HomeMy WebLinkAbout0008 LAURIES LANE - Health r
8 LAURIES LN. , MARTONS MILLS
III
~ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
8 Lauries Lane
Property Address
HUD/Cityside Management Corp. 22 Medallion Center, Greely Street, Suite 5, Merrimack, NH 03054
Owner Owner's Name
information is required for Marston Mills MA 02648 October 15, 2010
every 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. Please see completeness checklist at the end of the form.
Impotent: A. General Information
When filling out '
forms on the
computer,use 1. Inspector:
only the tab key
to move your
Michael McDowell
cursor-do not Name of Inspector
use the return
key. The Building Inspector of America
Company Name
2 Brookside Circle
Company Address
Wilbraham MA ® 01095 ' o
" City/Town State Ham-, Zip Code Z
800-626-4408 156 c�
Telephone Number License Number -n
co
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and the0he
information reported below is true, accurate and complete as of the time of the inspection.The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
hX4
October 15; 2010
Inspector's Signature Michael McDowell MM/mjl 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.
I1
Mrs•09/08 Title 5 Official Inspection Form:Subsurface Sewage isposal Syst •Pac 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
8 Lauries Lane
Property Address
HUD/Cityside Management Corp. 22 Medallion Center, Greely Street, Suite 5, Merrimack, NH 03054
Owner Owner's Name
information is required for Marston Mills MA 02648 October 15, 2010
every page. Cityrrown 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:
HUD owned house. House is vacant, all utilities are off.
B) System Conditionally Passes: N/A
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•09/08 Title 5 OfBdal Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 8 Lauries Lane
Property Address
HUD/Cityside Management Corp. 22 Medallion Center, Greely Street, Suite 5, Merrimack, NH 03054
Owner Owner's Name
information is required for Marston Mills MA 02648 October 15, 2010
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.): N/A
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health)`.
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health: N/A
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 8 Lauries Lane
Property Address
HUD/Cityside Management Corp. 22 Medallion Center, Greely Street, Suite 5, Merrimack, NH 03054
Owner Owner's Name
information is required for Marston Mills MA 02648 October 15, 2010
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment: NIA
❑ 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 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
❑ ❑ N/A 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 Y2 day flow
t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 8 Lauries Lane
Property Address
HUD/Cityside Management Corp. 22 Medallion Center, Greely Street, Suite 5, Merrimack, NH 03054
Owner Owners Name
information is required for Marston Mills MA 02648 October 15, 2010
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ❑ NIA Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ❑ NIA Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ❑ N/A Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ❑ N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd. N/A
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 CM 15.304.The system owner should contact the appropriate.
regional office of the Department.
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
8 Lauries Lane
Property Address
HUD/Cityside Management Corp. 22 Medallion Center, Greely Street, Suite 5, Merrimack, NH 03054
Owner Owner's Name
information is required for Marston Mills MA 02648 October 15, 2010
every 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?
❑ ❑ N/A Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
❑ ® Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 2 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 gpd
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
8 Lauries Lane
Property Address
HUD/Cityside Management Corp.22 Medallion Center, Greely Street, Suite 5, Merrimack, NH 03054
Owner Owner's Name
information is required for Marston Mills MA 02648 October 15, 2010
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents:
0 �I
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? N/A ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage 66 gpd
9 ( Y 9 (gpd))
Detail:
Last 2 years water usage totaled 48,000 gallons, divided by 730 days, equals 66 gallons per day
(gpd).
Sump pump? ❑ Yes ® No
Unknown
Last date of occupancy: Date
Commercial/Industrial Flow Conditions: N/A
Type of Establishment:
Design flow(based on 310 CM 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
8 Lauries Lane
Property Address
HUD/Cityside Management Corp. 22 Medallion Center, Greely Street, Suite 5, Merrimack, NH 03054 _
Owner Owner's Name
information is required for Marston Mills MA 02648 October 15, 2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Unknown, HUD owned house, none at board of
health.
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):
Septic tank, leaching pit
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 8 Lauries Lane
Property Address
HUD/Cityside Management Corp. 22 Medallion Center, Greely Street, Suite 5, Merrimack, NH 03054
Owner Owner's Name
information is required for Marston Mills MA 02648 October 15, 2010
'
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
Septic system appears to be original with house(1986), based on materials used and their condition.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 14 inches
feet
Material of construction:
❑ cast iron ❑ 40 PVC 4 inch ABS
® other(explain):
Distance from private water supply well or suction line: 28 feet
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Building sewer exits rear foundation wall 12 feet in from right rear corner.
Septic Tank(locate on site plan):
Depth below grade: 10 inches
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: 8'Lx5'Wx5'D, Approx. 1000 gallons
Sludge depth: 0 to 1 inch
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
w 8 Lauries Lane
Property Address
HUD/Cityside Management Corp. 22 Medallion Center, Greely Street, Suite 5, Merrimack, NH 03054
Owner Owner's Name
information is -required for Marston Mills MA 02648 October 15, 2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 27 inches
Scum thickness 0
Distance from top of scum to top of outlet tee or baffle 6 inches
Distance from bottom of scum to bottom of outlet tee or baffle 18 inches
How were dimensions determined? With a tape measure & pole
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Fluid level was correct, that is, equal with outlet invert. Septic tank appears sound and tees
functional.
Grease Trap (locate on site plan): N/A
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•09/08 Ttle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
8 Lauries Lane
Property Address
HUD/Cityside Management Corp. 22 Medallion Center, Greely Street, Suite 5, Merrimack, NH 03054
Owner Owner's Name
information is required for Marston Mills MA 02648 October 15, 2010
every 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.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): N/A
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
I
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
"f 8 Lauries Lane
Property Address
HUD/Cityside Management Corp. 22 Medallion Center, Greely Street, Suite 5, Merrimack, NH 03054
Owner Owner's Name
information is required for Marston Mills MA 02648 October 15, 2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan): N/A
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber(locate on site plan): N/A
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
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:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
8 Lauries Lane
Property Address
HUD/Cityside Management Corp. 22 Medallion Center, Greely Street, Suite 5, Merrimack, NH 03054
Owner Owner's Name
information is required for Marston Mills MA 02648 October 15, 2010
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number:
one
❑ 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.):
There was no evidence of hydraulic failure. Leaching pit was dry at time of inspection. Top of
leaching pit is 33 inches below grade. Note: HUD owned house. House is vacant, all utilities are off.
Septic system has not been receiving normal daily flows for an unknown length of time.
Cesspools (cesspool must be pumped as part of inspection)(locate.on site plan): N/A
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•09/08. Title 5 official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 8 Lauries Lane
Property Address
HUD/Cityside Management Corp. 22 Medallion Center, Greely Street, Suite 5, Merrimack, NH 03054
Owner Owner's Name
information is required for Marston Mills MA 02648 October 15, 2010
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (coat.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan): N/A
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
8 Lauries Lane
Property Address
HUD/Cityside Management Corp. 22 Medallion Center, Greely Street, Suite 5, Merrimack, NH 03054
Owner Owner's Name
information is required for Marston Mills MA 02648 October 15, 2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below Sketch is not to scale
❑ drawing attached separately
=Inlet cover on septic tank XA=23'1" YA=18'8"
B=Outlet Cover on septic tank XB=28'2" YB=21'6"
C=Leaching pit XC=747' YC=67'5"
C
Vol
t
- t
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
4 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
8 Lauries Lane
Property Address
HUD/Cityside Management Corp. 22 Medallion Center, Greely Street, Suite 5, Merrimack, NH 03054
Owner Owner's Name
information is required for Marston Mills MA 02648 October 15 2010
every 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: 7 plus feet
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:
Basement concrete slab floor is approximately 7 feet below grade. There is no evidence of chronic
water penetration or sump pump pit in basement.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16.of 17
Commonwealth of Massachusetts
• Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 8 Lauries Lane
Property Address
HUD/Cityside Management Corp. 22 Medallion Center, Greely Street Suite 5 Merrimack, NH 03054
Owner Owner's Name
information is required for Marston Mills MA 02648 October 15, 2010
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
tNns•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17
aTOWN OF BARNSTABLE --
LOCATION �!`'�, f}P� SEWAGE # ( 6 0
�J
VILLAG ,o ASSESSOR'S MAP & Lo. D
INSTALLER'S NAME&PHONE NO. 4 ��;
SEPTIC TANK CAPACITY :��1
LEACHING FACILITY: (type) �,+.T_� (size)
NO.OF BEDROOMS
i BUILDER OR OWNER
PERMITDATE: -.A
� � 7 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
I
Y
9
L
I .
TOWN OF 3ARNSTABLE C."
0
LOCATION SEWAGE #
VII;LAGEx 3 ASSESSOR'S MAP & LO D
INSTALLER'S NAME&PHONE NO. �
SEPTIC TANK CAPACITY + Y a 0
LEACHING FACILrrY: (type) (size)
NO.OF BEDROOMS zy
BUILDER OR OWNER
PERMITDATE: (eC 1 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 NO feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
0S-�, �- . .
� _ s
No. 7t9 lqO Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 1
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
0ppYiration for Mtgogal 6potem Congtrurtion Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Ad or of o. a �r�s �" e/ Owner's Name,Address and Tell.No.
AaaS4rs
Assessor's Map/Parcel C3� Aff
l�
n s�
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow `' Ll gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Apswer when applicable �/UZ9=12 CC'
r S_
L to
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and mainte ance of the afore described on-site sewage disposal system
in accordance with the provisions o th vironment ode and not to place the system in operation until a C rtifi-
cate of Compliance has bee ued by t s He
Signe Date
Application Approved by Date
Application Disapproved for the follo ing re ons
Permit No. 1 On Date Issued
3•
` No. Fee
# THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
.. Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
01pprication for Migogar *pgtem Congtruction 3permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Locati nAdd re4or I of IJ1o. 1 Iq q-t,.. ; s j Owner's Name,Address and Tel.No.
!` 5 �1l l� M A r-X.I a.s yet ,` ( f 5"42)9
Assessor's Map/Parcel d«2 O
Installer's Name,Address,
cand Tel.No. — Designer's Name,Address and Tel.No.
,A
l OAt) 0 J VA ov �luL
Type of Building:
Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow �3 `3 O "gallons per day. Calculated daily flow gallons.
.� Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil -
'Nature of Repairs or Alterations(Answer when ap l cable / AJ& COO - IL �+
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and mainte ante of the afore described on-site sewage disposal system
in accordance with the provisions o o th ironment ode and not to place the system in operation until7_,�Pocate of Compliance has be=ued ar. f e
60
Signe Date ,4 �
A lication Approved by Date _
PP PP �
Application Disapproved for the folio ing re ons
Permit No. 2,o 2 1 On Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
" BARNSTABLE, MASSACHUSETTS
G Certificate of Compliance
THIS IS TO CERTM��hato
the O -site Sewage Disposal System Constructed( )Repaired(X)Upgraded.Abandoned( )by �� � Ai sqr u e% r 6 xj :�� r-
at �Uf 5�� �n I r;P s � I has been constructed in ac rdance
with the provision f f itle 5 the fo Disposal System Construction Permit No.dam. �dated G o v
Installer ( %r v C (o u) c Designer 5.9.+-. e 11 / A
The issuance of this permit shall o be construed as a guarantee that the systemwil•1-functiionyas desig e'd.� fl
Date Inspector 1401�I��J_ Art ��l l�
/J I
V t
---------------------------------------
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION.- BARNSTABLES MASSACHUSETTS
Migpogar *pgtem Congtruction permit
Permission is hereby granted to o struct( '*Repair( Upgrade( )Abandon( )
System located at p A r 1 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:Construction must be completed within three years of the date of this permit.
Date: Z 0 0 Approved by
A,
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1/6/99
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_ . gip: rda�TIC 'his}Form Is+ To_ B� '"sed Fo>r tiie 1�eL�air Of Faiaed
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d oaf ` . �7 8 It
, � 7 5-RI; 5e he Systems On.�V _ -
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CERTIi 'iCATION OF`SKETC*[_AND APPLICATION=FOR A DIS_ PO5AL
WORKS CONSTRUCTION P"�AMIT(TTTHOUT I)ESIGNEII PLANS)
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ty
hereby v.-r 1fy hat t 'apphcatlon for disposal works
d
:; caclstructlon ermit s1 e b me tinted.. /( O
P Yc -, _ concerning the
'r property located at a _ �.tl `► s_,�it J meets all of the '
` follbwing_,niena "
ik
}�����
r at'" k fta >tist =�,
• The faded slf m connected to a icsidential dv-{.cling only Tzerf are no commercial t,r Business
uses associated'wi;. the dwelling'`R
,;. •� The uil is classifi red as CLASS�I a� ,lfie percolation rate is less than or equ'I to 5-minutes per inch.
d,d ! '"M'� `•:"� ," M1 S
•_ nierc are no wetlands wi 1uh t^"0."lr,P'of the pro nosed septic sys em
= There ai no private weus,4' U3 nkl Kll&et of th:;proposed aepti',Sys em µ
There is no increase,in flow and/or change in u s,,proposed
� t. '' l •t .��aYa,�3xy� +� � }TxJ`r t�f Fxr tQ.. ,{ .. +az ��l }�
There ar no vanazices requested qr.needed=
r a !"Y.''• ij,, t Fy},;f f r.....' �'It ��� 5�` y}
•r i,The bottom`of.the proposed leac rig Facility vwih,tfr be located I*thin five feet above the
1 _
maximum adjusted groundwater table elevatic:.t ;ijust the groi nd•>rater tab e' using the Frimptor
r ,
method when aF plicableJ } f
• It the S..a'.S.will be located with 250 feet of any ve7,etated'well'a ids, the bottom of the propor:;r'
leaching facility will n�be located les than fours;:n(14)feet ah '.-the the maximum adjus,,b*
groundwater table r°'wvation, `, t
i Pleasd. complete the follo1 .wing '
K r.l'Top of Ground,Sud ke Fle,,uan(using�1S informatioj f) r(�
t B); r,� L-levatlon* +the MAX.high G.W.'Adju:7,rne'1
:DIFFERENCE BETWEEN�A` 8
1 fr. iTT
a -
SIG D E-ATE,
f ; r
r'� Y
f Sketch proposed plan lof`system on bask]: �..
wJ
q:hr;aA folder ed7t a ;,
49
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•ASS'ESSOR'S MAP N0. PARCEL fl'�, i
LOCATION _ SEWAGE PERMIT N'Q.
VILLAGE
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-
�INSTA LLER'S� NAME i ADDRESS
N
B U I L D E R OR OWN ER
-2 -t4o in iv
DATE PERMIT ISSUED
Al
DATE COMPLIANCE ISSUED
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