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HomeMy WebLinkAbout0067 LAURIES LANE - Health 67 Lauries Lane 027-101 Morstons,.Mills Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 67 Lauries Lane Property Address Wilfred Viger ......... Owner Owner's Name information.is required for.e.very Marstons Mills Ma 02648 9/24/2013 page. Cityrrown State Zip Code., Cote.&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. Impodant:When filling out forms A. General Infdrmation :on the:comp.Uter, use.only the tab 1. Inspector key to move your -cursor-do not Sean M, Jones use the return Name of Inspector key. Cap wide Enterprises .......... .......... Company Name —0 ;'71-- 153 Commercial St. Mashp Ma 02649 CftyfTow-n State Zip Code 508-477-8877 S14522 .- ..............I.................................. ...................................................... .............. ........................................ Telephone Number License Number B. Certification J certify that I have.personally inspected the sewage disposal systern 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 6(31:0 CMR 15.000). The system: ❑ Passes Conditionally Passes El Fails ❑ Needs Further Evaluation by the Local Approving Authority 9124/2013 Inspecte.r's Signature Date The system inspector shall submit a copy.of.this inspection report to.the-Approving Authority.(Board of Health or DEP)within 30 days of completitig this inspection.1f the system is 6 shared::system.or has a design flow of 10,00.0 gpd or greater, the inspector and the system owner shall.subrtilt the, report to the appropriate regional office of the DER 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 systerriwilt 7perform in the future under the same or diftrent,conditions of use. t5ins-3113 Title 5 Officia, cfI n Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Lauries Lane Property Address Wilfred Viger Owner Owner's Name information is required for every Marstons Mills Ma 02648 9/24/2013 page. CitylTown 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: 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. 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): The water level in the septic tank was approx 3' below the outlet invert. The tank is leaking at the seam and needs to be sealed or replaced. t5hs-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 67 Lauries Lane Property Address Wilfred Viger Owner Owner's Name information is required for every Marstons Mills Ma 02648 9/24/2013 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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: ❑ 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•3/13 Title 5 Offidal 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 67 Lauries Lane Property Address Wilfred Viger Owner Owner's Name information is Marstons Mills Ma 02648 9/24/2013 required for 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: ❑ 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 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 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 ❑ z Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/z day flow t5ins•3113 Title 5 Official Inspection Form: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 67 Lauries Lane Property Address Wilfred Viger Owner Owner's Name information is required for every Marstons Mills Ma 02648 9/24/2013 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. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for 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. 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. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 6 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 67 Lauries Lane Property Address Wilfred Viger Owner Owner's Name information is required for every Marstons Mills Ma 02648 9/24/2013 page. City/Town State Zip Code. Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ 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): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 67 Lauries Lane Property Address Wilfred Viger Owner Owner's Name information is required for every Marstons Mills Ma 02648 9/24/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail 2011 = 68 000 total =186 gpd 2012= 32,000 total = 88 gpd Sump pump? ❑ Yes ® No current Last date of occupancy: Date Commercial/Industrial Flow Conditions: 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts - Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 67 Lauries Lane Property Address Wilfred Viger Owner Owner's Name information is Marstons Mills Ma 02648 9/24/2013 required for every page. Cityrrown 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: 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): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 67 Lauries Lane Property Address Wilfred Viger Owner Owner's Name information is required for every Marstons Mills Ma 02648 9/24/2013 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: original system installed 1986 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 1 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joint were ok, no leaks, vented through the roof Septic Tank (locate on site plan): 8" 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 Dimensions: 1000 gallons Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts y Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form Not for Voluntary Assessments 67 Lauries Lane Property Address Wilfred Viger Owner Owner's Name information is required for every Marstons Mills Ma 02648 9/24/2013 page. CitylTown 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 Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The water level in the septic tank was approx 3' below the outlet invert. The tank is leaking at the seam and needs to be sealed or replaced. 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 t5ins-3113 Title 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 M 67 Lauries Lane Property Address Wilfred Viger Owner Owner's Name information is required for every Marstons Mills Ma 02648 9/24/2013 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): 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 t5ins-3/13 Title 5 official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 17 I - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Lauries Lane Property Address Wilfred Viger Owner Owner's Name information is required for every Marstons Mills Ma 02648 9/24/2013 page. City/Town State Zip Code Date of inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): oilDepth 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.): Distribution box was in good condition no rot, water level was even with outlet invert. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17 t ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Lauries Lane Property Address Wilfred Viger Owner Owner's Name information is required for every Marstons Mills Ma 02648 9/24/2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ 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.): At the time of inspection the leach pit was found to have 2.5' of available leaching with no distinguishable stain line 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 t5ins•3/13 Title 5 Official Inspection Form: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 67 Lauries Lane Property Address Wilfred Viger Owner Owner's Name information is required for every Marstons Mills Ma 02648 9/24/2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydrauli: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.): t5ins•3/13 Title 5 Official Inspection ForfR Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - 67 Lauries Lane Property Address Wilfred Viger ..._..------- . _._...___----......._.__..._-.......-__....._.._..._. Owner Owner's Name information is Marstons Mills Ma 02648 9/2412.013 requiredfor every _.._..._._..._-_.._...._...._..._.............-..._._.__..-._____- page. CrtyfTown State Zip Code Date of Inspection D. System Information (cent.) Sketch Of Sewage Disposal System: Provide a view.ofthe 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 ❑ drawing attached separately AV-a j�`- { c)li_ I A-I I a 3 33'L CC) l3:3 A-4 ?� t5ins-3M3 Title.5 Offdal.lnspeation Form;Subsurface Sewage:Dfsposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Lauries Lane Property Address Wilfred Viger Owner Owner's Name information is required for every Marstons Mills Ma 02648 9/24/2013 page. Cityrrown 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: 12'+ 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: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 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 67 Lauries Lane Property Address Wilfred Viger Owner Owner's Name information is required for every Marstons Mills Ma 02648 9/24/2013 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 t t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage.Disposal System•Page 17 of 17 i .. .... _. *.'. .1 .. _ :: Commonwealth of IfAassachusefts .. .. Tl , fIj. 'a In p �� Farr nubs dace ewa Dis oral S stator Form N, far Velt�n >}r Assessment p - : _ . , . .. 67�aurtes Lame Pfpecty Address . -- .1, .i urger Owner owners Marne infomationts Mir&#ansMrlls _; Ma 42618 1012'�.l.2.?1 ..required for every _ : page City!down #ate dip Ctle. #fiats of Jrion inspecttr tt restil;its must be suh►iiittI.d oh this fortaa Ittsgec#tern fprrns may:not tte,.saltereci m ata way P.isaso see t:otnpietertiess che..okiist;at theand ofthe" rt .. tmpoitant When A: General information A .qio, >S .. __ . , .tl a Computer;-. jI�..1�.-.I.:1 J:...-,.�----:-.I.I.�...:-�..��.I..-�:-�.:�--.�.: uaeoolythelab 1 Imp. ctor key ta,tnbv6�onr cursor do not: - 1j : .wftie:returrr . Sean M Jones f�/. key,. Najnef inspector :: . . Capeuuide �n#e rises - � rao; Campny Marne — -- — 1 3C.5 ..ornmercal;St. Mashpee Ma. 02 Cityfit3wn State, ip:.. .;. . i'elepf.one Num ericense:(Cumtr . B Gertrf>frva#ion . . - . I certify that.. have personally 1J�sp Geed the; ewa a dis asaf s ,tat st this urld that th1e 9 p infortha>aen reported below is#rue,.a�crufete er►a carxtp(ete as of#,fte#tCnrot tha irtapsrrtfoi 1',11e ttistro -- . was perfined Jsed yin my tralr�rn aid expanenee i�J the;prbpe�functet�and mtrtf ;rtaile a an s)ta sewage deposal`systems 1 ar+t a DEi?appre red systetrr nsp I ,r P":, tarn to Sf3irtion 15;3 4 t} .. Title 3(;IP CMR 15 040) Th"e syst rrt ® Passes ❑ Con�iltitsn�1�L.Passes Q Vatis :. .. ❑ Needs FurthervalUatie�n bythe,Locaiptouing A�tttc?t�ty ... : . .. . . ,, 1— ..: 10f2112t3't3 InspecfOrs S►griature Date __ The syrsterr4 traspec#or shl subm�t�copy of tuts inspatron Depart to the I�ppra�iit+ Autlttm r+ aard . of He2lth ar QEp)within 3d d1.ays oi<c....- . #r ibis inspeat+an I r e system Is a sf�ared system r has a design:flow of'10,ti0pc#or gr+eater�the'Jpspectflr and the s�isterrt Q`niraer shalt 5abmit the . .:reporC_ta the appropriate rngtonal office df the DEp Tt a ongit al sh ied be sent fa.the sys#e awher Al 1 . .. . ,. and copies sent 4.to'tt�e buyer, if appl> l�le, and_the apprawng suthoify . .. . .... ... . r. . . P k**Thts report only describes eondit>IVJasat#hetirne Qf insp #ttttt ar►d cinder thecoadtions ofase at that time This inspection dsse not addr ss hc. ttie s�+sbett� r ail petf rtta ira the fu ut .untl : . the same or`dtfesatat cor%ditiot of uair . . . . _.. .............. .. ......_._ ...zo....I��......I.. , '::L . .. . . . . � . .I 'L ... . ...�r ..L, � r .- :r : .:I r "I— ::i/ -i:���i!����� :: . . . � . ...: . :' :'L' .. . .11 L . L . : p :Z, I V:�:,.!*.1�, . :,r:':j: : .. � . L I . . ... r I I''.. :. . r ... I.... r L L. .. ..... .;�'.::L' ::i ... .....r'�L':L� 15ins.,:.3/13. Title S.Offia�inspecflr, , SuOs,rlecaSsWagg OispogalSYaCetu "§ :1:Of t7 r Commonwealth of Massachusetts _ Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Lauries Lane Property Address Wilfred Viger Owner Owners Name information is Marstons Mills Ma 02648 10/21/2013 required for 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: 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. 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•3/13 Title 5 Official 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 67 Lauries Lane Property Address Wilfred Viger Owner Owner's Name information is required for every Marstons Mills Ma 02648 10/21/2013 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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: ❑ 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•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 3 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'f 67 Lauries Lane Property Address Wilfred Viger Owner Owner's Name information is Marstons Mills Ma 02648 10/21/2013 required for every page. Cityrrown 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: ❑ 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 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 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 po,nding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•3/13 Title 5 Official Inspection Form: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 yr. 67 Lauries Lane Property Address Wilfred Viger Owner Owner's Name information is required for every Marstons Mills Ma 02648 10/21/2013 page. Cityrrown 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. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for 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. ❑ Z 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 ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Mrs•3113 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 r 67 Lauries Lane Property Address Wilfred Viger Owner Owners Name information is required for every Marstons Mills Ma 02648 10/21/2013 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ 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): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t51ns•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Lauries Lane Property Address Wilfred Viger Owner Owners Name information is required for every Marstons Mills Ma 02648. 10/21/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: 2011 =68,000 total =186 gpd 2012= 32,000 total = 88 gpd Sump pump? ❑ Yes ® No Last date of occupancy: currentDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 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 "( 67 Lauries Lane Property Address Wilfred Viger Owner Owner's Name information is required for every Marstons Mills Ma 02648 10/21/2013 page. Cityrrown 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: 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): t5ins•3/13 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 °y 67 Lauries Lane Property Address Wilfred Viger Owner Owner's Name information is required for every Marstons Mills Ma 02648 10/21/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: original system installed 1986 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet 0 C mments on condition of joints, ( � s, venting, evidence of leakage, etc.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): Depth below grade: 811 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons Sludge depth: 3" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Lauries Lane Property Address Wilfred Viger Owner Owner's Name information is required for every Marstons Mills Ma 02648 10/21/2013 page. Cityrrown 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 3' Scum thickness .5" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? opened covers took measurements Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Water level was even with outlet invert, outlet baffle intact and in good condition. 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 t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 4 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Lauries Lane Property Address Wilfred Viger Owner Owner's Name information is required for every Marstons Mills Ma 02648 10/21/2013 page. Cityrrown 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): 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sawage Disposal System•Page 11 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 67 Lauries Lane Property Address Wilfred Viger Owner Owner's Name information is required for every Marstons Mills Ma 02648 10/21/2013 page. Cityrrown State Zip Code Date of iinspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box was in good condition, no rot, water level was even with outlet invert. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 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 67 Lauries Lane Property Address Wilfred Viger Owner Owner's Name information is required for every Marstons Mills Ma 02648 10/21/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching 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, etc.): At the time of inspection the leach pit was found to have 2.5' of available leaching with no distinguishable stain line. 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 t5ins•3/13 Title 5 Official Inspection Form: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 67 Lauries Lane Property Address Wilfred Viger Owner Owner's Name information is required for every Marstons Mills Ma 02648 10/21/2013 .page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 :..:-.::::...:..1::..,::.I:11...---1:::w:-..'..:I1*:-*..::..a::.:.*...,.:.:I..:-:::::::::-..:..:-::...�I.........,.:�-�...1:�....�.:l-... - .:-..':.�l..:.:..�.::.-�.:....�."I-.:....:1..:::::..... C...d.a omon,..:--lI1.:.�-.:..--.....::w--.+.-I..:.,.:..I-.::.. ei°Ith a Massahseits Tff :1I s �ar.:.,,::.:..'.1:.'.....-.�.::1-...:� .'p--:.."�:-.....--:-..I:.-..s.-�:1:.l-.!.-.-.',-....,.-:..-..--.I,.�':..-:.*....:..:.8:..**.,..:.-....�..- S.uba(rface Sewage Dispersal System Porn -Not for Voluntary Assessments .. .�.I:-q.A..:..,::.:.I...��:-.��. . . . . . 67Laur$es Lone: f?rppetCy address :I VirOted 1/ic}er ...:,.�.. Ooer ! Owner's 14arr►e rquirecl foreveyI ©tiS Miffs Nfa 06t$ 1 ( 'il0:::.:-:l...Ii::-::.:,:::::l---�-..�::::.:-:.:'1 '.::..'''...'...-.:..'..''-0.-.,..-:-I...'..&...:�I.::..iI.—..:—,.:.1-.::..:1.*....11.\-.�'..p.-*..:.-:.M.....:::-..:..�i.+..:.I.:::.:.-..::.-�..-:I::.:.:'...�:..::1-::�..-..I-"..:.:,...:.:..:F:.��...-.!.�L��....:.�.��:.�I:..., page.: . CrtyiTaum Stag ZrpGode Date;:vfiinspeirbn Dytem nfia�r`naton Gant } : Sketch ©f 5irwege Disposal System P% de views of th>r sewage d.tsposal sys>;eti f.!r>--V. d*+" tie;a to at feast two permanent reference laridrrlarks or lerchmarks, Lacatel3 a�i,Ell wltht 'ig4€eat�.Qc;to where publ�e water supply enters the bur ding,check erne of l Cie bogies txelaw hand s�Ce'tctr ine;are Meow . . . ❑ drawing attached aeparately _ . . .. _ :: ... _. . . : , : . 4 .. .. .: ... ... .... . O:: ,... . . . .. .: p a . :: . .. ..... ...._.. . _. o. ..: : :: A A., . f-; - .. ... - f 370 �3 A Z. �: . 3s ', D .II . . . A3 3 : . .J : .. 3:: . .. `/3 . . _... u�4cst p : : ..--- .::... .. _.. ;: 7'� : . :: .. .. t 1 7�+ : . . + *I. .. .. I. . I�5 bftic+al1. In1.sped}9n Form 3tiesurface•5ew�ga rNaposat5y, !RaB815 Qr t, : . :- Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 67 Lauries Lane Property Address Wilfred Viger Owner Owner's Name information is required for every Marstons Mills Ma 02648 10/21/2013 page. Citylrown 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: 12'+ 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: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 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 67 Lauries(Lane Property Address Wilfred Vigar Owner Owners Name information is required for every Marstons Mills Ma 02648 10/21/2013 page. CitylTown 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 ASSESSOR'S MAP NO. 0a7 -lp/ PARCEL LOCATION -*67 SEWAGE PERMIT NO. I o r 6 6 L.rv. 3 7 I VILLAGE I N S T A LLER'S NAME, i ADDRESS 5_an� S mic- Gsr � e U I L D E R OA OWNER � ex ��C?�6160 &�L �e o� v e• DATE 'PERMIT ISS DATE COMPLIANCE ISSUED zy L oT �.6 ASSESSORS MAP NO: PARCEL NO.: ( o ,. - �. ...:..:. i $.......'... ............ ,-'N0............ .. ... E COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ------....0..W.N...............oF.SARNSTA.3. 1-E.--------------•---.....----- Appliration for Dispuiia1 Viirkg Tomitrnrtion Prrutit Application is hereby made for a Permit to Construct (L/If or Repair ( ) an Individual Sewage Disposal System at: ..Lo __.CA_.Ca...1....AVRI-Ej,S....LAWE... N..-1. NlIL.1-5.-------•.---.-•---- 1 S �.tA}...E--- .0 � n r..lw.... y '...k4� . D ies VCLA1 V Installer iry��'C' Address Type of Building -%&tVSW#X Size Lot............................Sq. feet V Dwelling—No. of Bedrooms...............0......................Expansion Attic Garbage GrindeWd Other—Type of Building __..... No. of ersons. Shower — Cafeteria Vb 04 Other fixtures :----------------------•------- - W Design Flow................. __............gallons per person r y. Total//j�ail fl o �w------..50 .._..._._....__....gallons. Rd Septic Tank—Liquid capacit/ allons Length__ ,. . Width T. __. Diameter________________ Depth_ . W Disposal Trench—No..................... Width......................... Total Length.......-... Total leaching area....................sq. ft. x Seepage Pit No�W� Diameter.._./..-. .... Depth below inlet....... ........... Total leaching area6p_.sq. ft. Z Other Distribution box ( ) Dosing to ( /) ,/ p/ Percolation Test Results Performed by....... .t._cJ Q �-•............................. Date._T /7 ,86....._.. ,_l Test Pit No. 1................minutes per inch Depth of Test Pit...._...........__.. Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a .......................i 0 Description of Soil..............��.. ., .. - ----------. 'Qpl .0 - -- - -- - x ............................................. - 1. - � 1..�� ..... �[�1�� U Nature of Repairs or Alterations—Answer when applicable............................................................................................... Agreement: The undersigned agrees to install the Vedescribed Individual Sewage Disposal System.in accordance with the provisions of TITLE 5 of th tate Sa y Code—.The undersigned fu er agrees not to place the system in operation um" Ce sate o liance s been iss d by the board of heLILf Si ned_ A�....... ..... Dat Apli n A pr d By-------------------------------------------- ----- ...... Dat Application Disapproved for the following reasons:• --•-•-----•-----------------------•---••-------------------•--------•---•............................... •-•-•----•----•..............................................•-----------....---•--------..............-------•.....---•---•--•---•-••----•-----•••------•-•-•-••-•-••••-•--••-•-•••••-•--•-•••----- Date— PermitNo......................................................... Issued....................................................... Date --------------------------------------------------------------------- P 1 i, • No........_.... .r N ass ......'. ... .. ..... 1= THE COMMONWEALTH OF MASSACHUSETTS •�`�� BOARD OF HEALTH ...........................................oF. .1 �-i �.� ---........................... . • . . Appliration for Disposal Works Tonstrurtion Frrutit i Application is hereby made for a Permit to Construct (V% or Repair ( ) an Individual Sewage Disposal System at: L atio es s —�y O)c�(� -O or Lot`N� L- a 6 Y � i/ ��-�.\ n !' '... \� r k—. .!. ` ....... ..._..J.CIC Ires4.�1t.lJ Installer py rvl Address Type of Building Size Lot...........................Sq. feet U Dwelling—No. of Bedrooms...........................................Expansion Attic,,() Garbage Grinderl(%/,j `4 Other—Type of Building ______. No. of ersons.,,.�..•................. Shower i � 1/ W YP g ..... P �(/) — Cafeteria�(!� dOther fixtures .,_............................................... �- Design Flow.....................:.:...................gallons per person _er day. Total daiI flow............................................_ gallons. Septic Tank—Liquid capacitallons Length _. ... Width ..... ... Diameter________________ Depth..`f:........ Disposal Trench—No..................... Width.................... Total Length......... Total leaching area....................so. ft. 3 Seepage Pit NoZr!--- _.. Diameter... .... Depth below inlet.................... Total leaching area:-%!�.�r:_sq. ft. Z Other Distribution box ( ) Dosing tank ( ) • ra . Percolation Test Results Performed by.......................................................................... Date.. �- ; r ,aa Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ODescription of Soil..............l%..... �� �� �............................) ............................. • 7- -----------....__--•____________________________ V _ . -•-•--•............................................. -----•--••----•--------- =-7 ---- •- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the a0edescribed Individual Sewage Disposal System_in accordance with the provisions of TITLE 5 of th tate Sa ry Code The undersigned�' th fu er agrees not to place the system in operation un Ce sate o lianc s b iss d by the board of signed.. .............11l ?/1 ........ . '�...... _.... Date Apli n A pr ed By..............................................................................`...............--- ........................................ Date Application Disapproved for the following reasons:..............••_•_____.._.....__•_____•__-••_____........_._...______._.._...._-_-_-___-__-_--___________...._ ..---•------•--------------------•---------...-•-----•--•--.......................--•----------•--.........--------------•--...._..-------....-•--•--.....----•----------...----•--•••--..............._ Date PermitNo...................................................--- Issued-............................................--.......-- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ` ....../Cr�6.. :/...........OF../- 'F f/..'/(% i...................................................... Tntifiratr of Toutpliattrr THIS IS TO CERTIFY, That the In • idu�l Sewage Disposal stem constructed (�' or Repaired Yl f �CA c� ; ( ( ) In 4 at-•---`:(�%_....::----.�_....�_` -------------•--.....---.-'-.-------.-.._---------..........---.tt IT ................................................. - _ has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code 2asescribed in the application for Disposal Works Construction Permit No.--•' --._tea ../.... datedTHE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUAREE THAT THE SYSTEM WWII.L_.FUN TION SATISFACTORY. DATE. rtf ry ,(. r ...... ..• --.. Inspector.....: 1,�!�.... -•-•-------------•--- ............................ THE COMMONWEALTH OF MASSACHUSETTS M%-#�'T cad t y -) h e BOARDS OF . •�- .. . HEALTH `t + , cw.: I � . .. ......q-g t-2; 7 ............ Fs...-No. 0 $. L- ADispo al Works Tonstrnition frrnt Sle*_ K Permission is hereby granted_______ _________- �.� h hQ _......................................................... Y` to Construct' ( -. r Repair ( ) an In ivid al Sewe Dispgl system �S ~---- at No........................... Psj t,v t Str et µ 'as shown on the application for Disposal Works Construction Permit Dated. ........ 1\ ) B d oval ({,ATE...........`s .l .--- ................................... FORM 1255 A. M. SULKIN, INC., BOSTON .�,:• r. TOP OF FOUNDATION • : CONCRETE COVER all CONCRETE COVERS 717,11�4"CAST IRON 12"MAX. nnn�. FC- y8 xo OR SCHEDULE40 12"MAX. • ' P.V.C. PIPE 4"SCHEDULE 40 P.V.C.(ONLY) . ' PITCH 1/4"PER.FT. PIPE- MIN. -T- LEACH PITCH 1/4"PER.FT. PIT PRECAST EIINVERV ion xy" • a LEACHING e' 'y SEPTIC TANK INVERT INV�RT 0. e . �' e•; PIT OR DI ST. EQUIV. e INVERT EOU.33. .. BOX ELY...tP... ;; _ :�; 'e' El.`.��XS3 �. ..... GAL. INVERT r- •'� EL INVERT w�. w :;�; 3/4"TO I I/, ' . EL Y/! :.' �� WASHED U. W STONE, /z a ' 3 oxs ' D I A. y PROR LE OF ;�6xs' ND GROUND WATER TABLE SEWAGE. DISPOSAL SYSTEM NO. SCALE J° s?or / SOIL LOG WITNESSED BY DATE .y1��/: TIME„ j? /l�E�✓ BOARD OF HEALTH TEST HOLE I TEST HOLE 2 . . . . . .ELEV .. .. . . . .. . ENGINEER DESIGN DATA : NUMBER OF BEDROOMS 3 . . . TOTAL ESTIMATED FLOW •� 3Q . GALLONS/DAY BOTTOM LEACHING AREA /�, , , SO.FT. /PIT SIDE LEACHING AREA . . . � �. , . . . SOFT/ PIT GARBAGE DISPOSAL . . N. � . .(50% AREA INCREASE) TOTAL LEACHING AREA .a�,3. SQ.FT 3�i3 /I,�D �f�t/17/E.c JSXo) PERCOLATION RATE :CAS 5. . ,-� , MIN/INCH ./V.Q .t'JATER ENCOUNTERED LEACHING AREA PER PERCOLATION RATE .. SQ.FT. NUMBER OF LEACHING PITS . .Q� . . . . . . . , . . APPROVED BOARD OF HEALTHl/3 6?� •. . . . . 37J:el-?V DATE. . . . . . . 767h l AGENT OR INSPECTOR a. ' No Tr VAR/fY -6-5 70a, MAffgcy. co 1 A 814 . . . . . . . . . . . . . . gNATAVV i PETITIONERs'74/4/ ST, 'po►� �;.� EL. 7.�X.. . . . . . .. , — TOP,OF FOUNDATION _ CONCRETE COVER R -- CONCRETE G°OVERS 4' CAST IROIJ OR SCHEDULE 40 4"SCHEDULE 40 PV.C.(ONLY) 12 MAX. P.V.C. PIPE �— 7 PITCH 1/4"PER.FT. PIPE - LEACH MIN.- PITCH 1/4'PER.FT..° PIT e o IN ERT �oay, — PRECAS yy LEACHIN EL 3'T..Ya�... IIJV R :.,. e'. SEPTIC TANIC DIST. INVERT p . o•; PIT OR e Li INVERT �dDO EL.. / . L. . : BOX ELY.SXf6. ..� �►_ ;i' E V y QUI e; EL...�.!'I.�... . . . .. .. GAL. INVERT .•� EL.`�•S,f'J.6. INVERT �w o � "' 3/4"TO I I, EL .•?r.p�r. a WASHED ° c STON; 12- 30 —•�--6'D)A. _•�• t , /Z DIA. v PROFI LE OF GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM NO SCALE S I L LOG WITNESSED BY : PATE /�7 YG. .... TIME. . . . . . . . . . . BOARD OF HEALTH e TEST HOLE I TEST HOLE 2 �. Ti9coBi' ELEV. .y7Xy/ ENGINEER ELEV. .. .. . . . . . . �j. 77717, `-3 0/ �o su DESIGN DATA : NUMBER OF BEDROOMS 3 , TOTAL _ESTIMATED. FLOW 33 GALLONS/DAY BOTTOM. LEACHING AREA . . • . SO.FT. /PIT SIDE LEACHING AREA . . . �S �, SO.FT./'PIT ••. GARBAGE DISPOSAL . .!��. . . (50% AREA INCREASE) /7ED 5/1� rvQ TOTAL LEACHING AREA . 63, , . , , SQ.FT f4 3y)(yi PERCOLATION RATE .!��` 5 h11N/INCH N�. ..// .WATER ENCOUNTERED I LEACHING AREA PER PERCOLATION RATE .. . . . . . SQ.FT. NUMBER OF LEACHING PITS APPROVED . . . . . . BOARD OF HEALTH /e?—. 3;/5!�dJ- /13 SF DATE. � . . . . . . . . . . . . . . . . . . . ' CAD. •r< .a AGENT- OR INSPECTOR �o if1.( - y�Y Sip%AL SqN i . . . . . . . . . . . . . 9�y CA.d.R� s. ./ A✓ 0. 8 PETITIONER f - FI L xtjr/N9 ov. AM % I 2EPlvywt� a o NC--R/ LI✓1M 11 AM 11 {i 'REMOVC (rA8L.G V/ALL 7`,b CL-f IN7 v�. r. ,/(1CcL-._I/..L-:�/_�_�_ I i I NSTALL I 1- SC I J) a0 , AA le.IX O �+ II 7'a"cH o&V Dx -,G h I GXG POST I 4 r� ! 0--2-)( 14td0 4ot,r-1l !, — �Tr%/! /GG /3s 12/r•' �Z'6 Jo/ST /L 6CL— — 2_2vc orrJ atKl0�r/L O•G• 14AIDLF ��� � EXIIT//N'cl D/N, AM 1 RON IN(UL a �1 ,Orr r rn � ril 6 rr /RL=M0VV-- 3A(l 4srAAIJ1"/N4l H .�Orrt h _-.__.___. NL'NL OIN/N`! R/"1 x f 21(6 "Us-��ST�JD • -/G Y3G STGnlfiAl nrT An -/6 "oc.Y�PLY &Y'WALLS PT "oc R-/ /NI!41- -7,o,r LL-_-L'd L-'AgFuR D /, c/ ,— -oTv t � N i FOU/v/ a-r.,6Al 1 _ 6 /V FOOT/Nq / .-.I — - �I 'T�1! � i��. :1.•.r/�./._-.— +—lam I� z. N. .T�' , —L--•� —•a.��-fir._ / ...._--v-._._..._.. J—_r • L—�. t�-_ --- ............ --- .. ............. - _. ------ 420 r, b a 6 7 �s� SCALE: F ' '(a APPROVED 0Y: DRAWN BYbA DATE:6 _/,t s B REUSED ORAWINO NUMBER D. A. 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