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0040 LAUREN DRIVE - Health
40 Lauren.Drive_ MArstons:Mills O V, ,L _ - - A = 102... 212. Assessing As-Built Cards Page 2 of 2 o '(al K D red or 16d Le T CIIJ https://www.townofbarnstable.us/Departments/Assessing/Property_Values/HMdisplay.asp.mappar-047... 8/11/2020 �o(� COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION stj 102- ��c�I ID �•y eye Irll , /,RCR 21�2_ �__m JAN 0 4 2005 r"r TOWN OF BARNSTABLE TITLE'5 _ HEALTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: /() ;_1 Owner's Name: Owner's Address: � l OQ�P Y /J� Date of Inspection�7)p,rp� 6z' . _4 :SooS! Name of Inspect • plea a print) ` T, r 6 Company NamezQ Mailing Address: Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: /Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 3�0 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 repor to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to_he 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 I'l fi OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address. ` P Y Owner: (�, Date of Inspection: Y Inspection.Summary: Check A,B,C,D or E/ALWAYS complete all of Section D. A. ystem Passes: I have not found any information which-indicates that any of the failure criteria.described in 310 CNIR 15.303 or in 310 CMR 15.304 exist.Anv failure criteria not evaluated are indicated below.'' Comments: B: System Conditionally Passes:. i One or more system components as described in the"Conditional Pass"section need to be replaced.or repaired. The system, upon completion cf 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 inspectior_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(§)are.replaced obs ruction 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 f , Page 3 of 1'1 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART'A CERTIFICATION,(continued) Property Address: Owner: Date of Inspecti 4 %. 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 Jr less than 5 ppm,provided that no other failure criteria are triggered. A-copy of the analysis must be attacYed to this form. 3. Other: 3 Page 4 of I 1 i OFFICIAL,INSPEC.TION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner:Kt' 7k t' ^ r Date of Inspection^ 0-j,oco(I D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to ea&of the following for all inspections: Yes No/ td . Backup of sewage into facility or system component due to overloaded or'.c]og�ed 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 disoribution.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 groundwater 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. 1/ 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 accepta:)le water quality analysis. [This system passes if the well water analysis, performed at.a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence.of ammonia nitrogen and nitrate nitrogen.is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached.to this form.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what wal be necessary to correctthe 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• 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.—I WPA)or a mapped Zone II.of a public water supply well If you have answered"yes"to any queston 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 3.10 CMR 15.304..The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'FORM : -PART B CHECKLIST Property Address: ) >�� K Owner: W114,?19vL'"' _11P. Date of Inspectio • 0/, 60 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_ V 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 ? ZHave 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) LIZ Was the facility or dwelling inspected for signs of sewage back up? V _ Was the site inspected for signs of breakout? 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? IZ— Was the facility owner(and occupants if different from owner'i 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. V _ 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 Page 6 of 11 OFFICIAL INSPECTION•FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property A dress: i Owner: ' Date of Inspectio FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):,,_ Number of bedrooms(actual): DESIGN flow based on 310 CIl R 15.203 (for example: I W gpd x#of bedrooms): Number of current residents: Does residence,have.a garbage grinder(yes or no): lLK5 ` Is laundry on a separate sewage system es or no): if yes separate inspection required] Laundry system inspected 44y�s or no); / Seasonal use: (yes or no):V0 ... Water meter readings, if av ila ble(]as-2 years usage(gpd)):�,j" Sump pump(yes,or no): v ` Last date of occupancy: ��2,h�ZQ, P�KCO COMMERCIAL/INDUSTRIAL.,/'i 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: ; Was system.pumped asp - 'of ene ins—pecti n(yes o): If yes,volume pumped: gallon`--How was quantity pumped determined? Reason'for pumping: TY 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'. opy of the DEP,approval _Other(describe): proximate age of all component date in aped now )and source of information: MA J P - Were sewage odors detected when arriving at ttre site(yes or no F Paee 7 of 1 1 ` OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: `L Date of Inspection CDOO 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:Zoocate 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: 3Z Scum thickness:1 o0 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle' i. How were dimensions determined: , Comments(on pumping recommenFations, nlet and outlet tee or baffle condition, structural integrity, liquid levels related to outlet invert, evidence of leakage, tc.): Ap GREASE T , (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 OFFICIAL:INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 Owner: 7*>'A—, 9- Date of Inspection- / / 60 J a TIGHT or HOLDING TAN tank must be pumped at time of inspection)(locate on site plan) P P 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:-LZ(if present must be opened)(locate on site plan) Depth of Liquid level above outlet inverU: Comments(note if box is level and distribution to.outlet§'e Pual, y evidence of solids carryover, any evidence of akage into or out of box, etc.): Y PUMP CHAMBER• ,� (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note.condition oepump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: ' Date of nspection• c� SOIL ABSORPTION SYSTEM (SAS): !/(locate on site plan, excavation not required) If SAS not located explain why: Type 1 ching pits,number:_ 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, t )' = �Z av CESSPOOLS✓"� (cesspool must be pumped as part of inspection)(lccate 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.): PRI7N(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 Page 10 of I] i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: (/ Date of Inspectio ,� /,J-00 SKETCH OF SEWAGE DISPOSAL.SYSTEM Provide a sketch of the sewage disposzl system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where pu'olic water supply enters the.building. f I`° IIII t(p �1 '3Y) �Iif) 14 lo� 0 ro-- Page 11 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) .Property Address: Owner: �f Date of on~ ^�/, �UC✓ T SITE EXAM Slope Surface water It�Azq Check,cellar Shallow wells Inspecti Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained f om system design plans on record- If checked, date of resign plan reviewed: Observed site (abutting property/observation hole within ISO 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: 17 f 11 Permit Number: Date: Completed by: HIGH GROUND-WATER LEVEL COMPUTATION Site Location: j6Q . _. Lot No. Owner: 1T®/1V49� Address: //�� Contractor: �b .a�141 Cor1� Address: `13-' J9 Notes: STEP 1 Measure depth to water tEble fL ��J2 tonearest 1/10 ft. ........:...................................................................... .Date 7 month/day/Year i STEP 2 Using Water-Level Range ?one and Index Well Map locate site and determine: D OA Appropriate index we I.................................................... OWater-level range zone ..................................................... STEP 3 Using monthly report "Current Water Resources Conditicns" determine current depth to water level for index well ........................... month/year STEP 4 Using Table of Water-levcA Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3..), and water-level.zone (STEP 2B) determine water-level adjustment .......................................................................................... .STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to .eater levelat site (STEP 1) ............................................................................................................. Figure 13.--Reproducible computation form. 15 / 0 �piw. J i I I • I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments qq 5� 40 LAUREN DRIVE — ------- Property Address DENNIS AND NANC_Y DESIATA Owner Owner's Name information is MARSTONS MILLS _ MA 02648 6/21/07 required for — State Zip Code Date of Inspection every page. City/Town Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer, use 1. Inspector: only the tab key to move your MICHAEL DEDECKO — -------- cursor-do not Name of Inspector use the return key. COMPASS REALTY DEV CORP Company Name rae P.O. BOX 2384 Company Address MASHPEE _ MA _ 02649 _ City/Town State Zip Code 508-221-5003 _ —.-----------.--- .-.---.___. Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this add�ets and t-i'`A the--: information reported below is true, accurate and complete as of the time of the ilt_spection. The inspection was performed based on my training and experience in the proper function and eta intenarZed of or}site sewage disposal systems. I am a DEP approved system inspector pursuant to Sectio"5.3 - of Title 5 (310 CMR 15.000). The system: CD rn ® Passes ❑ Conditionally Passes ❑ Fai s ❑ Needs Further Evaluation by the Local Approving Authority 6/21/07 Inspector's Signa ure Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 35 DEER HOLLOW•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 e Commonwealth of Massachusetts , Title 5 Official Inspection Form — Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w,• 't 40 LAUREN DRIVE --- ----- — —..._..---- Property Address DENNIS AND NANCY DESIATA _ -------- ------ Owner Owner's Name information is MA 02648 _6/21/07 required for MARSTONS MILLS _ — — -- econ ----- ----- every page. City/Town State Zip Code Date of Inspti I 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: 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 35 DEER HOLLOW•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form s� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments /`. 40 LAUREN DRIVE __ _—_--_--_---------.__--- - Property Address DENNIS AND NANCY DESIATA Owner Owner's Name information is MARSTONS MILLS MA 02648 6/21/07 required for - —— --_ every page. Cityrrown 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. 35 DEER HOLLOW•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 r -Commonwealth of Massachusetts -- Title 5 Official Inspection Form -- Subsurface Sewage Disposal System Form Not for Voluntary Assessments a 40 LAUREN DRIVE Property Address DENNIS AND NANCY DESIATA _______--------- _. Owner Owner's Name information is MARSTONS MILLS MA 02648 6/21/07 required for every 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 '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 35 DEER HOLLOW-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 40 LAUREN DRIVE — - — -- Property Address DENNIS AND NANCY DESIATA — --. — ---- ---- Owner Owner's Name information is MARSTONS MILLS MA 02648 6/21/07 required for State Zip Code Date of Inspection every page. City/Town 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. El ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply El El Area 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. 35 DEER HOLLOW 06106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 r Commonwealth of Massachusetts Title 5 official Inspection uFormsments Subsurface Sewage Disposal System Form Not for Y -� -� 40 LAUREN DRIVE Property Address _ �__._...._.. DENNIS AND NANCY DESIATA Owner owner's Name MA 02648 6/21/07 __ information is MARSTONS MILLS required for --- — - ----- State Zip Code Date of Inspection every page. City/Town 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) ® M 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)] Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 35 DEER HOLLOW 08/06 i .�,,o�• -Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V~ 40 LA _ UREN DRIVE I Property Address DENNIS AND NAN_CY DESI_A_TA Owner Owner's Name information is required for MARSTONS MILLS MA 02648 6/21/07 --- — ---- -- — -- -- ------------ every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: 3 Number of bedrooms (design): 5 Number of bedrooms (actual): --- --- --- DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 _ 0 Number of current residents: Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d N/A _ g ( Y 9 (gP ))� Sump pump? ❑ Yes ® No N/A Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: b flow Design (based on 310 CMR 15.203 : -- -- - 9 ( 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): ----------------__-----------___ ._...-. ..._. -_-... .._. . 35 DEER HOLLOW•06106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 'commonwealth of Massachusetts 60 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 LAUREN DRIVE _ Property Address DENNIS AND NANCY DESIATA Owner Owner's Name information is MARSTONS MILLS MA 02648 6/21/07 required for — ---- every page. City/fown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: ' Source of information: NIA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: llons— ----------- ---- — - -- .. ga 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: N/A — -- ----- --- ---- - -..__.._.. Were sewage odors detected when arriving at the site? ❑ Yes ® No 35 DEER HOLLOW•08106 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 ems - 40 LAUREN DRIVE Property Address DENNIS AND NANCY DESIATA — --- Owner Owner's Name information is MARSTONS MILLS MA 02648 6/21/07 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 4' Depth below grade: feet Material of construction: ❑ cast iron Z 40 PVC El other(explain): Distance from private water supply well or suction line: Town water -- - ----- --- -- feet Comments (on condition of joints, venting, evidence of leakage, etc.): joints tight, yes vented, no sign of leakaa e. Septic Tank (locate on site plan): 1' Depth below grade: feet --- --- ---- ----- - Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: Years -- - - Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------- 1500 gallons Dimensions: _ 3" Sludge depth: ----------.--------..._ 33" 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 9 ------ -- ---- _-- - 14" Distance from bottom of scum to bottom of outlet tee or baffle --- How were dimensions determined? measured . ----"" - 35 DEER HOLLOW•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of.Massachusetts Title 5 Official Inspection Form R — i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments n �.' 40 LAUREN_DRIVE _ -- Property Address DENNIS AND NANCY_DESIATA _--__._________._.__-.___..-._.------.---._..- Owner Owner's Name information is MARSTONS MILLS MA 02648 6/21/07 required for State Zip Code Date of Inspection every page. City/Town 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.): no need top mp tee's intact structurally sound, liquid level equal with outlet invert, no 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): 35 DEER HOLLOW•08106 Title 5 Official Inspection Form,Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 LAUREN DRIVE Property Address DENNIS AND NANCY DESIATA Owner Owner's Name — -- -------- --- ---- information is required for MARSTONS MILLS MA 02648 6/21/07 --------- every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: -- --- --- ------... ------ Capacity: gallons ------ - ----- Design Flow: --------------- - ---- g 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 equal with 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.): d-box is level and distrbution equal no solid carryover, no leakage Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 35 DEER HOLLOW•08/06 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 11 of 15 . Commonwealth of Massachusetts Title 5 Official Inspection Form — - Subsurface Sewage Disposal System Form Not for Voluntary Assessments 4 =- t 40 LAU R E N DRIVE _..----_—.- —.----...------------- Property Address DENNIS AND NANCY DESIATA Owner Owner's Name information is MARSTONS MILLS MA 02648 6/21/07 required for every 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: i Type: ❑ leaching pits number: __-- 4 ® 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.): soil sand-gravel, no sign of hLdraulic failure, ponding dry, no damp soil, ve etation normal.___ 35 DEER HOLLOW 08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 f . Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ems; , 40 LAUREN DRIVE Property Address DENNIS AND NANCY DESIATA Owner _.. ------ --------- -------------------------- Owner's Name information is required for MARSTONS MILLS MA 02648 6/21/07 --- ------ --- - -- -- ----------------__ --- -..._.. every 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.): 35 DEER HOLLOW-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form (:1 _ Subsurface Sewage Disposal System Form Not for Voluntary Assessments 40 LAUREN DRIVE Property Address DENNIS AND NA_N C Y D E S I ATA -- Owner Owner's Name information is M_ARST_ONS MILLS _ MA 02648 6/21/07 required for _- ---- -------- --- every 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. g A 3 0- zis ��. 71 3` 35 DEER HOLLOW•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 r b ,Commonwealth of Massachusetts Title 5 Official Inspection Form - - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 LAUREN DRIVE Property Address DENNIS AND NANCY DESIATA Owner Owner's Name information is MARSTONS MILLS MA 02648 6/21/07 _ required for _ every page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to ground water: 80.89 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: BARNSTABLE GIS You must describe how you established the high ground water elevation: BARNSTABLE GIS 35 DEER HOLLOW•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 TOWN OF•BARNSTABLE v LOCAVON 31-04o,, J)R- SEWAGE # a00%77f VILLAGE ASSESSOR'S MAP & LOT 01-2 INSTALLER'S NAME&PHONE NO. ^�d�o7i/�'�.ai�. ov yag$9a6 SEPTIC TANK CAPACITY 15-aw LEACHING FACILITY: (type) 'D C r` Clwm .t l7� (size) .13")(0�; P NO.OF BEDR S r BUILDER O OWNE � ��i� PERMITDATE: /il' V-41 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) l-VV 1' Feet Furnished by ()sg!✓ clok= eP241,V4" �R O G C C'1 O /IV as ir i & 36' - 63-3ry - � TOWN OF BARNSTABLE LOCATION f* 4t0 LAur'Et)s Able- SEWAGE # vMLAGE m' rn;(tS ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. laokfbon Sepik, SEPTIC TANK CAPACITY 3— (aX CesSewle. M good oort,li ConC�'�iaA R�fln �'4,b9 eL</vn LEACHING FACILITY: (type) (size) NO.OF BEDROOMS o� BUILDER OR OWNER Chvc k ROP-r/Z- PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 10 F/ Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Mom Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachin facility) 3o?S Feet Furnished by 4` 441ft. �� 7/11 r � at y � �Y bd f _3 SS' TOWN OF BA MTABLE Y LOCATION e. C t SEWAGE # VILLAGE ASSESSOR'S MAP & LOT`®ZZI'Z. N�✓-��UZ�Q�S NAME&PHONE NO. ` `77I'� SEPTIC TANK CAPACITY I. c. LEACHING FACILITY: (type) ie) NO. OF BEDROOMS _ BUILDER ER O R e �r�0 do►`- 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 iR 5 Ilan /40 3� 7a7 0- . 7,1 No, i ��./ ° Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pplication for Migo$ar *pgtem Construction Permit Application for a Permit to Construct( . )Repair( )Upgrade(✓)Abandon( ) ®Complete System ❑Individual Components Location Address or Lot No. `D l® /„411'&e e 0/, Owner's Name,Address and Tel.No. Assessor's Map/Parcel j (s�� —i�y�Jr. c g/ 141 e_/ "" ~rq00, Installer's Name,Address,and Tel.No. f/f t Designer's Name,Address and Tel.No. dOM1101) COjV_4,7`, oww 452��e_ Type of Building: Dwelling No.of Bedrooms Lot Size 7, 00 sq.ft. Garbage Grinder(-1-0 Other Type of Building 'Wee No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow /l gallons per day. Calculated daily flow rSJr� gallons. Plan Date Number of sheets / Revision Date Title Size of Septic Tank /.✓�®O Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) ��� � am�� Date last inspected: Agreement: The undersigned agrees io ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this oard of eal Sign Date Application Approved by Date Application Disapproved for the following reaso Permit No. Date Issued N L x#,�- r THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. 11 =z` l PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pplication for Migozal bpgtem Construction Permit Application for a Permit to Construct( . )Repair( )Upgrade(V)Abandon( ) Complete System ❑Individual Components Location Address or Lot No. v lQ�rP# Owner's Name,Address and Tel.No. �c/ / Assessor's Map/Parcel q �/ r` � / 1`tgkw,? �9ors�c�r�s .t�,//s Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. AO,OPIVA�li Cons `, „ 0,Ww C��e 7,71-93�' 3�1z -0 ell Type of Building: Dwelling No.of Bedrooms J Lot Size 71r000 sq.ft. Garbage Grinder(_1e_P Other Type of Building RCS) Ph/G e No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date 11/L AV Number of sheets Revision Date Title Size of Septic Tank /5—DO Type of S.A.S. Description of Soil; /Z 46 3 Y Z_ Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Heal Sign Date Application Approved by _ 4, ? Date Application Disapprove for the following reason v Permit No. Date Issued _... -- THE COMMONWEALTH OF MASSACHUSETTS s BARNSTABLE, MASSACHUSETTS Certificate of Compliattce THIS IS TO CER,Tr�Y, that he On-site ewage Disposal System Constructed( )Repaired( )Upgraded(P ) Abandoned( )by �l� 4 /On-site 5 , at I/o lWi ,4 /llo s A5 --V/ has-been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Designer The issuance of ;s pepnit shall not be construed as a guarantee that the syste will function as d signed. Date I a 1 t 7 1 o t Inspector r�( �. /t All . 1 .,� . No. �,,,,— ----------- ---— ------------Fee t v THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mi5pozar 6potem Construction Permit Permission is hereby granted to/Construct( )Repair( )Upgra e(V/)Abandon( ) System located at Ile) G ���°dI �r• C/I`SJ`��lS /�7/��5 and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Co uslte mple ed within three years of the date o Otis Date: �/ Approved by i c; r / r TOWN OF BARNSTABLEi v LOCATION SEWAGE # 1OOl-73-r VILLAGE / f ASSESSOR'S MAP & LOT—J!L Z 12 INSTALLER'S NAME&PHONE NO. �/� r' �"`� v SEPTIC TANK CAPACITY LEACHING FACILITY: (type) L 2 �� (size) NO.OF BEDR S BUILDER O OWNE PERMITDATE: ��' y COMPLIANCE DATE: Separation Distance Between the: L- Feet Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility (If any wetlands exist l00 Feet within 300 feet of leaching facility) Fu-Wished by I � � �� OO C Dow 64,�e- Gr rf ' � $� 36, 93- GS' 63.3s6" i i r SUBURFACE, SEWAGE DISPOSAL SYSTEM IN -SPECT a. � S I FO (,' �� y Address of, property �� :��9Ut` 1V' eft. /j?.. j"9 Owner's t Ch`u`ck: Po `Date of 'Inspection 1,-1.1- P��2 " < ke A PART A CHECKLIST F't Check r if the j,foil wing have been done: 1 " - Pumping,4nformation was :requested` of, they owner, occupant, and Board of Health.A �, • None of ,the:system, components have been pum ed for at least two{-weeks P. and` the!system-.has.' been receiving normslgflow .rates,_,duri ' ' that . ;period. =, Large° volumes sof water `have not been`introduced into the system recently or•z asp part ;of .this inspection. 4 As built 'plans have, been` obtained and examined 'Note 'if they Lare not t available with N/A. ✓ The facility or�tdwelling, was inspected for. signs of',;;sewage back-up. . 'The .site'.was" _inspected vfor signs�,,o breakout., _ A11 system components, -excluding the SAS' ' been "located on the ;site x. cisspob a ✓._` =The'.'sept c;tta.nk ;manholesi were uncovered, 'opened, •and.,-thei,lfiterior of .w tithe'`septic tank,-'was inspected 'for .condition of: baffles;or. tees° r rr materialI of constructioTn,. :,dimensions, depth 'o.f liquid,y depth of sludge,.Ldepth:, Of, scum. _ . r _V' _ The size��and location;of the .SAS on. the site has been determined, based on 'existing''information, or approximated by� non=intrusive methods. a'' ✓ The., facility..,rowner ;(ands occupants_,y if different `from .owner) ,were 'provided with` nformat; on ,on the proper-maintenance r:of ISSDS.` 40, e _4 , i . i g. + E . r n ti y r . w ,,S'UBSURFACE `SEWAGE. DISPOSAL,, SYSTEM. INSPECTION FORM PARTS B. ,4 4 r , h •; „ , SYSTEM INFO' . RMAT,ION _ r , k :�4 x Y A .k ..> _ FLOW, CONDITIONS If residential,. s c1 :numbser of bedrooms, a number=o'f. current residents G garbage ' st grinder, yes•, or no Y , Y s� laundr connected` to .s :em , ,eyes or nog= lug <seasonai use, yes or 'no � yIf `nonresidential, calculated flow: ?Water meter readings, if available:. � .= g Last date�,of occupancy GENERAL INFORMATION a. . Pumping records and source, of information:" -MotvE , q ; L xSystem,, pumped.as part of inspection, yes or, no . if 'yes, volume pumped` 750ys. "Reason for pumping: r Type of system W Septic tank/distribution box/soil absorption system � . 'Single cesspool y Overflow `ces pool: . Privy a: - . 4 • -0ro Shared°. system> (yes or no) (if Qyes; attach. previous -inspection records, if any) ,Other (explain), s Approx mate age of all` components,x Date installed', -if known. Source of information: r 30y1`S. hloowanql%. . W10 Sewage odors detected whene..arriving- at the site, yes or -no ' a r. r i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ` g ( y PART B SYSTEW INFORMATION continued SEPTIC TANK: WA (locate-on- site plan) depth below giade:n14 material ,of construction:, f concrete etal� _' FRP} other(explain) dimensions;: x sludge depth .- > distance 'from top of udge` to bottom of outlet`- tee or- baffle scum thickness - . distance from to of. scum. to top of outlet tee'or baffle distance from ottom" of� scum to bottom of outlet tee or baffle Comments: , (recommends 'on for pumping, condition of, inlet and' outlet 'tees' or baffles,, depth of - quid. leveltin, relation= to outlet invert, , structural integrity, eviden. of leakage,: recommendations4for-, repairs, etc. ) DISTRIBUTION BOX: 4UIq (locate on site plan): . depth of -'liquid Level above. outlet inve Comments:- .(note(note if level and- distribution .is equal, ev' ence of °solids carryover; evidence of leakage into ,or out of box, re mmendation for repairs; etc. ) Y PUMP CHAMBER: VA iv (locate on `site plan)` ;. a. pumps in w king 'order., yes or no Comments:, ; e a . (note condi on offipump chamber, condition of pumps and .appurtenarfces, recommend ions for maintenance or repairs,etc. ) ' IT —7 t r.' ..' 1 i x' - . $' * q,=.,r, ri >,.> q: - . a . �,," d8f +t a p, . z =� �,• .�.� R;= �, it., BUHSIIRFACE SEWAGE. DISPOSAL,.SYSTEX INSPECTION FORMA APART' B` q U° .SYSTEM INFORMATION continued g SOIL•AHSORPTION. SYSTEM_ (SAS) �. oca. on ite'' plan, _if- possible, -•excavation not -required," but may be x::n• a[¢pp3. ximat - mehodn- . s) a y v� If- not determjned to be:, present, explain = g IT .gib.. Type. ; leaching Pits and number leaching chambers and number M � leaching 'galleries` and 4-number leaching, trenches, number, ngth .., �:. Teaching .fields, number mensions overflow cesspool, n er. y t, .$ w Comments: ».; .- (note bond-i n. of soil, signs of hydraulic failure, level of ponding,, , condition ofveg.etation'; recommendations �'for�maintenance or`Trepairs,etc. ) W s _ CESSPOO`i;S' (locate on'` site plan) ' 9 t, r number F and 'conf iguration =.t,X$ g1Oc�G CesSpoo is W Neuu� �) pth-top �. de of liquid to Anlet i ��� 4 nv,ert depth of solids la er ' ,1 depth of ,scum a layier_ dimensions;ofrcesspool _ 6xg ; 1 •. materials of construction : cP,►,���'R/� indication of Ygroundwa ;k ter i,nfl�ow '(cesspool must ,be pumped. as , part of inspection) y. r. �lo Comments: . (note condition of' soil,, signs of hydraulic failure, level of' pondng, , - A , ` condition of wegetat�ion recommendations for maintenance or repairs,etc.') All 3eess�bo1 WG6, in A.a,(Jualk',lkj of'jtr At �me, eR rn50ec�o'� t ac Ce PRIVY: 1-�olrB (,eS5Peol For, iK,4L cn locates-on site plan) !-fox8 cessoo,`l Fug cef 4tv-L9AF3;.f_. dry" materials of construct 'on dimensions _ depth., of,solids, '` Comments: , (note condition;of soil, signs _,of hydraulic,, failure, level,, of pond ng, `' condition .of` vegetation re.eonmendatioris for maintenance or repairs,etc. ) w SUBSURFACE SEWAGE DISPOSAL SYSTEM INBFECTION FORM -0 PART B ' SYSTEM;..INFORMATION continued', - y SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at -least two permanent references landmarks or benchmarks locate all wells \within .100' to 3S4 `� e > DEPTH TO: GROUNDWAT a , a0 depth to groundwater , method of determination or approximation.: t F" ` Nr�h orevn t1 RSoac po+�e�,(r�+1 i - e NX 3 ! .' q. A° ^s.¢•Y °.:�, „: a Bey 'n° 4k . . SUBSURFACE .SEWAGE,DISPOBAL.ZSYSTEM*INSPECTION: FORM" ' f� ., �5:• ;,• fi' ;PART C r FAILURECRITERIA , Indicate# esP• i y , no, ,or` not determined (1Y HN, or ND);. Describe basis of determ nat oniin all instances- If "'not,=determined', explain why, not) . - _WBackup., of..sewage;` into `fac #1 ty N €° - e ? t ` �� � a .a. ,s �' F " :�� '•f` � y;"' �. ter,, - � ' ,.. _ Discharge or ponding of,'ef:flue.nt to the surface of the ground�'or surface waters? V y *' N' • Static,, liquid lever in `they distribution box above outlet invert?, ,aro y _ Liquid'° depth-, in;.cesspoa1 <6," below,$invert.±.or- available volume< 1/2 da:E f l'ow? . &equired pumping 4k'=times' or-more �in the fast jyear? number of times pumped IJ septic tank is metal? cracked?- structurally unsound? 'substanti•al wdnfi�ltrat ion?, substantial 'ekfiltrat on?` tank„ failure 'imminent? Is any -portion of the'-SAS, cesspool ,,or';privy.: r ° T below the `high groundwater `elevation? 4• u& Y° within '50 feet of a' surface water? r : Within 100 feet "'of `a, surface water supply �or Ftributary to a "surface water supply? r N within ua Zone I_ 'of a publ is ewel l? r within -50 feet'of ,a bor`de.ring vegetated wetland or salt marsh 4 (c,esspoolss:and privies` only., not thel,,SAS)? . 4within 50 feet of aM1priva`te water+ suppl well? , u r f h lens than 100 feet but greater than 50 feet from a private water supply well'- ,with"not acceptable 'water'`quality'''analysis? If the well has been analyzed to be acceptab.le, attach copy of well water analyst:; for` coTform bacteria,{ volatile organic compounds, ammonia -nitro en ,- and nitrate nitrogen.. TOWN OF BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D - CERTIFICATION-r -_ -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS i:k W LAVV\ &Pipe M&(Skn5 i'h111s. ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME C-huck P0Pt+Z_ PART D - CERTIFICATION NAME OF INSPECTOR W01. �0 rVn COMPANY NAME winsan SCPpc, COMPANY ADDRESS 1// G9pr E1/6 1196?_ Street Town or City State ZIP COMPANY TELEPHONE ( 508 ) 71S - 7gt3� � CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate, and complete as of the time of inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems. Ch7- System c one: PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have conducted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form. Inspector Signature Date 7-/7-9s One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF HEALTH. * If the inspection FAILED, the owner or operator shall upgrade the system within one year of the date of the inspection, unless allowed or required otherwise as provided in 310 CMR 15 . 305 . partd.doc _ - ---- I T C71 N D N EL, 6.3' SYSTEM PROFILE_ TEST HOLE LOGS ACCESS COVER TO WITHIN 6' OF FIN. GRADE (NOT TO SCALE) ~`- - - -- - T ACCESS C❑VER (WATERTIGHT) TO D.A. OJALA, SE ENGINEER: WITHIN �- F F MINIMUM 75' OF COVER OVER PRECAST I IN 6' ❑ FIN. GRADE DE DAVE STANTON a ST. 2% SLOPE REQUIRED OVER SYSTEM WITNESS \~ 11 1 3 01 =CLING T•7' ys _ RUN PIPE LEVEL 2' DOUBLE WASHED PEASTONE DATE' / l 84.6' FOR FIRST 2' _ < 2 MIN/INCH _ -!� PROPOSED 1 80 PER(. RATE � _ 4' A N 'PT 6 r 80 3'G LLf7 S_ IC 1 1 0 - b.4 I 03 ,� 8 6 �. _, � rRc�M`� ,'gl t 80.71 TANK (H- 10 ) CLASS SOILS P# CARAGC a `] GAS �X� 79.99' -- 0 C1 C1 C7 0 C7 C� Cl RAFFLE F30.16' r�c�t7c� 0 79.80, M Q M M n M 0 0 [] �4' AT SIDES HAMftI_INS r 00 = 0 © l3 a 00 � I�I E L E V. POND �_____6' CRUSHED STONE OR MECHANICAL ' cv 2' Cl 0 0 0 0 0 C-1 O 0 0 77.80' 01 84.1 COMPACTION. (I5.221 [23) - r' A raFllzra "iF,slt�tU"rY DEPTH OF FLOW` F . = 4' 3/4' TO 1 1/2' DOUBLE WASHED STONE 1 ' ( 1 % SLOPE) ( 1 % SLOPE) SL RAGE NVC.RT ELF IATION TEE SIZES: 2.5Y 3 2 TO PROP SEPTIC i r,�.K 10 4" / VERT u-rVATiON (17�)P INLET DEPTH 3AVITY r';O\A` AT IA!N: 1.5% OUTLET DEPTH 14' B LOCATION MAP NO1" TO SCAI-E .OPE) F h.OR TO SETTING ANY CC)Iv9'IONENTS LS DWELLING � 25Y 5. 6 81 / I-APCI_1- 212 s 15 'D' BOX 21 LEACHING 6 2' 34' .3' ASSESSORS MAP 102 '! FOUNDATION- SEPTIC TANK - 30 FACILITY C1 b GARAGE 84' MED/COS 4.8 2.5Y 7/4 . C2 122't 71.6' MS a so.� W/GRAVEL_ a ry a 4�<<o a N a w � 80� 2,5Y 7/4 1�1 4 BENCH MARK - TOP OF CONCRETE 78 BOUND. EL. = 80.9 (ASSMD G.I.S.) I C3 + 13.o NOTE: WATERLINE LOCATION MED/COS _I �� APPROXIMATE. CONFIRM PRIOR TO AN' EXCAVATION 2.5Y 7/4 1 50" 71.6' NO WATER ENCOUNTERED NOTES + 84.6 SEPTIC DESIGN; (GARBAGE DISPOSER Is NOT ALLOWED > 1. DATUM IS APPROXIMATED FROM CIS ELEV. i } 6 ABAND. WELL �' SIGN FLOW: 4- BE:DROOM�: ( � '� GPD) _ �a� GPD 2. MUNiCIPAi_ WATER 1�.____ 550 �q^,a��j�/, USE A GPD DESIGN FLOW 3. MINIMUM PIPE PITCH TO BE 1/8' PER �00-I . ^ 8 �' {' - ��`s >'EPTIC TANK: 550 4. DESIGN LOADING FOR ALL PRLCAS'T UNITS TO Bfi AASF-10 I4- 10 C >=t --- _ GPD ( 2 ) = 1100 s3. 1500 5. PIPE JOINTS TO BE MADE WATERTIGIII + USE ' A ____ GALLON SEPTIC TANK 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITI-I MASS. PROP RE-ROUTE LEACHING: ENVIRONMENTAL CODE TITLE V. PLUMBING PROP. "WYE' o / + 5.0 y - SIDES: 2(42 + 12.83) 2 (.74) = 162 7, THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO BE s + 85.7 + 84.7-- USED FOR LOT LINE STAKING. <�' * 22_" AK+ 84.8 82 'MTTOM: 42 x 12.83 (.74� - 398 S. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4' PVC. v " OTAL! 758 S,F, 561 GPD 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEAI_C.D WITI-101.I1 EXIST. + INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINE.0 DWELL: 6 SP UC a .09 _USE (4) -500 GAL LEACHING CHAMBERS ACME OR FROM BOARD OF I-IEALTI-I. + HOL Y s5.7 5 + 84.6 + 84.9 EQUAL) WITH 4' STONE ALL AROUND 10. PUMP & REMOVE (OR FILL_ W/CLEAN SAND) EXISTING C:F�SSPOUI_S. + 85.4 - + W.P E DECK ' 0„ O A / PL LEGEND \ \ ++ 5.6 T1-i OAI + 84.2 ( a PROPOSED SPOT ELEVATION y �' <s< + f 1.-i J' OAK + 84.9 OF - h PROP. F,�w 40 LAUREN DRIVE- LOT 2 C.O. �j �4.3 HOLL SLEEVE SEWER LINE FOR 10' EITHER %, 100x0 EXISTING SPOT ELEVATION T F _ 75,o00t SO. FT. �' SIDE OF CROSSING WITH WATERLINE IN THE TOWN 0 1313: ACRES 85.7 HOLLY 4.0 0 100 PROPOSED CONTOUR ( MARSTONS MILLS) B A R N S�1 A( >I_--F a � 4.1 3.8"Olt, 83.4 ----- 100 EXISTING CONTOUR PREPARED FOR: 0 BORTOLOTTI CONS TRUCTION/STRATHIE - 83.6 WATER AND .6 83.9 �Ai - S BLDG SEWER LINE ELEC. / 83.5 L� ' 83.8 + 84.9 3.0 r BOARD OF HEALTH f -P 82.8 MA SCALE: 1" 1Q' DATE: NOVEMBER 12, 2001 ''00'„ s ,!'PROVED DATE / PROP. RE-ROUTED PLUMBING 0� of 508-362-4541 Cp 81.8 p0' Fax 508 362-9880 GARAGE TF = 84.1' down cape engineering, inc, -p 68. 75' ... CIVIL ENGINEERS #k�r��An F N OJALA LAND SURVEYORS t}i CIgVIy�y. As wp -26 E, 93, main st. yarrloul h, r1a 02E�75 trST ' L' � ' T��. DA'0"F,