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HomeMy WebLinkAbout0089 LAKESIDE DRIVE - Health 89 LAKESIDE. DRIVE, MARSTONS MILLS A=102-134 r! TOWN OF BARNSTABLE � � .7 YtE.f F 5 #Z:S Assmoirs�► :&�.OT' IN�TA�.I.ER'�PdAltitE c4 3'giQ1dE 3v4 SEPT[ .Z AVK C"ACITX X. NO:OF BEI3OQMS —3 EtJ1sDBR OR o'er PBItRd�TDATE ,ofm lm, LATE. Separation Distance Betweenc Maximum Adustecl Grnantlwat�r Tate to the Bottom of Leact►mg fad PuYae Water Supply i�tell aad Ing Facility {sE toay wei3s exut as sits or wit n?Efd feeC of Je srg.facsLtY) T�eet Edge of Wetland and I.eaehtng#"aa7ity If any wetlands exist within 3ll(}ket,gf tead ng faal�ty) feet Fimushed by .�---. ._�._:----- vo cLc 06 1 3 ®-D - a6 ' a-, 18,9_ 13y • "''� Commonwealth of Massachusetts , ^ Title 5 Official Inspection Form _ i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �_�;!✓ 89 Lakeside Dr ' Property Address K) Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is Marstons Mills MA 02648 6-1-17 31 required for every 0 page. City/Town State Zip Code Date of Inspection t-" 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. A. General Information 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S 13971 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 16.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 6-1-17 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. I ****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. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 VW VS Commonwealth of Massachusetts Title 5 Official Inspection Form ' .�5 Subsurface Sewage Disposal System Form Not for Voluntary Assessments a_ %% 89 Lakeside Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 6-1-17 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: System is in good working order with no sign of failure. 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. 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): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts ail Title 5 Official Inspection Form f 'iq Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 89 Lakeside Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 6-1-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ 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): 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form J1.I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments g&` 89 Lakeside Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 6-1-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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. ❑ 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. 3. Other: D) System Failure Criteria Applicable to All Systems: pp Y 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 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts :a=1 Title 5 Official Inspection Form 'i.;l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 89 Lakeside Dr m�Y Property Address Bank Owned (Contact David Holt c@ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 6-1-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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 well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts � Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 89 Lakeside Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 6-1-17 page, City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330_ t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts a=1 Title 5 Official Inspection Form �l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t: �,_�_�;!✓ 89 Lakeside Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 6-1-17 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water mete,readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: UnknownDate 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: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts lal f Title 5 official Inspection. Form I' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �s 89 Lakeside Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 6-1-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other (describe below): General Information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 i Commonwealth of Massachusetts al Title 5 Official Inspection Form I� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 89 Lakeside Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 6-1-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1997 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 36"feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank (locate on site plan): Depth below grade: 30"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) a If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 12" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts :a=1 Title 5 Official Inspection Form �� ' ��I Subsurface Sewage Disposal System Form Not for Voluntary Assessments 89 Lakeside Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 6-1-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 1" 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 15" How were dimensions determined? Tape 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 is in good condition with baffles installed and no sign of leakage. 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 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ail f� I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - W 89 Lakeside Dr Property Address 'Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 6-1-17 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.): 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): 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form N Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 89 Lakeside Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is Marstons Mills MA 02648 6-1-17 required for every II page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): Good condition with water at working level and no sign of back-up from field. 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.): * III If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I Commonwealth of Massachusetts vi,i Title 5 Official Inspection Form 'i�`i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 89 Lakeside Dr T Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 6-1-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3-Infiltrators ❑ 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.): Infiltrator field in good working order and empty at inspection with no sign of back-up into d-box or surrounding stone. 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts t Title 5 Official Inspection Form R+ 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �_J;!w 89 Lakeside Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 6-1-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts �al Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 89 Lakeside Dr � Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 6-1-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 t+ f � d(o / �11� !. ie l ,�Jwe.l� A �YW■ t b -3 - 7 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts al Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 89 Lakeside Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for everyMarstons Mills MA 02648 6-1-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database- explain: You must describe how you established the high ground water elevation: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ;1� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 89 Lakeside Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 6-1-17 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Stt { f Town of Barnstable Department of Health, Safety, and Environmental Services Health Division 367 Main Street, Hyannis MA 02601 Office: 508-790-6265 Thorns A McKean FAX: 308-775-3344 Director of Public Heahh 1llit sAATfeI'ABi�, MAC. p t679. s�P [ENGINEER T ] TO: U�� (Date) 01 '7K? ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned b you located at Lame s► as in S P Y Y Y ' ,�/�i�e. was inspected on I by /��5 �- (gyp. ( a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15-.00)due tor4he following: -0 )rJ0Q-1 - G t7I c G(osas -S You are directed to hire a licensed professional engineer (PE) to design a system that will bring the septic system in compliance with 310 CMR 15.00, The State Environmental Code, Title 5 within twenty-one (21) days of your receipt of this letter. You are also directed to hire a licensed septic system installer to install the system components within forty- five(45) days of your receipt of this order. You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings, onto the surface of the ground, or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health Town of Barnstable 40 -171 0 tP'S 8 91 � � Sep f TTI � 765 WAKEBY ROAD,MA STONS MI CONSTRUCTION,� S MA 02648 y��yopSTgB�99j 508-771-9399 508428-8926 FAX: 608-428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Z PART A CERTIFICATION Property Address: Date of Inspection: e/1 !�7 Inspector's Name: Ow is Name and Address: CERTIFICATION STATEMENT: I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection.The inspection was per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The System: Passes Conditionally Passes ,.-Needs Fu., er Ev tion the Local Aproving Authority ��Faits ' � Inspector's Signature: Date: j1 The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty(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 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: A)SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined 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 comple- tion of the replacement or repair,passes inspection. Indicate yes,nor,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 sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of The Board of Health): " - 1 - f I • :f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 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 potion of a cesspool or priry is within a Zone l 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 an for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 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 .s; 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 t.• 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. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: ✓ Pumping information was requested of the owner,occupant,and Board of Health. None of the system components have been pumped for atleast two weeks 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. As-built plans have been obtained and examined. Note if they are not available with N/A. j/The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. k!� The site was inspected for signs of breakout. _L/All system components,excluding the Soil Absorption System,have been located on site. _ ,[The septic tank manholes were uncovered,opened,and the interior of the septic tank was in- spected for condition of baffles or tees,material of construction,dimensions,depth of liquid, � pth of sludge,depth of scum. hee size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3- 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: (/ Depth below grade: Material of Construction: . concrete metal FRP_Other (explain) Dimisions:g S'X 6- 1YS' Sludge Depth: _Scum Thickness: Distance from top of sludge to bottoir.of outlet tee or baffle' 3�/ Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid 1 eve 1 in lation to utlet invert,structural integri ,evidence of leakage,etc. GREASE S�_d� Depth Below.Grade: Material of Construction:_concrete_metal_FRP Other. (explain) Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: 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.) TIGHT OR HOLDING TANK:IL Depth Below Grade: Material of Construction:_concrete_metal_FRP Other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm Level: Comments:.(condition of inlet tee,condition of alarm and float switches, etc.) DISTRIBUTION BOX:✓ , Depth of liquid level above outlet invert: Comments: (note if le I and distributi n is equal evidence of solids car over,evidence of eakag into or out of box,etc.) �Clt�e 0 Z�+�4iyt. _ PUMP CHAMBER:A)b Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) -5- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: j Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. rr it DEPTH TO GROUNDWATER: Depth to groundwater: /'y Feet , MethQdofyD termination or Ap roxi ation: /��'��14 � �� a, -7- ' TOWN OF BARNSTABLE LOCATION D �� SEWAGE # �''�— 9� �. 3 .k, S� . r+LLAGEi ��.5 ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. po j SEPTIC TANK CAPACITY LEACHING FACILITY: (type) II;L L'n 1"s (size) A NO.OF BEDROOMS '3 BUILDER OR OWNER I� PERMIT DATE: !2"/9— `$ - COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility an wells exist � PP Y B tY (R Y 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 1 � �, .,, . �; h � , ��� �. ,_ `� J ��o � � VNo. <�` �' Fee $5 0 .0 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pprication for Migooal *pztem Congtruction 30ermtt Application for a Permit to Construct Repair x Upgrade( )Abandon( ) ❑Complete System ❑Individual Components PP ( ) P ( ) Pg Location Address or Lot No. 89 Lakeside Dr Owner's Name,Address and Tel.No. 4 2 8-1.0 5 9 Assessor'sMap/Parcel Marstons Mills Fred Mula Q9 Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. Wm E Robinson Sr Septic Sry PO Box 1089 , Centerville, MA Type of Building: Dwelling No.of Bedrooms 2/3 Lot Size sq.ft. Garbage Grinder( n6 Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil sand Nature of Repairs or Alterations(Answer when applicable) Title 5 Leaching consisting of a new D-Box, and three stonepacked infiltrators. 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 Certifi- cate of Compliance has been issued by this oard of He th. Signed Date "I G Application Approved bye � Date, y Application Disapproved for the following reasons Permit No. ` `° le Date Issued s r No. Fee r THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYicatiou for Migaal *p6tem Cougtruction-Vermit Application for a Permit to Construct( )Repair( x)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 89 Lakeside Dr Owner's Name,Address and Tel.No. 4 2 8—1 0 5 9 Marstons Mils Fred Mula Assessor's Map/Parcel /OZ— / Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. Wm E Robinson Sr Septic Sry PO Box 1089, Centerville, MA Type of Building: Dwelling No.of Bedrooms 2/3 Lot Size sq. ft. Garbage Grinder( no Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures 9nZ — f r Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil sand IV Nature of Repairs or Alterations(Answer when applicable) Title 5 Leaching consisting of a net D-Box, and three stonepacked infiltrators. bye last inspect/ted: Agreement: The undersigned agrees to ensure the c9pstruction 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 Certifi- cate of Compliance has been issued by t is oard of He th. — ef-7 Signed t t Date J G 1 Application Approved by Q Date 7 Application Disapproved for the following reasons Permit No. v /� Date Issued `Y ' COMMONWEALTH OF MASSACHUSETTS Mula BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired(xx)Upgraded( ) Abandoned( )by Wm E Robinson Sr Septic Sry at 89 LakesiddeDrive, Marstons Mtbils P. hags ben constru fed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit N � -dated Installer Wm E Robinson Sr Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date - Z, ^7 Inspector `�� �f No. --------------------------Fee 50.00 f THE COMMONWEALTH OF MASSACHUSETTS " Mula PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHSETTS lwtgpozar *potem conotructiou Vermti Permission is hereby granted to Construct( )Repair(x)Upgrade( )Abandon( ) System located at 89 Lakeside Dr, Marstons Mills Installer: WM E Robinson Sr Sept Sry 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. Provided:Captruction must be completed within three years of the date of th' ermit. Date: ` Approved b i NOTICE: This form is to be used for the repair of failed septic systems only CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I,William E. Robinson, Sr.,hereby certify that the application for disposal works construction permit signed by me dated Q!G- q 7 , concerning the property located at 89 Lakeside Dr, Marstons Mills, MA meets all of the following criteria: *here are no wetlands within 300 feet of the proposed septic system. 'Mere are no private wells within 150 feet of the proposed septic system. 1/fhe obseved groundwater table is 14 feet or greater below the bottom of the leaching facility. here is no increase in flow and/or change in use proposed. There are no variances requested or needed. SIGNED: DATE ;z LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 60 (Attach a sketch plan of the proposed system. Also if the licensed insWler proposes a certification plot plan,this plan should be submitted). I � - 1 t 1 I I 1 Q i r � :N O� FARISTAD TO L.E LOCAn-ON 1 d k� i c'�. SEWAGE' VILLAGE S ��S ASSESSOR'S MAP& LOT a 2 J 31-� INSTALLER'S NAME&PHONE NO._Ry 6 / SEPTIC TANK CAPACITY LEACHING FACILITY: (type)- ��'' e S. (size) /� 'ozS•-'a NO OF BEDROOMS BUELDER OR OWNERPERMIT DATE:, --COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 1 f Town of Barnstable o� >naxsTas�, Department of Health,Safety,and Environmental Services MASS. Public Health Division i639• �0 367 Main Street,Hyannis MA 02601 Office: 508-790-6265 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health February 17, 1998 Mr.Fred Mula 127 Fort Meadow Drive Hudson,MA 01749 ORDER TO COMPLY WITH 310 CMR 15.00,THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned by you located at 89 Lakeside Drive,Marstons Mills was inspected on August 19, 1997 by Robert Bortolotti a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00)due to the following: • Back-up of sewage into facility or system component due to an overloaded or clogged soil absorption system. You are directed to hire a licensed professional engineer(PE)to design a system that will bring the septic system in compliance with 310 CMR 15.00,The State Environmental Code,Title 5 within twenty-one (21)days of your receipt of this letter. You are also directed to hire a licensed septic system installer to install the system components within forty-five(45)days of your receipt of this order. You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings,onto the surface of the ground,or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH Thomas A.McKean,R.S., C.H.O. Agent of the Board of Health F� m SENDER: ■Complete items 1 and/or 2 for additional services. I also Wish to receive the W ■Complete items 3,4a,and 4b. following services(for an m •Print your name and address on the reverse of this form so that we can return this extra fee): card to you. ai ■Attach this forth to the front of the mailpiece,or on the back if space does not pepermit. 1, El Addressee's Address d ■Write-Return Receipt Requested'on the mailpiece below the article number. 2. ❑ Restricted Delivery N ■The Return Receipt will show to whom the article was delivered and the date C delivered. Consult postmaster for fee. ° 3.Article Addressed to: 4a.Article Number a, z � Vq� s� c ZQGG /ICU/OJ .3 E E ,,:r 4b.Service Type �2 7 �O/ T /l�1eC?(Y® k�i��E— ❑ Registered Certified M �� o Im ❑ Express Mail El Insured I /7 ❑ Return Receipt for Merchandise ❑ COD 7.Date of Delivery ° 5.Received By:(Print Name) 8.Addressee's Addr s( if re end fee is paid) ® r t� ~ 6 Sig :(Ac)dressee or Age t) w $ PS Form 3811, December 1994 102595-97-13-0179 Domes 'c ipt :ti S f i Z 2CJ3 498 580 US Postal Service Receipt for Certified Mail No Insurance Coverage Provided. Do not use for International Mail See reverse Sentto /—zeal Street&N ber iz 7 Tf / Pos Offirq,SlatGv IP Code 017 C/� i Postage $ Certified Fee Special Delivery Fee Restricted Delivery Fee a) Return Receipt Showing to Whom&Date Delivered a Retum Receipt Showing to Whom, Q Date,&Addressee's Address O TOTAL Postage&Fees $ co -- CO) Postmark or Date LL rn o_ off' COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PRO T T 1 ONE WINTER STREET, BOSTON, MA 02108 617-292- •0 r W1LLIAM F.WELD OCT 2 f��® UDY CORE C"Governor ?�.y Secretary ARGEO PAUL CELLUCCI B. R s 9jTy�9pSTgB Dq Comm s one Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM T lF PART A CERTIFICATION 9 C� Property Address: 89 Lakeside Dr, Marstons Millskddress of Owner: Fred Mu a Date of Inspection: 9-;L3-of-/ (If different) 127 Fort Meadow Dr Name of Inspector: Wm E Robinson Sr Hudson, MA 01 749 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: Wm E Robinson Septic Service Mailing Address: PO Box 1089 , C'ent-ervi 1 1 eT MA 02632 Telephone Number4 508 7 7 5_A 7 7 6 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: Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: l Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 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, 8, C, or D: AJ SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. CO MENTS: BI SYS EM 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. Indicat 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, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is 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 04/25/97) Page 1 of 10 DEP on the World Wide Web: http:IMrww.magnet.state.ma.us/dep j Printed on Recycied Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 89 Lakeside Dr, Marstons Mills Owner: Mu 1 a Date of Inspection:."oZ3-� '] B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled 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] URTHER 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 PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid). 3) THER >� 1 (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 89 Lakeside Dr, Marstons Mills Owner: Mu 1 a Date of Inspection: ';L 3 s g D) SYSTEM FAILS; You ust indicate ei;,;er "Yes" or "No" as to each of the following: 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. Yes No Backup of sewage into 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 SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the 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 I 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) LARG SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: he following criteria apply to large systems in addition to the criteria above: he system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to ublic health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requireme is of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 89 Lakeside Dr, Marstons Mills Owner: Mu 1 a Date of Inspection: 19—a 3—9 '1 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No _ Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks 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. As built plans have been obtained and examined. Note i4 they are not available with N/A. >eS _ The facility or dwelling was inspected for signs of sewage back-up. , < _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. -- _ All system components, excluding the Soil Absorption System, have been located on the site. 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. The size and location of the Soil Absorption System on the site has been determined based on: �lS _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. _ Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is .4 unacceptable) [15.302(3)(b)] (revised 04/25/97) Page 4 of 10 I - - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 89 Lakeside Dr, Marstons Mills Owner: Mula Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow:-,rr O R.p.d./bedroom for S.A.S. Number of bedrooms:lz�i3 Number of current residents: Garbage grinder (yes or no): A e> Laundry connected to system (yes or no):,6L-f Seasonal use (yes or no): ± O 1995 - 37, 000 gals Water meter readings, if available (last two (2) year usage (gpd): Sump Pump (yes or no): e!L 0 1996 - 46, 000 gals Last date of occupancy: COMMERCIAUINDUSTRIAL: Typ of establishment: Desi n flow: gallons/day Grea a trap present: (yes or no)_ Indu rial Waste Holding Tank present: (yes or no)_ Non- anitary waste discharged to the Title 5 system: (yes or no)_ Wat r meter readings, if available. La date of occupancy: OT ER: (Describe) Las of occupancy: GENERAL INFORMATION PUMPING RECORD and source of information: _ iL SystepKpumped as part of inspection: (yes or no),,'3 If yes, volume pumped: ® O gallons Reason for pumping YZJ je v 6 S TYPE OF SYSTEM L,-<eptic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: %O_o O A.� /� 1 cil, $ 4 Sewage odors detected when arriving at the site: (yes or no)/4-O —� X-977 9 7-Sa (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 89 Lakeside Dr, Marstons Mills Owner: Mu l a Date of Inspection: '9-,Z!l d 917 B LDING SEWER: (Loc eon site plan) Dept below grade: Mat ial of construction: _cast iron _40 PVC _other iexplain) Dist nce from private water supply well or suction line Dia eter Com ents: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:f/ (locate on site plan) c Depth below grader Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate Df Compliance _(Yes/No) Dimensions: a- �• Sludge depth: 3-S' ` a Distance from top of sludge to bottom of outlet tee or baffler Scum thickness: J --3 J Distance from top of scum to top of outlet tee or baffle:_ Distance from bottom of scum to bottom of outlet tee or baffle: )PI- How dimensions were determined: O f4-/L' Tl,L- .tip a e® c. C 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.) fD O-b 9,61 GREAS TRAP: (locate site plan) Depth be ow grade: Material f construction: _concrete _metal __Fiberglass _Polyethylene —other(explain) Dimensi ns: Scum th ckness: Distance rom top of scum to top of outlet tee or baffle: Distance om bottom of scum to bottom of outlet tee or baffle: Date of la t pumping: Comment (recommen ation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, a idence of leakage, etc.) (reviaad 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 89 Lakeside Dr, Marstons Mills Owner: Mu l a Date of Inspection: �°j -;L3--4' -7 TI HT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (IC a on site plan) Depth below grade: Materi I of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dim sions: Capa ty: gallons Design flow: gallons/day Alarm evel: Alarm in working order_ Yes; _ No Date previous pumping: Com ents: (cond Lion of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP HAMBER:_ (locate n site plan) Pumps i working order: (Yes or No) Alarms working order (Yes or No) Comm ts: (note c dition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 89 Lakeside Dr, Marstons Mills Owner: Mula Date of Inspection: 9—;2 3-071 / SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number: leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation etc.) Cy 22! e , CE POOLS: _ (Iota a on site plan) Numb r and configuration: Depth-op of liquid to inlet invert: Depth f solids layer: Depth f scum layer: Dimens ns of cesspool: Material of construction: Indicati n of groundwater: inflow (cesspool must be pumped as part of inspection) Comment (note cond ion of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on ite plan) Materials of nstruction: Dimensions: Depth of soli Comments: (note conditio of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page a of 10 y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 89 Lakeside Dr, Marstons Mills Owner: Mula Date of Inspection: 9— 2. g 1 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 1 N I ; r V- l vo r Y 1 � �✓I'Z o ar C e� r1 r;Z G-k-� f �. � �j l�0 w .t. (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 89 Lakeside Dr, Marstons Mills Owner: Mula Date of Inspection: ;Z 3—cl '7 Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record ✓ Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own word how you established the High Groundwater Elevation. (Must be completed) (revised 04/25/97) Page 10 of 10 r TOWN OF BARNSTABLE a LOCATION SEWAGE # VILLAGE �f 1 \" \� ` ASSESSOR'S MAP & LOTAS� - f INSTALLER'S NAME 4 PHONE NO. i SEPTIC TANK CAPACITY_lbo(�,-j LEACHING FACILITY:(type) 14 (size) 3C NO. OF BEDROOMS `PRIVATE WELL OR UBLIC WATER BUILDER OR OWNER U L '4 DATE PERMIT ISSUED:_ ' DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No o !� :.Lf^ Ice '-2 © = vu r No. ,,..�'_ Flzs. ............... THE COMMONWEALTH OF MASSACHUSETTS BOAR® HEALTH �N.. ..........O F.............. .. .. --------..... ....... ApplirFation for Disposal Works Tonstrurtinn Prrmit Application is hereby made for a Permit to Construct ( ) or Repair (° ) an Individual Sewage Disposal System.at ....... .. .:............. ...... _.. ........ ..... o or tiddress -------------------------------------------- Lot No. r Address a -- .. -� ..... .. ...- ... -- ,, t" nstaller Addre UType of Building Size of............................Sq. feet Dwelling No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ------------------------------------------------•--------------------•--.--•--------------------•---•-•----------••---•-_------..._............_---• W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. ..-................. Width.........._......... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No...................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ r3� Test Pit No. 2................minutes per inch Depth of Test Pit------_............. Depth to ground water........................ a •---•-------------------------------------------•-••---•-----------•_-----------•---...._---•-------........................................................ 0 Description of Soil........................................................................................................................................................................ w U Nature of Repairs or Alter 'ons—An6wer_%h4e OW ____ _ ________ --•-----••---- •. . ••-•--- •---- . ---------------------•--•------•---------------------_------.......--------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iIT1L 5 of the State Sanitary Code—The i n ersigned further agrees not to place tl}e sy em in operation until a Certificate of Compliance has b issu by th-e boar health. Signed•-- ` .._.. . ... '... ..!' ems" .. t Application Approved By. Date Date Application Disapproved for the following reasons:.......................... •---•--••---------•-------•-------•--------••-•-•--•-----------------••--••---...... ................................•-...-•-...----•---------•--•----------------_-----•....-•---------•-_••-I-----•--••----------•--•----•-•-----------•----------------••--------•---------•-----_••_---__- f Date .. ...... ...... , . Issued._...../�/ ------------. Permit No. Date r No` .........:...... Fps.. �.' ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD ®,F HEALTH _ Allpfiration for Disposal Works Tontrnrtion Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal IV _ rat ...-•---- •. ---. .................................................... Location-Address or Lot No. ..::..::�::-�:.. . . .. ............................................. ............................................................... ....................----........ '� i Owner 1 Address s ear ,�_.. 'Installer Addr s Type of Building Size of............................Sq. feet Dwelling_—No. of Bedrooms.............• .._._................._.._...Expansion Attic ( ) Garbage Grinder ( ) PL4Other—Type of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures .................................. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ rZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P1 -••-••--•--------•----------•--••---•....-•-•-•••••-•---------------•-•............-----------------......................................................... 0 Description of Soil........................................................................................................................................................................ x W U Nature of Repairs or Alterations—Answer when'' palie able... -------------•-------------•-•------•----------------------••--•--------------•-- �„ r, '" d ..._ .. ...----•-•------- ------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT1. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the bolfd­ok health. Signed-----t•---•-•--•- ,�' �? r ^�^._t—.r.�.�-- Date Application Approved B d Da t e Application Disapproved for the following reasons:.................. ........_'•----•--••••-•---••--------•----•--------------•---------•----•------•-•-----...... F •-•------••••-•-•••...............•---••----••-------•-•-••-------•---•-.....-----------•----••----------'---•-•--•-----••---•---••••------•-•---•••----.....••---------••----------------•-----....----- Permit No.. .�1--------.�___-,%......................... Issued...... '_11 ..,f7-. Date Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 44V AV ............................ Trrtif irFatr of TomptiFana THIS_ IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by ""�� °� -.. '`•� . � ' ............. / -------•------------------------------------------------------•-••----.......-••...... �?� a�1e 1*� ... .r� -����P �yt-" �. ; 1stalle� r t 1 / f A� at--•--zR • - -----•.... . > ----- .-�;�<._..�. ..? ....... .�/�' = `�a`t:-....... .................................. has been installed in accordance with the provisions of T ITIZ' 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.___-_- .. _ ._.f�4 .. da.ted_...._ .10 __. � THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......-••---•--..4 C::.7 - -97 r----••---•-•------•------------- Inspector........AD.............................................................- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH A........... ....................... '/ �� �r ................. FEE.,.,? . -- DiopooFal Works Tontrnrtion andt Permission is hereby granted..------ -k-z.li".------ -�.V.? ............................................................ to Construct ) or/Rep�i�r ( ) a In ' 'dual Sew a Disposal System at No....... , fx �'. .. � :...�.. 1 � s.. ,, ............. Street as shown on the application for Disposal Works Construction Permit ----- f$---- ------ �.._. DATE_ . --� I- A' Board of Health FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS