolini use the return key. Name of Inspector 17 Playground Lane Company Address Yarmouthport MA. 02675 idyl i ow,± :Mate tip i ooe 508 362-3555 S14454 Telephone Number License Number B. Certification i =sY.i t6iy t!fat f-i avu pwl-6vt iaiiy t!IG.6vw6gG U6-spu66i syatai ti Et4-LH13 c1U6 6.73 4-AHU t1 1s1i t€€i. information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 16.000).The system: n P6iCCAC 1-1 rnnriitinnaliv Pascac n FaiI ❑ Needs Further Evaluation_bX the Local Approving Authority 2/9/18 Innn nn4n.'n Cinnn6.:.n J 1'lnfn The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. rzwrai-W141 €€fie:'tJwclai impetWm-rEtal::.jubctlace UelYau-1;5[lQw:jyuget-Fagerot 1/ � 'US ii,;ommonweann oT iwassacniusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 BLACK OAK ROAD i�.ts..+sq rj.uiou FREEDMAN ELEANOR TR Owner Owner's Name information is required for every Marstons Mills MA 02648 2/9/18 page. CityrTown State Zip Code Date of Inspection B. Certification (cont.) €!I.IiJGI.ftVF F JF.{FI ICiFdl it. L,rl[GLf\ ti,Ci,L,EJ VF- F=f tFFVFdYaS E..V1411.i€Y.EG all VF QV;-EFVF F U 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 inrlir�tcri hcl�iei Comments: Fit e3��€GI11 4sidF lidFilVlldll� i�dif.S�G3 ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not IACEGI 14 if€IGE.i, ¢Jivd3G:GAfitd€!€. 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. PS!flGtdt .'tGIJIF4 kdF€€i YYF€€ I.id3� fl€.7i./Gi:.EtVF€ I€ ft i."Y 3Ef l{lril{t d€!� .7VC{114.i, t IVi€Gdri€1 IE�d!!l3 €1 d i.sGFEt€44dtG Vi Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 carinmonweann of Massalanusens Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 BLACK OAK ROAD a.�,-'jj r . .- FREEDMAN ELEANOR TR Owner Owner's Name information is required for every Marstons Mills MA 02648 2/9/18 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): I-1 hrnLon nino/c\ ono ronlnncrl n v M Ai n Kin /Gvnhin holnur\ ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ;- i-ire-systen, reguire€t pimping Bore than 4 times a year ate to orOKen c;obstructea p3pe`S. t ne system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ 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, c*fofii 2nel#ho cnvirnmman+- ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 commonweann of ritassacnusens Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 39 BLACK OAK ROAD -r7v�rorTy iiuwca� FREEDMAN ELEANOR TR Owner Owner's Name information is required for every Marstons Mills MA 02648 2/9/18 page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) 4. 3ystarrr Mir rail uruess me ouaru ui nWautr(atlu ruuiru vvaict JuNa.rilul, Ie ally/ 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 SuE py. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has aseptic 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: Tina ayaiarti f.raaac; ri erg w�rr avatcr arraryora, F�rvrreecca atvr`y; left im.cti 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: Lrt 4y-Ifir,vattuti."%of nut let P4jFIIVa I1U tv Ali You must indicate"Yes"or"No"to each of the following for all inspections. Yes No n n Backup of sewage into facility or system component due to overloaded or ClUggeU Z)/AO Ui ces5poi:i El IS due or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El 0 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 ❑ 0 t5ins•11/10. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Lommonweann of massacnusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments rY. 39 BLACK OAK ROAD ri�}yciy riuuT@ate FREEDMAN ELEANOR TR Owner OwnePs Name information is required for every Marstons Mills MA 02648 2/9/18 page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) YUS rvu ❑ 0 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑x ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. n n Any portion of cesspool or privy is within 100 feet of a surface water supply or inoutary to a surface water supply. ❑ ❑x Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Z Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ❑x Anv 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.] - -- - -- - --- - - - -- ------ i i l�3y�i6tl�s a cCss}rvui sv�vnly a iauliliy wn11 a uC$tlj,t1 iivvv ul cwvy}�u- 10,000gpd. ❑ R 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. izj urge oybieffrb rrr i�t cvnsrrMtf a farc,�e�ybierrr LfM bybierrr rrrrr:;i nerve a Uacririy Miir 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 Nc u u me`system is within 4wleet of a surrace onnKmg water suppiy ❑ ❑ 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 or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 commonweann of massacnuseas Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 BLACK OAK ROAD rivNciiy nuuioa� FREEDMAN ELEANOR TR Owner Owner's Name information is required for every Marstons Mills MA 02648 2/9/18 page. Cityfrown state Zip Code Date of Inspection C. Checklist tri ICuK II a IC l auvv1I Iy I IdvC uuui I uvi iu. r uu rrlutn if ulUdw yUb ul I Iv d5 lu Cdu1 I v1 a IC IUIIUWII ly. Yes No , ❑x ❑ Pumping information was provided by the owner, occupant, or Board of Health n n \Moro ona of fhn evelom a mm^nncn4e ni imnorl ni if in 1ho nrovin"e fiAin woolre7 ❑ ❑x Has the system received normal flows in the previous two week period? ❑ M Have large volumes of water been introduced to the system recently or as part of this inspection? ❑x ❑ Were as built plans of the system obtained and examined?(If they were not ..:L.l.l.. ....i.. ..n AI/A, ❑ Was the facility or dwelling inspected for signs of sewage back up? p ❑ Was the site inspected for signs of break out? FZ ❑ Were all system components, excluding the SAS, located on site? u u vvere the septic tank manhoies uncoverea, openea, ana 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? 13Z ❑ 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 uCCI I(lCltfl IIIIIICCf Daseu ❑x ❑ Existing information. For example, a plan at the Board of Health. M ❑ 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)] C. 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): commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 BLACK OAK ROAD r i vpv ty nuc4i oaa FREEDMAN ELEANOR TR Owner Owner's Name information is required for every Marstons Mills MA 02648 2/9/18 page. Citylrown State Zip Code Date of Inspection D. System Information iia��r INilull. U Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑x No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ❑x No Laundry system inspected,, u res u No Seasonal use? 0 Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes 152 No Last date of occupancy: Date Commercial/industrial Flow Conditions: . Type of Establishment: L)tVwy.I rIIVW kuCIZtvU VI I J 1 V\rlvif[ I V.GVJ). Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Inrfi iefriml%Atnafe hnlriinn fon4 nrecenf7 1-1 Vee I-1 Kin Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Lommonweann of Massachusettts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 BLACK OAK ROAD vivpeiTy rmicFvz's. FREEDMAN ELEANOR TR Owner owner's Name information is required for every Marstons Mills MA 02648 2/9/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): v�nlrrai 6niornlauun Pumping Records: Source of information: Mine evefnm nu imnerl oe nor+of fhe inener%finn) I� Vee Ix� Aln If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: ii ytit;Ui ay54vill; ❑x Septic tank, distribution box, soil absorption system ❑ Single cesspool r� nverflnw r•ecennnl ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11l10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 c \' Lornmonweann of massamusetts - Title 5 official Inspection Forums Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r� 39 BLACK OAK ROAD riJNcFip nuuioaz _ FREEDMAN ELEANOR TR Owner Owner's Name information is required for every Marstons Mills MA 02648 2/9/18 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) NI.!(.11OXllilaie aye Vi all uam IliJidiieu ([I fulOwl1) afIu$OUIt.:e OI 11i1,uillidUU11. Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Rnilrlinn Cnumr/Inr�t•e nn ci4e nl�n\• Depth below grade: 1.5' feet Material of construction: ❑ cast iron ❑40 PVC 0 other(explain): Distance from private water supply well or suction line: i"T feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of leakage.System vented through the house vents. avF ut; i i2i1K(iUL;dw Uri zilud Pid[1). .. Depth below grade: 2.5' feet Material of construction: R1 rnnnre�e I—1 mef�l F-1 fihernlxe l-1 nnhie4hrlene l� n+her/evnloinl ii iar m m liieiai, ilsi aye. years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 211 cli irino rlcn4h• t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Lomonweann of massacnusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '~ 39 BLACK OAK ROAD -rti,F,oiy nuuica5 FREEDMAN ELEANOR TR Owner Owner's Name information is Marstons Mills MA 02648 2/9/18 required for every page. Cityrrown state Zip Code Date of Inspection D. System Information (cunt.) deNiw ia+iK(wlli.) Distance from top of sludge to bottom of outlet tee or baffle33" Scum thickness 1" Mcfnnrc frnm inn of ery"m +n+nn of e% i+Ie++co nr hofflc 711 Distance from bottom of scum to bottom of outlet tee or baffle 11" How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, Pump tank every two years.Inlet and outlet tees are in place.No evidence of leakage. i7Iu4,C 1 filp it iUL;du:,UI1 ,liu pidl1). Depth below grade: feet Material of construction: r_1 n F-1 n+hcr(cvnloin\ Dimensions: Scum thickness iil8ial lue ifulil iuN ui sculii iu i0p vi ouiici iCw of Dame Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 17 c:ommonweann or massacnusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 BLACK OAK ROAD r i�Nc�iy i•iuui oar FREEDMAN ELEANOR TR Owner Owner's Name information is required for every Marstons Mills MA 02648 2/9/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) UU1tltIlC11t5 (UlI putIlpilly IGGUII[II IV[ludllull,, illiUL dllu UuuUi lCC UI UdniC W(IuluUll, JuUGtUldi I[IiVyllty, liquid levels as related to outlet invert,.evidence of leakage, etc.): i r�iii ud nt�iuniy 1 at1R(l'Gt Iti li luJl 0e(JUI11(JCU ai 1tI11C VI It IJNCGIIVI 1j(iuuatC VI I sne pidl I j. Depth below grade: Material of construction: n nnnrre+e I-1 me+�I I-1 fit�ernl�ce I-1 nnlve+h�ilene I-1 n+her levnl�inl Dimensions: Capacity: Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No uaie ui iasi.put-liputy. Date Comments (condition of alarm and float switches, etc.): "Attacn copy of current pumping contract(required). is copy attached'? Li Yes u No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonweann of Massacnusetts Titre 5 Official 1-nspec$ion Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y� 39 BLACK OAK ROAD r TuPcFTy -wuica' FREEDMAN ELEANOR TR Owner Owner's Name information is Marstons Mills MA 02648 2/9/18 required for every page. CityfTown State Zip Code Date of Inspection D. System Information (cunt.) ulsii�uuiw'i ®UR tli i.JIC361-IL IIIUSL uC Ui.1C1ICU) �IUI:dLC UII SItC iJlial-1). Depth of liquid level above outlet invert no Comments (mote 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 level.Box has one outlet Iateral.No evidence of leakage. rump%'e1ainuer (iucdw UI1 sliu pidn). Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No I'nmmcn4c lnnin nnnrlifinn of ni imn.r hnmKcw nnrirlifinn'nf nm emnc onrl nnn"rfennne%nc e4r \• .7U11 NUSVf(lt9Ui➢ 7)i7tetil (JHJ) (IUGd1U UII bIIC pidl1, excdvdUUll nui 1UgU11U i). If SAS not located, explain why: - -- - - - - ... :------------------ ------- --- uommonweann of massacnusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 39 BLACK OAK ROAD r Ivpcl ty i•ivvivas FREEDMAN ELEANOR TR Owner Owner's Name information is required for every Marstons Mills MA 02648 2/9/18 page. Citylrown State Zip Code Date of Inspection D. System Information (cunt.) ❑x leaching pits number: 6'x6 with 2`stone ❑ leaching chambers number: rl In�rhinn n?Ilnrice raumhcr• ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: u Innovativeraiternauve system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy soil.no signs of hydraulic failure.Pit had 1'of water at time of inspection. %.t;b9poUes(L;UbZj.JUUi II IUSt tJtr PUI I IIJCU H5 IJHI t UI If IZ IPUL;UUl 1) (IUL;dLV UI I Situ pill 1). . Number and configuration Depth—top of liquid to inlet invert Ilon}h of cnlirlc.lwcr Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Lornrnonweann o>t massacnusens Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 39 BLACK OAK ROAD FREEDMAN ELEANOR TR Owner Owner's Name information is required for every Marstons Mills MA 02648 2/9/18 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) %�unHnienis l[iuie wnuiiiun ui suii, siynb ui i ryuidu]ic idiiut G, 1Vve1 of Pui lull iy, cu1 iuiiiun ui veyeiduui i, etc.). rr®vy k1UUdL6 ufi biic Nic+iij. Materials of construction: Dimensions Danfh of Q„r,i-z Comments(note condition of soit, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): °A Goriamvnweann ai- mssssctiusetts IM Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 BLACK OAK ROAD FREEDMAN ELEANOR TR Owner Owners Name information is Marstons Mills MA 02648 2/9/18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) OKMLA! Vi 0,UWL1VtZ LI1Z1JJU%1U1 QybLuiit. riuv3-iv-is view Ui uiu Suwc_-�4u uibpu��Y f lul7t lY 3E:lCYt:lF Yt�tiE'':i tS at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below 5 tsirts•I I/90 Title S Of ad Form:Subsurface Sewage OisposaY Syetam•Pape 15 of 17 commonweann oti' Massacnusens - Titre 5 official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 39 BLACK OAK ROAD ri VFUILy iUUI a� FREEDMAN ELEANOR TR Owner Owner's Name information is required for every Marstons Mills MA 02648 2/9/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) �ei.e C]C�n1. Check Slope ❑x Surface water M r`hpn4 cellar ❑ Shallow wells Estimated depth to high ground water: separation from bottom of LC is 15' feet Please indicate all methods used to determine the high ground water elevation: u vptalnea Trom system aeslgn plans on recora If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ful ('laen�oii .,�+h Inngl 12ngrrl of I-Isg10,_avnlgir,- As-Built ❑ 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 92-0001 annual ranges of groundwater elevations. 0t;1UIU 111111y IIJIM 11I1,PMAIU11 F-WIJUIL, ,Urr I WIXIJIL%,U11JP1VLV111e9'tsIMURIML U11 11WAL IJdy1±. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Lommonweann o4 nmassacnusens - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 BLACK OAK ROAD i=a�Nc�ay rauui ca5 FREEDMAN ELEANOR TR Owner Owner's Name information is required for every Marstons Mills MA 02648 2/9/18 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist u inspection Summary: A, B, L, D, or E checked Inspection Summary D (System Failure Criteria Applicable to All Systems) completed System Information—Estimated depth to high groundwater .^.t,�,^a:airn,Me.ea—1 S_—+-- sins•11110 ( Title 5 Official Inspection.Form:Subsurface.Sovmgo Disposal.System-.Page 17 of 17 al At vo,w OWN' Y A 0-"v A"I Q011 A� o j1h AS,Nov, ""'e..", A, Way A fat � K_ flax ya OAKS, vows"; AT 1 4 71 'N A'N N 402 "It �0,K ton, YOU !'7p �b�ikf Y 10 'e" 1 y 7 7-7�_ APT �q �,J: 04 N,""'z, an �� ho TA AV, it Qvy ac- onni EYE: 41A, - gA IV, can o 7� _je �iw 71 K ML SPA i7_ VIZ. Pan MAW pow; WAS C ....... . ................. di. NOW -4- ROOED,SY 00 gin Kn % ASS 0 AAA v" wo* DRAWJ�G, NUMBE� Ql sit to, Q Allow oil v 0, A 0" : L NAT, J101 it fill lot