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HomeMy WebLinkAbout0314 LAKESIDE DRIVE - Health L akeside Drive s Mills P 02 195 ��� r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 314 Lakeside Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 6-30-10 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way. A. General Information 1. �J Inspector: I Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 City/Town State Zip Code 508-495-0905 S13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 C M R 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further valuation by the Local Approving Authority 6-30-10 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 16 l Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 314 Lakeside Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 6-30-10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. 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 t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 314 Lakeside Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 6-30-10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 314 Lakeside Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 6-30-10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: " This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6° below invert or available volume is less than % day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 314 Lakeside Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 6-30-10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D: Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5insp official document•03/08 Tittle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 314 Lakeside Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 6-30-10 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) Z ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp official document•03/08 Trtle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 314 Lakeside Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 6-30-10 page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 4-2010 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 •r �. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 314 Lakeside Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 6-30-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1993 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 314 Lakeside Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 6-30-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 18"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints,venting, evidence of leakage, etc.): Good condition. Septic Tank (locate on site plan): Depth below grade: 12"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000 gal Sludge depth: 101, Distance from top of sludge to.bottom of outlet tee or baffle 22" Scum thickness 0 Distance.from top:of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 314 Lakeside Dr Property Address . Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 6-30-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: - feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 314 Lakeside Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 6-30-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 c rt, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 314 Lakeside Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 6-30-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1-1000gal ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit in good condition and empty at inspection with stain line 20"from bottom of pit. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 f Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 314 Lakeside Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 6-30-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): t5insp official document•03108 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 314 Lakeside Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 6-30-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. • D C A- -10-13` -r-aD' 6-0-06, 8-r 43� t5insp official document•03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 I Y r' e s• . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 314 'Lakeside Dr Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Marstons Mills MA 02648 6-30-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database - explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 20'. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 15 r1UN/ V2010/WED 09: 00 AM C-0-MM WATER DEPT. FAX No, P, 001 Centerville-Osterville-Marstons Mills Water Department P.O.BOX 369-1138 MAIN STREET OSTERVILLE,MASSACHUSETTS 02655 www.commwater.com - OFFICE OF •���"' BOARD of WAM COM�MS1oNBRS � w/�TE R � WATER SUPEFUNTENDBNT DE PT. M.No.50.8-428-6691 FAX No.508-428-3508. FAX CONTYMNICATIONS•MESSA.GE DATE: CQ r cJ�v U TO: ATTN: FROM: JV SO4/e�&� FA.X# �D5 WE ARE SENDING t57? PAGES.INCLUDING THIS COVER LETTER. PLEASE CALL 508-428-6691 IF YOU DO NOT RECEIVE THE TOTAL NUMBER OF DOCUMENTS ;JUN/3L%2010/WED 09: 00 AM C-0-MM WATER DEPT. FAX No, P, 002 Centerville-Osterville-Marstons Mills Water Department P.O.BOX 369-U38 MAIN STREET OSTERVILLE,MASSACHUSETTS 02655 www.commwater.com i• OFFICE OF WATER BOARD OF WATER COIvliMSIONERS WATERSUPERINTENA&NT k1DEPT. TEL,No.508-428-6691 June 29,2010 FAX No.508-428-3508 Today Real Estate Attn. Ms.Nancy Holt .1533 Falmouth Road Centerville,MA 02632 Re: Account#4937 ortgage Assoc. 314 Lakeside Drive Marston Mills,MA Dear As a follow-up to our conversation today with our office staff, on Tuesday, June 29, 2010 during the process of acquiring an actual meter reading and installing a new radio-read meter, our technician discovered that there is a cross- connection from a private well to the public water supply in the home mentioned above. According to the Rules &Regulations of this Water Department and the Drinking Water Regulations of the Commonwealth of Massachusetts, 310 C.M.R. 22.22,there shall be no cross-connections, which is in violation. This well line connection needs to be disconnected as soon as possible. At-the present time the water meter has been removed and the valves are tuned off before the meter connection and private plumbing side. Could you please give our office a call when the well line has been disconnected. If you have any questions,please feel free to call me at 508-428-6691. Very truly yours, Herbert L. Mc Sorley Assistant Superintendent cc:Board of Health,Town of Bamstable HLMCS/jw /00r� � 7 ? I ✓�� COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION C(DPY Iro TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 314 Lakeside Drive 2 2Q03 Marstons Mills MA 02648 Jut Owner's Name: Jason& Tara Charlton N of gARNSTAg�E Owner's Address: Same TO�NHEALTN KEPT. Date of Inspection: June 19 2003 Name of Inspector: (Please Print) James M. Ford Map: 102 Company Name: James M. Ford P.O. Box 49 Parcel: 195 Mailing Address: Lot: 176 Osterville MA 02655-0049 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper,function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority F is Date: June 25, 2003 Inspector's Signature: - 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 I ****This report only.describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 Page 1 f I' Page 10 of 11 "ClcaECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 314 Lakeside Drive Marston Mills, MA Owner: Jason&Tara Charlton Date of Inspection: June 19, 2003 Map: 102 Parcel: 195 i SKETCH OF SEWAGE DISPOSAL SYSTEM Lot: 176 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. 4 a i f� 3 y s a 13 a. 3 0 33 as 1�3 10 Health Master Detail Page 1 of 1 H��I�kl� �"I�Ster Logged In As: TOWN\cabotj Health Master Detail Thursday, J Application Center Parcel Lookup Selection Items Parcel Septic Perc Well Fuel Tank C(OPY Parcel: 102-195 Location: 314 LAKESIDE DRIVE, MARSTONS MILLS Owner: ERICKSON, RYAN, & Business name:'i Business phone: Rental property: F Deed restricted: F Number of bedrooms : 0. Contaminant released: F Fuel storage tank permit: r- Save Parcel Changes ! Return to Lookup Parcel Info Parcel ID: 102-195 Developer lot: LOT 176A Location:314 LAKESIDE DRIVE Primary frontage: 100 Secondary road: Secondary frontage: Village: MARSTONS MILLS Fire district:C-O-MM Sewer acct: Road index:0858 Interactive map: GP (Groundwater Protection Overlay Town zone of contribution: District) State zone of contribution:IN Owner Info Owner: ERICKSON, RYAN, & Co-Owner: LECLERC, BETH Streetl: 314 LAKESIDE DRIVE Street2: City: MARSTONS MILLS State: USA Zip: 02648 Cour Deed date:8/12/2003 Deed reference: 17452/001 Land Info Acres: 0.23 Use: Single Fam MDL-01 Zoning: RF Neighborhood: 010 Topography: Level Road: Paved Utilities:Septic,Gas,Public Water Location: Construction Info Building No Year Built Effective Area Bedrooms Bathrooms 1 1968 1304 2 Bedrooms 1 Full Buildings value:$113,300.00 Extra features: $0.00 Land value: $161,800.00 http://issql/intranet/healthMaster/HealthMasterDetail.aspx?ID=102195 7/3/2008 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION 'VEl RECE Property Address: 314 Lakeside Drive Marston Mills, MA 02648 NIL � 2 2003 Owner's Name: Jason&Tara Charlton Owner's Address: Same OF BARNSTABLE TOWN EPT. HEALTH D Date of Inspection: June 19, 2003 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Map: 102 Mailing Address: P.O. Box 49 Parcel. 195 Osterville,MA 02655-0049 Lot. 176 Telephone Number: (508)862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fis Inspector's Signature: Date: June 25, 2003 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 i e Page 2 of I 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 314 Lakeside Drive Marston Mills. MA Owner: Jason&Tara Charlton Date of Inspection: June 19, 2003 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ 1 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: 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: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 314 Lakeside Drive Marstons Mills,MA Owner: Jason&Tara Charlton Date of Inspection: June 19, 2003 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ 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: 3 Page 4 of I 1 , OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 314 Lakeside Drive Marstons Mills, MA Owner: Jason&Tara Charlton Date of Inspection: June 19, 2003 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No _ ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. _ ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] 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 System: 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. 4 Page 5 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 314 Lakeside Drive Marston Mills, MA Owner: Jason&Tara Charlton Date of Inspection: June 19, 2003 Check if the following have been done: You must indicate`yes"or"no"as to each of the following: Yes No ✓ _ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ _ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ _ Was the site inspected for signs of break out? ✓' Were all system components,excluding the SAS,located on site? ✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ Existing information. For example,a plan at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 `J Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 314 Lakeside Drive Marston Mills.MA Owner: Jason& Tara Charlton Date of Inspection: June 19, 2003. 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): 330 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): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied CONEVIERCIAL NDUSTRIAL 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: Pumped in 2001 -per owner 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: May 24193-per as built card 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: 314 Lakeside Drive Marston Mills, MA Owner: Jason&Tara Charlton Date of Inspection: June 19, 2003 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron 40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 12" 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: 1000 gal. Sludge depth: I" Distance from top of sludge to bottom of outlet tee or baffle: 31" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert. There were no sign of leakage. GREASE TRAP: None (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.): 7 Page 8 of 11 d OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 314 Lakeside Drive Marstons Mills, AM _ Owner: Jason&Tara Charlton Date of Inspection: June 19, 2003 TIGHT or HOLDING TANK: None (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: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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.): The D-box was level No solids were present PUMP CHAMBER: None (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.): 8 Page 9 of I I b OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 314 Lakeside Drive Marston Mills. MA Owner: Jason&Tara Charlton Date of Inspection: June 19, 2003 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 6'x 6'0000 gal.) leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): The pit had]'of water on the bottom The scum line was at the same level. There were no signs offailure. The bottom to-grade was 8' The cover was 20"below grade CESSPOOLS: None (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: None (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.): 9 s e Page 10 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 314 Lakeside Drive Marston Mills, AM Owner: Jason& Tara Charlton Date of Inspection: June 19, 2003 Map: 102 Parcel: 195 SKETCH OF SEWAGE DISPOSAL SYSTEM Lot: 176 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. exk a � A 3 y 3 a 13 a. as q3 10 r ' Page 11 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 314 Lakeside Drive Marston Mills, AM Owner: Jason&Tara Charlton Date of Inspection: June 19, 2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 40' +/- 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 kcal Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using the Barnstable topographic map and the Cape Cod Commission water contours map,the maps were showing approximately 40'+/-to ground water at this site. This report has beer prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. II Date: TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAMEOFBUSINESS: BUSINESS LOCATION: 3I4 Lake. +car. '�c�, �aSnS � AS N4 6-afM MAILING ADDRESS:_. Sary,,Lt Mail To: Board of Health TELEPHONE NUMBER: O Town of Barnstable CONTACT PERSON: P.O. Box 534 EMERGENCY CONTACT TELEPHONE NUMBER: Hyannis, MA 02601 TYPEOFBUSINESS: Does your firm stor any of the toxic or hazardous materials listed below, either for sale or for you own use? YES NO This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS. Quantity Quantity Antifreeze(for gasoline or coolant systems) Drain cleaners NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salt (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet Fuel Photochemicals (Fixers) Diesel fuel, kerosene, #2 heating oil NEW USED Other petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Battery acid (electrolyte) Swimming pool chlorine Rustproofers Lye or caustic soda Car wash detergents Jewelry cleaners Car waxes and polishes Leather dyes Asphalt & roofing tar Fertilizers Paints, varnishes, stains, dyes PCB's Lacquer thinners Other chlorinated hydrocarbons, NEW USED (inc. carbon tetrachloride) Paint & varnish removers, deglossers Paint brush cleaners Any other products with "poison" labels (including chloroform, formaldehyde, Floor & furniture strippers hydrochloric acid, other acids) Metal polishes Laundry soil & stain removers Other products not listed which you feel (including bleach) may be toxic or hazardous (please list): Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS ��Py0F7NET��yn TOWN OF BARNSTABLE • MARNSTADLE, i "6 9 a UP BUILDING INSPECTOR a. APPLICATIONFOR PERMIT TO ............................................................................................................................. TYPEOF CONSTRUCTION ........................................... ...............................?.................................................:... ...............Gf.....Z.Z'...............19........ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ProposedUse .................. ........................................................................................................................................................ Zoning District ......................Fire District ................................ /�J 1 � L �&- ki..... .../v4""�LkQ.......Address 41•�� cs/- 4L"' L. Name of Owner ....... ........ ..(. }�....... ................................................ Nameof Builder ...;. ( �� ` i< < L -�-,.... .f. ................................................Address ............................... -'................................................... Nameof Architect ..................................................................Address .................................................................................... Number of Rooms � e0o"....a�.c� (6d`k Pa` Foundation ....... � SOW CCC)1—CVi-L' - V..".. ` �........ ...Roofing /� ..�t Exterior .................. :........................ L 7.. ...........................` �....................... Floors ..lOCf t c2J 0o s . .......uC�..........-..................................................Interior ..........a�. Heatin C7. 1. 0'`V � J ):.....Plumbing � 1.✓�/��..........d......................Approximate Cost t...d CJO Fireplace .......... ..... ............................. �... Difinitive Plan Approved by Planning Board ________________________________19________. /C;�7Q S Diagram of Lot and Building with Dimensions u � � tin � m d v7 Ll Q 1_G.1 C� Q Z 7 W > Q Z 0 (Do co ¢ / W <' 1.3_ ca U- W ( ` ©� IVti �� � _ J _I I S ---- -- -�- w w cn co 0 < 4 O � ' � o < � z za I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ... ........ - �...... ..........:.......1�.,.................. f TOWN OF BARNSTABLE .00AMN 3/y �_G ke 5 i e-/0/', SEWAGE # ASSESSORS MAP & LOT NSTALI.EMS NA.ARE&PHONE NO. ;EP71C TANK-CAPACITY oD ,Eacl�lNc >?ACILr: (t1+pc> P�- -- (sizc) 10.OF BEDROOms 3 MILDER OR OWNER 'E MITDATE: _____, COMPLIANCE DATE: eparation Distance Between the: rlaxim rn Adjusted Groundwater Table to the Bottom of Leaching Facility eee Irivate Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) -- Idge of Wetland and Leaching Facility(if any wellands exist within 300 fee of leachi b facility) / /. �_____.�_... eet Furnished by� �� Eo: � t , A _ TOWN OF BARNSTABLE s/ LOC'AT10N p t 4 ,a bf: SEWAGE # q 3" 183 ij LLAGE W . Mills ASSESSOR'S MAP & LOT �0 - INSTALLER'S NAME&PHONE NO. L-OT /7 4o SEPTIC TANK CAPACITY /M G/��•p LEACHING FACILITY: (type) 4;X �� P-r (size) /T Al NO. OF BEDROOMS 3 BUILDER OR OWNER —yQSD^ C�ng r�Ton 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 leac 'ng facility) Feet Furnished by-TA S —�to �0 R eat a � rq 3 y 3 13 3 ao.e 33 as q3 P TOWN OF BARNSTABLE I' LOCATION�/�/ �/.c�,s�� /�r�� SEWAGE # VILLAGE ASSESS%R'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) size) pG cc NO. OF BEDROOMS_3PRIVATE WELL OR.--PUBLIC WATER BUILDER OR OWNER �' g L DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ®� c .I . Q i �� ;�. . , � ' .� � � • 4 t • ,, '+ \ �- � ` � W -� THE COMMONWEALTH OF MASSACHUSETTS C cED BOARD OF HEALTH � t 6 a I q 5 TOWN OF BARNSTABLE ` li . � Di�ipwml Works Tomitrnrtinn "amit Application is hereby made for a Permit to Construct ( ) or Repair (XX) an Individual Sewage Disposal System at: 314 Lakeside Drive Marstons Mills , Mass . .....--•-•-•-•...................................••--------••------------••••-•.............------ -••-----•---------........------•-•--•--------...............•----------......---•----......--•••- Loca Lion-Address or Lot No. Shester Mickunas ..............................................................................---------- ------ •------•----•-------------._.......-•------•----••---•---......-----••-----------...............•. W J.P.Macomber Jr. owner Address , Installer Address d Type of Building Size Lot............................Sq. feet UDwellingX— No. of Bedrooms...............3-------------------.---.--Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) aOther 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. 3 Seepage Pit No..................... Diameter-------------------- Depth below inlet..................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ------------------------------------------•--------------- .._.................. •---- ........... ....---••...................................... •.............. 0 Description of Soil----------------------------------------•-.............---------------------•--------------------------------------------------------------------------............----- x Sand & Grave 1 .....______ V W --------------- -------------------------------- -- •--------------------------------•------.._..------------------------------....---•---•---•---•---------------••-••----•--•-------................ UNature of Repairs or Alterations—Answer when appplicable.....1--10��...�.1lop---tank-,1-d•istribut on box,l-1J00 Fallon...leaching p1t.�Packed...in stone 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 ben sue by the tt oar of health. 4/21/93 Signed --------- .......✓..... .................. ................................. .... .............:...... Date ApplicationApproved By ................... .......Z-- ............................................................. .... .-.a..a- .� .. Date Application Disapproved for the following reasons: ...................................................................................... ..........:.....................................'--.....C.y�--'--- ——— _ — — ...................................---------. - - ...... --...................... .' .-- -........................................... ................ eDat --............... Permit No. ..........(.. >__J... 3...... . ........ Issued -------............................. ..................... ........... Date r-r--^��-.-_:;..�.,.--r.....�:4�. •.�..a.r-�...r::- -_..-�-....--....-r�....tl-.,+.�.+,.�.-.:�r,,.��...-,r..-.w�..-a1.,...�--.�.-�.---�t..�--•�-4,.�c:r•--t•�"`'rit...:.i;��...:si>A�;..,:�.:.s...n.,,.yi►i..7G.c.�. L.-`i�ii�'b�.t ,�. s THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliralion for Diripwial Worlai Cnomitrur#inn "Front Application is hereby made for a Permit to Construct ( ) or Repair (KX) an Individual Sewage Disposal System at 314 Lakeside Drive Marstons Mills , Mass ..........-•-•----------•-------•-......----•----------•---•.................................•-•-• --•---•-------•----•--------•----•--•-----••----••--•..............-------•---•--.........._--.... Location-Address or Lot No. Shester Mickunas W J.P.Macomber Jr. owner Address Ins tat Icr Address co UType of Building Size Lot............................Sq. feet Dwelling r No. of Bedrooms...............3--_.__-_-__-_-___---.---_-Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building No. of persons............................ Showers � YP g ---------------------------- P ( ) — Cafeteria ( ) Otherfixtures --- ---------------------- ------------------------ ------------------ --------------- -----------------------•------•. -•-••- 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 ( ) 1.4 Percolation Test Results Performed by............ ............................................................. Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water....................,... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 .--------------------------------------------------------------- ------------------ ------------ -..... ..... -............. -.......... ..... .--........ .-----..... 0 Description of Soil-•.................... -------------------------------------------------------------- •---------------- -..------- ••..... -.............•••-••••• vSand-- 8c...Gray.e 1...................................................................................---------•--•-------•--.........._...:---..._........_......... W ............................•----•--------------••-----------------------------•-----------------------•......----------------------•-•---------------••---------•----------.......------------.._..... U Nature of Repairs or Alterations—Answer when applicable.__--1-1GGG__.�allonl.... ta'n'1, .l-distr bu,t'Jon rox.1-1000-_�.allon..leaching.nit.packed in_-•stone..........:............................................. 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 i9sue- by the boar of health. Signed .- �p! - .. �.�.� G�`�- ...._. ................ .--�/21/93........ ` Date Application Approved B s'�'1 -� .... ......... .............................. . ............... .....1 -..�a...-..%. .. Dare Application Disapproved for the fo lowing reasons: .................... ..............--............................. ........ . ........................................ .... ............................................................................................................. . . --- .................. .......... ... -- . ................. .......................Dace PermitNo. --------- - �� ....... .. .... ...... Issued ---------------..................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE (Iler#tfirate of OuTomplianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (XX ) byJ--P Macomber Jr.........................................------.------- ---------------...............----.--------------........ ............------------------------------------------ ma:aie� at 31.....Lak.e.s .de...Dr . -.e....Mar.st.ons----Mi.1.ls..,Mass.• ...... - - - - ........ - ..... 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. ------ ..R...}._._.. dated .......................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. . DATE............_.. .._.I' _ .. 1.-.,i.. *......_...._..._... Inspector ................ . L..�/". - _... ............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE �i��n�ttl >arl�� �u�t�tr�s#ilan �rrnti# omber---Jr..----------------------- Permission is hereby granted----------J'---P-'-M--- --ac ----------------------------------------------------------------- to Construct or Re air y'XX an Individual Sewage Disposal System atNo..a. La.........................................rst-p�s 1L1- .�_AMas-s..------------------•---------. Street as shown on the application for Disposal Works Construction Permit No�3-_1.93... Dated........................................... Board of Health DATE...........-.................................................................... FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS