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HomeMy WebLinkAbout0068 GOOSEBERRY LANE - Health 68 GOOSEBERRY LANE MARSTONS MILLS A= 102 - 073 / - \ Commonwealth of Massachusetts 41 Boa- e�3 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 68 Gooseberry Lane Property Address p t William Foster Jr. Owner Owner's Name / information is Marstons Mills V Ma 02648 10-14-2020 required for every page. City/Town State Zip Code Date of Inspection it Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information on the computer, use only the tab Brett Hickey key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. 374 Route 130 c� Company Address Sandwich Ma 02563 City/Town State Zip Code nm (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ■❑ Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails BreBrettHickey Digitally signed by Brett Hickey ll k ,r:"Date:2020.1ai609:15:51-0a'oo' 10-14-2020 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts �p Title 5 Official Inspection Form 11 i, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments lF' 68 Gooseberry Lane V Property Address William Foster Jr. Owner Owner's Name information is Marstons Mills Ma 02648 , 10-14-2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1,2, 3, or 5 and all of 4 and 6. 1) 'System'Passes:1 ❑■ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The system was in working order at the time of inspection. 2) System.Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 68 Gooseberry Lane Property Address William Foster Jr. Owner Owner's Name information is Marstons Mills Ma 02648 10-14-2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ , obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) 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. a. 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: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts i, Title 5 Official Inspection Form w Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t u 68 Gooseberry Lane Property Address William Foster Jr. Owner Owner's Name information is Marstons Mills Ma 02648 10-14-2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (Cont.) ❑ 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 b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has,a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *"This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes. No ❑ 0 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ 0 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts �? Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u— / 68 Gooseberry Lane Property Address William Foster Jr. Owner Owner's Name information is Marstons Mills Ma. 02648 10-14-2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ O Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow ❑ Q Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ El Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Q Any portion of cesspool or privy.is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ 0 Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ El 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.] ❑ El The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ 0 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. 5) 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 CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments t.- 68 Gooseberry Lane Property Address William Foster Jr. Owner Owner's Name information is Marstons Mills Ma 02648 10-14-2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no" for each of the following for all inspections: Yes No El ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ 0 Were any of the system components pumped out in the previous two weeks? El ❑ Has the system received normal flows in the previous two week period? ❑ 0 Have large volumes of water been introduced to the system recently or as part of this inspection?. ED ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ El Was the facility or dwelling inspected for signs of sewage back up? 0 ❑ Was the site inspected for signs of break out? 0 ❑ Were all system components, excluding the SAS, located on site? F-1 ❑ 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: 0 ❑ Existing information. For example, a plan at the Board of Health. ❑ Q 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts �- Title 5 Official Inspection Form I� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 68 Gooseberry Lane Property Address William Foster Jr. Owner Owner's Name information is Marstons Mills Ma 02648 10-14-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 2 Number of bedrooms(design): Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220/GPD Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes 0 No Does residence have a water treatment unit? ❑ Yes 0 No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes 0 No information in this report.) Laundry system inspected? ❑ Yes 0 No Seasonaluse? ® Yes n No Water meter readings, if available(last 2 years usage(gpd)): See below Detail: 2019- 21,000gallons 2018- 19,000gallons Sump pump? ❑ Yes ❑■ No Last date of occupancy: June 2020Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. 68 Gooseberry Lane �tlt Property Address William Foster Jr. Owner Owner's Name information is Marstons Mills Ma 02648 10-14-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: 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 below): 3. Pumping Records: Source of information: Owner- last pumped June 2020 Was system pumped as part of the inspection? ❑ Yes H No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts �d ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 68 Gooseberry Lane V� Property Address William Foster Jr. Owner Owner's Name information is Marstons Mills Ma 02648 10-14-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: El 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: 2014 per plans Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron M 40 PVC ❑ other(explain): Town water Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form �= 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 68 Gooseberry Lane Property Address William Foster Jr. Owner Owner's Name information is Marstons Mills Ma 02648 10-14-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: 9 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 1500gallons Dimensions: A 11 Sludge depth: �} 32" Distance from top of sludge to bottom of outlet tee or baffle 1" Scum thickness 6" Distance from top of scum to top of outlet tee or baffle 1511 Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection. The tank is not in need of pumping at this time but should be pumped every two years for maintenance. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 68 Gooseberry Lane Property Address William Foster Jr. Owner Owners Name information is Marstons Mills Ma 02648 10-14-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: NAfeet 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.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 c � Commonwealth of Massachusetts Title 5, Official Inspection Form y Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t , 68 Gooseberry Lane u— Property Address William Foster Jr. Owner Owner's Name information is Marstons Mills Ma 02648 10-14-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. Distribution Box (if present must be opened) (locate on site plan): 0" Depth of liquid level'above outlet invert Comments (note if box1s level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The d-box was in working order at the time of inspection. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 68 Gooseberry Lane V Property Address William Foster Jr. Owner Owner's Name information is Marstons Mills Ma 02648 10-14-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): NA * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: 14'x22' rX] leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments L °„ 68 Gooseberry Lane V Property Address William Foster Jr. Owner Owner's Name information is Marstons Mills Ma 02648 10-14-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The SAS was in working order at the time of inspection. Field showed no evidence of past back up when viewed. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): NA 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.): l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 68 Gooseberry Lane Property Address William Foster Jr. Owner Owner's Name information is Marstons Mills Ma 02648 10-14-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): NA Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts I Title 5 Official Inspection Form i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i 68 Gooseberry Lane Property Address William Foster Jr. Owner Owner's Name information is Marstons Mills Ma 02648 10-14-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately r r . _S1r°A H.t:.E. SuWAGE L F, 4C 2 # e EA, . Ai .... Mrr:;asx�9xxrnaz�.T.,�E�;Ya�vzrz: �.wwz*�'i��tixw:. - Matxirsaaca'st l3S�exkaCai'.t::Yrtsira'nG3:ew.�ipax"r"'it.?ist S.Y.}tile.E'tc.trx,..rv'e refl.aeT;a.,Pxec��;.1F^':�sa:z2iYa.' :w...._:.v. P-�:rs: k"'r'£vzx tez Waxer Sex'r"93'+93' WCII:azrcS 6..z^rsi:3 nP, 1�;::el ik;Y'(,T.["`;�z;Sry'we•c2#v«rs.aat cry. i i��axx tiwCti3a�ir3 ar,�i.s„scc.ksix:�z d attxlr't3 Qlf antipd;ti�.•rr.4,ir's.1.w esaes�ava'xYaiio . ......... __ _..-- a� , 3 , .31 1 c f 3 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts t Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 68 Gooseberry Lane Property Address William Foster Jr. Owner Owner's Name information is Marstons Mills Ma 02648 10-14-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑■ Check Slope ❑� Surface water ■❑ Check cellar ❑■ Shallow wells Estimated depth to high ground water: No GW @ 132" feet Please indicate all methods used to determine the high ground water elevation: El Obtained from system design plans on record 4-28-2014 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: A plan on file at the local Board of Health was used to determine high groundwater. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts ,jp Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 68 Gooseberry Lane V� Property Address William Foster Jr. Owner Owner's Name information is Marstons Mills Ma 02648 10-14-2020 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ❑■ A. Inspector Information: Complete all fields in this section. ❑■ B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ■� C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ■❑ D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 Town of Barnstable t'al Department of Regulatory Services M e Public Health Division AM Date _ 63P- I 200 Main Street,Hyannis MA 02601 r�n,w•�° Date Scheduled Time Fee Pd: Soil Suitability Assezmentfor Se, e Die s C, e Performed By: , Witnessed By: Ae Location Address 6� C�Gb�e� Owner's Name /��t'Kt ' ` s �•�(S Address l7�,�1U-Su2 p�VV��pP Assessor's Map/Parcel; j()1 --6-13 L / Engineer's Name C� NEW CONSTRUCTION V �^�, !�_/.1�1 e- :�A _0 REPAIR Telephone hi ��lO.tJ Ze (i� AS SUC(if`, Land Use i ��,G` Z(�l2 � � � 7 )''Iz .F:GJti , O 177 . ab 5lopes(96) Surface Stones Distances from: O en Water Bod 1006 f P y ft Possible Wet � , �ft 'Drinking Wafer Well t.J ft Drainage Way $401 I ft Property Line Z y 3 t 4e ft Other k r 'e1 ft SIM,TCH:(5lreet name,dimensions of lot exact locations of test holes& e c tests a lands to proximity to holes) cle ,E. a v%c.e o 8 C> d o _n 470V C��Sc��ry tiny @a10 Parent material(geologic)IL t l3 _4 �"`'s' Depth to Bedrock A�` Depth to Groundwater. Standing Waterin Hole: �<��^ Weeping ftatn Pit truce AJla « � Estimated Seasonal High Groundwater DEJ TEH'd1Vba1'AUON FOR SEASONAL A.WL0J1Y WATER TABLE Method Used: Depth Observed standing in o . Ole: In, Depth to Soil mottlem! Depth to weeping from side of obs.hole: In, Oroundwater Adjustment Index Well#. Rcading Date: ll-, Index Well level \ A ,Pastor L _ Ark.Ciruundwatnrlxvel r f PERCOLAr> 10N TEST Uatl M ld-Tlwa 04se Observation Hole# 5r C7 T1111e at 9" �Depth of Pere ZH Time at 6" Start Pre-soak Time @ '//w� '6% 7,wt ety� Time(9"-6") End Pre-soak I t. Rate Minjiucl, Site Suhabillty Assesemsnq Site PasseB Site Palled: Additional Testing Needed(Y/N) Original: Public Heallh Division Observation Hole Data To Be Completed on Back----------- *"If percolation test is to be conducted within 100' of wetland, you fliust iimst notify the Barnstable Couservation Division at least one (1) week prior to beginning. OnsEP'rlc�rr!Rr_PORM.Doc DE E,P:O fBSER VA.TION HOLE LOG Hale# � 2C(mil 5.3 . Depth from Soil Horizon Soil Texture .Sdil Color Soil Other Surface(in.) (USDA) (Munsell Mottling (5lnucture,stones;boulders. —IWXTm onsl4teacv %Oravel) It ?s.fe-,G�i Y 7/6 �CevkJA et✓4 DEEP OBSERVATION HOLE LOG Hole# X �o Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. . o sisteney,% ravel w K41 DE,E 'OBSE,RVATIOlm;'MOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other surface(iu.) (USDA) (Mmusell) Mottling (Structure,Stones,Boulders. Co I to oy.95 Oravol) DE,EP OIBSE,RVATION HOLE, LOG Mole It Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stonei,Boulders, consistency. 6(1fayph x p'lood Insurance hate Man: Above 500 year flood boundnry No- Yes Within 500 year boundary No Yes Within 100 year flood boundary No Yes Depth of Katurall* OccurrinL-Pervious�luterial Does at least four feat of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? ,r If not,what is the depth of naturally occurring tier ious matofial? Certification I certify that o' n r� 1 ,t r(date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . tie and expert c described in CMR 15.017. � :ri the required tralnm xp r s p U Signature Date QAS EPT IC\PRRCPORM.DOC TOWN OF BARNSTABLE LOCATION L1@bebo" kqne SEWAGE#,aQi4 VILLAGE Mat, ftjjs ASSESSOR'S MAP&PARCEL 138 7-1.' INSTALLER'S NAME&PHONE NO. llq th '71"14•-,'ZD-,38(7 SEPTIC TANK CAPACITY LEACHING FACILITY. (type) o (size) NO. OF BEDROOMS OWNER nth Z I5 't\ , r PERMIT DATE: 5 XO N COMPLIANCE DATE: S i Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY A B 3 ' 132`2-" pax O 3 9 lop az° Fee No. r YJ�/ 14 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 4plitation for Mispo9af 6pstrdt Cunstruttion Vermit Application for a Permit to Construct( ) Repair 010 Upgrade( ) Abandon'( ) ❑Complete System ❑Individual Components Location Address or Lot No. fig `-ao;,i9-rly Lav-,I`11�s ,,, Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 10-1 '73 s5 G rAum W_ ST Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. r1".j-T T I/FCA,,&s4o" 4-L C. [As' svpve x ZY)c- Soa-826--3619 Z18 VrAfj VJN� R0- HARvrct-1 azc.4s 'M-L1-7-73A0 41 k 6A 5AND-w-c-b MA OZ661 Type of Building: Dwelling No.of Bedrooms 2- Lot Size 10,57$ sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) IWO gpd Design flow provided ZZ S gpd Plan Date 4-Z.8-14 Number of sheets Z Revision Date N/A Title '54,+ �,-Cw W &. i P(An Size of Septic Tank 47 150� Type of S.A.S. P .( Description of Soil Sax W.- Nature of Repairs or Alterations(Answer when applicable) AQ W cw� 4. &U, 5A 5 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. L Date J- Application Approved by Date, 1 Application Disapproved by Date for the following reasons Permit No. `L� Date Issued 5110111 No.r_0)Q — i- �; Y Fee ' ' f THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF,BARNSTABLE, MASSACHUSETTS a2pplication for 06posal "pstetlh Construction Permit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Ga G—A L u,,_ j�1�s� �j;Owner's Name,Address,and Tel.No. Assessor'sMap/Parcel luz,, 'Z 55'1cC rQm ;4. MA n152.V Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. 0_' k,.j a-s'„ku.t /E,011k S Sta,,.. LLC. fps sv2visY Z JC- soa-sag-3619 Zis AlvlvG 2.n. 1-IARUc-! 4oz64i 77y-Z-7-736c) lu, F.+ CAA !�pND,_,cie MA OZ557 Type of Building: Dwelling No.of Bedrooms Lot Size !(:,S 7$ sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) '$, gpd Design flow provided ZZ F3 gpd,-- `..Plan Date Ll-L F3- !4 Number of sheets 2 Revision Date ,A Title Sj, + <'IIJo.Ga_ Rkpn.;r PIS„ Size of Septic Tank 15OG Type of S.A.S. f3 Description of Soil Sq_Q L J t,ole. 1a.,s Nature of Repairs or Alterations(Answer when applicable) nQ, , Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in 1 accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of 4 Compliance has been issued by this Board of Health. Date ` (' >C- 1/'7 Application Approved by Date.jciI16 //L Application Disapproved by ! Date for the following reasons Permit No. C L Date Issued S. b / --------------------------------------------------------------------------------------------------------------------------------------- TR F COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( X) Upgraded( ) Abandoned( )by sTam at ��]�o��� � t MCC ��� /�/./�� has been constructed in accordance 41 with the provisions of Title 5 and the for Disposal System Construction Permit N67btl- / dated 6 /1 Installer)rr-711 Sint Designer at/,d I Da d-V #bedrooms Z Approved design flow�� gpd The issuance of this pe it shall not be construed as a guarantee that the system vill4unction as designed. Date L; � Ll ?' Inspector I �f ,t�- . --------------------------------------------- - -------------- -------------- ---------------------------------------- No. D CV L{ - P-) `I ', Fee 1 C)O THE COMMONWEALTH OF MASSACHUSETTS t, PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS ]Disposal 6pstetn construction permit A. Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon 4`6 ( ) System located at GS eb,+r!z 44 9 t /��►'1n�n c /"t•��C # and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided.Construction must be com ete within three years of the date of this permit. Date Approved by , Town of Barnstable Regulatory Services ti Thomas F. Geiler,Director mms MAZ Public Health Division 9q'�°rEo s`0� Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Z® � r Fax: 508-790-6304 Date: S ` (4 - C Q.- Sewage Permit# 44- Assessor's Map/Parcel Installer & Designer Certification Form Designer: Installer: OA/0 SIUAIC-- Address: ,4�"11S , /?Z9 Address: - ��w•c/,% A(A, GZ�43 &l9. dA11&1#/ l`' On -& cST J4)0- was issued a permit to install a (date) (installer) septic system at SUS 60 Y L ��'i based on a design drawn by �- (address) / e_ dated (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic syste m)y ) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Stripout(if requir dd '`as° s ected and the soils were found sati factory. nsta ler's Signature) 74 (Designer's Signatur (Affix Designe'T's tamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. q:\ofce forms\designercertitication form.doc Bk 28125 Pa144 a18382 05-05-2014 a 01 % 20p DEED RESTRICTION WHEREAS, MICHAEL R. CURTIS and CHRISTINE M. CURTIS, are the owners of Gooseberry Lane, Marstons Mills, Massachusetts 02648 (hereinafter referred to as Lot 51, #68 Gooseberry Lane, Barnstable, Marstons Mills, Barnstable, Barnstable County, Massachusetts 02648 and being shown on a plan entitled "Subdivision Plan of Sand Shore a wooded area in Marstons Mills, Barnstable, Massachusetts for Hia Pearl Corp."which plans is duly recorded with the Barnstable County Registry of Deeds in Plan Book 138, Page 25. WHEREAS, MICHAEL R. CURTIS and CHRISTINE M. CURTIS, as the owner(s) of said lot has agreed with the Town of Barnstable Board of Health to a restriction as to the number of bedrooms which can be included in the present home built on said lot as a pre-condition to obtaining a disposal works construction permit in compliance with 310 CMR 15.000 State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage; WHEREAS, the Town of Barnstable Board of Health, as a pre-condition to granting a disposal works construction permit for a septic system in compliance with 310 CMR 15.200, State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage, and authorizing the issuance of a_permit for the installation of a new Title V septic system on the property; is requiring that the agreement for the restriction on the number of bedrooms in any house constructed on the lot be put on record with the Barnstable County Registry of Deeds by recording this instrument. HOWEVER, if the premises are ever connected to a town sewer system, this restriction will become null and void. NOW,THEREFORE, MICHAEL R. CURTIS and CHRISTINE M. CURTIS do hereby place the following restriction on their above-referenced land in accordance with their agreement with the Town of Barnstable Board of Health,which restriction shall run with the land and be binding upon all successors in title: 1.- 68 Gooseberry Lane, Marstons Mills, Massachusetts 02648 may have constructed upon the lot a house containing no more than TWO (2) bedrooms. Michael R. Curtis and Christine M. Curtis agree that this shall be a permanent deed restriction affecting the house located on 68 Gooseberry Lane, Marstons Mills, Massachusetts and being shown on the plan recorded with said Deeds in Book 138, Page 25. For title, see Deed recorded with the Barnstable County Registry of Deeds in Book 15606, Page 70. Executed as a seale rument s / day of May, 2014. ichael R. Curtis Christine M. Curtis COMMONWEALTH OF MASSACHUSETTS ab/G es County, ss; May , 2014 Then personally appeared the above-named Michael R. Curtis and Christine M. Curtis, who proved to me through satisfactory evidence of identification, which were Z/c en s eS , to be the persons whose names are signed on the preceding or attached document, and swore or affirmed to me that the contents--of the document are truthful and accurate to the best of their knowledge and,,,l fef'"And, acknowledged to me that they signed it voluntarily for its stated purpose. �••••• o y WZ� Nota Notary Pu}tl My C 0=02mi sion017 Janus t, •••'�o �` IL i� BARNSTABLE REGISTRY OF DEEDS f COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS W DEPARTMENT OF ENVIRONMENTAL PROTECTION a ' RECEIVED F W C. 5" JUL 1 7 2002 TOWN OF BARNSTABLE TITLE 5 HEALTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A �z S 1 9 CERTIFICATION n Property Address: 68 GOOSEBERRY LANE MARSTONS MILLS,MA 02648 M" I UO O'73 Owner's Name: AMY &VINCENT`MARINO SI Owner's Address: 68 GOOSEBERRY LANE MARSTONS MILLS, MA 02648 Date of Inspection: 6/25/02 Name of Inspector: (please print) JOHN GRACI Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. UOk2119 TEATICKET, MA.02536 Telephone Number: 508-564-6813 PAX 508-'564-7270 CERTIFICATION STATEMENT , 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: X Passe'st _ Condfhe es _ Needluation by the Local Approving Authority Fails Inspector's Signature: ki4Date: 6/25/02 The system inspector shall submhis inspection report to the Approving Authority(Board of Health or DEP)within 30 days ofcompleting this inspesystem 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 oftice of the DEP. The original should be sent to the system owner and copies sent to•the buyer, if applicable,and the approving authority. Notes and Comments ; SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE._, ****This report only describes conditions_at the time of inspection and under the conditions of use at that lime.This inspection does not address how the system will perform in the future under the same or different conditions of use. �I Tilly 5 Incnrrlinn hnrm (,/i v?finn I 1 Page 2 of OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 68 GOOSEBERRY LANE MARSTONS MILLS,MA 02648 Owner: AMY & VINCENT MARINO Date of Inspection: 6/25/02 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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: SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. 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 recair,�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. n/a 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`brtank 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 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 unevep.distribution box. System will pass insp�.tion if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a 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: n/a F Page 3 of I 1 g •�� OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A x CERTIFICATION(continued) Property Address: 68 GOOSEBERRY LANE MARSTONS MILLS,MA 02648 Owner: AMY & VINCENT MARINO Date of Inspection: 6/25/02 ' C. Further Evaluation is Required by th'e Board of Health: _ Conditions exist which require furtherevaluation 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`Boilrd`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 I of a public water supply. _ The system has a septic,tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance n/a "This system passes if the well`water'analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is.equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be a`tfached to this.form. 3. Other: 5 Z Page 4 of OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 68 GOOSEBERRY LANE MARSTONS MILLS, MA 02648 Owner: AMY & VINCENT MARINO Date of Inspection: 6/25/02 D. System Failure Criteria•a,p.plicable to all systems: You must indicate"yes"or"no"fo,each of_the following for alLinspections: Yes No X Backup of sewage into facilit.y or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to`the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool = ;;.,, . X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool.is less than 6"below invert or available volume is less than '/z day flow _ X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped n/a. X Any portion of the SAS,cesspool or privy is below high ground water elevation. _ X Any portion of cesspool or`privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privyy4 within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis,performed at a DEP certified laboratory for:coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this for (Yes/No)The system fails. 141ave'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 now of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systemsiiil addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200.feet of a tributary to a surface drinking water supply X the system is located,in a nitrogen.sensitive area(Interim Wellhead Protection Area—I WPA)or a mapped Zone It of a public water supply well If you have answered yes"to anyquestion in Section E the system is considered a significant threat,or answered "ycs" in Section D above the large sys.(66 has tailed.The owner or operator elf 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. d Page 5 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURF.ACE.SE_WAGE DISPOSAL SYSTEM INSPECTION FORM PART B `.' CHECKLIST Property Address: 68 GOOSEBERRY LANE MARSTONS MILLS,MA 02648 Owner: AMY&VINCENT MARINO Date of Inspection: 6/25/02 Check if the following have been done.;You must indicate "yes" or"no" as to each of the following: ti. Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period`? X 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 available note as N/A) X _ Was the facility or dwellidg ibspected for signs of sewage back up`? X _ Was the site inspected'for signs of break out'? X _ Were all system components,excluding the SAS, located on site'? X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of constfuction,idimensions,depth of liquid,depth of sludge and depth of scum'? X _ 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 rmation. For example,a Ian at the Board of Heal th. Existing info , X _ p p g X _ Determined in the field`(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CM 15.302(3)(b)] ,. t it yicl `rz.. 5 Page 6 of 11 s OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM "INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 68 GOOSEBERRY LANE MARSTONS MILLS,MA 02648 Owner: AMY & VINCENT MARINO Date of Inspection: 6/25/02; FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 2k; ,.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: 2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no):.NO Seasonal use: (yes or no): NO €4 _ Water meter readings, if available(fast 2 years usage(gpd)): UJW-Q Q Sump pump(yes or no): NO 0( - 'j U,OD-0 Last date of occupancy: n/a Y COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CM 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the,inspection.(yes or no): NO If yes, volume pumped: n/agallon's How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy ; _Shared system(ycs or no)(ifycs,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the'DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1965 BY OWNER Were sewage odors detected when arriving at the site(yes or no): NO .ii Page 7 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE-SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 GOOSEBERRY LANE MARSTONS MILLS, MA 02648 Owner: AMY& VINCENT MARINO Date of Inspection: 6/25/02 BUILDING SEWER(locate on site plan) Depth below grade: 30" Materials of construction:_cast iron _40 PVC Xother(explain): ORANGEBURG Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting, evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on:site plan) Depth below grade: 24" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a ls^age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 6' X 6' BLOCK CESSPOOL"y Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 4" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to Bottom of outlet tee or baffle: 14" How were dimensions determined: MEASURED Comments(on pumping recommendatio-ns, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): CESSPOOL AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP:_(locate on site plan) 3 1 Depth below grade: n/a Material of construction:_concrete metal_fiberglass_polyethylene_other(expla'-a): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottorn of outlet tee or baffle: n/a Date of last pumping: n/a l Comments(on pumping recommendations, inet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a 41i 7 Page 8 of 1 1 I, " OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 GOOSEBERRY LANE MARSTONS MILLS, MA 02c 48 Owner: AMY & VINCENT MARINO Date of Inspection: 6/25/02 TIGHT or HOLDING TANK:,(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a 3 Material of construction:_concrete metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons :.. Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:_(if present mu'st.be opened)(locate on site plan) Depth of liquid level above outlet invert: n/a 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.): n/a PUMP CHAMBER: _(locate:on site plan) t Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a fit:. • ti i j S 1tJ 4 t,S1 • .-. i !I AI I'. R Page 9 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 GOOSEBERRY LANE MARSTONS MILLS, MA 02648 Owner: AMY&VINCENT MARINO Date of Inspection: 6/25/02 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type n/a leaching pits, number: 0 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a „/a leaching trenches, number, length: n/a n/a leaching fields, number: nla 6' X 6 BLOCK CESSPOOL overflow cesspool, number: q n/a S , innovative/alternative system f A Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): OVERFLOW IS STRUCTURAL> Y SOUND AND FUNCTIONING PROPERLY.TSYSTEM SHOWS NO SIGNS OF FAILRE.THERE IS 6" OF LEACHING LEFT IN IT. BOTTOM IS AT 10'. CESSPOOLS: (cesspool must be pumped as,part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or 6):-NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) 3 Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs'of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a tl F, ' ail 4 Page 10 of OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 GOOSEBERRY LANE MARSTONS MILLS,MA 02648 Owner: AMY & VINCENT MARINO Date of Inspection: 6/25/02 f 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. v,<<L <;, r AB 3 C t i Y s in Page I I of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C `SYSTEM INFORMATION(continued) Property Address: 68 GOOSEBERRY LANE MARSTONS MILLS, MA 02648 Owner: AMY &VINCENT MARINO Date of Inspection: 6/25/02 b SITE EXAM c t� r _Slope _Surface water _Check cellar Shallow wells ' Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators,installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 12+ FT. 1- t f f . AL CommonweaM of Massachusetts John Grad Executive Office of Er Mronmen rtai Affairs D.E.P. Title V Septic hLspector Department of P.O. Box 2119 ► , Environmental Protection �- 36 Teatick (508) 564-6813 A� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION NOV <,'` 7 Property Address: 68 Gooseberry Lane Marston Mills Address of Owner: 1?•. 4 15 Date of Inspection:11107/95 (If different) '" re-', Name of Inspector:John Grad Hall 'c:"�•', v Company Name,Address and Telephone Number: ✓� CERTIFICATION STATEMENT 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X Passes _ Conditionall Passes _ Needs Fu er Ev luation By the Local Approving Authority Fails Inspector's Signature: Date: 1iam The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. 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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B,C,or D: A] SYSTEM PASSES: X I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined", explain why not.) The septic tank is metal, cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11115195) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 1 e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 68 Gooseberry Lane Marston Mills Owner: Hall Date of Inspection:11/07/96 _ Sewage backup or breakout or high static water level observed in the distribution box is due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced _The system required pumping more than four 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 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public water supply well. The system has aseptic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm. 3) OTHER D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage in facility or system component due to an 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 cesspool. SAS is in hydraulic failure. (revised 11/15195) 2 , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 69 Gooseberry Lane Marston Mills Owner: Hall Date of Inspection:11107196 D] SYSTEM FAILS(continued) 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). Numbers of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 11115195) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CH ECLIST Property Address: 68 Gooseberry Lane Marston Mills Owner: Hall Date of Inspection:11107/96 Check if the following have been done: x Pumping information was requested of the owner,occupant, and Board of Health. x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. I GaAs built plans have been obtained and examined. Note if they are not available with N/A. x The facility or dwelling was inspected for signs of sewage back-up. x The system does not receive non-sanitary or industrial waste flow. x The site was inspected for signs of breakout. x All system components,excluding the Soil Absorption System,have been located on the site. x The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge, depth of scum. x The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. x The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11115195) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 68 Gooseberry Lane Marston Mills Owner: Hall Date of Inspection:11107196 FLOW CONDITIONS RESIDENTIAL: Design flow: 0 gallons Number of bedrooms: 1 Number of current residents: 1 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings,if available: nla Last date of occupancy: n1a COMMERCIAL/INDUSTRIAL: Type of establishment: ►da Design flow:0 gallons/day Grease trap present:(yes or no) No Industrial Waste Holding Tank present: (yes or no) No Non-sanitary waste discharged to the Title 5 system: (yes or no) No Water meter readings,if available: n1a Last date of occupancy: n1a OTHER:(Describe) n1a Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System has not been pumped in the last two years. System pumped as part of inspection:(yes or no)�'t�e5 If yes,volume pumped: 0 la;lons Reason for pumping: TYPE OF SYSTEM X Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records,if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source information: 35 years Sewage odors detected when arriving at the site:(yes or no) No (revised 11115195) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contlnued) Property Address: 68 Gooseberry Lane Marston Mills Owner: Hail Date of Inspection:11107196 SEPTIC TANK: (locate on site plan) Depth below grade: n1a Material of construction:X concreate_metal_FRP_other(explain) Dimensions: n1a Sludge depth:rda Distance from top of sludge to bottom of outlet tee or baffle: n1a Scum thickness:rda Distance from top of scum to top of outlet tee or baffle:n1a Distance form bottom of scum to bottom of outlet tee or baffle:n1a Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) Na GREASE TRAP:_ (locate on site plan) Depth below grade: Na Material of construction: _concrete_metal_FRP_other(explain) Dimensions: rda Scum thickness:rda Distance from top of scum to top of outlet tee or baffle:n1a Distance from bottom of scum to bottom of outlet tee or baffle: n1a Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) n1a (revised 11115195) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6s Gooseberry Lane Marston MIIIs Owner: Hall Date of Inspection:11107196 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: rila Material of construction:_concrete_metal_FRP_other(explain) Dimensions: n1a Capacity: n1a gallons Design flow: rila gallons/day Alarm level: n1a Comments: (condition of inlet tee, condition of alarm and float switches,etc.) n1a DISTRIBUTION BOX: (locate on site plan) . Depth of liquid level above outlet invert: n1a Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.) n1a PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) n1a (revised 11/15195) 7 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 68 Gooseberry Lane Marston Mills Owner: Hall Date of Inspection:11/07/96 SOIL ABSORPTION SYSTEM (SAS):X (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present, explain: Na Type: leaching pits,number: n1a leaching chambers,number:n1a leaching galleries,number: n1a leaching trenches,number,length: Na leaching fields,number,dimensions:n1a overflow cesspool,number:6'x6'block Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) The leach pit is structurally sound and functioning property.The pit was empty at the time of the inspection. CESSPOOLS:X (locate on site plan) Number and configuration: one Depth-top of liquid to inlet invert: 2' Depth of solids layer: 6. Depth of scum layer: 3' Dimensions of cesspool: 6'x6' Materials of construction: block Indication of groundwater: none inflow(cesspool must be pumped as part of inspection) Na Comments:(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.) The cesspool is structurally sound.Recommend pumping system everyone year for maintenance. PRIVY:_ (locate on site plan) Materials of construction: n1a Dimensions: n1a Depth of solids: Na Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PrivyComments (revised 11115195) a . . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 Gooseberry Lane Marston Mills Owner: Hall Date of Inspection:11/07196 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' IZAI CNA 3a� DEPTH TO GROUNDWATER Depth to groundwater:12 feet method of determination or approximation: IISGS Maps and Charts (revised 11115195) S� ' TOWN OF BARNSTABLE. 6�, e. LO ATION COOS r C� 1n ti0 SEWAGE # � VILLAGE 04�5 S yr\ ASSESSOR'S MAP &LOT /®7, s d7 INSTALLER'S NAME&PHONE NO. (' SEPTIC TANK CAPACITYcr LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDEROR(�O �� (( PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet 1 Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by � }: ��' �2'6 ���� � � . �f �/ ��� i°�-?S� �i`�o RACE LANE LOCUS DATA ..: CgKESI CURRENT OWNER MICHAEL CURTIS N or CHRISTINE CURTIS m 149 LOCUS PLAN REFERENCE 138-25 o z IDEED REFERENCE 15606-70 _ LOT 50 EXISTING LEACHING PITS TO BE PUMPED, CRUSHED & ZONING DISTRICT RF / GP I r ! AND ABANDONED IN LOT 65 28 ROUND CONCRETES ACCORDANCE WITH TITLE 5. „ BOUND FOUND.,, b LOCUS MAP FLOOD ZONE C /r Ns 8T0 NOT TO SCALE: I 0 00 W 100.00 ASSESSORS MAP 102 I I I r I 14 0109 PARCEL 73 I I / OVERLAY DISTRICT ZONE If I I , , I/ LOT 51 8 LOT AREA 10,575f S.F. I I 10,575 t S.F.io / S SITE & SEWAGE REPAIR PLAN ► � � r �� LOT 64 �68 I I a , GOOSEBERRY L A NE I 13 /�PORCH/ / I IN I W o W MARSTONS MILLS I I M ( 0W I Q o / oa o DATE: APRIL 28, 2014 I Q N I #68 aZ , EXISTING p DECK .3 o I r ^ 14.0 11.5 PROPOSED 14 x22 2DWELLINGM 08 H Z - LEACHING FIELD OWNER/APPLICANT: I .�W_ — 85 S o - #2 MICHAEL �c CHRISTINE N I , N CURTIS I I \20 s I 23.8' \ `— GAS D.T.H. 55 GREEN STREET LEI CESTER, MA 01524 %°s I o o'OBOX D SHEET 1 OF 2 j UTILIT��( — — _ J POLE I `-' � N 87*00'00" W 100.00' SHED PREPARED BY: EAS SURVEY, INC. \-,NOFhJ4 L'OT 52 141 R T. 6 A o`'� EDWAARD9ctiGs� 1500 L 0 T 6,.3 0 20 30 40 SANDWICH M A 02563 BENCHMARK F PROPOSED STONE �' CORNER OF CONCRETE GALLON SEPTIC ' �No. 28980 BULKHEAD. ELEV=87.00 TANK PH. (508) 888-3619 GRAPHIC SCALE: • CELL (508) 527-3600 °� A 1 INCH = 2 0 FEET EAS.SURVEY©YAHOO.COM Ll�' "' SYSTEM DESIGN "f RAISE COVERS TO WITHIN 6" OF FINISH GRADE OBSERVATION PORT TO EXISTING DESIGN FLOW TCF = 87.00 FINISH GRADE GRADE / SCREW ON CAP BEDROOMS AT 110 GPB/D Z22 GPD GRADE 86.30 ELEV. 85.00 FINISH GRADE \ \ ELEV. 85.10 ELEV. GRADE REQUIRED SEPTIC TANK GROUND ELEVATION 85.00 9, ///ate /�� � �///ate- �/ a� � �� a� �� �� ___220 x_2 _ 440 GAL. � �i TtE 22' ®S=0.105 M TOP ELEV 82.30 ENDS SEPTIC TANK PROVIDED = _-1,400_GAL. EXISTING 4" PVC 12' CADS=0.033 y SCH 40 2 MI-"N-3'rMAX 4" PVC SCH 40 13" CADS= 0.01 S=0.005 (EXISTING TO REMAIN) iNV.= , , ° ° °°°°°° °°°°°°, ° ° ° ° ° �,° ° ° ° °°°° z . N SIZE OF LEACHING FACILITY REQUIRED �,- INV•= 85.00 INV. ? ° ° ° ° ° ° , ° ° ° ° ° ° °°°°° °°,°°°,°° ° 82.70 10"TEE 14"TEE _ ° ° o o ° ° ° ° ° ° ° ° ° ° ° ° DESIGN PERC RATE _ _<_? / EllTO REMAIN °°°°°°°°°°°°° o ° ° o ° o o o°o°o°o°o°o°o° °o°o°o o° o _ t. 5'-7„ INSTALL 82.50 g' �` I° °°e°° ° ° o°°o°°°° ° ° ° , ° ° ° ° ° o ° ° _wIIN. INCH GAS BAFFLE 3 OUTLET 14' x 22 LEACHING FIELD LONG TERM APPL. RATE_0.74_GPD/S.F. 4 BAND STEEL 4'-61/2 4'-1" LIQUID LEVEL H-10 DB3 CONNECTOR INV.=82.10 INV.=81!80 INV.=81.69 L81.19 SIZE OF LEACHING SYSTEM PROVIDED: INV.=81.93 1 _I iv o 220 _ 0.74 SF/GPD 298 S.F. MIN. REQ. DATUM: BOTTOM (3) 4" PIPES 5' ON CENTER n 'n USING A 14' x 22' LEACHING FIELD ° ° ° ° ° =78.15 VERTICAL DATUM: PROPOSED 1,500 GALLON ELEV.74.0 MSL± / BARNSTABLE GIS SEPTIC TANK SET ON LEVEL OBSERVATION PORT TO WITH A MINIMUM OF 6" STONE UNDERNEATH BENCH MARK USED: STABLE BASE CORNER OF CONC. BULKHEAD GRADE / SCREW ON CAP 14' x 22' = 308 S.F. ELEVATION 87.00 CONSTRUCTION NOTES: #14-0109 FILTER FABRIC 308 x 0.74 G/SF = 228 GPD 1. CONTRACTORS / INSTALLERS SHALL VERIFY GRADES ANDo o 0 o 'o 0 0'0°00 °°°o° 0 0 o 0 o 0 0 0 00000°000 0 0 0 ELEVATIONS AND SITE CONDITIONS PRIOR TO COMMENCING o ° °o° °g°$o$ng°o °o° °oo°a e o 228 GPD PROV > 220 GPD REQ.= 8 GPD RES. iA o o o 0 0 0 0 0 oo°o°o° SITE 8c SEWAGE WORK ON THE SITE. °o ° ° ° ° ° „° ° , °°°oaoa000 0 REPAIR PLAN 2. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE o °e°°° °°°°° ° °°o ° o- :o°°°°° :o.... NO (GARBAGE DISPOSAL / GRINDER ALLOWED) WITH DEEDED OR ZONING REGULATIONS. OWNER / APPLICANT 2' 5' 5' 2' IS TO OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. P#14330 #t�U3. VEHICULAR TRAFFIC, PARKING OF VEHICLES AND PLACING v MATERIALS OVER THE SEPTIC TANK, DISTRIBUTION BOX AND 14,0' D.T.H. #1 ib D.T.H. #2 ib GOOSEBERRY LANE S.A.S. AREA IS PROHIBITED END VIEW DATE: 4-17-2014 DATE: 4-17-2014 GROUND ELEV. 85.3 GROUND ELEV. 85.0 GENERAL NOTES: I CERTIFY THAT I AM CURRENTLY APPROVED BY THE NO GROUNDWATER NO GROUNDWATER IN 1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. DEPARTMENT OF ENVIRONMENTAL PROTECTION TO CONDUCT TITLE V AND THE TOWN OF BARNSTABLE RULES AND REGULATIONS SOIL EVALUATIONS AND THAT THE RESULTS OF MY SOIL A M A R S TON S MILLS FOR SUBSURFACE DISPOSAL OF SEWERAGE. EVALUATION ARE ACCURATE AND IN ACCORDANCE WITH 310 LOAMY SAND LOAMY SAND 2. AT LEAST ONE ACCESS POINT OVER TANK TEES SHALL BE CMR 15.100 THROUGH 10YR 4/3 10YR 4/3 DATE: APRIL 28, 2014 ACCESSIBLE WITHIN 3" OF FINISH GRADE, WITH ANY REMAINING 4" 6" ACCESS PORTS BROUGHT TO WITHIN 12 OF FINISH GRADE. _ __ ___ ___ ______ B 8 3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE EDWARD A. STON CE FIED SOIL EVAL ATOR LOAMY SAND LOAMY SAND OWNER APPLICANT: CAPABLE OF WITHSTANDING H-10 LOADING UNLESS 7.5YR 6/6 7.5YR 6/6 OTHERWISE SPECIFIED. 28" 30" M I C H A E L 8C C H R I S TI N E 4. THE EXCAVATION CONTRACTOR SHALL VERIFY THE LOCATION i OF EL. = 83.0 EL. = 82.5 OF ALL UTILITIES PRIOR TO ANY EXCAVATION. �� gq` DTH #1 ia INDICATES DEEP CU R TI S 5. ANY MASONRY UNITS USED TO BRING COVERS TO GRADE �o� DA D `yG� TEST HOLE OR WITHIN 6" OF GRADE SHALL BE MORTARED IN PLACE. a� C C 42" #5 5 GREEN STREET 6. FINISH GRADE SHALL HAVE A MINIMUM OF 0.02 FEET PER F H R. MEDIUM SAND MEDIUM SAND FOOT OVER THE S.A.S. AND DISTRIBUTION BOX. „ INDICATES 2.5Y 7/6 2.5Y 7/6 LE I C E S TE R MA 01524 7. SEPTIC TANK SANITARY TEES SHALL BE CONSTRUCTED OF ,P o P-1 42 PERC TEST SCHEDULE 40 PVC AND SHALL EXTEND A MINIMUM OF 6" ABOVE FG/STERN THE FLOW LINE AND SHALL BE ON THE CENTERLINE AND g a NO MOTTLING SHEET 2 OF 2 LOCATED DIRECTLY UNDER THE CLEAN OUT MANHOLES. AN TAR NO WEEPING 8. THE INLET PIPE INVERT ELEVATION SHALL BE NO LESS THAN + PREPARED BY: 2 INCHES NOR MORE THAN 3 INCHES ABOVE THE INVERT =mop. 132" INDICATES ADJ. GROUNDWATER NO G.WATER NO G.WATER ELEVATION OF THE OUTLET PIPE.. 9. THE SEPTIC TANK SHALL HAVE A MINIMUM COVER OF 9 INCHES` NO OBS. GROUNDWATER EL. = 74.3 132" EL. = 74.0 132" E A S SURVEY, INC. 10. THE OUTLET SANITARY TEE SHALL BE EQUIPPED WITH A GAS ' B.O.H. BAFFLE 4 INCHES IN DIAMETER AND, CONSTRUCTED OF 4 PVC NO OBSERVED GROUNDWATER 141 R T. 6 A DONNA MIORANDI 11. ALL PIPES SHALL BE SCHEDULE 40 PVC SEWER PIPE.AND SANDWICH M A 02563 SHALL BE SLOPED 1/4 INCH PER FOOT MIN. EXCEPT FOR THE DEPTH TO BOTTOM OF HOLE 11'- ' SOIL EVALUATOR FIRST TWO FEET OUT OF THE DISTRIBUTION .BOX WHICH SHALL ; ED. STONE BE LEVEL VARIANCES REQUESTED BACKHOE OPERATOR. PH. (508) 888-3619 12. CHANGES OR REVISIONS TO SEPTIC DESIGN REQUIRE NOTIFICATION NONE SOILEARTH TYPE: &1STONE (CHRIS) CELL (508) 527-3600 TO EAS SURVEY INC. FOR B.O.H. AND DESIGN ENGINEERS.REVIEW AND APPROVAL. PERC RATE: <2 MIN. PER INCH EAS.SU R VEY©YAH OO.COM 13. MAGNETIC TAPE ON ALL COMPONENTS. LOADING RATE: 0_74 GAL/SF/MIN$ ,