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Home My WebLink About0102 GOOSEBERRY LANE - Health 102 Gooseberry Lane - - _ _ _ ----- — -----------_-- Marstons Mills A= 102 — 070 II I f Commonwealth of Massachusetts �� " `J Title 5 Official Inspection Form 19 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 102 Gooseberry Lane r Property Address P Kurtoglu r„> Owner Owner's Name '• information is required for every Marstons Mills Ma 10/17/18 . page. Cityrrown State Zip Code Date of Inspection �►� I'*:a 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 Chad hathaway key to move your Name of Inspector cursor-do not HPS use the return Company Name key. P.O.Box 151 � Company Address Forestdale Ma 02644 City/Town State Zip Code few 774 274 2581 12866 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 10/17/18 Inspector's S 5plure Date The system inspector shall It 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 r� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �o 102 Gooseberry Lane Property Address Kurtoglu Owner owner's Name information is required for every Marstons Mills Ma 10/17/18 page. Cityrrown 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: ® I have not found any information which indicates that any of the failure criteria described in 310 CM 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Septic tank was pumped during inspection for maintenance. pump every 2 years undeer normal use. Septic in working condition no failure criteria was encountered 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): i t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 102 Gooseberry Lane Property Address Kurtoglu Owner Owner's Name information is required for every Marstons Mills Ma 10/17/18 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.7/26/201 S Title 5 Official Inspection Form:Subsurface Sewa ge Disposal System•'Page 3 of 18 c Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 102 Gooseberry Lane Property Address Kurtoglu Owner Owner's Name information is required for every Marstons Mills Ma 10/17/18 page. Cityrrown 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 ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 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 102 Gooseberry Lane Property Address Kurtoglu Owner Owner's Name information is required for every Marstons Mills Ma 10/17/18 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 ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Yz day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia q nitrogen and nitrate nitrogen is equal to or less than 5 PP m 9 9 provided that no other failure criteria are triggered.A co of the analysis p s 99 PY Y and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® 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 Commonwealth of Massachusetts ,F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 102 Gooseberry Lane Property Address Kurtoglu Owner Owner's Name information is required for every Marstons Mills Ma 10/17/18 page. Cityrrown 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 ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 102 Gooseberry Lane Property Address Kurtoglu Owner Owner's Name information is required for every Marstons Mills Ma 10/17/18 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No. Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 i Commonwealth of Ma ssachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4 102 Gooseberry Lane k Itz ' - Property Address Kurtoglu Owner Owner's Name information is required for every Marstons Mills Ma 10/17/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No 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: pumped at time of inspection by Debarros Septic Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity tank size q y pumped determined? Reason for pumping: maintenance(over Due) t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts - (o Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 102 Gooseberry Lane Property Address Kurtoglu Owner Owner's Name information is required for every Marstons Mills Ma 10/17/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 2008 Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 5. Building Sewer(locate on site plan): Depth below grade: 2'feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 20+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): no signs of poor venting or leaks t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 r Commonwealth of Massachusetts +� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 102 Gooseberry Lane •V Property Address Kurtoglu Owner Owner's Name information is required for every Marstons Mills Ma 10/17/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1.5feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 gal H10 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 1500 gal Dimensions: Sludge depth: 10" Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 8" Distance from top of scum to top of outlet tee or baffle 2" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? tape and sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): tank was pumped during the inspection 10/17/18 pump every 2 years for maintenance. tees in place. no visable cracks or leaks t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 I Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 102 Gooseberry Lane Property Address Kurtoglu Owner Owner's Name information is required for every Marstons Mills Ma 10/17/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: N/A feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 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: N/A 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 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 c °•� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 102 Gooseberry Lane Property Address Kurtoglu Owner Owner's Name information is required for every Marstons Mills Ma 10/17/18 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: N/A 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): Depth of liquid level above outlet invert 0" 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.): Dbox level no signs of backing up Dbox has no visable decay or leaks. Partial riser on Dbox cover to within 2 feet of grade t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 c Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 102 Gooseberry Lane Property Address Kurtoglu Owner Owner's Name information is required for every Marstons Mills Ma 10/17/18 page. Cityrrown 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.): *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: Inspected through Dbox and probed stone no evidence of hydraulic failure Type: ❑ leaching pits number: C® leaching chambers number: 1 500 gal L. i ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: i ❑ 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 102 Gooseberry Lane Property Address Kurtoglu Owner Owner's Name information is required for every Marstons Mills Ma 10/17/18 page. Cityrrown 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.): 1 500 gal L.0 with 4'of stone around it 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 102 Gooseberry Lane Property Address Kurtoglu Owner Owner's Name information is required for every Marstons Mills Ma 10/17/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 102 Gooseberry Lane Property Address Kurtoglu Owner Owner's Name information is required for every Marstons Mills Ma 10/17/18 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 O 0 a I 3i ' p A IL_I____3 3) 33 l -3 a t5insp.doc•rev.7/2612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 f Commonwealth of Massachusetts �n Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 102 Gooseberry Lane Property Address Kurtoglu Owner Owner's Name information is required for every Marstons Mills Ma 10/17/18 page. CityrFown 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: 30'+feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: town GIS mapping You must describe how you established the high ground water elevation: lot El. over septic el. 72 low in immediate area 42'. Bottom of SAS 7' below grade Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 102 Gooseberry Lane Property Address Kurtoglu Owner Owner's Name information is required for every Marstons Mills Ma 10/17/18 page. Cityfrown 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 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 LOCATION OD?- SEWAGE#Zzrg— ed VILLAG �, / ASSESSOR'S MAP&PARCEL*fOZ �U t �i� r�6�S /�? INSTALLER'S NAME&PHONE NO. o / �pt � /iUB= SEPTIC TANK CAPACITY /jGV LEACHING FACILITY:(type) 1ZAGII MgM&X (size) V NO.OF BEDROOMS OWNER PERMIT DATE: ^�'�j�'��q�' COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility feet Private Water Supply Well and Leaching Facility(if any wells exist on site or within 200 feet of leaching facility) feet Edge of Wetland and L'aching Facility(if any wetlands exist within 300 feet of leaching:facility). feet FURNISHED BY � r �r' � �� ® �.� 3�` �� TOWN OF BARNSTABLE LOCATION l t�Z 6.00Sc gpRRK LA w SEWAGE # VR.LAGE't4\MZ570V45 MU-J ASSESSOR'S MAP &LOT (0Z 70_ INSTALLER'S NAME&PHONE NO. . SEPTIC TANK CAPACITY r)oh e LEACHING FACILITY: (type) I OGk CeSSQOD (size) G NO.OF BEDROOMS BUILDER OR OWNERGEO in Verg Du RoId PERMUDATE: COMPLIANCE DATE: Separation.Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by PCV ` Tech 1112107 LEACH P[T I W E Ll i i EXIS`ING \ll DWELLING r # IZ2 W _Z ' J �I W. W GOOSEBERRY L /�NE Al; N. d oE2j" 2_6Z_ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZIppYication for Migogal *pgtem (Con0truction Permit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) [:].Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address,and Tel.No.40e— 00 6 Assessor's Map/Parcel 07— Installer's Name,Address,and Tel.No.��1~�� 9di�D.S✓�' � Designer's Name,Address and Tel.No.Z?4v/tO ;9', M9f 8A) Type of Building: Dwelling No.of Bedrooms 2 Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 2-2-0 gpd` Design flow provided 2 3 '1 , 76 gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank �. G ® Type of S.A.S. C,-L , C Nn.,-$,T Description of Soil Nature of Repairs or Alterations(Answer when applicable) ! / adlf/,L,� .�-1�'L_b��,o-/�✓� ?, Date last inspected: Agreement: The undersigned agrees to ensujhonstruction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Titlea Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Health. Signed Date Application Approved by s. Date Application Disapproved by: Date for the following reasons Permit No. C_,::� Date Issued •x • �� .x ..,:.�, -F ..,i ...ry n, v....• . _., n•-^�-'+'a +^s,...E r .. r 41 • �j� C � G / ..�NO. •LU60' !fit? -- Fee �od THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes pplication for Misspozal *p.5tem Con0truction Permit m Application for a Permit to Construct( ) Repair X Upgrade( ) Abandon( ) ❑.Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address,and,Tel.No.�dGe' �U15aD 1 Assessor's Map/Parcel#/C7Z .4* /az- �lj�«y X n Installer's Name,Address,and Tel.No.�G t✓I�M�D�I f' Designer's Name,Address and Tel No.V 4Y/Q 25. m4f pA) 46S- ?33 77 Type of Building: Dwelling No.of Bedrooms 2. Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures i Design Flow(min.required) Z ZO gpd~ Design flow provided 2 3 '1 , 776 gpd Plan Date Number of sheets Revision Date Title f Size of Septic Tank !�G O Type of S.A.S. t- q�2 j Description of Soil �A f ' �� S Nature of Repairs or Alterations(Answer when applicable) � /� 9,/f//j,•' •• � iG 7-4 e7,C„ / Sn 91PI/G, /-1_4G// e4l^at ' Date last inspected: Agreement: d The undersigned agrees to ensure the onstruction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of he Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this VrdAf Health. a Signed _ ' 'n Date K_�/� Application Approved by - H /�) r Date - Application Disapproved by: r Date for the following reasons d t ZOOS Permit No. ! o S 2,0 Z' Date Issued ———————————————————————————————------------- THE COMMONWEALTH OF MASSACHUSETTS i BARNSTABLE, MASSACHUSETTS + Certificate of Compliance .. THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ✓) Upgraded ( ) Abandoned( )by (G g o 2 G,E i, 30 Q-b '+at W Z C:,�o6 S e $F e g-( L&.4 E INIkOrsT6t4V I LL has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permil.No. Zoofi" ZO 2 dated S (" G" Z0061 Installer sco-y\ r� M a ��1..to Designer b"y I �. �`� A SbN #bedrooms Approved design flow 2 O gpd The issuance of this permit shall n/�t be con trued as a guarantee that the syst m�fu fibn as designed. Date / 70 Inspector M. U,...r„_ -------------------------------------------- No. W O:9" 25 Z Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS &5po5al �bp!gtem Construction Permit r. Permissioi'is,hereby granted to Construct ( ) Repair ( Upgrade ( ) Abandon ( ) 'S stenilocated at �a-g-.l �q 1g Y S`tU.v C. and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. j Provided: Construction must be completed within three years of the date of this pe tt. ' Date �' " Z 0 O Approved by Mai 20 08 02: 51p p. 1 ' '(awn of Barnstable ;Fta ReguhltorY Services 'Thom as T'. Ceiler, Director Public Health DivisiOn MAM 0 'I'laomas MrKc:axi,Director 200Main Street, Ily.,atueis,MA 026)01 Fax: 50$_'/90-63014 508-862-4644 Izastaller &Pesi rasa CertifiCati0al F0rn1 6 45A Installer-taller: Eton �----.. Address: Address.G. _ — -- J J -e' was issur-d a pennit to install a (d1 e) (install ) --77 _based on a design draw"10y se,plic system at 107, - (address) dated ' i (designer) ' 1/�Jccjtt.jfy that the septic systenl referenced avove was installed sul�statiti^lly a.ccca.rdin� to c design m , which ay Include minor approved changes such as lateraa relocation of the d.:.stribaation box and/or septic tank_ I certify',that the septic system referenced above was installed witla'mn i changes (i.e. greater than 10' lateral relocation of then SAS or any veartieal relocation of any component of the septi�;�system)but in accordance with State &Local Regtilations. Pkua rcvis7oy,4 r r certified as-bilt by designer to follow. IbAV (lrast�rller's kP ature) MASONrM �y s �o.�oss o afore) (Affix• e t��'s St�i�Here) (] Cr S Sign PUBLIC f ASE �gE� TU BA IeIC��l��.F J[Td:,�L°�.`H DIVISION. L1''WFI14IC..A,.— OF CO � ��. v�rs�,x, �(��.a�or SSUED �livrH. B®x� ��®> �� , ,wpm BUILD CAX-0 ARE REC°f YWA) uy ji ,:lS��; S�AI�EE PU�LI ALTA l)Y'V1SI`O?v�e Q: certification Form Bk 22921 P 69 -027256 05-20-2008 of 10 2 25u DEED RESTRICTION WHEREAS, George Dubord_of 130 Arrowhead Place, Stratford, CT 06497 is the owner of 102 Gooseberry Lane, located at Marstons Mills MA duly recorded in Barnstable County Registry Of Deeds in Plaa-Book_6801 , Page_193 ; Assessors Map 102, Parcel 070. WHEREAS, _George Dubord as the owner 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 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 building permit for the construction of a single family home on this 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 document, deedr NOW, THEREFORE, Goerge Dubord does hereby place the following restriction on his above-referenced land in accordance with his 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. _102 Gooseberry Lane_ay have constructed a house containing no more than two (2 ) bedrooms. Executed as a sealed instrument day of s't oo'? Owner's dignature CO ONWEALTH OF MASSACHUSETTS a3lsiga � w 3ar ss 18311b'Ad00 3n N- d l d , 20 0� SQS3a�o Aa1s"_--- d Then p.0 pally appeared the above-named Au.Nnoo aiedlsr,aba known to me t be the person who executed the foregoing instrument and acknowled ed the sam to b%114_�!) Zreeact and deed, before me, Notary Public DONI AJ.SCHULZE M commission expires: NuWy Public r` Q.1V YCom a waftof Macsechuaette rirM m : (date) DeOMftr6,2013 BARNSTABLE REGISTRY OF DEEDS DEED RESTRICTION WHEREAS, George Dubord of 130 Arrowhead Place, Stratford, CT 06497 is the owner of 102 Gooseberry Lane, located at Marstons Mills , MA duly recorded in Barnstable County Registry Of Deeds in Plan Book_6801 , Page_193 ; Assessors W Map 102, Parcel 070. HEREAS, _George Dubord as the owner 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 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 building permit for the construction of a single family home on this 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 document, deedr NOW, THEREFORE, Goerge Dubord does hereby place the following restriction on his above-referenced land in accordance with his 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. _102 Gooseberry Lane—ay have constructed a house containing no more than two (2 ) bedrooms. Executed as a sealed instrument day oft�I��' Owner's dignature COMMONWEALTH F MASSACHUSETTS ss J.� 20 OF Then p r nally appeared the above-named known to me t be the person who executed the foregoing instrument and acknowled ed the sam .to be . free act and deed, before me, Notary Public DONItA J•SCHI+LZE My commission expires: >UvYEuy PublicCommme,ft Uf MaGuchusetts My Cimmiaon Expires (date) 4eo=Wre,2013 Town of Barnstable P# Department of Regulatory Services Public Health Division Date Z//,�w -•—�y�._. i63y h u� 200 Main Street,Hyannis MA 02601 Date Scheduled AO Time Fee Pd. - Soil Suitability Assessment for Sewage Disposal Performed By. AA-A 0 6• V V I�I Witnessed LOCATION& GENERAL INFORMATION r .9 Location Address Owner's Name J ) � 10 2 Goo 6�f Lo�� V I s y t 5 Address IYl o►r5.Fo aS /ol, Assessor's Map/Parcel: O 2 ,o—7 C1 Engineer's Name 1)0\1,t O So n NEW CONSTRUCTION REPAIR Telephone# 5�8 8 33- 117 /c.,n SO 8 1y-,� Land Use Slopes(�o) `� Surface Stones Distances from: Open Water Body_1__11� ft Possible Wet Area __� ft Drinking Water Well� ft Drainage Way / ft Property Line / ft Other ft SKETCH:(Street name,dimensions of ll exact locations of test holes&pert tests,locate wetlands in proximity to holes P tY ) ��k2� loo Parent material(geologic) � Depth to Bedrock t Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater DETERNIINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: __— _ in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in, Groundwater Adjustment fr. Index Well# Reading Date: Index Well level Adj.factor— Adj.d and Ater Ley!)__ PERCOLATION TEST Date e Observation Hole# - o� Depth of Perc Time at 6" Start Pre-soak Time @ Time(9"-6") End Pre-soak Rate MinJlnch ► ' / Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1) week prior to beginning. �; Q:ISEPTICVERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.% ravel) A L 1.01ZA fu �,� r DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consist Consistencv.% i DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consi ten Flood Insurance Rate Man: Above 500 year flood boundary No_ Yes Within 500 year boundary No Y Yes. Within l00 year flood boundary Nov Yes Depth of Naturally Occurring Pervious Material ` . Does at least four feet of naturally occurring pervi uspq serial exist in all areas observed throughout the area proposed for the soil absorption system? Ifs If not,what is the depth of naturally occurring per ious material?!� Certification � I certify that on /® (date)I have passed the soil evaluator examination approved by the Department of Envi onmental Protection and that the above analysis was perfor ed y me consistent with . the required traini4expe d exp rience described in 310 CMR 15.0I . Signat Date � v� Q:%SEPTICIPERCFORM.DOC }„ E' SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A , ture I item 4 if Restricted Delivery Is desired. ❑Agent is Print your name and address on the reverse X ❑Addressee so that we can return the card to you. g, R eivxiby ted ame) Date of Dekwry I ® Attach this card to the back of the mailpiece, i or on the front if space permits. fD. Is delivery address different from Item 1? Yes 1. Article Addressed to: If YES,enter delivery address below: ❑No 3. Service Type ®Certified Mail ❑Express Mail ❑Registered ❑Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes I 2. Article Number ►anAfF r� Ititi�7OtO5 1r1:uo �O.�QO jO191 �0652` !! romseZ,late r. ,,.•: :r.r Pr:r, r:, PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1s40 UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid USPS I Permit No.G-10 . I I I I • Sender: Please print your name, address, and ZIP+4 in this box • I' I I I � � ,a 4 Town of Barnstable I ' Health Division 200 Main Street i H_v_annis_MA_02fi0_l- - - I I I � I II I i I Town of Barnstable Barnstable THE�F Taw AMmmicaCity Regulatory Services Department I 1.� nARNS-rAut.E, 9 " 39.9. Public Health Division ATFD MA�a' 200 Main Street Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO January 3, 2008 George & Vera DuBord 130 Arrowhead Place Stratford, CT 06497 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 102 Gooseberry Lane, Marstons Mills MA was inspected on November 2, 2007 by David Coughanowr, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system FAILED under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: A single cesspool system is an automatic failure in the Town of Barnstable. You are ordered to repair or replace the septic system within Two (2) years from the date of this notification.- - ;� Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE B0 OF HEALTH Tn S c eafz,R. CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures\102 Gooseberry Lane.doc 7005 1160 0000 0191 0652 I 1 �� , Commonwealth of Massachusetts ct a W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '',M ,•'" 102 Gooseberry Lane Property Address George and Vera DuBord Owner Owner's Name information is required for Marstons Mills MA 02648 November 2 2007 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. y T o Important: A. General Information ' When filling out = forms on the _ computer,use 1. Inspector: =4 1 only the tab key 1 -- �J to move your David D. Coughanowr =?I cursor-do not Name of Inspector use the return key. Eco-Tech Environmental Company Name 43 Triangle Circle Company Address Sandwich MA 02563. City/Town State Zip Code 508 364-0894 1328 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority COTE=A septic system consisting of a single cesspool automatically fails per Barnstable Board of Health regulations. SUM-j, Z, 4r✓��------ R S November 2, 2007 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5-2802.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 102 Gooseberry Lane Property Address George and Vera DuBord Owner Owner's Name information is required for Marstons Mills MA 02648 November 2 2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ 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: Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed t5-2802.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 102 Gooseberry Lane Property Address George and Vera DuBord Owner Owner's Name information is required for Marstons Mills MA 02648 November 2 2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. t5-2802.doe-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 ' I f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 102 Gooseberry Lane Property Address George and Vera DuBord Owner Owner's Name information is required for Marstons Mills MA 02648 November 2 2007 every page. Cityl-rown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. t5-2802.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 t Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 102 Gooseberry Lane Property Address George and Vera DuBord Owner Owner's Name information is required for Marstons Mills MA 02648 November 2, 2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. Single cesspools ® ❑ The system fails. I have determined that one or more of the above failure fail in Barnstable criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5-2802.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 102 Gooseberry Lane Property Address George and Vera DuBord Owner Owner's Name information is required for Marstons Mills MA 02648 November 2 2007 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ N/A Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? No Tank ❑ ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health: ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5-2802.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 102 Gooseberry Lane Property Address George and Vera DuBord Owner Owner's Name information is required for Marstons Mills MA 02648 November 2, 2007 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): n/a Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a-no plan Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage d 48 gpd 9 ( Y 9 (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: undeterminedDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): t5-2802.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �^M 102 Gooseberry Lane Property Address George and Vera DuBord Owner Owner's Name information is required for Marstons Mills MA 02648 November 2 2007 every page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Owner's agent Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system ® Single cesspool ❑ Overflow cesspool 1 ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Age unknown. Dwelling was constructed in 1966. No design plan found at Board of Health. Were sewage odors detected when arriving at the site? ❑ Yes ® No t5-2802.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �^M 102 Gooseberry Lane Property Address George and Vera DuBord Owner Owner's Name information is required for Marstons Mills MA 02648 November 2 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 1 Depth below grade: feet Material of construction: ® cast iron ❑ 40 PVC Orangeburg ® other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints,venting, evidence of leakage, etc.): Sewer appears structurally sound with no evidence of backup or leakage into dwelling Septic Tank (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? t5-2802.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 102 Gooseberry Lane Property Address George and Vera DuBord Owner Owner's Name information is Marstons Mills MA 02648 November 2 2007 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): t5-2802.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 102 Gooseberry Lane Property Address George and Vera DuBord Owner Owner's Name information is required for Marstons Mills MA 02648 November 2, 2007 � every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5-2802.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 102 Gooseberry Lane Property Address George and Vera DuBord Owner Owner's Name information is required for Marstons Mills MA 02648 November 2, 2007 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology- Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): t5-2802.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ;M 102 Gooseberry Lane Property Address George and Vera DuBord Owner Owner's Name information is required for Marstons Mills MA 02648 November 2 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 1 single Depth—top of liquid to inlet invert 5 ft Depth of solids layer 6 in Depth of scum layer trace Dimensions of cesspool 5 ft x 6 ft approximately Materials of construction Concrete block Indication of groundwater inflow ❑ Yes ® No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Cesspool contained 6 inches of effluent. Surrounding vegetation appeared normal. Cesspool is made of concrete blocks. NOTE ON BLOCK CESSPOOLS—Block cesspools consist of concrete blocks arranged in a beehive formation held in place by gravity and soil pressure. Driving vehicles over or near block cesspools could potentially destabilize the structure and lead to collapse. DO NOT DRIVE VEHICLES OF ANY SORT NEAR rFCCPr)r11 .Ginn/a racennnl evctcme arrinmatiralhi fail ncr Rarnetah/a Rnarrl of Haa/th ranrrla}inne Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5-2802.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 102 Gooseberry Lane Property Address George and Vera DuBord Owner Owner's Name information is required for Marstons Mills MA 02648 November 2, 2007 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. NOT TO SCALE LEACH T?--P, 66 U F� ut M EXISTING DWELLING # 102 W _Z J W H G 3I GOOSEBERRY LANE NOTE ON BLOCK CESSPOOLS—Block cesspools consist of concrete blocks arranged in a beehive formation and are held in place by gravity and soil pressure.Driving vehicles over or near block cesspools could potentially destabilize the structure and lead to collapse.DO NOT DRIVE VEHICLES OF ANY SORT NEAR CESSPOOL t5-2802.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 r Commonwealth of Massachusetts W Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 102 Gooseberry Lane Property Address George and Vera DuBord Owner Owner's Name information is required for Marstons Mills MA 02648 November 2, 2007 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to ground water: 30+feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database- explain: Barnstable GIS Department records You must describe how you established the high ground water elevation: Town of Barnstable GIS Department records indicate that the property is over 30 feet above groundwater table. t5-2802.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 f Town of Barnstable THE ray, Regulatory Services s,.xxsrns,e Thomas F. Geiler,Director 9$ ' AM •�� Public Health .Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts;Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the "Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. _ w ? ASSESSORS MAP : TEST HOLE LOGS No"TES: � , x PARCEL: 04C ' .__.___.____._�. ___.___T_�--- SOIL EVALUATOR: AVI M090 L J _ FLOOD ZONE: ..._. �Itf l� �._. __ .__ . , _ - WITNESS : I) 1At '� , 1) The installation shall comply with Title V and Town of$arnstablee Board REFERENCE: � (�� f DATE: of Health Regulations. l� PERCOLAT I N RA a : G � �11A . 1 , 2) The installer shall verify the location of utilities, sewer inverts and septic % q,�� p components prior to installation and setting base elevations. TH- 1 _ TH-2 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8"per foot. The first two feet out of the d-box to the leaching shall be level. LP� ) 4) This plan is not to be utilized for property line determination nor any other 10 �J� �x Irai purpose other than the proposed system installation. 5) All septic components must meet Title V specifications. 6) Parking shall not be constructed over H10 septic components. DION �f1 P _____-__�.�- 1 7) The property is bounded by property corners and property lines. LOCATION MAP 8) The property owner shall review design considerations to approve of total }F �1qV 1) design flow and number of bedrooms to be considered for design. Receipt 0 �� of payment for the plan and installation based on the plan shall be deemed q; � i �, �� approval of the design flow by the owner. �N 9) The existing leaching or cesspools shall be pumped and filled with material per Title V abandonment procedures. Those within the proposed SAS shall be removed along with contaminated soil and replaced with clean washed wo sand per Title V specs. f 10)System components to be 10 feet from water line. Sewer lines crossing the # water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if SEPTIC SYSTEM DESIGN applicable. 11) If a garbage grinder exists it is to be removed and is the responsibility of the ,(� 1 FLOW ESTIMATE owner to ensure such. ` ! j i q. 12)The installer is to take caution in excavation around the gas line. f 0 / 13)The installer shall verify the location, quantity and elevation of the sewer N% ( 0 j,r/ lines exiting the dwelling prior to the installation. � ( ZZ0GAL/DAY x 2 DAYS - 'L)qo GAL ` Cl USE 1500 GALLON SEPTIC TANK r SO I LABSORPT ON -SYSTEM i fix, t ZX A: SIDE ARE BOTTOM AREA: . X I of Zb SEPTIC SYSTEM SECTION *� � _-___��. ��'� _ '��t cam'° �.........�„�.,.�� _ _�~u_ �,.�r_.�� •,;-�.:.__......,.�...�,�...,. .., .�... ._..._. -- ._ ' TT 4—tfox ?U,l loll Z. :s. SEPTIC TANK _. _. t r _ 62 14saN m SITE AND SEWAGE PLAN LOCAT I ON : I�}Z C--mn 1. .l MIA PREPARED FOR : .`�XIt �." ►° '�. SCALE: ( —7-0 DAV I D B . MASON T2� DATE: S W DBC ENVIRONMEN AL DESIGNS EAST SANDWICH . MA DATE HEALTH AGENT ( 50$ ) 833- 2 177 W 3 W 2 1