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Home My WebLink About0157 LAKESIDE DRIVE - Health 3;R a -7 r akeside+DI'lve — - - 1VIar'stons A : 102 174 r� I i / oz —r7 Commonwealth of Massachusetts Title 5 Official Inspection Form i; Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Me 157 Lakeside Drive Property Address Fanny Mae . Owner Owner's Name / information is Marstons Mills 1/ MA 02648 8-25-15 required for every - page. Cityfrown State Zip Code Date of Inspection 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. General Information � R ```��ltttnunUrp�i on the computer, j ! �p St1 OF use only the tab 1. Inspector: ,��4 '• 'ssy°�' key to move your 0'X ••• '••c3 cursor-do not if;" JAMES lass use the return James D.Sears ke Name of Inspector _ :y Y• ?*s• CapewideEnterpnses,LLC �y Company Name �'., € T 1�F� •�� 153 Commercial Street ��S•I N 5P Company Address P Y Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 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 L42� 8-25-15 spector'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. t5ins•3113 Title 5 Official krspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 157 Lakeside Drive Property Address Fanny Mae Owner Owner's Name information is required for every Marstons Mills MA 02648 8-25-15 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: The system is a 1000 Gal. Tank D Box and pit. 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-3M3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 157 Lakeside Drive Property Address Fanny Mae Owner Owner's Name information is required for every Marstons Mills MA 02648 8-25-15 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-3113 Title 5 official Inspection Forth:SubsuAace Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 157 Lakeside Drive Property Address Fanny Mae Owner Owner's Name information is required for every Marstons Mills MA 02648 8-25-15 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: 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 is less than 6"below invert or available volume is less than %day flow �'i — t5ins-W13 Title 5 Official Mspecbon Fonrt Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments / 157 Lakeside Drive Property Address Fanny Mae Owner Owner's Name information is required for every Marstons Mills MA 02648 8-25-15 page. Citylrown 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•3113 Title 5 Official Inspection Forth:Subsurfaoe Sewage Disposal System-Page 5 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 157 Lakeside Drive Property Address Fanny Mae Owner Owners Name information is required for every Marstons Mills MA 02648 8-25-15 City/Town page. 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). 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 157 Lakeside Drive Property Address Fanny Mae Owner Owner's Name information is required for every Marstons Mills MA 02648 8-25-15 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal. Tank D Box and pit. 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 ruse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 2012-10,000 Gal Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 2012Date 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 4 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 157 Lakeside Drive Property Address Fanny Mae Owner Owner's Name Information is required for every Marstons Mills MA 02648 8-25-15 page. Cityrrown state Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 157 Lakeside Drive Property Address Fanny Mae Owner Owner's Name information is required for every Marstons Mills MA 02648 8-25-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1995 Permit # 95-278 New Tank and New D Box 8-2015. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 22"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.): Pipeing is 4" PVC SCH 40. Septic Tank(locate on site plan): 1' 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: 1000 Gal. Precast H-10 Sludge depth: 0 t5ins•3H 3 Title 5 Otfidal Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 157 Lakeside Drive Property Address Fanny Mae Owner Owner's Name information is required for every Marstons Mills MA 02648 8-25-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cunt.) 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? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): New Tank 8-20-15 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 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y�. 157 Lakeside Drive Property Address Fanny Mae Owner owner's Name information is required for every Marstons Mills MA 02648 8-25-15 page. Cityrrown 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 157 Lakeside Drive Property Address Fanny Mae Owner Owner's Name information is required for every Marstons Mills MA 02648 8-25-15 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) 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.): D Box is 16"x16"-26" below grade w/one line out. Box is new 8-2015 w/cover at 4". 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. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 12 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 157 Lakeside Drive Property Address Fanny Mae Owner Owner's Name information is required for every Marstons Mills MA 02648 8-25-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number. 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is a 1000 Gal. Precast H-20 pit. Pit at 40"below grade w/cover at 1'. Pit is dry. No sign of over loading or solid carry over. 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 . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments p� 157 Lakeside Drive Property Address Fanny Mae Owner Owner's Name information is Mar required for every stons Mills MA 02648 8-25-15 page. Citylrown 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 157 Lakeside Drive PmpertyAddress Fanny Mae Owner Owner's Name information is required for every Marston Mills MA 02648 8-25-15 page. Cityrrown State Zip Code Date of inspedion D. System Information (cunt.) 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 I3-► �La ' 35� R E141 t . �EC-k- o ; 15ins•3113 Title 5 Official Inspection form:&Osurface Sewage Oisposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments " 157 Lakeside Drive Property Address Fanny Mae Owner Owner's Name information is required for every Marstons Mills MA 02648 8-25-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells NO Estimated depth t high ground water: 20' 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: Abutting property and down the street drop's off 20'+. Bottom of pit at 9'-6" below grade. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments yf 157 Lakeside Drive Property Address Fanny Mae Owner owner's Name information is required for every Marstons Mills MA 02648 8-25-15 page. Citylrown 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•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION �S 7"`c�56�!� P, SEWAGE# C)6 tS= pZS�y VILLAGE,A,/ ,tJ5 ASSESSOR'S MAP&°PARCEL 109 -(�of INSTALLER'S NAME&PHONE NO. �Pt"W�.Cf `7� -88�72 SEPTIC TANK CAPACITY ,, 'OCR LEACHING FACILITY: (type) ` L (size) NO.OF BEDROOMS X MIA- NQW 4w,[ 04, OWNER Ifi2N PERMIT DATE: COMPLIANCE DATE: / Separation Distance Between tie: 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 leachi acility)n - Feet FURNISHED BY (�'L.�—/CA k� No. (5`00 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE, MASSACHUSETTS Yes 0(ppliCation for Disposal 6pstem Constructions Permit Application for a Permit to Construct( ) Repair(X) Upgrade( ) Abandon( ) ❑Complete System K Individual Components Location Address or Lot No. i 5-7 /�b(CSi�E prZ MM Owner's Name,Address,and Tel No. r_ IFAAM � Assessor's Map/Parcel 10 a, P® po �„IARS� A-c c.C, Installer's Name,Address,and Tel.No. SOS.1+71—M 17 Designer's Name,Address;and Tel.No. OWAXa Lc.•_ by A I/ /� Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided /1X gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Boa f He Si Date Y"4~l 5 Application Approved by Date y Application Disapproved by Date for the following reasons Permit No. /� '� Date Issued �(j� No. I !�� 1 _ T Fee I• THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN,PF BARNSTABLE, MASSACHUSETTS Zipprication for Misposar 6pstem (Construction 3permit Application for a Permit to Construct( ') Repair(X) Upgrade( ),Abandon( ) ❑Complete System K Individual Components Location Address or Lot No" 057 I 1.4(Z5(A E M M M Owner's Name,Address,and Tel.No. (AP_ca 0jy Fi4pt t,2 l FW&W lE F'{vkE Assessor's Map/Parcel Q a, PO DO)C 3 MA4R T7;D&A A4 C.C. Installer's Name„ EAddress,and Tel.No. $08-47-7—88 i7^ `Designer's Name,Address,and Tel.No. CAP eW l b a LR*tW4(9 e6 i Lx- r f' Type of Building:- Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons,., Showers( ) Cafeteria( ) Other Fixtures ,, tt Design Flow(min-:required) gpd Design flow provided NX gpd Plan Date Number of sheets Revision Date a Title Size of Septic Tank Type of S.A.S. Description of Soil I Nature of Repairs or Alterations(Answer when applicable) R��cil (G l�Ll�t1 �to tUr� iV SI-t 7164 T*IuL �� Ed- t o �D -73 w A-a�� y IN�T. .... ., •^� Date last inspected: J Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Bo f Health Si led Date Application Approved by , Date Application-Disapproved by Date for the following reasons Permit No. Date Issued Zl1� ----------------- ----------It/------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS' N Q w Se BARNSTABLE,MASSACHUSETTS (� tr p,�9 Certificate of Compliance THIS S TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(re) Upgraded( ) Abandoned at 15'7 L KC-S(a6 D R t u v 14 M has been constructed in)ccor jce / r_ with the provisions of Title 5 and the for DisposalSystem Construction Permit No.� / /dated Installer CmE�tDc F&j7&- A-6LCS LAG Designer 1A f #bedrooms & Approved desi ow A gpd The issuance of this permit shall not be construed as a guarantee that the system will ctio`nas design d. Date �/, I �� Inspector---- % ----------------- No. �`'' Fee THE COMMONWEALTH OF MASSACHUSETTS ! PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS -Misposal ,0pstem Construction 3permit Permission is hereby granted to Construct( ) Repair(X) Upgrade( ) Abandon( ) System located at 157 6,kli5-5oe b�UuG Iv1Ak3'Z'c4,r> fit./uC and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Cons - ction must be completed within three years of the date of this permit. Date y Approved by Commonwealth of Massachusetts ` Title 5 Official Inspection Form Not for Voluntary Assessments ;M Subsurface Sewage Disposal System Form Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 6/1512000. Inspection forms may not be altered in any way. A. Certification 1. Property Information: I y1 157 Lakeside Drive 3 Property Address Gregg Farmer Owner's Name same Owner's Address Marstons Mills MA 02648-1921 City/Town State Zip Code Date of Inspection: 10/29/10 Date 2. Inspector: Matthew L. Childs Name of Inspector same Company Name 4 Orchid Ln. Company Address W. Yarmouth MA 02673 City/Town State Zip Code 508-989-1479 Telephone Number Certification Statement: I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of 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 10/29/10 F Inspector's Signature Date — The system inspector shall submit a copy of this inspection report to the Approving Authority (64�rd of Health or DEP)within 30 days of completing this inspection. If the system is a shared sVstern_or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit then 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. z ****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. Farmer.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M A. Certification (cont.) 157 Lakeside Drive Property Address Marstons Mills MA 02648-1921 City/Town State Zip Code Gregg Farmer 10/29/10 Owner's Name Date of Inspection 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: passes 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 sourid, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: N/A Farmer.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 157 Lakeside Drive Property Address Marstons Mills MA 02648-1921 City/Town State Zip Code Gregg Farmer 10/29/10 Owner's Name Date of Inspection 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 ❑ obstruction is removed ❑ distribution box is leveled or replaced ND Explain: N/A ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: N/A 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 Farmer.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments wM Subsurface Sewage Disposal System Form A. Certification (cont.) 157 Lakeside Drive Property Address Marstons Mills MA 02648-1921 City/Town State Zip Code Gregg Farmer 10/29/10 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (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: 0 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: N/A **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: N/A Farmer.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ;M Subsurface Sewage Disposal System Form A. Certification (cont.) 157 Lakeside Drive Property Address Marstons Mills MA 02648-1921 City/Town State ZipCode Gregg Farmer 10/29/10 Owner's Name Date of Inspection D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: i 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 '/2 day flow El ® 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. ❑ z 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] Yes No ® 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. Farmer.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form a Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 157 Lakeside Drive Property Address Marstons Mills MA 02648-1921 City/Town State Zip Code Gregg Farmer 10/29/10 Owner's Name Date of Inspection 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. Farmer.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments SV Subsurface Sewage Disposal System Form B. Checklist 157 Lakeside Drive Property Address Marstons Mills MA 02648-1921 City/Town State Zip Code Gregg Farmer 10/29/10 Owner's Name Date of Inspection Check if the following have been done. You must indicate"yes" or"no" as to each of the following: YES NO ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? (If they were not ® El 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(3)(b)] Farmer.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information 157 Lakeside Drive Property Address Marstons Mills MA 02648-1921 City/Town State Zip Code Gregg Farmer 10/29/10 Owner's Name Date of Inspection 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 gpd. Number of current residents: 2 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 N/A 9 ( Y 9 (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CM N/AR 15..203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): N/A 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: N/A Last date of occupancy/use: N/A Date Other(describe): N/A Farmer.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 157 Lakeside Drive Property Address Marstons Mills MA 02648-1921 City/Town State Zip Code Gregg Farmer 10/29/10 Owner's Name Date of Inspection General Information Pumping Records: Source of information: owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: N/A gallons How was quantity pumped determined? N/A Reason for pumping: N/A 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 7/5/95 per disposal works construction permit on file at Barnstable BOH. Were sewage odors detected when arriving at the site? ❑ Yes ® No Farmer.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form wM C. System Information (cont.) 157 Lakeside Drive Property Address Marstons Mills MA 02648-1921 City/Town State Zip Code Gregg Farmer 10/29/10 Owner's Name Date of Inspection Building Sewer(locate on site plan): 1' Depth below grade: 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.): All in good working order at time of inspection. Septic Tank(locate on site plan): Depth below grade: 1.5' 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 ❑ Yes ❑ No certificate) Dimensions: 8'x5'x5' outside 1000 gal. Sludge depth: .4' Distance from top of sludge to bottom of outlet tee or baffle 2.6 Scum thickness .3' Distance from top of scum to top of outlet tee or baffle 4 Distance from bottom of scum to bottom of outlet tee or baffle 1' How were dimensions determined? sludge judge Farmer.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cont.) 157 Lakeside Drive Property Address Marstons Mills MA 02648-1921 City/Town State Zip Code Gregg Farmer 10/29/10 Owner's Name Date of Inspection 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 shows no signs of leakage and appears to have been maintained regularly at time of inspection. Grease Trap(locate on site plan): Depth below grade: N/A feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): N/A Dimensions: N/A Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A � Distance from bottom of scum to bottom of outlet tee or baffle N/A Date of last pumping: N/A 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.): N/A 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): N/A Farmer.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 I Commonwealth of Massachusetts Title 5 Official Inspection Form } Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 157 Lakeside Drive Property Address Marstons Mills _ MA 02648-1921 City/Town State Zip Code Gregg Farmer 10/29/10 Owner's Name Date of Inspection Tight or Holding Tank(cont.) Dimensions: N/A Capacity: N/A gallons Design Flow: N/A gallons per day Alarm present: ❑ Yes ❑ No Alarm level: N/A Alarm in working order: ❑ Yes❑ No Date of last pumping: N/A Date Comments (condition of alarm and float switches, etc.): N/A Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0.0' 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.): D-box shows no signs of leakage or solids carryover at time of inspection. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Farmer.doc•11/2004 Title 5 Official'Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 Commonwealth of Massachusetts - = Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 157 Lakeside Drive Property Address Marstons Mills MA 02648-1921 Cityrrown State Zip Code Gregg Farmer 10/29/10 Owner's Name Date of Inspection Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): N/A Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 ❑ 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.): 1 6'x10' precast pit w/T of stone had 2'of water and stain lines at 4'. SAS does not show any signs of hydraulic failure. Farmer.doc-11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ;M Subsurface Sewage Disposal System Form C. System Information (cont.) 157 Lakeside Drive Property Address Marstons Mills MA 02648-1921 City/Town State Zip Code Gregg Farmer 10/29/10 Owner's Name Date of Inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A Depth -top of liquid to inlet invert N/A Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction N/A Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A Privy (locate on site plan): Materials of construction: N/A Dimensions N/A Depth of solids N/A Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A Farmer.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 ► Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 157 Lakeside Drive Property Address Marstons Mills MA 02648-1921 Cityrrown State Zip Code Gregg Farmer 10/29/10 Owner's Name Date of Inspection Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. w/s #157 O A-1-30' B-1-27' A 2-26' B-2-34' A 3-27' B-3-46' Farmer.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form I ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form .1M S•ye C. System Information (cont.) 157 Lakeside Drive Property Address Marstons Mills MA 02648-1921 City/Town State Zip Code Gregg Farmer 10/29/10 Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: 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: pate ® 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: Hand auger 16' , 5' below bottom of sas and found no water. Adjustment at time of inspection was .5' leaving adequate groundwater seperation. Farmer.doc•1112004 Title 5 lOfficial Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 6/15/2000. Inspection forms may not be altered in any way. A. Certification 1. Property Information: 157 Lakeside Drive Property Address Gregg Farmer Owner's Name same Owner's Address Marstons Mills MA 02648-1921 Citylrown State Zip Code Date of Inspection: 7/18/06Date 2. Inspector: Matthew L. Childs Name of Inspector same Company Name 4 Orchid Ln. Company Address W. Yarmouth MA 02673 City/Town State Zip Code 508-989-1479 Telephone Number Certification Statement: I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of 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 - �Signa ...__..._zi 7/18/06 Inspector ure 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. Farmer.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 A 1 Commonwealth of Massachusetts a u Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M A. Certification (cont.) 157 Lakeside Drive Property Address Marstons Mills MA 02648-1921 City/Town State Zip Code Gregg Farmer 7/18/06 Owner's Name Date of Inspection 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: passes 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: N/A Farmer.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments H yJe Subsurface Sewage Disposal System Form A. Certification (cont.) 157 Lakeside Drive Property Address Marstons Mills MA 02648-1921 Cityrrown State Zip Code Gregg Farmer 7/18/06 Owner's Name Date of Inspection 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 ❑ obstruction is removed ❑ distribution box is leveled or replaced ND Explain: N/A ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: N/A 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 Farmer.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form a Not for Voluntary Assessments Subsurface Sewage Disposal System Form ' M A. Certification (cont.) 157 Lakeside Drive Property Address Marstons Mills MA 02648-1921 City/Town State Zip Code Gregg Farmer 7/18/06 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (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: N/A **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: N/A Farmer.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 i Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ;M Subsurface Sewage Disposal System Form A. Certification (cont.) 157 Lakeside Drive Property Address Marstons Mills MA 02648-1921 City/Town State ZipCode Gregg Farmer 7/18/06 Owner's Name Date of Inspection 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 '/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 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] Yes No ❑ ® 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. Farmer.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 Commonwealth of Massachusetts - Title 5 Official Inspection Form ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (cont.) 157 Lakeside Drive Property Address Marstons Mills MA 02648-1921 Cityrrown State Zip Code Gregg Farmer 7/18/06 Owner's Name Date of Inspection 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. Farmer.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Checklist 157 Lakeside Drive Property Address Marstons Mills MA 02648-1921 Cityrrown State Zip Code Gregg Farmer 7/18/06 Owner's Name Date of Inspection Check if the following have been done. You must indicate"yes" or"no" as to each of the following: YES NO ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ 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 ® El 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(3)(b)J Farmer.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ^M0 Subsurface Sewage Disposal System Form C. System Information 157 Lakeside Drive Property Address Marstons Mills MA 02648-1921 Cityrrown State Zip Code Gregg Farmer 7/18/06 Owner's Name Date of Inspection 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 gpd. Number of current residents: 2 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 N/A 9 ( y 9 (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CM N/AR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): N/A 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: N/A Last date of occupancy/use: N/A Date Other(describe): N/A Farmer.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M C. System Information (cont.) 157 Lakeside Drive Property Address Marstons Mills MA 02648-1921 Cityrrown State Zip Code Gregg Farmer 7/18/06 Owner's Name Date of Inspection General Information Pumping Records: Source of information: owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: N/A gallons How was quantity pumped determined? N/A Reason for pumping: N/A 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 7/5/95 per disposal works construction permit on file at Barnstable BOH. Were sewage odors detected when arriving at the site? ❑ Yes ® No Farmer.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form WM C. System Information (cont.) 157 Lakeside Drive Property Address Marstons Mills MA 02648-1921 City/Town State Zip Code Gregg Farmer 7/18/06 Owner's Name Date of Inspection Building Sewer(locate on site plan): 1' Depth below grade: 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.): All in good working order at time of inspection. Septic Tank(locate on site plan): Depth below grade: 1.5' 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 ❑ Yes ❑ No certificate) Dimensions: 8'x5'x5' outside 1000 gal. Sludge depth: .3' Distance from top of sludge to bottom of outlet tee or baffle 3.6' Scum thickness .2' Distance from top of scum to top of outlet tee or baffle .4 Distance from bottom of scum to bottom of outlet tee or baffle 1' How were dimensions determined? sludge judge Farmer.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments y Subsurface Sewage Disposal System Form C. System Information (cont.) 157 Lakeside Drive Property Address Marstons Mills MA 02648-1921 City/Town State Zip Code Gregg Farmer 7/18/06 Owner's Name Date of Inspection 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 shows no signs of leakage and appears to have been maintained regularly at time of inspection. Grease Trap (locate on site plan): Depth below grade: N/Afeet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): N/A Dimensions: N/A Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A Date of last pumping: N/A 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.): N/A I 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): N/A Farmer.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form, Not for Voluntary Assessments Subsurface Sewage Disposal System Form M y y C. System Information (cont.) 157 Lakeside Drive Property Address Marstons Mills MA 02648-1921 Citylrown State Zip Code Gregg Farmer 7/18/06 Owner's Name Date of Inspection Tight or Holding Tank(cont.) Dimensions: N/A Capacity: N/A gallons Design Flow: N/Agallons per day Alarm present:. ❑ Yes ❑ No Alarm level: N/A Alarm in working order: ❑ Yes❑ No Date of last pumping: N/A Date Comments (condition of alarm and float switches, etc.): N/A Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0.0' 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.): D-box shows no signs of leakage or solids carryover at time of inspection. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Farmer.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 157 Lakeside Drive Property Address Marstons Mills MA 02648-1921 City/Town State Zip Code Gregg Farmer 7/18/06 Owner's Name Date of Inspection Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): N/A Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 ❑ 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.): 1 6'x10' precast pit w/T of stone was 1/2 full w/no signs of hydraulic failure at time of inspection. Farmer.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 h Commonwealth of Massachusetts Title 5 Official Inspection Form ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form Ww re`'y C. System Information (cont.) 157 Lakeside Drive Property Address Marstons Mills MA 02648-1921 City/Town State Zip Code Gregg Farmer 7/18/06 Owner's Name Date of Inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A Depth—top of liquid to inlet invert N/A Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction N/A Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A Privy(locate on site plan): Materials of construction: N/A Dimensions N/A Depth of solids N/A Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A Farmer.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cont.) 157 Lakeside Drive Property Address Marstons Mills MA 02648-1921 City/Town State Zip Code Gregg Farmer 7/18/06 Owner's Name Date of Inspection Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. IAM]k(esii(fte w/s #157 A B 0 A 1-30' B-1-2T A 2-26 B-2-34' A-3-2T B-3-46' Farmer.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form a Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M C. System Information (cont.) 157 Lakeside Drive Property Address Marstons Mills MA 02648-1921 City/Town State Zip Code Gregg Farmer 7/18/06 Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: 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: Hand auger 16' , 5' below bottom of sas and found no water. Adjustment at time of inspection was .5' leaving adequate groundwater seperation. Farmer.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 TOWN :;F BARNSTABLE LOCATION SEWAGE # VILLAGE///��S'p��S /'�/�� ASSESSOR'S MAP & LOT INSTALLER'S NAME 6& PHONE SEPTIC TANK CAPACITY LEACHING FACILITY:(type) � C/J (size) R �d NO. OF BEDROOMS PRIVATE WELL O PUBLIC WAT BUILDER O OWNG� /' -___ DATE PERMIT ISSUED: �S DATE COMPLIANCE ISSUED: � . VARIANCE GRANTED: Yes TO /� Tp y(. FT 3 -10 T - a A ` ��, � S7, M72- - 17� No.....75m:11 V Fxs... d............. THE COMMONWEALTH OF MASSACHUSETTS 5 BOAR® OF HEALTH TOWN OF BARNSTABLE Appliration for Ali-ripasul Workw Tnnitrnrtiun Frrmit Application is hereby made for a Permit to Construct (' ) or Repair (p an Individual Sewage Disposal System at: ocatcon- - ddre / ...... or Lot No. �— owner Addr W `- `--- .-----Gb 1c lS'TII!V__�i____------ 1.r ---74 ' r✓VI 1 ..LS ,.� Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling— No. of Bedrooms-------- __ ._..Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building ............................ No. of ersons-----..._..-_----_-----.---. Showers — a yp g p ( ) Cafeteria ( ) Q' Other fixtures --------------------------------- - W Design Flow................ ---------------gallons per person per day. Total daily flow.._..-...._._--_ ..............gallons. WSeptic Tank—Liquid capacity/4 ._-gallons Length................ Width--------------_ Diameter.--------------- Depth................ x Disposal Trench—No- -------------------- Width_.---------------- Total Length........ .-f_..... Total leaching area....................sq. ft. Seepage Pit No----------/------- Diameter-------/Q:....... Depth below inlet_--................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by------------------------------------------------------ ------------------- Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water.---..................-. rxq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 --•-----------• --------------------------------------------------------------------•--•------------......................................................... 0 Description of Soil-------------------------------------------------------------------------------------- --------------------------------------------------------------------------------- x U ---------------------------------------•--•---------------------•-...-------------•-------------------------.......-------------------------------------•-------....................................... W x Nat re of Repairs or Alterations—A�nswer�when a Mica 1 ��_- :-. � .. U lf�..... P..c ?•d*% =f 5�Pv . (! --- ..--- ../------------ ,[ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliant as een iss the board of health. Signed ------ - - - ----- ----------- ------------------------------ Application. 0 ch/ 9� Dace ApprovedBy ._._._...." J----- ... / ...... -............... ------- ' Date Application Disapproved for the following reafonr- ----------------------_....._..._. ------------------ ------------------------.._.----------------------------.......----.............------------------------------------------------------------------------------------- ......--------------------------------- Date PermitNo. ..........7 . g 7g---------------------- Issued ----------------------------------------------------------------- Dace . .� No..... Fxs............................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE F Applutttinn for Mi5pw ul lVorkii (fnmitrnrtiun ramit Application is hereby made for a Permit to Construct C ) or Repair (, ) an Individual Sewage Disposal System at: 2414-1( ------- --- ---------------------------•-------•---•------..................... •-•-•- -•--------------------------•---••-------•-•-•-------...........•..---------•--..... Location•Addre or Lot No. -------------------- - O�«nc�r --•--....... ------------Addrej�f� _27 G/"'I...C/.L(1-1%..�...- InstallerkJS�/V�/ /G/� / ��IS _�i 4 � dres�` 1...� r /I/) 1 l LS• UType of Building Size Lot...`.......................Sq. feet Dwelling—No. of Bedrooms.__.._- 3...................Expansion Attic ( ) Garbage Grinder aOther—Type of Building ............................ No. of persons._._..........._-- Showers ( ) ( ) QIg Other fix��----------------g----------- ----P---------- --------- -------------------- --------------��----------•-----•-------�-------- d W Dessi n Flow---------- -- - p .gallons per person per day. Total dailyflow.................................. ........gallons. IY4 Septic iameter x Disposal Trench Ji Tank—Liquid actty.G�aWidthns t LengthTotal Length Width.............. Total leaching area__ Depth-......sq. ft. Seepage Pit No....--..T/------- Diameter.......1�6........ Depth below inlet....4 ........... Total leaching area.. .............sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed bY--------------------------------------------------------------------------- Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit........_..._....... Depth to ground water........................ L7. Test Pit No. 2................minutes per inch Depth of Test Pit_.--_----------_. Depth to ground water....................--.. 9 ---------------------------------------------------------•-•........•-••••-••-•-••-•-•..........•---........................................................ 0 Description of Soil........................................................................................................................................................................ x _.... W U Nature of Repairs or Alterations—Answer when applicable....._,../..! ..................rll� . ...�3 ............. 60t-�- � 7•a►.i - � -.�(/ ---- ...... E G Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliances as een iss b the board of health. Signed ------ - - ...._......... ��[eM - APPllcation,Approved BY ----- ---- ......... _-/_ ... /a.te Application Disapproved for thtollo g reason.f- -------------------------------------------------------------------------.._...------------------------------ ..............-------------------------------------1/------`------------..._.------..------------..._........---------------------------------------------------------------------------------- ._.. ..........._....... ( 1/ .... ..7.V- Date Permit No. _...... Issued Dare ---- -------ov»d-v--- ®.ter--I-------+.------—o_,--------. --- THE COMMONWEALTH OF MASSACHUSETTS _/7� BOARD OF HEALTH TOWN OF BARNSTABLE (11-Er#tftcttte of C�omplinurr THIS IS TO CER Y, That the Individual Sewage Disposal System constructed ( ) or Repaired ( AQ b Ci.Xi?J t¢, r Gt AJ se�r"-i u�r Y -_...._............._.......- _....-.........-_..... _.... .- ... - - _..... Installer at ----------------------......-....-----------------4 .- -----------_e,, �L T/O.E ©j� '-------- /I.�..l iL 1.l.S has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ------ �1-.7 -------- dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST EA,AS A GUARANTEE THAT THE SYSTEM WILL FUNCJJON SAP5FACT RY. DATE.....7-_�.� __ p ` -------- --.----------- Ins ecto .. - -.:.1/..................... ........ y !— —y—— —— ...THE COMMONWEALTH OF MASSACHUSETTS /e�2 BOARD OF HEALTH q. Q TOWN OF BARNSTABLE �O _ No...r..S .:a�Ll FEE........................ Ehapnoal Worhp Tianitrutuon Vantit Permission is hereby granted--------_------------- �!1�a u?!�-----------�?'�-.. ............ �� .. --- ----- to Construct ( ) or Repair ( an Individual Sewage Disposal System at No. 5�- f'S r_,�--- /�� ` �" Street as shown on the application for Disposal Works Construction Permit No.. _SZ _ Dated_._-.. ..^... .�.^_.___ ----••.......................... r ------------------------------------------------------ Board of Health DATE-----------`3-- -� .................................. FORM 36508 H0198S A WARREN.INC..PUBLISHERS