HomeMy WebLinkAbout0174 LAKESIDE DRIVE - Health 174 LAKESIDEV,,#,MARSTONS MILLS
TOWN OF BARNSTABLE
LOCATION Y ZA(gj Si i,Qp SEWAGE #MA
VILLAGE 19"d A1115 ASSESSOR'S MAP & LOT O ?,r O 3
.INSTALLER'S NAME & PHONE NO. A & B CANCO 775-6264
SEPTIC TANK CAPACITY D
LEACHING FACILITY:(type) 2i7 li ll/,14I'f (sue) J t X
NO. OF BEDROOMS PRIVATE WELL O UBLIC ATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: ,
VARIANCE GRANTED: Yes No
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NO.OF BEDROOMS
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PERMUDATE: 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 eaching facility) Feet
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Septic System Inspection Report
' 174 Lakeside Drive
Marston Mills, Massachusetts
May 18, 2001
' Prepared For:
' Craig and Carolyn Larson
60 fair Acres Drive
Marston Mills, Massachusetts 02648
Prepared by:
Willam E. Robinson, Jr. Septic Inspections
' 43Tomahawk Drive
Centerville, Massachusetts 02632
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COMMONWEALTH OF MASSACHUSETTS
NKW' ExECUT OFFICE OF ENVIRONMENTAL AFFAIRS
a
+ d NE DEPARTMENT OF ENVIRONMENTAL PROTECTION
Sy0
TITLE 5
I ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
' CERTIFICATION
Property Address: 174 Lakeside Drive,Marstons Mills
II ' Owner's Name: Craig and Carolyn Larson
Owner's Address: 60 Fair Acres Drive,Marstons Mills,MA. 02648
Date of Inspection: May 18,2001
' Name of Inspector:(please print) William E.Robinson,Jr.
Company Name: William E.Robinson,Jr.Septic Inspections
Mailing Address: 43 Tomahawk Drive
' Centerville,MA. 02632 .
Telephone Number: (508)775-7986
' 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 stem:
P ( ) system:
X Passes
' Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
' 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.
Notes and Comments
The.septic system appeared to be in good functioning condition on the day of inspection.
t ****This report only describes conditions at the time of inspection and under the conditions of use at that
P Y P
time.This inspection does not address how the system will perform in the future under the same or different
' conditions of use.
' Page 2 of 11
' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
' PART A
CERTIFICATION (continued)
' Property Address: 174 Lakeside Drive,Marstons Mills
Owner: Craig and Carolyn Larson
Date of Inspection: May 18,2001
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
' A. System Passes:
' X 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 septic system was found to be in good working condition on the day of inspection.
' B. System Conditionally Passes: N/A
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
' explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the
' existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
' ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
' obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
' distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
' broken pipe(s)are replaced
obstruction is removed
ND explain:
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' Page 3 of 11
' OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 174 Lakeside Drive,Marstons Mills
' Owner: Craig and Carolyn Larson
Date of Inspection: May 18,2001
' C. Further Evaluation is Required by the Board of Health: N/A
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
' is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
' _ Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
' _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well".Method used to determine distance
' "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria 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.
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3. Other:
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' Page 4 of 11
tOFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
' PART A
CERTIFICATION(continued)
' Property Address: 174 Lakeside Drive,Marstons Mills
Owner: Craig and Carolyn Larson
Date of Inspection: May 18,2001
D. System Failure Criteria applicable to all systems: N/A
You must indicate`yes"or"no"to each of the following for all inspections:
' Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool—
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than''/Z day flow
' _ X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
' _ X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
No (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.
' E. Large Systems: N/A
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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—1WPA)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.
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
' Property Address: 174 Lakeside Drive,Marstons Mills
Owner: Craig and Carolyn Larson
Date of Inspection: May 18,2001
' Check if the following have been done.You must indicate`yes"or"no"as to each of the following:
' Yes No
X Pumping information was provided by the owner,occupant,or Board of Health(none available)
X Were any of the system components pumped out in the previous two weeks?
I ' X _ Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
' X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
' X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out?
' X _ Were all system components,excluding the SAS,located on site?
X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of
I ' the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
' The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes / No
' X _ Existing information.For example,a plan at the Board of Health. (as-built plan)
_ X 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)]
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' Page 6 of 11
' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
' PART C
SYSTEM INFORMATION
Property Address: 174 Lakeside Drive,Marstons Mills
Owner: Craig and Carolyn Larson
Date of Inspection: May 18,2001
' RESIDENTIAL FLOW CONDITIONS
Number of bedrooms(design): 2 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220 gpd (299 gpd provided
' based on size estimate in the field)
Number of current residents: 3
Does residence have a garbage grinder(yes or no): No
' Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): N/A
Seasonal use:(yes or no): No
Water meter readings,if available(last 2 years usage(gpd): 1999—71K gals.(195 gpd),2000—203K gals.(556 gpd)
(increased waster use from leaky toilet that has since been fixed)
Sump pump(yes or no): No
Last date of occupancy: Currently occupied.
COMMERCIALANDUSTRIAL N/A
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
' Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):_
' Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water meter readings,if available:
Last date of occupancy/use:
' OTHER(describe):
GENERAL INFORMATION
' Pumping Records
Source of information: Barnstable Sewage Treatment Plant—No information available.
Was system pumped as part of the inspection(yes or no): 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)
' T Tight tank _Attach a copy of the DEP approval
X Other(describe):(3 Infiltrator units w/stone—l01x261x2'—Size estimated in field. No design plan on file.)
' Approximate age of all components,date installed(if known)and source of information:
Installed in 1992—BOH information
Were sewage odors detected when arriving at the site(yes or no): No
Page 7 of I I
' OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
' PART C
SYSTEM INFORMATION(continued)
' Property Address: 174 Lakeside Drive,Marstons Mills
Owner: Craig and Carolyn Larson
Date of Inspection: May 18,2001
' BUILDING SEWER(locate on site plan) X
Depth below grade: 1.5'
' Materials of construction:X cast iron X 40 PVC_other(explain):Cast iron leaves building,PVC enters
septic tank.
Distance from private water supply well or suction line: N/A
' Comments(on condition of joints,venting,evidence of leakage,etc.):
No evidence of leakage,all joints appear to be in good condition on the day of inspection.
SEPTIC TANK: X (locate on site plan)
i ' Depth below grade: 2.33'(28")
Material of construction: X concrete_metal fiberglass_polyethylene
' _other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: 8.5'x 5'x 4'
Sludge depth: 5"
Distance from top of sludge to bottom of outlet tee or baffle: 27"
Scum thickness: 5"
' 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: 16"
How were dimensions determined: Direct measurement
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
' as related to outlet invert,evidence of leakage,etc.):
Inlet and outlet tees in good condition. No signs of leakage,liquid level at outlet invert. Pumping is
recommended at this time.
' GREASE TRAP: N/A (locate on site plan)
Depth below grade:_
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:
' Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
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' Page 8 of 11
' OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
' PART C
SYSTEM INFORMATION(continued)
' Property Address: 174 Lakeside Drive,Marstons NEW
Owner: Craig and Carolyn Larson
Date of Inspection: May 18,2001
' TIGHT or HOLDING TANK: N/A (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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: N/A(if present must be opened)(locate on site plan)
' Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
' leakage into or out of box,etc.):
PUMP CHAMBER: N/A (locate on site plan)
' Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
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' Page 9 of 11
' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
' PART C
SYSTEM INFORMATION(continued)
' Property Address: 174 Lakeside Drive,Marstons Mills
Owner: Craig and Carolyn Larson
Date of Inspection: May 18,2001
' SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
' If SAS not located explain why:
Type
leaching pits,number:_
leaching chambers,number:
X leaching galleries,number: 3 Infiltrator units surrounded by stone(10'long x 36'wide x 2'deep).
' 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.):
' The SAS was not excavated due to its type and depth below the surface. It was found to be in good working
condition on the day of inspection based on evidence found in the other system components.
CESSPOOLS: N/A (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 or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: N/A (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.):
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' Page 10 of 11
' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
' PART C
SYSTEM INFORMATION(continued)
' Property Address: 174 Lakeside Drive,Marstons Mills
Owner: Craig and Carolyn Larson
Date of Inspection: May 18,2001
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.
' Please h ea a see attached sketch
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' Page 11 of 11
' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
' PART C
SYSTEM INFORMATION(continued)
' Property Address: 174 Lakeside Drive,Marstons Mills
Owner: Craig and Carolyn Larson
Date of Inspection: May 18,2001
' SITE EXAM
Slope: Flat in SAS area,sftht slope everywhere else
Surface water: Site borders on Shubael Pond
' Check cellar: No water
Shallow wells: None in area
Estimated depth to ground water 8 feet(below the ground surface at the SAS after adjustment)
' Please indicate(check)all methods used to determine the high ground water elevation:
' Obtained from system design plans on record-If checked,date of design plan reviewed:
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)
' X Accessed USGS database-explain:
' You must describe how you established the high ground water elevation:
The depth to seasonal high groundwater was determined by using information from the previous report
where the high groundwater was estimated using the USGS method. James Sears completed the previous
' inspection report for the site in 19%.
In his report Mr. Sears found that groundwater was encountered approximately 12.66' below the ground at
the SAS. The site is located in Zone B of USGS indicator well SDW-253(Zone B),which had an adjustment
of 4.7 feet upwards in February of 1996(according to the Cape Cod Commission)to reach the seasonal high
elevation.
The bottom of the SAS on-site was found to be 6.33 feet below the surface by Mr. Sears. When the bottom
' measurement is subtracted from the depth to groundwater, Mr. Sears found that groundwater was 614"
below the bottom of the SAS. When the seasonal adjustment of 4.7'is applied to that distance,the separation
from the bottom of the SAS to seasonal high groundwater is approximately 1.631.
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' Septic System Sketch
Septic Tank
38'
11'
' S
28' H
15, #174 B B
S A
A 46' E
S L
29' P
O
100, +1- N
D
Lakeside Drive
' Cross Section
Ground Surface
' 28"
4,33'
E-1
SAS 7.96'
' Foundation Septic Tank
1.63'
' Seasonal High Groundwater
' William E. Robinson, Jr. Site: 174 Lakeside Drive
Septic System Inspections Marstons Mills, Massachusetts Not to scale
43 Tomahawk Drive
' Centerville, MA. 02632 Distance to
Date: May 18, 2001 pond is an
(508) 775-7986 estimate only
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LOCUS MAP & SEPTIC SYSTEM SKETCH
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Name: SANDWICH Location: 041°41'43.5" N 070'24' 17.1" W
Date: 5/19/2001 Caption: Locus Map
Scale: 1 inch equals 2000 feet 174 Lakeside Drive
Marstons Mills, MA
' Copyright(C)1997,Maptech,Inc.
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' Inspectors Certificate
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THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BE IT KNOWN THAT
William E Robinson, . Jr.
Has satisfied the Department's qualifications as required and is hereby
authorized to use the title
CERTIFIED TITLE 5 SYSTEM INSPECTOR
as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the
General Laws. Issued by The Department of Environmental Protection.
April 20, 1995
Acting Director of the ton of Water Pollution Control
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Commonwealth of Massachusetts Executive Office of Environmental Affairs FRE I"VE®
epartment of Environmental Protection HDE-Fi.
William F.weld AANSTAuLE
Govemor
Trudy Coxe
Sec,
.
.. 'EOEA
David B. Struhs
Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
MAP# R I D.� PART A
PAR#_gQ:(p CERTIFICATION Property Address: 174 LFlkest ue ,1IZ. MA RsTo n+nS r'()s Address of Owner: Alines 1+T
1TI1 r e
Date of Inspection: o2-.20-9(, (if different)
Name of Inspector: T meS -D- Se,a2s
Company Name, Address and Telephone Number:
A & B Canco 350 Main Street West Yarmouth, MA 02673 (508) 775-2800
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 Fur.her Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Date: o2-a20-9(0
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 ov ner and cupie• x ai io mu bj)e;, if app;icab�c' and the aiipro,in` au!howv.
INSPECTION SUMMARY:
Check A, B, C, or D.
A) SYSTEM PASSES:
V 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.
8) SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
Indicai� ye_, no, or not determined!(Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not)
_ The septic tank s metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
(revised 8/15/95) 1
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One Winter Street a Boston,Massachusetts 02108 Q FAX(617)556-1049 Q Telephone (617)292-5500
i, Primed on Recycled Paper .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: LA KCS1 De -DQ, rnArsTCns m,LLS
Owner: P&wes TX'TH'L
Date of Inspection: .2—•20-9&
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):
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] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) "'SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONAiENT:
_ The sysien) nas a septic tank and suii auD ipoun Dybrem and is within 103 feri to a surface water suppl'j or tributary to a
surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a well water analysis for coliform bacteria 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•
D] SYSTEM FAILS:
,!'have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Backup of sewage 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 of
cesspool.
(revised 8/15/95) 2
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C
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: I TY AAKe-s l ac 7Z��tve, mv9 r,-%- ans M. Ills
Owner: Agnes-Z."r,e
Date of Inspection: P2—ao—9(P
D] SYSTEM FAILS (continued):
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 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] LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The design flow of 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 conditions exist:
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area 0WPA) or a mapped Zone 11 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
requirementsbf D4 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 8/15/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 114 LAKest0e-�2`ve, Mf1R3Tans fni (f-S
Owner: Agnes ^bu4 h`
Date of Inspection: a- .26 — 4(a
Check if the/following have been done:
✓ Pumping information was requested of the owner, occupant, and Board of Health.
-- NOT'
✓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 if they are not available with N/A.
�[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.
✓AII system components, 4kluding 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 existing information or
approximated by non-intrusive methods.
_✓The faciiiiy o�%i.c: wnd uccuud,,t, if d;fieren; ir,n, c,,,er; -. erc provided with information on the proper maintenance of Sub-
• Surface Disposal System.
(revised 8/15/95) 4
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 1?q kAaS r DC O 2. rY1 Ae-5"AS M 1 11•5
Owner: A&ncs A✓+h'*e-
Date of Inspection: a_-Lt>
FLOW CONDITIONS
RESIDENTIAL:
Design flow:g2aZd gallons
Number of bedrooms: Z
Number of current residents: O
Garbage grinder(yes or no):_UQ I
Laundry connected to system (yes or no): Al0
Seasonal use.,(yes or no):_U
Water meter readings, if available: 19R't/ - 31, 000 6AII oN s 1945— 3��Oo0 GAc.�ooJ S
Last date of occupancy: 8Cr' 1995
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flow:_gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available.
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
maje
System pumped as part of inspection: (yes or no) VLO
If yes, volume pumned. gallons
Reason for pumping.
TYPE OF SYSTEM
Septic tan Inuum oil absorption system
Single cesspool
Overflow cesspool.
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Other(explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information: I I f Q ?er'n+J=$L 9 a-36
Sewage odors detected when arriving at the site: (yes or no) IVD
(revised 8/is/95) S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 171 l_AKeSt6G l�-iUL, mpa-%To^S n'A is
Owner: AGnes Ijv+h e
Date of Inspection:
SEPTIC TANK:
(locate on site plan)
Depth below grade: 7k
Material of construction: concrete _metal _FRP _other(explain)
Dimensions: /000 GF}t,UtA QreeAST
Sludge depth: I"
Distance from top of sludge to bottom of outlet tee or baffle: obi"'
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:'
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.) 1 AoiK iz A r weP_�i.+6 c.eVe� • =n le-* -- ouT(e--f" 4eq 19= 'I -T
7AAlk coufgs Ate Ult f3eloks 6rAoe . C-6ueCtS 5'Awt,.D Be- "iSeD
GREASE TRAP:_
(locate on site plan)
Depth belov+', grade:
Material of construction: _concrete _metal _FRP —other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from botio- ni c,t,- to hnttnm of oWlet 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
integrhy, evidence of leakage, et(.)
trevised B/15/95) 6
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 17J4 LAKes'of, 1>'1 ue� ONA2ST6AS Mill S
Owner: A Cnes Ds f-h;e
Date of Inspection: 2-.2 o-
TIGHT OR HOLDING TANK:_
(locate on site plan)
Depth below grade: r
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.)
I
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribt::ic- e:; ;:'. e.idc.^.ce of sold ca �.n.e , evidence of leakage into or out of box, etc.)
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 8/15/95) 7
E
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1V4 L•AKes(De '4)'e•;ve- MrR2sTons rnr fIS
Owner: . ' ' AGne5 Ovi
Date of Inspection:
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:
r _
Type:
leaching pits, number:_
leaching chambers, number: ✓
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
There_ f ice. .3 L-eAcs1/IJ 6 mi Lr L r f n roe s . LeAcH l;r6 rs t/ .
CESSPOOLS: _
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum iayer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection;
Comments: (note condition of soil, sign- 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.)
(revised 8/15/95) 8
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: ��� (,fjK�st�� br(ue MA 2sT"oals m I(S
Owner: "bu+h-L
Date of Inspection:. a_a 0-- q(P
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
90,4D
1jd ck
DEPTH TO GROUNDWATER
Depth to groundwater: //- feet _
method of determination or approximation: NAND ✓6 %L S/ /y0�
T
(revised 8/15/95) A/ v/ �D 9
` .y o Iry
,//ors
4
(/1.11111� �•�11�11!��•' f).lt� •_,may„�- ,__ ••
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HIGH GROUND-WATER LEVEL COMPUTATION
f11�� 2101 '
Site Location: I rN L1'W s IAe -D2i v,_ m ptr S-Mri S m i( I S Lot No. Pf}R
Owner: A ones� � C, Address:
Contractor: Af Es CAnCo _ Address: 35�
Notes:
T
STEP 1 Measure depth to water table
...... Date
to nearest 1/10 ft. .......... I'
month/day/Year
'1.
i
STEP 2 Using Water-Level Range Zone S.
and Index Well Map locate
site and determine: SD0/
(A Appropriate index well.................................................... 0253 i.
OB Water-level range zone ..................................................... Q
STEP 3 Using monthly report "Current
Water Resources Conditions"
determine current depth to I Jq� Sa
water level for index well ........................... month/veer
STEP 4 Using Table of Water-level Adjustments
for index well (STEP 2A), current depth
to water level for index well (STEP 3),
and water-level zone (STEP 2B) �+17
determinewater-level adjustment ..........................................................................................
STEP 5 Estimate depth to high water
by subtracting the water-
level adjustment (STEP 4)
from measured depth to water
levelat site (STEP 1) ............................................................................................................. 7'
Figure 13.--Reproducible computation form.
15
�t Fes$.. d.:_ .......
r ....-- .�_..._.. .e Gl
�'"` THE COMMONWEALTH OF MASSACHUSETTS
' ~ � Date
s BOAR® OF HEALTH
TOWN OF BARNSTABLE
, llpfirFa#ion for Dhipoii ai Workii Tomitxnrtinn ramit
Application is hereby made for a Permit to Construct ( ) or Repair (►.�an Individual Sewage Disposal
System at:
17 q 1--A/S E S t��' 7�.._.. `nn: 5�'d!�'S ---�-���5------••---•--•--•----•----•..................•
......----•.....__....... . ..... .. . ............
Location-Address or Lot No.
1GtJC'S c'Tl-l )-��........................._...•--- -..__.._..--.-.---•-------------------••--•-------•--...........----....._........_...---.....•••-
Owner Addres
W f� '� C 1q J c 0---•-.._..--•--------------------------••-•-•• ham'-d . - �•= � _NMO U T'1'l
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms......y................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of ersons____________________________ Showers
a YP g ---------------------------- P ( ) — Cafeteria ( )
0 Other fixtures -------------------------------------------------------------------------------------------------•--••-----------------------......-•--..._•---------
I W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................. Width................ Diameter---------------- Depth................
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 ( )
1-4 Percolation Test Results Performed by.......................................................................... Date........................................
,4 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
GT., Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................
-----------------------------------•----...-----...----•-----------.._._..----------••-•••-••••••-••...............
__......
___•----------- -------•---_-----
ODescription of Soil........................................................................................................................................................................
x
U .--------------------------------------•••••-------------------------------•--•---••----------------------•••------------------------------------------------...........................................
UW ----------•-----------------•----------------------------------------------------------...-------------- -----------------
, Nature of Re ai s or terations—Answer when applicable .__>��0__9! __ __...d-'o______________________
....
....
I-- -`--..47,4�..............••--------------...------••-•--•---------------•---------------------------•----•-------•••-----
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 Co p is has been i ue by the board of health.
1
Signed ---- . .1..... - ----- ,a 9 v Z
Date
Application Approved BY - ... �..- ........ ........ - ------ .-..i....>-3-0.-..-- .-
Dale
Application Disapproved for the following reasons- ----------- -------------------------------------------------------------------------------- ...................................
------------------------------------------ -------------------------------------------------------------------------------------------------------------------------------------------............ --------------------- .........
Dace
Permit No- -------------C `.-.. ,... ... Issued .. -----------------------
Dace
02 -
No. --._.__--•-...._...... Fss...: a._`.........
THE COMMONWEALTH OF MASSACHUSETTS
v
BOARD OF HEALTH
T W N F O O BARNSTABLE �
AVV irFa#inn for BhipasFal Works TouBtrnrtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at:
�..?� ..... �<' :...................... ..................../ .
.............. ----...---.............._•---...___......•....
Location-Address or Lot No.
......1;�G IJ S c a-T.............................................. ...........•--.....-•-----•-•-•----•--•----...........----•-•----•--••------..........---•-•--....
Owner Address
...._....................•.... •••••---•••---...••-••-•-•......-•-•-•...............•••....... ....� ...........
i.............................................
Installer
Address
Type of Building Size Lot............................Sq. feet
U Dwelling No. of Bedrooms__.... .................. ._...Ex Expansion Attic� g— -----.--. p ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
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........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
(s, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
19
0 Description of Soil............................................................................... ............................................................
U
----------------------------------------------------•-----------•--•--------------------------------- --------------------------.......................................................i Nature of Repairs or Alterations—,Answer when applicable._._-_--__ __.J_aQ .�?- ._ "• •, __...'�-! .................''
�• ,,� "- fit , wp _
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 Compliance has been iss ed by the board of health.
:.
Signed �- --- el
----------------------------------------
Date
.................
Application Approved By ------------------------. J... /
----------------------------------------------- -------------
Application Disapproved for the following reasons- ------------------------------------------------------ ------ -------------------------- -------------......................
- - - ----- --- -------------------------------------------- ----- ----------------- -- ---- ------------------------------------------------------------------------------ ........................................
Dare
Permit No. "...... ............................ Issued . -------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH ..
TOWN OF BARNSTABLE
'IT r#tftca#e of Conaptianee
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ;I or Repaired
by ........,tom. '. - Cwr- _r.� ---------------------------- --..---............------------------.......---------..........----------- -- ..-------- --.........-----................................
Installer at ..... --------- K ..S.! �.........I,-)2.:...... T"i �W)...<... ..................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. ...............01.-.. .l..........-- dated ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION�...�. ..jj.
.. SATISFACTORY.
....... �� Ins ectorDATE................... . .. ..--------------------------....-. ----
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
FEE.......O...
Disposal Works Tuun#r ilan amit
Permission is hereby granted_.. `--.---•--Cf......�C--�----------------------------•---------------•-----•-•---•-•--...----.......••••--.......
to Construct ( ) or Repair ( gran Individual Sewage Disposal System
at No....../2�......t_Fa/•C c t � '5- 1�_ �% . 'vim �1v,�l
----------------------------------•-••.-•--......•. •--•-•......-----•...........-•--•--•--•-•---•-•••....----••--••--•-•••----•-•......•-•.....
Street q
as shown on the application for Disposal Works Construction Permit No.� _:n34.. Dated..........................••..............
l\
0 O� Board of Health
DATE -----...----••......•.............
FORM 36508 H088S&WARREN.INC..PUBLISHERS ,