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0286 LAKESIDE DRIVE - Health
286;Lakeside Drive Marstons Mills P� 4. h 02/28/2011 10;31am MARY M MANNING 5084201284 #115 Page 01/01 Dep.rUnm t of Pubric HeaM-ChiiamW Lead'PdsonWg PMet>tian Progmtn t*tading NOU CSti0m Please t iefie all et< term cleady.hmomVjda or Mook torans wai be retwm&UA Im PaintAp o R v yr.eaN�'I�.,r i . .S�c u.cos #,:: 985 . bspecdon DadsLead ` ire property i s GJ/,��.ta. Ar,-xTu.,�/'I.ZLs .9zip coft-La7-_6,`f 0 ©L i �p �gwa&.�91.6zeT L• /�7 .r.,+ �1•�,' LidffAkVLb ___ - Zip Code G►, G :Tdeplro.Nuigbei•ildk� Addr4ss vrhtxe the work wilt be'dvne= . &gam(i ) sueecAddc�_ss The Pr6perty is a_L_ "fira1l Simla Suil Y. .q T g paint iumt thigh risk) o Makrag lw=(moderate m ' Appbw y� +$�. ear for o Demolition risk) a contoneaart removal(love ri* Smog � a livid t �) com ponmt r�ovaU�t a -C��°B o Other. © D.Wing a Cwpimg basdmaids cn 3 L i rr l and will l y, 1."! i.The work will be dose in the a V U'c or weekends.T he work v�nll begun _R Ta Case of Bray �9r;�. .r.rr:•� DaytimeY'tto `03o2'a livening a The Property Owner blast complem aid sign tbe4oHowing infe"U'den: .1 oefy dw o* sired permms who have complied with the hang mWiremeats of the WWmadmeft Lead Poisoning Pmvedion aid Caul Reg, Winak105 0&460.00%will induct delead og wad$.I&rthet•=tify that the=ffiorized pe,*,,)"go exceed the scope,ofhislher amhorky and will be performing only those aetivW08 inamwd above.Al of the im&ormatia® .tained in this docmmt is true mmd eommt to the best of my'lmewl .- and belief. ��/�� .• Signed �� - �.1 rx��� . Do The totlowing peopiel In"t be taotif ed ten bays before big work: 1. Occ ofthe dwelt unit 2. All otlzr o=qm=ofthe rosidentisi premises,if aay work vvrU be done in dje eammon areas b3aiaood I�ad poisoning Preve an program DPH Fart(781)774-6700 mum n 5 Randolph Strcet,Carlton,MA 02021 �4. A*cgm aid IAW Pmgran;DOS.MA 02114 �(sf 7)626-6W 19 Sued St i Floor,Bosoan, S. Ord B&mwg ICY �theta�e i$del the Stata> oY]iistane :call the�p►II'iabor�ael Casa at(f l�71'1-847p. � r TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date ®� Time: In Out Owner f-tLR ( .ApiNIrJG Tenant VAcA Address w� ( 0 16% Address2c%- PMNLC, 1s MI L-L.s 1, W MAC 111) M)L,:5,A/)/- Compliance Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply Cat aj— L )L 5. Hot Water Facilities V 6. Heating Facilities 0 V1 O S 7. Lighting and Electrical Facilities ( OF S CL`T1 b 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service / 11. Space and Use V 12. Exits 13. Installation and Maintenance of Structural Elements / 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17.Temporary Housing 18. Driveway Width 19. Number of Tenants Observed AA- PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms 3 Number of Vehicles Allowed (max) Number of Persons Allowed (max) 6 Person(s) Interviewed-( Inspector 7 If Public Building such as Store or Hotel/Motel specify here Vif Town of Barnstable P# l Department of Regulatory Services „ MASS, : Public Health Division bate 200 Maio Street,Hy nuis MA 02601 PfD MAy A 1t / / l ✓ Date Scheduled Tiine Fee Pd.j_,�o v t Soil Suitability Assessment fog- Se is s ` Performed By: DA 'IA b• GV(Niyow( Witnessed By: I,OCAT�ON& GENERAL;INFORMATIOliT �v Location Address 7.46( / _-k,7 k b r Owner's Name L,/27 044 5_0 5 V"` 11. S Address W1.�° Lr%!t S�GC� �r- Assessor's Map/Parcel �0,A Engineer's Name V�i NEW CONSTRUCTION ( REPAIR V1, Telephone# SO 5--j( �� Land Use l�cS�'��rl�t I Slopes(46) �b Surface Stones nQ Distances from: Open Water Body CD ft Possible Wet Area �O D .ft Drinking Water Well G6� r ft Drainage Way 4 ft Property Line ft Other ft SEFETCII:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) too• ooF, j G O I O � O .gyp 4 To' lj_l) Fa T.0 �i0.00t ILK ��E DZKIv1;7 . Parent material(geologic) 14 40�` DVfWuS4 ®eptfh tq Rldr ck „ Depth to Groundwater. Standing Water in Hole: ��� �q _ Weeping from Pit Face Estimated Seasonal High Groundwater o vet L-0 P et DETERMINATION FOR SEASONAL.HIGH WATER TABLE Method Used: No l Depth Observed standing in obs.hole: In, Depth to soil mottles: h� a+ KZ_ In. Depth to weeping from side of obs.hole: In. Groundwater Adjustment bidex Well# Reading Date: Index Well level� _ Adj:factor Adj.Groundwater'Level PERCOLATION TEST Date e.t LLM Observation t Hole# Time at 9" A,— Depth of Perc /l Z M Time at 6" Start Pre-soak Time @ V -0 Time(9"-6") End Pre-soak RateMin./Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) / Original: Public Health Division Observation Hole Data To Be Completed on Back ----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one(1) week prior to beginning. Q:\S EPTIC\PERCFORM.DOC DEEP.OBSERVATION MOLE LOG Hole# t Depth from Soil Horizon Soil Texture .Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,,Boulders. orisistency,%Gravel) 1141 LoClM r)eible CCU -3o' Loam S;Hd L 56 FI'14yble C'4h 1-P, DEEP OBSERVATION HOLE LOG Dole# 2 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.% a K`3Z Loq My S4nd 10 y r- fry b/P Z^ 19 C ed 5q DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistency. Flood Insurance Rate Map: Above 500 year flood boundary No— Yes Within 500 year boundary No V, Yes Within 100 year flood boundary No. Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring per ious material exist in all areas observed throughout the area proposed for the soil absorption system? D!5 If not,what is the depth of naturally occurring pervious material? Certification I certify that on t�ev (date)I have passed the soil evaluator,examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the requir aini ,exper'se and experience described in 10 CMR 15.017. oF.M pit � j" AS , ¢ ZD �� � ti Signature Date r ono DADVID U COUGHANOWIR Q-.WEPT1C\PERCFORM.DOC s0 41C E N SEA /� FVALUP,aO� ` r , y?Yor-OY�P I No. O i Fee lob THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 9pplication for MisposaY *pstrm Co=stem Permit Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Individual Components Location Address or Lot No.0-216 glgf� �/" Owner's Name,A dress,and Tel.No. /y✓'/r� l y� , oCe� Assessor's Map/Parcel Installer's e,Address,and Tel.No. ///� / i0�j` De ' ner' a�'(f Q `?S1i s me,Address, d Tel.No., 1 _1 ��i mri�Gc ��' �51V7 Type of Building: Dwelling No.of Bedrooms Lot Size &,e,00 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 33o gpd Design flow provided 1 6 0 gpd / Plan Date Number of sheets Revision Date Title Size of Septic Tank d Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) S Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. oe Si Date Z,4? cj/- y Application Approved by lu_ _ Date lb 'Z ( ' % Y Application Disapproved by Date for the following reasons cc�� Permit No. 3 Date Issued ( — .-� No. _°l�' t� � 1 � +,. ' Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer'' ' PUBLIC HEALTH DIVISION,,- TOWN OF BARNSTABLE,,MASSACHUSETTS Yes 2pplitation for Disposal *pstem Construction permit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) omplete System ❑Individual Components Location Address or Lot No.0,•g`C )-A S/q�� �/` Owner's Name,A dress,and Tel.No y Assessor's Map arcel _ I 41, Installer's Name Address and Tel.No.�//��yy� Desi ner's Name,Address,and Tel.No. Zj �,'�iG� ��a�j 2. Gti'E'STGyy4s 1�pe of Building: Dwelling No.of Bedrooms Lot Sizej��J sq.ft. Garbage Grinder( ) Other Type of Building ,o No.of Persons Showers( ) Cafeteria( . ) .._. Other Fixtures f)AiA _i:N. Design Flow(min.required) �� gpd Design flow provided gpd Plan Date ` "'�- Number of sheets Revision Date Title ,3 } Size of Septic Tank /� O�U'd Type of S.A:S. Description of Soil Nature of Repairs or Alterations(Answer when applicable)���� / / � "2 Date last inspected: The)undersigned agrees.toe sure the construction and maintenance of the afore described on-site sewage disposal system in accordance with4lie,provisions of Title I of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this,Bo4d of Health. 1 t 1Si _ � Date?/� f ' Application Approved by i Date Application Disapproved by Date a for the following reasons' Permit No. �d I y' 3� Date Issued 6—.2 ---------------------------------------------------------------------------------- ---------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Certificate of Compliance !a THIS IS TO CERTIFY,that the On-site Se age Disposal system Constructed( ) Repaired(� Upgraded( ) !I Abandoned( )by at r% has been constructed in accordance l with the provisions of Title 5 and the or •'sposal System Construction Permit No. V —39 6 dated Installer Designer �� oll , #bedrooms / Approved des' flow 73d gp' The issuance of this .e it shall dot b 'construed as a guarantee that the system 11 functi as de i ed. 41"0 Date / g Inspector ---------------------------- �� ------------------------------------------------ --- ------ ------ -�--------------- -- No. d j� 2?� Fee 0� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposar 6pstem ConstCUction J)Prmit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit 1 y Date �� ( �� Approved b l 1 w i ,� sinF urrury pw rri 100.00' D-BOX ril 29 ft x )0 ft x 2 ft 1500 ;y! LEACHNG GALLERY on ® GAL H-20 UMTS INSTALLED SEPTIC r,y TANK 1 i 1 ' GARAGE o • SLAG o o Fmw o o . o �Xisr��a BEDROOM ®WELL_/Afp 1 � � REFER TO ORIGINAL DESIGN 1 LAREA OT' 173-A PLAN-FOR SOIL LOGS AND = ro000 :tOTHER DESIGN CRITERIA. BOOR 138 PAOE25 SR mAP 102 Pa 26 REFER TO AS BUILT CARD 1ooA0' FOR LOCATION OF SEPTIC COMPONENTS IN FIELD. PLAN SCALE: I In— 30 ft Q 30 60 O 10 20 30 PRINT ON 6=112 x II In PAPER - - FOR PROPER SCALE DESIGN FLOW: 3 BEDROOMS X 110 GPD = 330 GPD 29.0 ft SEPTIC CTANK, 330 GPD X 2 DAYS = 660 GALLONS STO NF INSTALL NEW 1500 GALLON SEPTIC TANK. NE UNIT N DISTRIBUTION Box, vm M SH USA{ INSTALL 3 OUTLET DISTRIBUTION BOX D 'fyG SOIL ABSORBTION AVID SYSTEM, �w S THE LONG TERM ACCEPTANCE RATE FOR A CLASS ONE D. SOIL WITH A PERCOLATION RATE BELOW 5 MINUTES N Cbj jNOVy/R PER INCH = 0.74 GALLONS PER DAY PER SQUARE FOOT. tt 8.5 1t 14 It 1 8.5 ft 4 It NO. 1893 A 29 ft x 10 ft x 2 It LEACHNG GALLERY CAN LEACH, BOTTOM AREA = (29 a 10) = 290 aq. f 500 GALLON DRYWELL �Pc�G gTca TOTAL AREA = + + + 166 xq ft. RISER TO WITHIN OfAfENSfONS B DETAl� INSTALL ONE ITHIN INREF TfON s �P FLOW CAPACITY - 0.74 x 446 - 330.04 galidog INCHES Of FINAL GRADE INSTALL A 29 ft x 10 ft x 2 ft GALLERY AS CONFIOLMED 6 IHDICA ON AS BORLi BELOW.FLOW CAPACITY -33004 gal/day WHICH EXCEEDS F.4 THE 330 gal/day REQUIRED FOR A THREE BEDROOM DESIGN. 36 USE A T a SEWAGE DISPOSAL a2h SYSTEM AS BUILT PLAN -SERVING EXISTING DWELLING CROSS SECTION VIEW INSTALL AN APPROVED GEOTEIInLE AL F FA0.41C OVER SrOaZ RT AF MANNING, Jr. { , px1y jhI't� OWNERS! OF RECORD .� ta�zly`'•tm:.i1!'! 1'1tr`E 28 it Y2 ti Omq: ?m�,,, �a ;, ,a; 286 LAKESIDE DRIVE °E'" MARSTONS MILLS MA 91 In so in 31 to F.O. BOX 126sWEST CHATHAM. MA PROPERTY ADDRESS i20 in 02669 DnTEi 1ANUA N 25. 2015 508 364-0894 l vt :SDS-3867 Th1S PLAN IS INTENDED SOLELY FOR INSTALLATION OF THE SEPTIC SYSTEM 'EPICTED#ON IT. FOR ANY OTHER CHANGES TO THE PROPERTY INCLUDING PLACEMENT OF ADDITIONS, SHEDS. FENCES OR SWIMMING POOLS, OWNER SHOULD CONSULT WITH MASSACHUSETTS REGISTERED LAND SURVEYOR.if - � . . D GAR LAMTILITY R POLE OT OWED 70 71 100.00, 72 0 ,PROPOSED SOIL ABSORPTION ►B In SYSTEM OAK g , 1 -SEE DETAIL O \ ON BACK 73 2 THIS IS A 10 ft TO fr �O CLEAN �/ / COLOR ' � OUT WATER L/ 111 PLAN \ METER \ USE COLOR PLAN ONLY GARA FlF PIT 4i FOR INSTALLATION vn X FULL DETAIL IS BEST 1z 0 SLAB, O C VIEWED IN �� TOP OF FNDN 10 F FULL COLOR p NON EL = 72.25 l_ 1 0 - of z WEXIS T�� 0 p\ UU) TIN a�ra�� C. 3 � BEDR0O 9 WATER LINE \ DE p INC; WATER METER PIT® 74 L�16L� aV GAS LINE ELECTRIC LINE UTILITY POLE CONTOUR 1 1 \: LOT 173-A \ AREA = 10,000 sf f I PLAN 960K 138 PAGE 25 e �pgLE®GIS DATpy 1 ASSR Map 102 Pa 26 \ SHED ELEVATION om A°'° 70.83 eQ�� 100.00' 72 0F 7r WATER MEj� 74 73 L E �C�C�nNID PLAN SEPTIC COMPONENTS NOTES 1500 GAL SCALE: I In = 20 ft SEPTIC TANK PUMP, COLLAPSE & FILL EXISTING CESSPOOLS. 20 40 EXISTING TREE REMOVAL AT INSTALLERS DISCRETION. O LEACH PITI 0 10 20 CESSPOOL INSTALL FENCE OR OTHER BARRIER TO PRINT ON 8-1/2 x 14 in PAPER DISTRIBUTION Box p PREVENT VEHICLES FROM DRIVING OVER SEPTIC SYSTEM OR INSTALL H-20 RATED FOR PROPER SCALE TEST PIT COMPONENTS. ll— OV P rl TOP OF FOUNDATION RAISE COVERS TO WITHIN • EL = 72.25 i +— 6 in OF FINAL GRADE 'f 71.50 . 7 D-BO MAX USE H-20 68.50 69.75+ 15000, LLON o p 00 PRECAST EXISTING SEPTIC TA K 68. 6 in 50 67.83 DRYWELL ce 68.75 SEE DETAIL ON BACK 68.00 STONE SQL ABSORpT�QN r� sroNE BASE BASE 67.75 DETAIL 31 ft e 26 ft 6-10 ft SYSTEM -SEE ON BACK 65.75 NO GROUNDWATERV4, LO BELOW RACE LANE tH DF!I�4,SS9 �(N Of MA MOTTLING OBSERVED _ 59.73 Ss9 -. �Dvl� CyG� AVID �yG� e SEWAGE DISPOSAL _ D. SYSTEM PLAN COUGHANOWR V; COUGHANOWR 0 m W No. 1093 No. 461 -TO SERVE EXISTING DWELLING W W2 ¢ ALBERT O Z m J NING 2 Q [Sj� $A I SOi4 P� i OWNERnSI OF' RECORD, Jr. T O J coJ ►/•� e LAKESIDE - • ' 286 LAKESIDE DRIVE sTgF NOT PO BOX 1265 MARSTONS MILLS MA . . FT TO PROPERTY ADDRESS MARSTONS MILLS, MA SCALE WEST CHATHAM. MA ^ L O C U S MAP 508 364 9 DATE. 0894 Ia 1/ OC JOB# SDS-3867 1 SOIL TE T LOG SOIL EVALUATOR: DAVID D. COUGHANOWR, ASE #461 DESIGN FLOW: 3 BEDROOMS X 110 GIRD = 330 GPD WITNESSED BY: DONNA MIORANDI, HEALTH DEPT. SEPTIC TANK: 3-30 GPD X 2 DAYS = 660 GALLONS TEST PIT 1 NO GROUNDWATER ENCOUNTERED INSTALL NEW 1500 GALLON SEPTIC TANK. PERC AT 62 In — 2 MIN/INCH IN C SOILS ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER DISTRIBUTION BOX: INSTALL UNIT DEPICTED BELOW. INCHES HORIZON TEXTURE (MUNSELL) MOTTLES SOIL ABSORBTION SYSTEM: 72.65 0-10 FILL - THE LONG TERM ACCEPTANCE RATE FOR A CLASS ONE 10-16 A SANDY LOAM 10 YR 4/3 NONE FRIABLE SOIL WITH A PERCOLATION RATE BELOW 5 MINUTES PER INCH = 0.74 GALLONS PER DAY PER SQUARE FOOT. 69.65 16-36 B LOAMY SAND 10 YR 5/6 NONE FRIABLE THE MODIFIED 'L' SHAPED GALLERY DEPICTED CAN LEACH: 59.98 36-152 C MEDIUM SAND 10 YR 5/4 NONE LOOSE BOTTOM AREA = 12.83 (16.5 + 8.5) 320.75 sq. ft NO GROUNDWATER ENCOUNTERED -1/2 (5 x 5) =-12.50 sq. ft. TEST PIT 2 2 MIN/INCH IN C SOILS SIDEWALL AREA = (11.5+12.83+3.67+8.5 ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER +12.83+16.33+7,48)x2 =146.28 sq. ft. INCHES HORIZON TEXTURE (MUNSELL) MOTTLES TOTAL AREA = 464 s ft. 72.40 0-6 FILL FLOW CAPACITY = 0.74 x 454 = 336 gal/day 6-18 A SANDY LOAM 10 YR 4/3 NONE FRIABLE INSTALL THE MODIFIED •L• SHAPED GALLERY AS CONFIGURED b9.73 18-32 B LOAMY SAND 10 YR 5/6 NONE FRIABLE BELOW. FLOW CAPACITY = 336 gol/day WHICH EXCEEDS 32-152 C I MEDIUM SANDI 10 YR 5/4 NONE LOOSE THE 330 gal/doy REQUIRED FOR A THREE BEDROOM DESIGN. 59.73 DI TRI = UTION BOX H2 i DIMENSIONS PIPES EXITING D-BOX TO 1• 1500 GALLON SEPTIC TANK ' ' •• BEFORE DOWN DIMENSIONS LASE • ' 1 I I 12 !n C MIN I in ^ NOT N TANK b u� TO TAPER TO 0 a SAS SCALE 6 in STONE BASE ," 5 ft— 21 in 2 CROSS SECTION VIEW y 0 8 in � n SOIL ABSORPTION f4 �� S ' STEM • • USE SHOREY PRECAST .. GALLON LEACHING DRYWELL 10 G k 12.83,ft ft-6 J (,� INSTALL TWO DRYWELL /n p, •-�A UNITS AS SHOWN v 8.5 ft WITH FOUR FEET OF STONE ALL AROUND. INLET CENTER OUTLET to COVER COVER COVER O _ .® 1, MARK INSPECTION OD RISER WITH 3 IN DROP w MAGNETIC TAPE. � FLOW LINE � � ® FROM 10 in = lq TO BUILDINGI 1n D-BOX *?. '��` DRYWELL 48 in 5•ft 16.33 ft A UNIT LIQUID GAS LEVEL BAFFLE 500 GALLON DRYWELL DIMENSIONS ® INSTALL ONE INSPECTION RISER TO WITHIN THREE INCHES OF. & DETAIL FINAL GRADE & INDICATE LOCATION ON AS—BUILT 6 in STONE BASE SEPARATION BETWEEN INLET & OUTLET G 33 USE TEES NO LESS THAN LIQUID DEPTH TM.m o in UNIT CROSS SEITTION VIEW oo, 02 in CROSS SECTION VIEW (SECTION A-A) INSTALL AN APPROVED GEOTEXTILE FABRIC OVER STONE - m ------------------- 28 314 in TO 24 !n 314 in TO in 1-112 In GRAVEL DEPTHTIVE 1-112 in GRAVEL 48 in 58 in 48 in 154 in INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT BEFORE STARTING WORK. ALL COMPONENTS INSTALLED SHALL MEET THE MINIMUM O REQUIREMENTS OF MASSACHUSETTS TITLE 5 SEPTIC CODE (310 CMR 15). INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND UTILITIES BEFORE EXCAVATING FOR SYSTEM. -ECO-TECH ENVIRONMENTAL RECOMMENDS THE INSTALLATVON OF LOW FLOW FIXTURES & APPLIANCES. AND PERIODIC PUMPING OF THE SEPTIC TANK. c SYSTEM IS NOT DESIGNED TO WITHSTAND VEHICULAR LOADING. DO NOT PARK OR DRIVE VEHICLES OVER SEPTIC SYSTEM. SEWAGE DISPOSAL SYSTEM PLAN 1286 LAKESIDE DRIVE MARSTONS MILLS MA OCTOBER 4. 2014 SDS-386 PG 2/2 oF Town of Barnstable "E .�"D . Regulatory Services Richard V. Scali,Interim Director . ,Susm AS& Public Health Division 1639. ' oru•+ Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Far: 508-790-6304 Installer& Designer Certification Form Date: CCT Ik Sewage:Permit# Assessor's Map\Parcel Designer: ®KUiL. C_6044 40W I`_ Installer: 1QI,lt j jMm—�lr��-p Address: 0 5 Goo kider R v{ J1� Address: b �w\�t_ e i, On 067 i,20 f( tJ.1 U�kl M �)1 W c4w was issued a permit to install a (date) (installer) septic system at Lgke�gc N1 ✓Q_ based on a design drawn by /' (address) �ltUla �• Cer 'h #�h�'I Zo(¢ � � dated- �� � c (designer) i 1 certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. V I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State& Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required) was.inspected and the soils were found satisfactory. I certify that the system referenced above was construct fiance with the terms of the I\A approval letters(if applicable) tiw.or,a'S.Z t)AVlt) , (Installer's Sign ture) CnUGi ANOWR No. 1093 �*tHI inpta;� (Affix Dest (Designer's Signature) g Stamp Here) PLEASE RETURN TO"I3A:RNSTABLE PUBLIC HEALTH, DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. QASepuc\Designcr Cenification form Rev 8-14-I3,doc TOWN O F BARNSTABLE Lt)CATION '� SEWAGE # VILLAGE �\ t a j ASSESSOR'S MAP& LOT I �Da 6 INSTALLER'S NAME&PHONE NO.SEPTIC TANK CAPACITY / LEACHING FACII.TTY: (type) ACC{S� 1� (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet. Furnished by �-- FA � �5 TOWN OF BARNSTABLE q LOCATION $� i{�,�\ _ ! &Ny SEWAGE#_201 '1-3� I VILLAGE Ak\\C ASSESSOR'S MAP&PARCEL VOZ' vZ�o INSTALLER'S NAME&PHONE NO.W 1l\l ft AA�o rsro uL SEPTIC TANK CAPACITY \ OCR d} LEACHING FACILITY.(type) , (size) SOCO NO.OF BEDROOMS [ OWNER I �F ` �a✓�n�` PERMIT DATE: COMPLIANCE DATE: OCT Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY Wt k \&N/1 \),� 'F¢D NT I � 6 2 A s '4 �� wl 3 A3 �is �63� 941 ` �� Commonwealth of Massachusetts Executive Office of Environmental Affairs Dept. of Environmental Protection Jitl One winter Street'Boston,Ma. 02108 Septic D.E.P. Titlee V S Septic Inspector Ir P.O. Box 2119 Teaticket, MA 02536 WILLIAM F.WELD (508)564-6813 Governor ARGEO PAUL CELLUCCI (_� . Lt.Governor b SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION PART A D� p CERTIFICATION Property Address: 286 LAKESIDE DR.MARSTONS MILLS Address of Owner: Date of Inspection: 11/12/98 (If different) Name of Inspector: JOHN GRACI MR.PICCIOULO;86 BAT WINTt I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) Company Name,Address and Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: x_ Passes This Inspection Is based on crlterla dented In Title V Conditional) Passes code 310 CMR 16.303.Myfindings are of how the system Is Y performing etthe time of the inspection.My inspection does _ Needs Further Evaluation By the Local Approving Authority not Impyany warranty or guarantee of the longevity ofthe Fails septic system and any of Its components useful life. n Inspector's Signature: Date: 1Vt919a The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A, B,C,or D: A] SYSTEM PASSES: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Conpltance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank,whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04 UXI?) One Winter Street • Boston,Massachusetts 02108 a FAX(617)556-1049 a Telephone(617)292-5500 t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 285 LAKESIDE DR.MARSTONS MILLS Owner: MR.PICCIOULO;88 BATES RD.WINTHROP MA. Date of Inspection:11112/99 _ Sewage backup or.breakout.or high.static water level obser.ved.in.the distribution box is due to a broken. or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply 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 the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: _ I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to all overloaded or clogged cesspool. SAS is in hydraulic failure. (revised MUM) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 286 LAKESIDE DR.'MARSTONS MILLS Owner: MR.PICCIOULO;84 BATES RD.WINTHROP MA. Date of Inspection:1111112193 D]SYSTEM FAILS(continued) Yes No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coiiform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04127)97) i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 286 LAKESIDE DR.MARSTONS MILLS Owner: MR.PICCIOULO;86 BATES RD.WINTHROP MA. Date of Inspection:11112198 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: _c_ — Pumping information was requested of the owner, occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal — flow rates during that period. Large volumes of water have not been Introduced Into the system recently or as part of this inspection. x — As built plans have been obtained and examined. Note if they are not available with N/A. x — The facility or dwelling was inspected for signs of sewage back-up. x — The system does not receive non-sanitary or industrial waste flow. _c_ — The site was inspected for signs of breakout. x All system components, excluding the Soil Absorption System,have been located on the site. x The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees, material of construction,dimensions, depth of liquid,depth of sludge,depth.of scum. x The size and location of the Soil Absorption System on the site has been determined based on The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is — — unacceptable)[15.302(3)(b)J (revised 04127197) i� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 288 LAKESIDE DR.MARSTONS MILLS Owner: MR.PICCIOULO;88 BATES RD.WINTHROP MA. Date of Inspection:11112/98 FLOW CONDITIONS RESIDENTIAL: Design flow: 0 9 P•d./bedroom for S.A.S. Number of bedrooms: 2 Number of current residents: 1 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings,if available:(last two(2)year usage(gpd): rda Sump Pump(yes or no): No Last date of occupancy: Na COMMERCIAL/INDUSTRIAL: Type of establishment: nla Design flow:0 gallons/day Grease trap present: (yes or no) Ho Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings,if available: nls Last date of occupancy: nfa OTHER:(Describe) rva Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: rda System pumped as part of inspection: (yes or no)No If yes,volume pumped: 0 gallons Reason for pumping: rim TYPE OF SYSTEM Septic tank/distribution box/soil absorptions system x Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records, if any) x I/A Technology etc.Copy of up to date contract? Other: MT141OW GALLON HIO PIT APPROXIMATE AGE of all components, date Installed(if known)and source Information: ORIGINAL C€li@POOL j0 WARD WITH N€W PIT IN®TALL€D APPROXIMATELY 10 Y€Aft®AGO. Sewage odors detected when arriving at the site: (yes or no) No (revised 0427)97) i 1• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 289 LAKESIDE DR.MARSTONS MILLS Owner: MR.PICCIOULO;89 BATES RD.WINTHROP MA. Date of Inspection:1111219a SEPTIC TANK: (locate on site plan) Depth below grade: rda Material of construction:_concreate_metal_FRP_Polyethylene_other(explain) If tank is metal, list age nle . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: We Sludge depth:roe Distance from top of sludge to bottom of outlet tee or baffle: rda Scum thickness:We Distance from top of scum to top of outlet tee or baffle:We Distance form bottom of scum to bottom of outlet tee or baffle:rda How dimensions were determined: rda 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.) rVa GREASE TRAP: (locate on site plan) Depth below grade: Ma Material of construction: _concrete_metal_FRP_Polyethylene_other(explain) Dimensions: Na Scum thickness:rds Distance from top of scum to top of outlet tee or baffle:rVa Distance from bottom of scum to bottom of outlet tee or baffle: nla Date of last pumpingr,d 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.) We BUILDING SEWER: (Locate on site plan) Depth below grade: 16- Material of construction:_cast iron_40 PVC_other(explain) Distance from private water supply well or suction IineTOWN Diameter: nla_ Qmments:(conditions of joints,venting,evidence of leakage,etc.) (revised 04127097) r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 285 LAKESIDE DR.MARSTONS MILLS Owner: MR.PICCIOULO;88 BATES RD.WINTHROP MA. Date of Inspection:11112/98 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: Na Material of construction:_concrete_metal_FRP_Polyethylene other(explain) Dimensions: Na Capacity: Na gallons Design flow: Na gallons/day Alarm level:_nfa Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) Na DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Na Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.) Na PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)No Alarms in working order(yes or no)vea Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) Na (revised 04127)97) L SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 288 LAKESIDE DR.MARSTONS MILLS Owner: MR.PICCIOULO;88 SATES RD,MNTHROP MA. Date of Inspection:11112198 SOIL ABSORPTION SYSTEM(SAS):x (locate on site plan,if possible;excavation not required, but may be approximated by non-intrusive methods) If not determined to be present,explain: rda Type: leaching pits, number: 1000 GALLON LEACH PIT leaching chambers,number:Na leaching galleries,number: rda leaching trenches,number,length: rda leaching fields, number, dimensions:rda overflow cesspool,number:We Alternate system: rda Name of Technology:__.Na Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) THE LEACH PR IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY,THE PIT WAS EMPTY AT THE TIME OF THE INSPECTION.PR HAS NOT HAD MORE THAN 2.6'OF WATER IN IT. CESSPOOLS:x (locate on site plan) Number and configuration: ONE Depth-top of liquid to inlet invert: EMPTY Depth of solids layer: rda Depth of scum layer: Na Dimensions of cesspool: e•xs• Materials of construction: BLOCK Indication of groundwater: 1143 inflow(cesspool must be pumped as part of inspection) Na Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) MAIN CESSPOOLS AND ALL COMPONENTS ARE STRUCTURALL SOUND.RECOMMEND PUMPING SYSTEM EVERYYEAR. PRIVY: (locate on site plan) Materials of construction: We Dimensions: We Depth of solids: rda Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) rda (revleed 04127)87) r U , r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 286 LAKESIDE DR.MARSTONS MILLS MR.PICCIOULO;86 BATES RD.WINTHROP MA. 11112198 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) A L A4 IAA 3� (rwloed0Af27At] Page ! of 10 T, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C + SYSTEM INFORMATION(continued) 285 LAKESIDE DR.MARSTONS MILLS MR.PICCIOULO;86 BATES RD.VANTHROP MA. 11112198 I Depth of groundwater 12• Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property,observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators,installers X Use USGS Data Describe in your own words how you established the High Groundvater Elevation.(MUST be completed) USGS MAPS AND CHARTS (revbedOW2719T) Page 10 of 10 i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION Y M Q 5<•�� RECEIVED AUG 1 . 2002 TITLE 5 TOWN OF BARNSSTjABLE HEA T OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY AS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 286 Lakeside Drive Marston Mills,MA Owner's Name: Edward Pesce Owner's Address: 286 Lakeside Drive Marstons Mills,MA 02648 MAP • 2(v Date of Inspection: July 6,2002 PARCM1-73 LOT Name of Inspector: (please print) John Churchill,P.E. Company Name: J.C. En 'neering Mailing Address: 5 Roundhill Blvd. East Wareham,MA 02538 Telephone Number: 508-273-0377 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes Conditionally Passes ��° JOHNw' Needs Further Evaluation by the Local Approving Authority CH JRHILL Fails cnnL No. 41807 Inspector's Signature: Date: �/U 2 The system inspector shall sub 't 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 ****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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 286 Lakeside Drive Marstons Mills,MA Owner: Edward Pesce Date of Inspection: July 7,2002 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: 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: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 286 Lakeside Drive Marstons Mills,MA Owner: Edward Pesce Date of Inspection: July 7,2002 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 15303(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. 3. Other: • Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 286 Lakeside Drive Marstons Mills,MA Owner: Edward Pesce Date of Inspection: July 7.2002 D. System Failure Criteria applicable to all systems: 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 NA 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''/: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—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. -- - - - Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 286 Lakeside Drive Marstons Mills,MA Owner: Edward Pesce Date of Inspection: July 7,2002 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 X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? N/A 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 the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Note: cesspool and leach pit covers opened and inspected 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. 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)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 286 Lakeside Drive Marston Mills,MA Owner: Edward Pesce Date of Inspection: July 7,2002 FLOW CONDITIONS RESIDENTIAL 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): 3 Number of current residents: 2 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): N/A Seasonal use: (yes or no): No Water meter readings,if available(last 2 years usage(gpd)): N/A Sump pump(yes or no): No Last date of occupancy: currently occupied year-round— COMMERCIAL/IPIDUSTRIAL Type of establishment: N/A Design flow(based on 310 CMR 15.203): End 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: Owner—system was pumped on 10/20/01 as part of routine maintenance Was system pumped as part of the inspection(yes or no): Yes If yes,volume pumped: 0 rox.750 gallons—How was quantity pumped determined? from pumper truck gauge Reason for pumping: System was pumped to examine structural integrity and general condition—no problems obs. TYPE OF SYSTEM _Septic tank,distribution box,soil absorption system X 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 X Other(describe): ces of with 1000 .Leach it overflow in series with ces 1 � �p 1 �1 Approximate age of all components,date installed(if known)and source of information: OrigM cesspool installed approximately 30 ego,with 1000 gal.Leach pit installed approximately 1990 Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 286 Lakeside Drive Marstons Mills,MA Owner: Edward Pesce Date of Inspection: July 7,2002 BUILDING SEWER(locate on site plan) Depth below grade: 20 inches Materials of construction: X cast iron _40 PVC_other(explain):�4"Vitrified Clay Distance from private water supply well or suction line: N/A Comments(on condition of joints,venting,evidence of leakage,etc.): Cast iron sewer leaving the house with VC pipe inlet to cesspool,all in good condition SEPTIC TANK: N/A (locate on site plan) Depth below grade: Material of construction:_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: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAP: 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.): Page 8of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 286 Lakeside Drive Marstons Mills,MA Owner: Edward Pesce Date of Inspection: July 7,2002 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.): is Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 286 Lakeside Drive Marstons Mills,MA Owner: Edward Pesce Date of Inspection: July 7,2002 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type X leaching pits,number: one N/A leaching chambers,number: N/A leaching galleries,number: N/A leaching trenches,number,length: N/A leaching fields,number,dimensions: N/A overflow cesspool,number: N/A 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.): 1000 gal,leach pit is structurally sound and fimctioning properly. Liquid level was 39 inches below inlet invert. CESSPOOLS: X (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: one with 1000 gal leach pit overflow Depth—top of liquid to inlet invert: 6 inches(at outlet invert elevation) Depth of solids layer: 59 inches Depth of scum layer: 1-2 inches Dimensions of cesspool: 6'X6' Materials of construction: Conc.block Indication of groundwater inflow(yes or no): No Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Cesspool is structurally sound and functioning properly. Recommend puMin aY 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.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 286 Lakeside Drive Marston Mills,MA Owner: Edward Pesce Date of Inspection: July 7,2002 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. �pws� B �G a zg � a p 314 2, 1 Gss�oL /000 3 L&S ) I PXT 1 0 � 1< V T;Ae"f T..—-44--T7,.—4n ciIlnnn 10 2 ® Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 286 Lakeside Drive M.arstons Mills,MA Owner: Edward Pesce Date of Inspection: July 7, 2002 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 18.4 feet 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: Based on Town of Barnstable GIS Unit data base and USGS Quad.Map,the site elevation at grade=72 ft. The depth to bottom of the leaching Ustem(on-site measurement)= 10.6 ft. Elevation of Shubael Pond per USGS Sandwich Quad.Map=43ft. Elevation of bottom of leaching,• 72'-10.6' 61.4'. Distance to estimated Proundwater elevation: 61.4'—43'= 18.4'. Therefore the bottom of system is>5 ft. above the estimated seasonal high oundwater elevation. 11