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HomeMy WebLinkAbout0086 LAURIES LANE - Health 86 Lauries Lane Marstons Mills A = 027 1000 i I i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal SyIftm Form-Mtn+ {or Voluntary Assessments a t4- — Property Address Owner Owner's Name information is requkedforevery I S____/�/ ocn y Gt/S�K 1 page. Cdyfrown State Zip Code Date of Inspec n •• tV N 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. Importaforf n A. General Information Bing out four.s on the corrQuter, 7� use only thetab 1. InspectorI key move your cursoo r-do not p.✓ O 1- use the return e,femme of Inspects Company Address z . �—a s �� ��i ✓¢ Oa- ro 4� aly/rown State Zip code LSO-9) a �o_ 9� Telephone tuber License umber B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title;(31 115.000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority G� 6 Inspector' signature Date The sys ern 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 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 system will perform in the future under the same or different conditions of use. t5ns•3M3 Title 5 Official Ins peCtlm Form Sutsuface Sewage DiSpOSE♦System•Page 1 of 17 Commonwealth of Massachusetts Title 5 4ffi�ial Inspection Form Subsurface Sewage; Drsp+bsal System Form -Not for Voluntary Assessments -Z- QL4jelef Z- R wL-- Property Address / ON ner Ow nes ame information is r' N �l - s 4 ('_ j 6 2 � � equiredforev Gt✓.S'7ti✓1 / / page. City/Town State Zip Code Date of ftfspefton B. Celrtificadon (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) :7�lhave m s: not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CM 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 13) 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 ex0ain. 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 wifl 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): i. k , S } O s-3.h3 Title 50ffidal l speabm Form SubsLrfwe Se%ege Dispwd Symm-Page 2cf 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage, L Disposal System Form//-Not for Voluntary Assessments O L Gi ca r e s Z— Property Address Ojv Herr information is Ow ner's Name I AW �&y/� / required for every 4 r S4' f 2 page. Ckyrrown State Zip Code Date of Ins echo B. Certification (coat.) ❑ 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 pi pe(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 CHAR 16.303(1)(b)that the system is not functioning in a mannerwhich 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 Sns•3H3 Title50fficiai ftpectionF arm subunace sewdge Disposai System•Page 3of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Giu ✓1-e5 Property Address Cw ner Ow nees Name 14/-o- information is Q 0,d 4 of f' A/f required for every page. Cilylrown State Zip Code Date of hs#cWn B. Certification (com) 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 stems: PP 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 ❑ ❑/ tatic 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 Sns'318 Title 5 Official lnspeoftFom[SubarfaceSavAQeDisposal System•Page 4of17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal SystemForm-Not for Voluntary Assessments/ -006 Property Address / O,v ner Qw oar's Name information's Al'4 � h-larequiiredforevery ✓ K s page. 5 crown State Zip Code Date of Mpeofion B. Certification (coat.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: . El ;/"�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. ❑ L1 Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ tad' >ny 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 am triggered A copy of the analysis and chain of custody must be attached to this form.] ❑ he 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 dd nking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA)or a mapped Zone Il 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. tyym.31 3 Ue Mfiaai trspwtcn Form SubsWa=Sew4ge Disp=d Sp%m•Fage 5of 17 Commonwealth of Massachusetts REMO Title 5 Official Inspection Form Subsurface Sewage DDisposaI System Form -Not 1br Voluntary Assessments Property Address / L ON ner ON ner's NamWC4VT information is / mquiredforevery , !� 111,1111f page. atyf row n State Zip Code Orate of kopeclion C. Checklist Check if the following have been done. You must indicate"yes'or"no"as to each of the following: Yes ❑ P ing information was provided by the owner, occupant, or Board of Health ❑ re any of the system components pumped out in the previous two weeks? ❑ as 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 NIA) 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? ell E01 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 laid (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): Number of bedrooms (actual): ?? DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Ons-3h3 Tile 5official Inspection Form Suburfew Sewage Disposal System•Page eof 17 Commonwealth of Massachusetts tngmn�W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments efUrie y Zti Property Address Cw nor Ow ner's Name ertormatlon is f required for every ✓ J 7�Kf /� Doi 3 ? /� page. ay/rown State Zip Code Date of hApwtbn D. System Information Description: / /000 / //p,roo / 1 "2�4a L, 0 0 lT q Number of current residents: 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 8---No Seasonal use? ❑ Yes No Water meter readings, if available past 2 years usage(gpd)): Detail: Sump pump? Yes No Last date of occupancy: Oath CommerciaUlndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM R 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: tsm-3113 Tile 5Official lropectimFare[Subsurface SevageD isposal System-Page7of17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments 2�1 6 -'e-11 "vies L-ski--C�-- Property Address l owner ON noes Nameinforrnation is /�11-r /� /J equQedfor every .- — . / / a ejr4,u page. Cityfrown State Zip Code Date of kfspeftn D. System Information (coat.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: ' _ Source of information: C71— Was system pumped as part of the inspection? ❑ Yes Er No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of S m: 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/Altemative 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 VA system by system operator under contract ❑ Tight tank.Attach a co of he D P t E approval. 9 copy PP ❑ Other(descri be): Ons-W13 McSOfficial impaction Form Subsutace SexageDisposal system-Page Sol W Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System F orm -Not fbr Voluntary Assessments U � L rr tt l-e L-6l� Property Address Owner Owner's Nainforfrationis me required for every �✓ �s ` �� page. Cdy/Town State Zip Code Date ofAns n D. System Information (corn.) ;o Approximate age of all components, date installed(f known)and source of in rmation: /9 -a h © 2, r✓1 a L Were swage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: feet Material of constructi;��Pvc� ❑ cast iron ❑ other(explain): 62'- Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material construction: concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: yews Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: a„ 3 „ Sludge depth: 15m-3M 3 Title 5 Official Inspection F arm Subsufe0e Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form e Not for Voluntary Assessments u w-s L 41--4 y--e-- Properly Address / Cw ner Cw ner's Name information is required for every Gi✓ a f /INJ11�4 Le)-) page. C F/Town State Zip Code Date of spe ' n D. System Information (coat.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness ii 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, eHdence of leakage, etc.): vl v-1,Z i✓l ✓1 L9 �` '-�L✓ 7—'�;ti 4., `at4� 1, Yes /r/1 O c7 o� - mac° 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 Ons-3h3 Tile 5Official Impecfian Farm Subsuface Sewage Disposal System•Page 10Gf 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address owner our ner's NameInformation is / required for every �✓'.f K S �7 �o` b o c� / page. Cdylrown State Zip Code Date of lopecifon D. System Information (coat.) 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: gam Design Flow. gallons per day Alarm,present: ❑ Yes ❑ No Alann level: Alarm in worldng 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 5M-3M3 'M950rfidd lmpertmFam Subsurece SewegeDisposal System-Page 11 d 17 i Commonwealth of Massachusetts ED Title 5 Official Inspection Form sments Subsurface Sewage Disposal System For-Not for Voluntary properly Address / ON ner p 1v nee s Name information is G YS7-0 Hl Zip oWe Date of pee n required for every State page. q�y/Town D. System Information (cons.) Distribution Box (if present must be opened) (locate on site plan): ✓- Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): pump Chamber(locate on site plan): ❑ Yes No pumps in working order. ❑ yes ❑ No; Alarms in working order. Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): ass. ' ff pumps or alarms are not in working order, system is a conditional p Soil Absorption System (SAS) (locate on site plan, excavation not required): #SAS not located, explain why: Tide 5 Official InspeofionFarm Suhsuface Sewage DISPOW System.Page 12 d 17 151M1s•3113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address / Owner ON ner's Name requvedfor every ✓.S�informationis K1 i page. aty/Town State Zip Cade Date of"bon D. System Information (cont.) Type- 0 Soo �� `/� (�/mil a v'� r ✓ 1 ❑ leaching pits number. ❑ leaching chambers number. ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovative/altemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): v Ca h G J ( 40ct&I 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 We-3M3 Title50f5ciA ins pectionfartc Sutsuface SewageDispwel System•Pie 13d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage DiisposaI System Form -Not for Voluntary Assessments Property Address / 1 ON ner ow ner's Name hfom'ation is l required for every dd 6 q jl C? --PAL page. Cnyfrown State Zip Code Date of IrApeeWn 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.): L9re-W3 Tile 50tfiaal Inspection Form Subsurface Sewage Disposal S)sWm•Page 14 d 17 Commonwealth of Massachusetts U1--juma Title 5 Official Inspection Form VSubsurface Sewage Disposal System Form -Not for Voluntary Assessments -e 6 /— a (A it L.-. � Property Address Ow net L /e, information is O'^f ner's Name 1//� required for every i/ S A G✓ 1 v�6 page. C Rylrown State Zip Code Date of Insliectiah D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two pe ent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where p c water supply enters the building. Check one of the boxes below. hand-sketch in the area below ❑ drawing attached separately a • 3 I �d 7/ 1S.2 L5m.W3 Tile50ffldal Impaction Form Subarface SewageDispasal System-Page 15d V Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments L R L4 N/-e.S Z-- RopertyAddress ON nor ON ner s Name Information is required every �rf vI / //�l � �� X page. City/Town State Code Date of ftpeftn D. System Information (cost.) Site Exam ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells AV _ Estimated depth to high ground water. 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 �ocal Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must descdjA how you est lished t e high groundwater elevation: Lf �4 N G k IOI.rNC `o <l`�G 4-o V1'e L1--1 -4�'Ot' di-I VD Before filing this Inspection Report, please see Report Completeness Checklist on next page. t&ris 3M3 Tile 5Offieial inspection Form Subsurface Savage Disposal s)ftm-Page 16 of 17 r �L\ Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address ei V� S Ow rter e�fom>ations tW nes Name /,� rmuaedforevey G i vl /f/Y ����" 3TI&I page. Wrown StaOe Z�Code t7ate of E• Rep�ort comple1beness Checklist B Inspection Summary:A, B, C, D, or E checked ;-S�Ystem' Summary D(System Failure Criteria Applicable to All Systems completed PI formation—Estimated depth to high groundwater L�'Sketch of Sewage Disposal System ether drawn on page 15 or attached in separate file 05-SO rMO50ffidd IMPBCOMFWM SuOGW=Srmge0+sposel symm•Pie 17 d 17 No.- -------- BOARD OF HEALTH TOWN OF BARNSTABLE Zippricat ion ArWell Con.1tructionpermit Application is hereby made for a permit to Construct (✓), Alter ( ), or Repair ( )a individual Well at: . 86 v Location — Address Assessors and Parcel ____------- Owner, Address Installer — Driller Address Type of Building 8 Dwelling—� -- _—_--— —---_— Other - Type of Building - No. of Persons--2 _---__..___—__—______--___- YP g--_--------- - Type of Well .y " 5C-N93' P'G 0 Gpm Purpose of Well. c`NV` Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation uptil a Certificat .of Compliance has been issued by the Board of Health. 3�2 I�IQ Signedftt: d to Application Approved By da e Application Disapproved for the following reasons: ----------------.-.-------------------------- date Permit No. Issued— -- � — ------- ate BOARD OF HEALTH TOWN OF BARNSTABLE (certificate Of Compliance THI IS TO CERTIFY, That the individual Well Constructed (✓), Altered ( ), or Repaired ( ) t by�.SlMd�n� Installe_-r.----------- - -------- at__ �o y�c as (� 1V\GL c'S�O`l\5 K&Shas been installed in accordance with the provisions of the Town of Barnstable Boar ;VHRlth to Well Protection u�! �Regulation as described in the application for Well Construction Permit No. -- ted-------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE - _ Inspector t No, ------- OD Fee— -, -------- BOARD OF HEALTH TOWN OF BARNSTABLE 01ppCicationAr; ell Co0tructionPermit Application is hereby made for a permit to Construct (✓), Alter ( ), or Repair ( )a individual Well at: g(o l.Av,���_Ln 1 N\vsionS NV\V — _— -_ spl� I OS Location — Address Assessors Nap and Parcel , _-------- Owner Address �1 _`nL--- -- , O..Bvx 2783 �leoY _M�oU653 -------- Installer — Drillei Address Type of Building J Dwelling---_---------- Other - Type of Building-- -----_--__— No. of Persons--2' Type of Well 'I" SCHyD PVC. — Capacity—1 0 E Ct--P -------___—_,_ Purpose of Well c`� � _YJa < -=Cn� US Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in,operation until a Certificate of Compliance has been issued by the Board of Health. Signed 3(2 ��{O1 — Application Approved By v —date Application Disapproved for the following 'reasons:6A ______z ---------.--------------___—__— —___ date Permit No. — Issued - ate BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS��IS"TO CERTIFY, That the Indivildual Well Constructed (✓), Altered ( ), or Repaired ( ) b Installer at W\tS — --- - has been installed in accordance with the provisions of the Town of Barnstable Board of Hgalth� to Well Protection Regulation as described in the application for Well Construction Permit No. T - Dated------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. iDATE ---— -_ — Inspector. =-—_—_- --- --------- ------------------------------------------------------------------------------------------------ BOARD OF HEALTH TOWN OF BARNSTABLE j ell Con5truct ion Permit � No. -ate/ ----L�¢ !— `;or �^� t t Fee I �OtW Vy��1 �i1�\�w 1�hL Permission is hereby granted-hu — to Construct ( `/), Alter ( ), or Repair ( ) an Individual Well at: No. $G L-o•�c i cs �� i YV10 s f o ri s_M, I f---- — -—-- -- ------------------------------ Street as shown on U a licad for a Well o struction Permit Il — / No.- _ _�� t!-- Dated--- l -- - ------------- ----- DATE (/� CA oar d of Health � -- I dC r Massachusetts Department of Conservation and Recreation Massachuserts Office of Water Resources CID Well Completion Report 06-APR-10 09:44:06 WELL LOCATION 274540 GPS North: 410 39.484' GPS West: -700 26.794' Address:86""Laurie's°RLane.� Property Owner/Client: William Little Subdivision Name:Marstons Mills Mailing Address: 86 Lauries Lane City/Town: Barnstable City/Town, State:Marstons Mills MA Assessors Map: Assessors Lot #: Permit Number:W2010-004 Board of Health permit obtained: Y Date Issued: 03/26/2010 Work Performed Proposed use Drilling Method Overburden Drilling Method Bedrock New Well Domestic Auger CASING From (ft) To (ft) Type Thickness Diameter 1.00 -62.00 PVC Schedule 40 4.00 SCREEN From (ft) To (ft) Type Slot Size Diameter -62.00 -65.00 Stainless Steel Well .012 4.00 Point WELL SEAL / FILTER PACK / ABANDONMENT MATERIAL From (ft) To (ft) Material Description Purpose wg WELL TEST DATA (ALL SECTIONS MANDATORY FOR PRODUCTION ,WFLLS) Date Method Yield Time Pumped Pumping Level Tim Eto Recover Re'ddvery (GPM) (hrs & min) (Ft. BGS) (; r`s & Min)^�,�O (Ft�BGS) 03/26/2010 Constant Rate Pump 15.0000 1:30 48.0000 ° 0:01 ! •444 r. �. STATIC WATER LEVEL (ALL WELLS) PERMANENT PUMP (IF AVAILA LE) Date Depth Below Ground W. Pump Description: Measured Surface (ft) Type: Inta a Depth3'N 03/26/2010 44 Nominal Pump Capacity: Horsepower: WELL DRILLER'S STATEMENT ADDITIONAL WELL INFORMATION Driller: Thomas E Desmond III Developed: Yes Fracture Enhancement:No Supervisor: Thomas Desmond III Rig #: 100 Disinfected: Yes Well Seal Type:None Firm: Desmond Well Drilling Inc. Total Well Depth: 65.000 Depth to Bedrock: Registration #: 764 Date Complete:03/26/2010 Comments: OVERBURDEN From To Description Color Comment Water Loss/Add Drill Drill (ft) (ft) Zone of Fluid Stem Drop Rate .00 20.00 Silty Clay Brown No N/A 20.00 65.00 Fine to Coarse Sand Brown Yes N/A BEDROCK From To Code Comment Water Drill Extra Drill Rust Loss/ # of (ft) (ft) Zone Stem Large Rate Stain Add of Frac Drom per ft 1�1 S. CERTIFICATE OF ANALYSIS Page: 2 �1 , �`"*# f `" Report For: Barnstable County Health Laboratory Sally Desmond Report Dated: 3/30/2010 Desmond Well Drilling Order No.: G1056446 P O Box 2783 Orleans, MA 02653 Laboratory ID#: 1056446-01 Description: Water-Drinking Water Sample#: Sampling Location: 86 Laurie's Ln.Marstons Mills,MA Collected: 3/29/2010 Collected by: Customer Received: 3/29/2010 EPA 524.2- Volatile Organics by GUMS ITEM RESULT UNITS RL MCL Method# Analyst Tested Note Chlorobenzene ND ug/L 0.50. 100 EPA 524.2 yn 3/29/2010 Chloroethane ND ug/L 0.50 EPA 524.2 yn 3/29/2010 Chloroform 0.78 ug/L 0.50 80 EPA 524.2 yn 3/29/2010 cis-1,2-Dichloroethene ND ug/L 0.50 70 EPA 524.2 yn 3/29/2010 cis-1,3-Dichloropropene ND ug/L 0.50 EPA 524.2 yn 3/29/2010 Dibromochloromethane ND ug/L 0.50 EPA 524.2 yn 3/29/2010 Dibromomethane ND ug/L 0.50 EPA 524.2 yn 3/29/2010 Ethylbenzene ND ug/L 0.50 700 EPA 524.2 yn 3/29/2010 Hexachlorobutadiene ND ug/L 0.50 EPA 524.2 yn 3/29/2010 Isopropylbenzene ND ug/L 0.50 EPA 524.2 yn 3/29/2010 Methylene chloride ND ug/L 0.50 5.0 EPA 524.2 yn 3/29/2010 Methyl-tert-butyl ether ND ug/L 0.50 EPA 524.2 yn 3/29/2010 Naphthalene ND ug/L 0.50 EPA 524.2 yn 3/29/2010 n-Butylbenzene ND ug/L 0.50 EPA 524.2 yn 3/29/2010 n-Propylbenzene ND ug/L 0.50 EPA 524.2 yn 3/29/2010 p-Isopropyltoluene ND ug/L 0.50 EPA 524.2 yn 3/29/2010 sec-Butylbenzene ND ug/L 0.50 EPA 524.2 yn 3/29/2010 Styrene ND ug/L 0.50 100 EPA 524.2 yn 3/29/2010 tert-Bu tyl benzene ND ug/L 0.50 EPA 524.2 yn 3/29/2010 Tetrach1or6ethene ND u �- "-5.0" EPA 524.2 yn 3/20/!6f __ Toluene ND ug/L 0.50 1000 EPA 524.2 yn 3/29/2010 Total xylenes ND ug/L 0.50 10000 EPA 524.2 yn 3/29/2010 trans-1,2-Dichloroethene ND ug/L 0.50 100 EPA 524.2 yn 3/29/2010 trans-1,3-Dichloropropene ND ug1L 0.50 EPA 524.2 yn 3/29/2010 Trichloroethene ND ug/L 0.50 5.0 EPA 524.2 yn 3/29/2010 Trichlorofluoromethane ND ug/L 0.50 EPA 524.2 yn 3/29/2010 Attached please find the laboratory certified parameter list. Approved By: -1'7a irector)i '3/3 ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 CERTIFICATE OF ANALYSIS Page: 2 Q - Barnstable Count Health Laboratory�:, ,. . Report For: Y Y `ys.'r;1fA:I Sally Desmond Report Dated: 3/30/2010 Desmond Well Drilling Order No.: G1056446 P O Box 2783 Orleans, MA 02653 Laboratory ID#: 1056446-01 Description: Water-Drinking Water Sample#: Sampling Location: 86 Laurie's Ln.Marstons Mills,MA Collected: 3/29/2010 Collected by: Customer Received: 3/29/2010 EPA 524.2- Volatile Organics by GUMS ITEM RESULT UNITS RL MCL Method# Analyst Tested Note Chlorobenzene ND ug/L 0.50. 100 EPA 524.2 yn 3/29/2010 Chlortiethane ND ug/L 0.50 EPA 524.2 yn 3/29/2010 - - Chloroform 0.78 ug/L 0.50 80 EPA 524.2" yn 3/29/2010 cis-1,2-Dichloroethene ND ug/L 0.50 70 EPA 524.2 yn 3/29/2010 cis-1,3-Dichloropropene ND ug/L 0.50 EPA 524.2 yn 3/29/2010 Dibromochloromethane ND ug/L 0.50 EPA 524.2 yn 3/29/2010 Dibromomethane ND ug/L 0.50 EPA 524.2 yn 3/29/2010 Ethylbenzene ND ug/L 0.50 700 EPA 524.2 yn 3/29/2010 Hexachlorobutadiene ND ug/L, 0.50 EPA 524.2 yn 3/29/2010 Isopropylbenzene ND ug/L 0.50 EPA 524.2 yn 3/29/2010 Methylene chloride ND ug/L 0.50 5.0 EPA 524.2 yn 3/29/2010 Methyl-tert-butyl ether ND ug/L 0.50 EPA 524.2 yn 3/29/2010 Naphthalene ND ug/L 0.50 EPA 524.2 yn 3/29/2010 n-Butylbenzene ND ug/L 0.50 EPA 524.2 yn 3/29/2010 n-Propylbenzene ND ug/L 0.50 EPA 524.2 yn 3/29/2010 p-Isopropyltoluene ND ug/L 0.50 EPA 524.2 yn 3/29/2010 sec-Butylbenzene ND ug/L 0.50 EPA 524.2 yn 3/29/2010 Styrene ND ug/L 0.50 100 EPA 524.2 yn 3/29/2010 tert-Butyl benzene ND ug/L 0.50 EPA 524.2 yn 3/29/2010 - Tetrachloroethetie ND ug/L--_ 0.50 �5.0 EPA 524.2 yn 3/29/2010 - Toluene ND ug/L 0.50 1000 EPA 524.2 yn 3/29/2010 Total xylenes ND ug/L 0.50 10000 EPA 524.2 yn 3/29/2010 trans-1,2-Dichloroethene ND ug/L 0.50 100 EPA 524.2 yn 3/29/2010 trans-1,3-Dichloropropene ND ug/L 0.50 EPA 524.2 yn 3/29/2010 Trichloroethene ND ug/L 0.50 5.0 EPA 524.2 yn 3/29/2010 Trichlorofluoromethane ND ug/L 0.50 EPA 524.2 yn 3/29/2010 Attached please find the laboratory certified parameter list. Approved By: ` a Director)i ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 03/30/2010 TUE 11: 57 FAX 5083627103 Barnstable CTY HealthLab --- Barnstable Health 0001/002 b 14R`sa CERTIFICATE OF ANALYSIS Page: 1 Report For: Barnstable County Health Laboratory �!s crtuSE!% Sally Desmond Report Dated: 3/30/2010 1 Desmond Well Drilling Order No.: G1056446 P O Box 2783 Orleans, MA 02653 Laboratory ID#: 1056446-01 Description: Water-Drinking Water Sample 9: Sampling Location: 86 Laurie's La.Marstons Mills,MA Collected: 3/29/2010 Collected by: Customer Received: 3/29/2010 EPA 524.2- Volatile Organics by GUMS ITEM RESULT UNITS RL MCL Method# Analyst Tested Note Dichlorodifluoromethane ND ug/L 0.50 EPA 524.2 yn 3/29/2010 Chloromethane ND ug/L 0.50 EPA 524.2 yn 3/29/2010 t Vinyl chloride ND ug/L 0.50 2.0 EPA 524.2 yn 3/29/2010 E Bromomethane ND ug/L 0.50 EPA 524.2 yn 3/29/2010 1,1,1,2-Tetrachloroethane ND ug/L 0.50 EPA 524.2 yn 3/29/2010 1,1,1-Trichloroethane ND ug/L 0.50 200 EPA 524.2 yn 3/29/2010 1,1,2,2-Tetrachloroethane ND ug/L 0.50 EPA 524.2 yn 3/29/2010 1,1,2-Trichloroethane ND ug/L 0.50 5.0 EPA 524.2 yn 3/29/2010 1,1-Dichloroethane ND ug/L 0.50 EPA 524.2 yn 3/29/2010 1,1-Dichloroethene ND ug/L 0.50 7.0 EPA 524.2 yn 3/29/2010 1,1-Dichloropropene ND ug/L 0.50 EPA 524.2 yn 3/29/2010 1,2,3-Trichlorobenzene ND ug/L 0.50 EPA 524.2 yn 3/29/2010 1,2,3-Trichloropropane ND ug/L 0.50 EPA 524.2 yn 3/29/2010 1,2,4-Trichlorobenzene ND ug/L 0.50 70 EPA 524.2 yn 3/2 912 01 0 1,2,4-Trimethylbenzene ND ug/L 0.50 EPA 524.2 yn 3/29/2010 1,2-Dibromo-3-chloropropane ND ug/L 0.50 EPA 524.2 yn 3/29/2010 1,2-Dibromoethane(EDB) ND ug/L 0.50 EPA 524.2 yn 3/29/2010 1,2-Dichlorobenzene ND ug/L 0.50 600 EPA 524.2 yn 3/29/2010 1,2-Dichloroethane ND ug/L 0.50 5.0 EPA 524.2 yn 3/29/2010 1,2-Dichloropropane ND ug/L 0.50 . EPA 524.2 yn 3/29/2010 E 1,3,5-Trimethylbenzene ND ugIL 0.50 EPA 524.2 yn 3/29/2010 . f 1,3-Dichlorobenzene ND ug/L 0.50 EPA 524.2 yn 3/29/2010 1,3-Dichloropropane ND ug/L 0.50 EPA 524.2 yn 3/29/2010 1,4-Dichlorobenzene ND ug/L 0.50 5.0 EPA 524.2 yn 3/29/2010 2,2-Dichloropropane ND ug/L 0,50 EPA 524.2 yn 3/29/2010 2-Chlorotoluene ND ug/L 0.50 EPA 524.2 yn 3/29/2010 4-Chlorotoluene ND ug/L 0.50 EPA 524.2 yn 3/29/2010 Benzene ND ug/L 0.50 5.0 EPA 524.2 yn 3/29/2010 Bromobenzene ND ug/L 0.50 EPA 524.2 yn 3/29/2010 Bromochloromethane ND ug/L, 0.50 EPA 524.2 yn 3/29/2010 Bromodichloromethane ND ug/L 0.50 EPA 524.2 yn 3/29/2010 Bromoform ND ug/L, 0.50 EPA 524.2 yn 3/29/2010 Carbon tetrachloride ND ug/L 0.50 5.0 EPA 524.2 yn 3/29/2010 I ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 I 03/30,/2010 TUE 11: 58 FAX 5083627103 Barnstable CTY HealthLab --- Barnstable Health /2002/002 __.. r L '► CERTIFICATE OF ANALYSIS ;o mod, Page: 2 Report For: Barnstable County Health Laboratory I \39srrtCtrtu�'� Sally Desmond Report Dated: 3/30/2010 Desmond Well Drilling Order No.: G1056446 P O Box 2783 Orleans, MA 02653 _.._. . ............................................... .._ _... _.. _ . _._.... Laboratory ID#: 1056446-01 Description: Water-Drinking Water Sample#: Sampling Location: 86 Laurie's Ln.Marstons Mills,MA Collected: 3/29/2010 Collected by: Customer Received: 3/29/2010 EPA 524.2- Volatile Organics by GUMS ITEM RESULT UNITS RL MCL Method# Analyst Tested Note i Chlorobenzene ND ug/L 0.50 100 EPA 524.2 yn 3/29/2010 Chloroethane ND ug/L 0.50 EPA 524.2 yn 3/29/2010 Chloroform 0.78 ug/L 0.50 80 EPA 524.2 yn 3/29/2010 cis-1,2-Dichloroethene ND ug/L 0.50 70 EPA 524.2 yn 3/29/2010 cis-1,3-Dichloropropene ND ug/L 0.50 EPA 524.2 yn 3/29/2010 Dibromochloromethane ND ug/L 0.50 EPA 524.2 yn 3/29/2010 Dibromomethane ND ug/L 0.50 EPA 524.2 yn 3/29/2010 Etylbenzene ND ug/L 0.50 700 EPA 524.2 yn 3/29/2010 Hexachlorobutadiene ND ug/L 0.50 EPA 524.2 yn 3/29/2010 Isopropylbenzene ND ug/L 0.50 EPA 524.2 yn 3/29/2010 Methylene chloride ND ug/L 0.50 5.0 EPA 524.2 yn 3/29/2010 e Methyl-tert-butyl ether ND ug/L 0.50 EPA 524.2 yn 3/29/2010 t Naphthalene ND ug/L 0.50 EPA 524.2 yn 3/29/2010 n-Butylbenzene ND ug/L 0.50 EPA 524.2 yn 3/29/2010 n-Propylbenzene ND ug/L 0.50 EPA 524.2 yn 3/29/2010 j p-Isopropyltoluene ND ug/L 0.50 EPA 524.2 yn 3/29/2010 sec-Butylbenzene ND ug/L 0.50 EPA 524.2 yn 3/29/2010 Styrene ND ug/L 0.50 l00 EPA 524.2 yn 3/29/2010 s tert-Butylbenzene ND ug/L 0.50 EPA 524.2 yn 3/29/2010 Tetrachloroethene ND ug/L 0.50 5.0 EPA 524.2 yn 3/29/2010 Toluene ND ug/L 0.50 1000 EPA 524.2 yn 3/29/2010 i Total xylenes ND ug/L 0.50 10000 EPA 524.2 yn 3/29/2010 trans-1,2-Dichloroethene ND ug/L 0.50 100 EPA 524.2 yn 3/29/2010 t trans-1,3-Dichloropropene ND ug/L 0.50 EPA 524.2 yn 3/29/2010 Trichloroethene ND ug/L 0.50 5.0 EPA 524.2 yn 3/29/2010 Trichlorofluoromethane ND ug/L 0.50 EPA 524.2 yn 3/29/2010 ..... ................------ - - ._........_._. ._.................. ---- - - ---- ..................... . _....__ ._._...__........__. -- -- Attached please find the laboratory certified parameter list. Approved By: a Director)i 3/3 �/2� � ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 S- 2 o 9�1 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS Z DEPARTMENT OF ENVIRONMENTAL PROTECTI d � d A I� � y\ Ve ✓. tg TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 86 LAURIES LANE MARSTONS MILLS,MA 02648 Owner's Name: AMY CHADBURN Owner's Address: 86 LAURIES LANE MARSTONS MILLS,MA 02648 2� Date of Inspection: 5/18/04 -'hrRCEL �u Name of Inspector: (please print) JOHN GRACI,INC. �C) -- - Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340JPTitlue (310 CMR 15.000). The system: X Passes _ Conditionall_ Needs Furthion by the Local Approving Authority Fails Inspector's Signature: Date: 5/18/04 The system inspector shall submit a co y of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. f the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall s bmit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ****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. l Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 86 LAURIES LANE MARSTONS MILLS,MA 02648 Owner: AMY CHADBURN Date of Inspection: 5/18/04 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: n/a 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 _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a Page Tof 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 86 LAURIES LANE MARSTONS MILLS,MA 02648 Owner: AMY CHADBURN Date of Inspection: 5/18/04 C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The.system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance n/a "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: n/a Page•4 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 86 LAURIES LANE MARSTONS MILLS,MA 02648 Owner: AMY CHADBURN Date of Inspection: 5/18/04 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow _ X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped SYSTEM WAS PUMPED IN JULY 2003. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply _ X 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. d Page 5*of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 86 LAURIES LANE MARSTONS MILLS,MA 02648 Owner: AMY CHADBURN Date of Inspection: 5/18/04 Check if the following have been done.You must indicate"yes" or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out X _ Were all system components,excluding the SAS, located on site? X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no X _ Existing information.For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION' Property Address: 86 LAURIES LANE MARSTONS MILLS,MA 02648 Owner: AMY CHADBURN Date of Inspection: 5/18/04 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 Number of current residents: 3 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use:(yes or no): NO Water meter readings, if available(last 2 years usage(gpd)):A4 ., Sump pump(yes or no): NO }� Last date of occupancy: n/a COMMERCIALANDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: SYSTEM WAS PUMPED IN JULY 2003 Was system pumped as part of the inspection(yes or no): NO If yes, volume pumped: n/agallons--How was quantity pumped determined?n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box, soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed (if known)and source of information: 1986 PER OWNER,SYSTEM 1999 PER PERMIT 99-162 Were sewage odors detected when arriving at the site(yes or no):NO ?Page-7 of 11 J` OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 86 LAURIES LANE MARSTONS MILLS,MA 02648 Owner: AMY CHADBURN Date of Inspection: 5/18/04 BUILDING SEWER(locate on site plan) Depth below grade: 18" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): WELL WATER-100+FT.AWAY SEPTIC TANK: X(locate on site plan) Depth below grade: 12" Material of construction:Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: L 8'6" H 5' 7" W 4' 1011" Sludge depth:2" Distance from top of sludge to bottom of outlet tee or baffle: 32" Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 18" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle:n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 86 LAURIES LANE MARSTONS MILLS,MA 02648 Owner: AMY CHADBURN Date of Inspection: 5/18/04 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:_(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): D-BOX IS STRUCTURALLY SOUND. PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a 0 Page I of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 86 LAURIES LANE MARSTONS MILLS,MA 02648 Owner: AMY CHADBURN Date of Inspection: 5/18/04 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type n/a leaching pits, number: n/a CHAMBERS leaching chambers, number: 2 n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): LEACHING CHAMBERS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE.CHAMBERS WERE EMPTY AT TIME OF INSPECTION.THERE ARE NO STAIN LINES,INDICATE THEY HAVE NEVER HAD LIQUID IN THEM.BOTTOM IS AT 5 FT. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no):NO Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 86 LAURIES LANE MARSTONS MILLS,MA 02648 Owner: AMY CHADBURN Date of Inspection: 5/18/04 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building. L►� 1 AA 3� n I o in ''age•I I of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 86 LAURIES LANE MARSTONS MILLS,MA 02648 Owner: AMY CHADBURN Date of Inspection: 5/18/04 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12 feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators,installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 12 FT. 1 �I 'r } ' F 1 Q 9 4 0ATE. 3/10/9.9 PROPERTY ADDRESS: $6 Lamrzes Lane Marstons Mills.,Mass . 02648 On the above date, I Inspected the "pt1c systom at the above address. This system conalsts of the following: �7 / 1 . 1-1000 gallon septic tank. • ; ( . 1660 2 . 1—Distribution box . 3. 1-1000 gallon precast leaching pit . • 8aeed bn my Int cn- ctlon, I certify the following condltlons: 4 . This is a -title -five - septic sy,st<em. . (..,.7•,$ rCod•e ) 5. Theleaching pit is--in hydraulic failure. 6. New leaching must be added to the existing system. 7. This will bring the system in. compliance with the new 1995 septic -code .' 810NATUM7, 74 , Hams J P.1•i�acomber Jn i �' J �/, O Company: J, P` _Hacotober. & y on'_Tnc,, •; (j �� , Addreas:_„g-0X_66—.-_---a-- CtWL0 v 1 Le ! _ Phone: -. _—_508�.75�333'a------_ TO'A'i'.Oi Shn9STF,oi.t THIS CERTIFICATION. DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MAMBER *& SON; INC. Tank PCs wpoolkLs schllelds .Pump+d 4 ln&UII d Town Sower Connections P.O. Box 60' Centerville, MA 02632.0066 77.5-33M 7754412 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET,BOSTON MA 02108 (617)292-5500 TRUDY C( Secre ARGEO PAUL CELLUCCI DAVM B. STRI Governor Commissii SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Prey Address: 8 6 L a u r i e s Lane Name of Owner Donald Teed Marstons Mills Mass. Addressofownw: 86 Lauries Lane Dataoflmpection: 3/16/99 Marstons Mills ,Mass. 02648 Name of Inspector:(Please Print) Jose ph P.Macomber J r. I am a DEP approved system Impactor pursuant to Section 16.340 of Tide 5(310 CMR 16.000) company Name: J.P.Macomber & Son Inc . Mailing Address: B o x 66 C:P n t P r v i 1 1 P,M a c c _ 02632 Teleplu—Number: CERTIFICATION STATEMENT 1 certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _ Passes _ Conditionally Passes _ eeds Further Evaluation By the Local Approving Authority Fsils Impectoes signature: !1 r Date: f� The System Inspecto all submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days c 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 own, shall submit the report to the appropriate regional office of the Department of£nvironmentat Protection. The original should'bs,sent toVW system owner.and copies sent to the buyer,if applicable,and the approving authority. . NOTES AND COMMENTS revised 9/2/98 page lorll h J Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(confmod) Pr yq ; 86 Lauries Lane Marstons Mills ,Mass . Owner. Donald Teed Dart.of Inspection: 3/10/9 9 INSPECTION SUMMARY: Chock A, B, C, or D: A. SYSTEM PASSES: V6 I have not found any-information which indicates that any of the failure conditions described In 310 CMR 16.303 exist. Any failure criteria not evaluated are Indicated below. COMMENTS' must be-added to bh `Px; sr; ng Gant; : gf-rn B. SYSTEM CONDITIONALLY PASSES: —AwOne 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. Indicate yes,no,or not determined(Y,N, or NO). Describe basis of determination In all Instances. If 'not determined%explain why not. The septic tank is metal,unless the owner or operator has provided the system Inspector with a copy of a Certificate of Compliance:(attached!Indicating that the tank was installed within twenty(20)years prior to the date of the Inspection;or the septic tank,whether or not metal,Is cracked,structurally unsound,shows substantial infiltration or exfiltration, or tank failure Is Imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed In the distribution box is due to broken or obstructed pipe(s) approval f the Board of box. The system will ass Inspection if(witha ov o or due to a,aroken,settled or uneven distribution y P PPP Health). broken pipes)are replaced obstruction Is removed distribution box is levelled or replaced - The system required pumpMg-more then fourtimes-a yeardue to broken or obstructed pipe(s). The Vystem wilFpess^ Inspection if(with approval of the Board of Health): " broken pipes)are replaced obstruction Is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL 1jYSTEM INSPECTION FORM PART A CERTIFICATION(continued) • PropettyAddreu: 86 Lauries Lane Marstons Mills ,Mass . Owner: Donald Teed Dau of Inspection: 3/10/9 9 D. SYSTEM FAILS: You ust Indicate either"Yes'or'No' to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is Identified below. The Board of Health should be contacted to determine what will be necessary to correct the falure. Yes No/ Backup of•sewags Into fecilityor-rystemcomponertt•due qo an overloaded orebg god StlSor-csaspool. =-'--'•' ` Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cessp ool. Static 1G ic liquid level in the distribution box above outlet Invert due to an overloaded or clogged SAS or cesspool. _ Liquid depth In cesspool la less than 6"`below Invert of available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(:). Number of times pumped_. Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Y Any portion of a cesspool or privy Is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy ls-within a Zone 1 of a public well.. Any portion of a cesspool or privy is within 60 feet of a private water supply well. Any portion of a cesspool or privy Is-I ss•than 100 feet but greater than 50 feet from a private water supply weU with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for •coliform bacteria,volatile organio•compounds,ammonia nitrogen-and nitrate nitrogen. - r. E. LARGE SYSTEM FAILS: You must Indicate either'Yes' or'No' to each of the following: The following criteria apply to large systems In addition to the criteria above: Ak The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system Is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes Nq the ayttem is within 400 feet of a surface drinking water supply the system•la-within 200 feet of�t*ibutaryto a+urfaoe drkikiwg water-wpplY•�• -— - --- J� the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system In accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further infor•(mation. revised 9/2/98 Pageaofll 1 , i • i SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART B CHECKLJST PropertyAddr.: 86 Lauries Lane Marstons Mills ,Mass . Ownw: Donald Teed Date of Inspection: 3/1 0/9 9 Check If the following have been done:You must Indicate either'Yes'or'No' as to each of the following: Yes No , Pumping information was provided by the owner,occupant,or Board of Health. — .Nona of the system compownts.kama:bwn poa%peel4apat-Jeastmwo•weekeaadthovystsm haabaeoaecaisaagwwaraifl< rates during that period. Large volumes of water have not been Introduced Into the system recently or as part of this Inspection. Ll As built plans have been obtained and examined. Note if they are not available with NiA. — The facility or dwelling was Inspected for signs of sewage back-up. The system does not receive non sanitary or industrial waste flow. — The alto was Inspected for signs of breakout. — All system components,ALding the Soil Absorption System,have been located on the site. — The septic tank manholes were uncovered,opened,and the Interior of the septic tank was Inspected for condition of ball or toes,material of construction,dimensions,depth of Uquid,depth of sludge,depth of scum. The size and location of the Soil Absorption System orrthe sit has been determined based on: Existing information. For example,Plan at B.O.H. — Determined In the field(If any of the failure criteria related to Part C Is at Issue,approximation of distance is unacceptable 115.302(3)(b)J The facility owner.(and.acrup;'+■,Jf diUsiaW from n ne,rJ ware,yravLdsd wUh Infn,malloo iDn the proper mainro e f SubSurface Disposal Systems. ' I 1 revised 9/2/98 Page 5of11 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:.86 Lauries Lane Marstons Mills,Mass . owns: Donald Teed Data of I-pec-d— 3/10/9 9 FLOW CONDITIONS RESIDENTIAL: Design flow:_ /10 j.p.d./bedroom. Number of bedrooms desi� ): ✓� Number of bedrooms(actua'l):� Total DESIGN flow.�� Number of current residents Garbage grinder(yes or no)._ Laundry. (separate system) (yes o no :_;I If yes,separateJaspaction.required _ Laundry system inspected (� es or Seasonal use(yes or no):4 r Water meter readings,if available(last two year's usage(gpd): Sump Pump(yes or no): Last date of occupancy:( I f w,e 11 has not been tested. in t.h e PAQ- 12 months. It should be done now. COMMERCIAL/INDUSTRIAL: See pages '6 A & 6 B Type of establishment: 4/14 Design flow: (1 aad 1 Be?", d on 15.203) Basis of design flow AM Grease trap present:(yes or no) Industrial Waste Holding Tank present:(yes or no)/V!1 Non-sanitary waste discharged to the Title 5 system:(yes or no)V—/? Water meter readings,If available: Allf Last date of occupancy: AM OTHER:(Describe) A14 Last date of occupancy: Allf GENERAL INFORMATION PUMPING RECORDS and source.of inform tion: System pumped'as part of inspection:1yes or no)4.V If yes,volume pumped: gallons Reason for pumping: TYP�OF YSTE]tAeptic tank/distribution box/soil absorption system � ingle cesspool Overflow cesspool �I Privy WC Shared system(yes or no) (if yes,attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract /11:p Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components,date Installed{if known)•and source.of4nformation:— 40g�, Sewage odors detected when arriving at the site:(yes or no),a revised 9/2/98 page 6orii BARNSTABLE COUNTY DEPARTMENT OF HEALTH & THE ENVIRONMENT Of e�qy P.O. BOX 427 sa SUPERIOR COURT HOUSE BARNSTABLE, MASSACHUSETTS 02630 • yASS PHONE: 362-251_ EXT. 337 SAMPLING INSTRUCTIONS FOR PRIVATE WELLS An improperly taken sample wastes your money and has neither scientific accuracy nor legal acceptance. 1. Obtain sterile sampling bottle from the County Lab or Town Health Department. Bottles sterilized at home are not acceptable. 2. It is recommended to use a straight faucet, preferably NOT swingtype. 3. Turn on the cold water and let it run for five (5) minutes. 4. Fill the bottle leaving one inch air space. Do not fill bottle to the top. Be careful not to touch the inside of the bottle or cap with the faucet, your hands, or anything else. 5. Fill out the reverse side of this form. The laboratory requires accurate and complete information. The person filling the bottle must sign the form 6. The charge for a routine well analysis (coliform bacteria, pH, conductivity, iron, nitrate, sodium and copper) is S25.00. Checks should be made payable to Barnstable County. Exact change is required if paying in cash. Additional tests require additional fees. Consult lab or a price list for exact information. 7. Samples are accepted Monday - Thursday from 8:00 AM to 4:00 PM and Friday 8:00 AM to 1:00 PM. They must be delivered to the lab within 6 hours of collection or 24 hours if refrigerated. 8. Completion of tests and results takes 7-10 business days. Results will be sent in the mail. 9. Special requests such as results in 2 -3 days and sample acceptance on Friday from 1:60 PM to 4:00 PM are available for an additional charge. Contact the laboratory for availability. NOTICE: WATER FROM THE SAME SOURCE CAN PRODUCE CONTRARY RESULTS IF TESTED AT DIFFERENT TIMES AND/OR DIFFERENT LOCATIONS THE COUNTY OF BARNSTABLE SHALL NOT BE LIABLE FOR DAMAGES RESULTING FROM THE RELIANCE ON RESULTS OF WATER TESTS ACCURATELY PERFORMED. PLEASE COMPLETE REVERSE SIDE OF FORM • � y ✓l PRIVATE WELL WATER SAMPLE -DATA COLLECTION SHEET VOC VIAL I4UI•IBERS FIELD BLAIJK BOTTLE ID NUMBER DATE REC ' D NAME COLLECTION DATE MAILING ADDRESS COLLECTION TIME WELL DEPTH 'STREET ADDRESS YEAR WELL INSTALLED MAP/PARCEL TELEPHONE COLLECTED BY: SAMPLE APPOINTI4ENT NEEDED ? REASON FOR TESTING: ( ) SUSPECT A PROBLEI•i (EXPLAIN) ( ) REQUIRED ( ) FOR INFORMATION ONLY ( ) NEW WELL ( ) REAL ESTATE TRANSACTION ( ) OTHER (EXPLAIN) DISTANCE OF WELL FROM POSSIBLE CONTAMINATION SOURCES (IN FEET) :L S5'I SEPTIC TANK\CESSPOOL FARM SALTED ROAD UST LANDFILL INDUSTRY GAS STATION OTHER TREATMENT USED: ( ) NONE ( ) WATER SOFTENER ( ) FILTER; SAI4PLE TAKEN BEFORE/AFTER TREATMENT (CIRCLE) ***************************************************************** RESULTS ************ ******************* ****************************** VOC ROUTINE CHLOROFORM TOTAL COLIFORM\100 ML 1, 1, 1 TRICHLOROETHANE (PPB) p}i CONDUCTIVITY IRON (PPM) IIITRATE-IIITROGEN (PPM) SODIUM (PPM) COPPER (PPM) 4 ANALYSIS DATE: ANALYSIS DATE: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 86 Lauries Lane Marstons Mills Mass. Owner: Donald Teed Date of I sspectkm:3/10/9 9 BUILDING SEWER: (Locate on site plan) Depth below grade Material of construction:_cast iron //40 PVC—other(explain) Distance from private water supply wall or suction line. 1Gd (— Diameter�_ Comments:(condition of joints,venting,evidence of taakage,•etc.) — Joints apbear tight No PV; dphrp of leakage System SEPTIC TANKMC)qFk (locate on site plan) JI Depth below grader Material of construction:—/Concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is(natal,list age 39 1s.age.confirmod by Certificate of Compliance AZ (Yes/No) 6 n �' r' Cr r`�1�, Dimensions: ,AV u��� 1.1�rdPi c.l Sludge depth: -V-W _ Distance from top roff sludge to bottom of outlet tee orbaffle J Scum thickness:V _ u Distance from top of scum to top of outlet tee or baffle:Distance from bottom of scum to bolt of outlet to or baffler How dimensions were determined: Comments: v in relation to outlet invert structurelminte rit (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level 9 Y. evidence of leakage,etc.( u MP to n k e v e r y 2'—3 y P a r G _ T n 1 P t- R n„t l p t t P p c are in place Liquid dP,nth at the nntl Pt i nuprt ; cz /,6" Tha GREASE TRAP- (locate on site plan) Depth below grade:A//f Material of con3tructi0n.A' concrete etaI4/4Fibergl ass OPolyethylengjj,�other(explain) Dimensions: VfA Scum thickness: Distance from top of scum to top of outlet tee or baffle: A /t Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) Grease trap is not present. I revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contir"od) Property Address:86 Lauries Lane Marstons Mills ,Mass . Owner: Donald Teed Data of Inspiaction3/10/9 9 T)GHT OR HOLDING TANK:A&/�(Tank must be pumped prior to, or at time of,Inspection) (locate on site plan) Depth below grader Material of constructionW4concretwVhmetaVlrll Flberglasa Polyethylene other(explain) AJA Dimensions: Capacity: gallons Design flow:gallons/day Alarm present 414 Alarm level: jI.4 Alarm in working order:Yes-VA NoLvf Date of previous pumping: Comments: (condition of Inlet tee,condition of alarm and float switches,etc.) -Tiprit or holding tanks are not nrpsent DISTRIBUTION BOX:Y (locate on site plan) r Depth of liquid level above outlet Invert:k_ Comments: (nots•If level and distribution is equal,evidenoe of solids carryover,evidence of leakage Into or out of box, etc.) — - — Distribution box hag one lateral Tharp is pvidpnrp of gnlids rnrry PUMP CHAMBER:.1 (locate on site plan) Pumps In working order:(Yes or No)—d�B Alarms In working order(Yes or No)�[� Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) limp chamber is not present revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PropertyAddres3:86 Lauries Lane Marstons Mills ,Mass . owner: Donald Teed Date of lnsp--d—n 3/10/9 9 � SOIL ABSORPTION SYSTEM(SAS). (locate on site plan,if possible:excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits,number:1 ?� leaching chambers,number: V leaching galleries,number: leaching trenches,number, length: � leaching fields,number, dimensions: overflow cesspool,number: Alternative system: Name of Technology: �j Comments: (note condition of soil,signs of hydraulic failure,level of pondingg, damp soil, condition of vegetation, etc.) Loamy sand to medium coarse sand . Leaching pit is in hydraulic fni 1 me Qni 1 c nrp rjamp Va9atnti nn j Q nnrmnl CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: /U Depth of solids layer: AW Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: AX inflow(cesspool must be pumped as part of inspection) 0 esspools are not present , Comments: (note condition of soil,signs of hydraulic failure,level of.ponding,condition of-vegetation, etc.) Cesspools are not nrPsPnt - PRIVY:.&J (locate on site plan) Materjals of construction: Dimensions: Depth of solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Privy is not present , revised 9/2/98 page 9ortl f J SUBSURFACE SEWAGE DISPOSAL SYSTV.M INSPECTION FORM PART C SYSTEM INFORMATION(continued) Nop.MAd&*": 86 Lauries Lane Marstons Mills ,Mass . Ownw: Donald Teed D'"of UuPecdOn:3/10/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes Into house) — $6 . Avq. 1 / b revised 9/2/98 Page loof11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PropertyAddresa: 86 Lauri es Lane Mar s ton s Mi11s ,Mass . Owner. Donald Teed Data of Inspection: 3/10/9 9 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep _ SITE EXAM Slope Surface water Check Cellar Shallow wells i Estimated Depth to Groundwater/2��Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record IV_/Observed.Site(Abutting property)observation hole,basement sump etc.) determined from local conditions Checked with local Board of health _Checked FEMA Maps Checked pumping records __ZChecked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Used water contours Map Gaherty & Miller 12/16/94 revised 9/2/98 Page 11of11 `+•r.+nrn.—n•rs*-Tr^ rnrnn•n,snrtrnn,sn.rr. r^.r+e+v.rrmenem mrav nvsrtgrss+ SO �\ 'TOWN OF Barnstable HOARD OF HEALTH SI)IISURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION `_ F•••ran•�•••.• —r,,,r.^..:rn�rm•rtia-rn.rmrrra+e•'rn'r—.•t�rrwe�arrtm"-rs+nsnRns+mias�rsrs nrnn�rerr�,r+�r+rr+r.•.-ar'-r•r-ter . —TYPO OR PRINT CI•EARLY— PROPERTY INSPECTED STREET ADDRESS 86 Lauries Lane Marstons Mills ,Mass. ASSESSORS MAP, BLOCK AND PARCEL # OWNER's NAME Donald Teed PART D - CERTIFICATION r NAME OF INSPECTOR Joseph P.Macomber Jr . COMPANY NAME J. P.Macomber & So-W Inc . COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 Street Town or City State i1P COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX (508 ) 790 _ 1578 q CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system a this address and that the information reported is true , accurate , and complete as of the time of The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on. site sewage disposal systems . Check one : System PASSED The inspection which I have conducted has not found any information which indicates that the system . fails to adequately protect public healLh or the environment as defined in 310 CMR 16 . 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. J6 System FAILED* r ,. The inspection which I have con -acted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 3.10 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form. Inspector SignatureAQX� Date /D One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the DOARD OF HHAL711. * If the inspection FAILED, the owner or"" " orator shall u P pgrade ' the system within one year of the date of the inspection, unless allowed or required otherwise as provided in 3.10 CMR 16 . 305 . partd .doc TOWN OF BARNSTABLE LOCATION g� LKUf-1'5 LN SEWAGE # ?q' /6 2- VILLAGE Mh-+25T.00S MILLS ASSESSOR'S MAP & LOT 027- IbS INSTALLER'S NAME & PHONE NO. ,,)A-m ES LLt� q;�zb, 0zr0 SEPTIC TANK CAPACITY /:00 2,al 1 extyrj►J LEACHING FACILITY:(type) 6'00 Sol CAArMl3 S (size) Z NO. OF BEDROOMS Z PRIVATE WELL OR PUBLIC WATER r21✓+ BUILDER OR OWNER -Dp►JALL;b DATE PERMIT ISSUED: 3, 30, 9g r DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No v'" I 20'-.D A2 -7"l D" 0 1 A 3 95 -7 ti 83 i J r. DNo. -`'' Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2ppii.cation for ;Dizpotal *pztem Cott6truction Permit Application for a Permit to Construct( )Repair( Y)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Q(,, LoocaiLt cz& bw E Owner's Name,Address and Tel.No. M/kris- ams rA t LLS -rt� Assessor's Map/Parcel Q(p L J ua_t try LA-#.j ©Z7— IDS R}2SToNS M ►U—S MFi o"q-8 Installer's Name,Address, d Tel.No. q U. 6 2 Tb Designer's Name,Address and Tel.No. J A M t�5bLLEZ— J tEivt C75- hLOLL-tt--A— (.0, 60% ?07— M Pr"1_oNS M I ULS M A Pee, box 702— /► A f1,S'7mu S PAID All Type of Building: Dwelling No.of Bedrooms -3 Lot Size 17 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 304�' 3°47 gallons. Plan Date 3 ° 3o a 19 Number of sheets I Revision Date N JA Title Size of Septic Tank 15'-bo ��. Type of S.A.S. ZX Soo 24 JLA-u4 c401o' "13UX4 Description of Soil Nature of Repairs or Alterations(Answer when applicable) j?tPLA Cjc F41 zL=D SAS Date last inspected: Q q 9 Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b3Hhis Board of HeaJ19. Signed Date 3` -3® ° 99 Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued t No Fee � .., . THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTA.BLE. MASSACHUSETTS application for Digpool *pgtem CQngtruction:;-Vermit Application for a Permit to Construct( )Repair( ✓)Upgrade( )Abandon( ) O Complete System O Individual Components Location Address or Lot No. Q G I-A-MR-t ErS CA'N E Owner's Name,Address and Tel.No. M A-ftSToNS M t LLS N A L.b J_E�G-b t Assessor's Map/Parcel % LA-u 2.t S (..i-lJ 6- f O Z•7— 10 S (In 0"ToNS M I LLS I mfA OZ1.4$ Installer's Name,Address, d Tel.No. a•j,Ej. b Z.-Wb Designer's Name,Address and Tel.No. R0. Pox ?0Z MA' Ird S MILLS I M A o -707_ /KAAS7b► '5 /ulc.t-S W1A Type of Building: Dwelling No.of Bedrooms Lot"Size .�7��1 sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 33o gallons per day. Calculated daily flow 300' 3N 7 gallons. Plan Date 3 ` 30, 9 9 Number of sheets ( Revision Date PJA Title Size of Septic Tank (S'^bo g - Type of S.A.S. Zx Sov !�aA jL4.e-N C4Ami3erk4 -. Description of Soil y� 1 Nature of Repairs or Alterations(Answer when applicable) PVVLA Cc FA-t LE-D S�}S Date last inspected: �� • 1999 Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b this Board of He Date ' 30 • �/9 Signed Application Approved by ��. Date Application Disapproved for the following reasons Permit No. �"' Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( ) Abandoned( )by J;�sq'1�ff f410 4,4 -T- at € rr ha a constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. "''' d Installer Designer The issuan e of thts ermit shad , t be construed as a guarantee that the�� *11 function designed Date Anspector`` / No.--�� ------------------------Fee---1� 16�� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE,, MASSACHUSETTS lwigpogal *pgtem Congtructton Permit Permission is hereby grante to Construct( ) pail )U grade( Abando ) System located, a _ -�---r— D 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:Constructio must be Vom leted within three years of the date oft Date: kApproved by (/�1 � ` � . � r 10/9197 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT ENGINEERED PLANS) LILG9— , hereby certify that the application for disposal works construction permit signed by me dated Mh4zA 30 1219 concerning the property located at 94, LA-Q LIf' L�� Mh'STOass MIL-g meets all of the following criteria: There are no wetlands located within 100 feet of the proposed leaching facility • There are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed There are no variances requested or needed. If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will I>Q.t be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) B)Observed Groundwater Table Elevation(according to Health Division well map) SIGNED: DATE: 3 3 0, °( LICENSED SEPTIC_SYSTEM.INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder:cert �i C/�4LC uLF�T�0�5 13 is 25 'IMSOe A 3?t$'it BOTTbM ^tZ—=A swaga W'dw QZ 41 S i DE-L JA-LL O� X � 52 E-WD WAU- "'"� ` i .}6q, -GTpa, A CA O Bo 0 34 LZAC,4106 AaFA ►'"V?DEED � 3 oq� PST Avtmto ►m o� o� O G--- EXIss V46 p 1500 4 ft- e4IjC, 5�r►c T�Noc �XISTt BED(Lnor� �ZE�, 6 161 r 'CD Pfr i,,1G fSS� To �w .. FACtt,rf LA-AA 7g5 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WrMOUT DESIGNED PLANS) L J! M e5 ga-tZ— hereby certify that the application for disposal works construction permit signed by me dated J, 30 ,Iq concerning the property located at :56 LA-u et 4---:5 L4AJ meets all of the following criteria: • The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There are no wetlands within 100 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the ma dmum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W.Elevation 47 S,,*, +the MAX.High G.W. Adjustment.-L= Jr DIFFERENCE BETWEEN A and B 3 2- ! SIGNED : DATE: 3, 3 0` [Sketch proposed plan of system on back]. q:health folder:cent 4 1 8 9`9'9 Y s COMMONWEALTH OF MASSACHUS S E _ Y EXECUTIVE OFFICE OF ENVIRONMENT IDS` John Graci DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 86 LAURIES LANE MARSTONS MILLS MAP 027 P 103 L 60 Name of Owner TEED Address of Owner: SAME Date of Inspection: 3/13199 Name of Inspector:(Please Print)JOHN GRACI 1 am a DEP approved system inspector pursuant to Secdon 15.340 of Tide 5(310 CMR 15.000) Company Name: John Graci Title V Septic Inspection Mailing Address: P.O.Box 2119 TeaTicket,Ma.02636 Telephone Number: (508)664-6813 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: _ Passes The inpection is based on criteria defined in Title V Conditionally Pa es code 310 CMR 15.303.My findings are of how the system is _ Needs Further a 'on By the Local Approving Authority performing at the time of the Inspection.My Inspection does X Fails not Imply any warranty or guarantee of the longgevity of the septic system and any of Its components useful life. Inspector's Signature: ( Date:3/13199 The System Inspector sha I submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM FAILS TITLE V INSPECTION.THE LIQUID LEVEL IN THE PIT WAS OVER THE PIPE.THERE IS NO LEACHING LEFT IN THE PIT. revised 9/2198 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 86 LAURIES LANE MARSTONS MILLS MAP 027 P 103 L 60 Owner: TEED Date of Inspection:3113/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: _ I have not found any Information which Indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are Indicated below. COMMENTS: n/a 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.if"not determined",explain why not. NO The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)Indicating that the tank was installed within twenty(20)years prior to the date of the Inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is Imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. NO Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction Is removed _ distribution box is levelled or replaced NO The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): _ broken pipe(s)are replaced _ obstruction is removed revised 9/2198 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 86 LAURIES LANE MARSTONS MILLS MAP 027 P 103 L 60 Owner: TEED Date of Inspection:3/13/99 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, The system has:a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance !/,a-(approximation not valid). 3) OTHER nLa revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 86 LAURIES LANE MARSTONS MILLS MAP 027 P 103 L 60 Owner: TEED Date of Inspection:3/13/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: X I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is Identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times In the last year NOT due to clogged or obstructed pipe(s). Number of times pumped n/a. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy Is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is In Hydraulic Failure. E. LARGE SYSTEM FAILS: You must Indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 86 LAURIES LANE MARSTONS MILLS MAP 027 P 103 L 60 Owner: TEED Date of Inspection:3/13199 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal Flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [1 5.302(3)(b)] X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 86 LAURIES LANE MARSTONS MILLS MAP 027 P 103 L 60 Owner: TEED Date of Inspection:3/13/99 FLOW CONDITIONS RESIDFNTIAI Design flow:_2H g.p.d./bedroom Number of bedrooms(design): 2 Number of bedrooms(actual):2 Total DESIGN flow: = Number of current residents:Z Garbage grinder(yes or no):NQ Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no)M Seasonal use(yes or no):.NQ Water meter readings,If available(last two year's usage(gpd): n(a Sump Pump(yes or no): NQ Last date of occupancy: pia, COM M ERCIAL/INDUSTRIAL Type of establishment: nfa Design flow: nla gpd(Based on 15.203) Basis of design flow: n/a Grease trap present:(yes or no):..ALQ Industrial Waste Holding Tank present:(yes or no): NQ Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ Water meter readings.if available:nla Last date of occupancy: n!a OTHER: (Describe) n!A Last date of occupancy: n/a GENERAL INFORMATION PUMPING RECORDS and source of information: SYSTEM WAS LAST PUMPED 3 YEARS AGO System pumped as part of inspection:(yes or no):NO If yes,volume pumped Wit- gallons Reason for pumping: nla TYPE OF SYSTEM X 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: n/a APPROXIMATE AGE of all components,date Installed(if known)and source of Information: SYSTEM WAS INSTALLED IN 1996 PERMIT#98-376 Sewage odors detected when arriving at the site:(yes or no): NO revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 86 LAURIES LANE MARSTONS MILLS MAP 027 P 103 L 60 Owner: TEED Date of Inspection:3/13/99 BUILDING SEWER: (Locate on site plan) Depth below grade: ]'6" Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: n/a Comments: (condition of joints,venting,evidence of leakage,etc.) n/a SEPTIC TANK: X (locate on site plan) Depth below grade: i Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) Wa If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): MQ Wa Dimensions: L 8'6"H 5'7"W b'10" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: $1" Scum thickness: Distance from top of scum to top of outlet tee or baffle:I"_ Distance from bottom of scum to bottom of outlet tee or baffle: 1C How dimensions were determined: MEAUSRE13 Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND,RECOMMEND PUMPING SYSTEM NOW AND THEN MAINTAINED EVERY TWO YEARS. GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) Dimensions: Wit Scum thickness: n& Distance from top of scum to top of outlet tee or baffle:j Distance from bottom of scum to bottom of outlet tee or baffle n(A Date of last pumping: n/a Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) WA revised 9/2198 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 86 LAURIES LANE MARSTONS MILLS MAP 027 P 103 L 60 Owner: TEED Date of Inspection:3/13/99 TIGHT OR HOLDING TANK: NQ (Tank must be pumped prior to,or at time of,Inspection) (locate on site plan) Depth below grade: nla Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene._ other(explain) n(a Dimensions: n/a Capacity: n(a gallons Design flow: nla gallons/day Alarm present: NO Alarm level:illa- Alarm in working order:Yes_No_: NQ Date of previous pumping: nla Comments: (condition of inlet tee,condition of alarm and float switches,etc.) nla DISTRIBUTION BOX: _ (locate on site plan) Depth of liquid level above outlet Invert:nta Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) IILa PUMP CHAMBER: NQ (locate on site plan) Pumps in working order:(Yes or No): NQ Alarms in working order(Yes or No): MQ Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) n& revised 9/2198 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 86 LAURIES LANE MARSTONS MILLS MAP 027 P 103 L 60 Owner: TEED Date of Inspection:3/13199 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: nla Type: leaching pits,number. 1000 GALLON LEACH PIT leaching chambers,number: -n& leaching galleries,number: -n& leaching trenches,number,length: n& leaching fields,number,dimensions: n& overflow cesspool,number: n& Alternative system: n& Name of Technology: -n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS PAST THE EFFECTIVE DEPTH OF LEACHING,THE LIQUID LEVEL IS OVER THE PIPE-AND THERE WAS NO LEACHING LEFT IN THE CESSPOOLS: _ (locate on site plan) Number and configuration: n(a Depth-top of liquid to inlet Invert: nla Depth of solids layer: n& Depth of scum layer. n& Dimensions of cesspool: n& Materials of construction: n/a Indication of groundwater: n& inflow(cesspool must be pumped as part of inspection)n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nta PRIVY: _ (locate on site plan) Materials of construction:nla Dimensions:n& Depth of solids: n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) D& revised 9/2198 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 86 LAURIES LANE MARSTONS MILLS MAP 027 P 103 L 60 Owner: TEED Date of Inspection:3/13/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a 4� Qq 3'S Rc col eA l� 41 t7 revised 9/2198 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 86 LAURIES LANE MARSTONS MILLS MAP 027 P 103 L¢0 Owner: TEED Date of Inspection:3/13/99 NRCS Report name: n& Soil Type: n& Typical depth to groundwater: n& USGS Date website visited: r& Observation Wells checked: NO Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 12 Feet Please Indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record X Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions _ Checked with local Board of health _ Checked FEMA Maps _ Checked pumping records _ Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) GROUNDWATER DETERMINED FROM USGS MAPS AND CHARTS AT 12+FEET revised 9/2/98 Page 11 of 11 TOWN OF BARNSTABLE LOCATION. SEWAGE # t VILLAGE ASSESSOR'S,1MAP& LOT INSTAL ER'S-NAME.&PHONE NO. SEPTIC-TANK CAPACITY LEACHING ACHING FACILITY: (type) (size) !) NO.OF BEDROOMS BUILDER.OR OWNER PERMTTDATE: COMPLIANCE DATE: 4C .- f Separation Distance Between the: Maximum Adjusted Groundwater.Table and Bottom of Leaching Facility" Feet Private Water Supply Well and Leaching Facility (If any wells exist r on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 fee of leac ng cili t-. Furnished b Y` r "O Ail %)d c7O ;�. .- . DATE:_ �19/96 , PROPERTY ADDRESS: -86 Lzruries Lane log Mass . 0648 On the above date, 1 Inspected the septic system at the above address. This system consists of the following: 1 . 1-1000 gallon Tank. 2. • 1-Distribution box. 6-Hole 3 . 1-1000 gallon Leaching pit. Based on my Insv*ction, I certify the following conditions: 1 . This is a title five septic syst.e•m.;, ( - 78 Code )- 2. The septic system, is in proper working order. at", th-"present time . 3 - . No repairs are needed at the present time. ) .: , Y • SIGNATURE: ` Name: J_P_M_ac'omber Jr.. Company:_ •P_ -Macomber. & Son-_Inc — •------- Address:--. ,,—b6-------1------- j`' Cente_rvilhe LMass__0.2632 ` F�1,• [�k y, Phone:---548 7-5�3338------- 4 F,'r l -119 V ' rt: THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY CP. MACOMBER & SON, INCanks-Cesspools-Leszhfleld: Pump*d & InsUlled Town Sewer Connections 66' Centerville, MA 02632-0066 72.5.3338 17`i-6412 Commonweafth of Massachusetts V Nam )L Executive Office of Environmental Affairs Department of Environmental Protection VAIII&M F.Weld Oovwncw Trudy Coxe u��r Paul Celluccl 8`r"7 David S.Struhs e ComrNubrwr e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address; 86 Lauries Lane Marstons Mills MA Address of owner. Date of Inspection:2/19/9 6 (If different) Name of Inspector. Joseph P. Macomber Jr. Company Name,Address and Telephone Number. J.P.Macomber & Son Inc. Box 66 Centerville ,Mass . 02632 508-175-3338 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: „t/Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature- Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A,B, C,or D: A] SY9 PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CUR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: 1/0 One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) AD The septic tank is metal,cracked,structurally unsound, shows substantial infiltration or exfiltration,.or tank failure is imminaat. The system will pass inspection if the existing septic tank is replaced with a yonforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 One Winter Street 0 Boston,Massachusetts 02108 9 FAX(617)556-1049 0 Telephone(617)M-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 86 Lauries Lane Marstons Mills ,Mass . Owner. Robert A. Finnigan Date of Inspection: 2/1 9/9 6 Bl SYSTEM CONDITIONALLY PASSES(continued) Sewage backup or breakout or 0 static water level observed in the distribution boa is due to broken or obstructed pips(s) or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health):. broken pipe(.)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: _41b Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH'WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water AV Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. Q� The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. d& The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. Alb The system has a septic tank and soil absorption system and In less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 3) OTHER (revised 11103/95) 2 c SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property address: 86 Laur i e s Lane Owner. Robert A. Finnigan Date of Inspection: 2/1 9/9 6 DI SYSTEM FAILS: • A) I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. j2&� Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. �Q Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. j.&" Per Liquid depth in cesspeol`is less than 6"below invert or available volume is less than la day flow. Requite pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped da Any portion of the Soil Abs(/;tion System,cesspool or privy is below the high groundwater elevation. AlAny portion of a cesspool 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 I 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 60 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety.and the environment because one or more of the following conditions exist: I�A 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 11 of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.. (revised 11/03/95) 3 ' L SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 86 Lauries Lane Marstons Mills ,Mass . Owner. Robert A. FinNan Date of Inspection: 2/1 9/9 6 Check if the following have been done: Pumping information was requested of the owner,occupant,and Board of Health. ,None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection, ,L//As built plans have been obtained and examined. Note if they are not available with N/A ZThe facility or dwelling was inspected for signs of sewage back-up. - The system does not receive non-sanitary or industrial waste flow ZThe site was inspected for signs of breakout. 2AU system components,i cluding the Soil Absorption System,have been located on the site. - The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baIDes or teas,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. - The sin and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. , The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub. Surface Disposal System. 1, (revised 11/03/95) 4 ti SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 86 Lauries Lane Marstons Mills ,Mass . Owner. Robert A. Finnigan Date of Inspection: 2/1 9/9 6 FLOW CONDITIONS RESIDENTIAL: • Design flow: • Number of bedrooms: Number of=rent residents: Garbage grinder(yes or no): Laundry connected to system(yes or no): °7 Seasonal use(yes or no):.d& n W ter meter if available: It a to o' t f' .4to)4 1�✓l71N Last date of occupmq: —1746 COMMERCLAL/INDUSTRIAL: Type of establishment: iU�4 Design flow: 11 A gallons/day' Grease trap present:(yes or no)� Industrial Waste Holding Tank present: (yes or no)_&l Non-sanitary waste discharged to the Title 5 system: (yea or no)•A Water meter readings,if available: 69 Last date of occupancy A) OTHER:(Describe) Last date of occupancy:_ GENERAL.INFORMATION PUMPINGAMORDS and source of information: ewevV o2 c°..W er System pumped as part of inspection: (yes or no) If yes,volume pumped: d0ab gallons Reason for pumping: yl?/Q/ 7"/'- e TYPE 9"YSTEM V Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Alb Shared system(yes or no) (if yes,attach previous inspection records, if any) , AIR Other(explain) APEROXIMATE AGE of all components,date installed(if)mown)and source of information: Sewage odors detected when arriving at the site: (yes or no) (revised 11/03/95) 6 O - Q -F I I r a c" C O7 C a0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART SYSTEM INFORMATION(oontinued) Property Address: 86 Lauries Ave Marstons Mills ,Mass . Owner. Robert A.. Finnigan Date of Inspection: 2/19/9 6 SEMQ TAN&1—/"VAUW '• e . e(locate on site plan) Depth below grade: Material of construction:Zncrete_metal_FRP_other(e:plain) Dimensions: / Sludge depth: " Distance from top of to bottom of outlet tee or baille:_� Scum thiclauess: Distance from top of scum to top of outlet tee or bafae:_� Distance from bottom of scum to bottom of outlet tee or baffle:__ Comments: (recommendation for pumping,condition of inlet and outlet tees or bafRea,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) — 3 Years , Inlet & outlet tees are t ucturall sound: e tic tank is struQtjga�ly §ouj�a; Tank shows no evi ence or leakage. o repairs are needed at this time. GREASE TRAP:Af011t^° (locate on site plan) Depth below grade: Material of construction:e ooncrete_metal_FRP_other(e:plain) Dimensions: AJA scum thicime". Distance from top of scum to top of outlet tee or baffle: d7,4 Distance from bottom of scum to bottom of outlet tee or baffle:_A1 R Comments: (recommendation for pumping,condi ion of inlet and tlet tees or baMas, depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) /1�D C_gwl�l'lE�► (revised 11/03/95) 6 i J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Address: 86 Lauries Lane Marstons Mills ,Mass . Owner. Robert A. Finnigan Date of Inspection: 2/19/9 6 TIGHT OR HOLDING TANK;, e (locate on site plan) e Depth below grads:,A Material of construction concrete_metal_FRP_other(ezplam) A.� Dimensions: AM Capacity: canons Design flow: ons/day Alarm level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) 0 DISTRIBUTION BOX: v (locate on site plan) Depth of liquid level above outlet invert: . Alt Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) Distribution box. has equal flow;no evidence of solids carry over,no evidence of leakage into or out of the distribution r - neededat this ime. PUMP CHAMBER: (locate on site plan) Pumps in working order.(yes or no)If/X Comments: (note condi' n of pump chamber,condition of pumps and appurtenances,etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) ProperVAddresa: 86 Lauries Lane Marstons Mills ,Mass . Owner. Robert A. Finnigan Date of Inspection:2/19/9 6 SOIL ABSORPTION SYSTEM(SAS>:,-•1,14394 A)A'W'� r` (locate on site per.it possible;ezcavatioa not requir4 but may be approximated by non-intrusive methods) If not determined to be present,explain: e Type: leaching pits,number leaching chambers,number._D leaching galleries,number._0 leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Comments:(note condition of soil,signs of hydraulic failure,level of ponding oondon of yegetation,efc.) 0-3 ' top loam subsoil, 31-13 ' medium sand. No signs oI or nond7g. All vegetation green & normal o repairs needed at this ti me i me CESSPOOLS:fe, (locate on site plan) Number and configuration: 47 A Depth-top of liquid to inlet invert:- AA _ Depth of solids layer:_ V Depth of scum layer— Dimensions Dimensions of cesspool: J Materials of construction: Indication of groundwater:__ N inflow(cesspool must be pumped as part of inspection) A/19 Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) PRIVY: *,04"C-- (locate on site plan) . Materials of construction: /Ifni Dimensions_ Depth of solids: &11� om (note condition of il,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) (revised 11/03/95)• g SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Address: Owner. Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: • include ties to at least two permanent references landmarks or benchmarks locate all wsM within 100' NfGl.� A�il1 �e�J4 1 Q G)l- 014 • DEPTH TO GROUNDWATER eM th to groundwatsrl�=4• feet _ method of determination or approximation: (revised 11/03/95) 9 - L y�Xs TOP OF FOUNDATION CONCRETE COVER CONCRETE COVERS 'ex lel7xo •'; 4"CAST IRON 2"MAX. 12"MAX. ' OR SCHEDULE 48 4' SCHEDULE 40 P.V.C.(ONLY) P.V.C. PIPE PIPE- MIN. LEACH ' PITCH I/4"PER.FT PITCH I/4'PER.FT. PIT PRECAST LEACHING • �INV RT ��" iy % PIT OR `•• ELS! X�... INVERT INVERT �'� SEPTIC TANK DIST. W ';'• EOUIV. . . EL..Y.J! . BOX ELY.rl ... >x ��• • INVERT F- '�; EL. ... /�•�'••• GAIT. INVERT INVERT a W w �: ::�� 3/4"TO I1/ EL'r .!'�. EL..y. i`'o WASHED y ' W �; ,r: �OSo /0 So y� --►�-�--WDIA. —+-� � PROR LE OF NQ GROUND WATER TABLE SEWAGE. DISPOSAL SYSTEM NO SCALE p- sg° S 1 L LOG WITNESSED BY DATE .11ff 0 Y..... TIME.. ... . .r1.(�E,E?✓, , . . . . . . . BOARD OF HEALTH j TEST HOLE I TEST HOLE 2 , , , , ENGINEER EL•EV..y7.XQ. . . . ELEV. o� DESIGN DATA : 0 -3 0/ <o NUMBER OF BEDROOMS . . . .3. . . . . . . : . . , TOTAL ESTIMATED FLOW . 3.3.0. . . GALLONS/DAY BOTTOM LEACHING AREA . ��3. . . . S0.FT. /PIT SIDE LEACHING AREA . . . � . . . . SO.FT./ PIT GARBAGE DISPOSAL . .eP. ..(50% AREA INCREASE) TOTAL LEACHING AREA . . . . SQ.FT 1 3-/3 /71fJ)A1,a PERCOLATION RATE . A . . . . . MIN/INCH LEACHING AREA PER PERCOLATION RATE .. SQ.FT. ./.4/0. .WATER ENCOUNTERED NUMBER OF LEA HI G PITS. . .Q G . . . gzg Z jAPPROVED . .. . . . . . . . . . . BOARD OF HEALTH / DATE. . . . . . . . . . Tom = yrf601 AGENT OR INSPECTOR kf i✓DJF t.( .j7 R.pkOcR/a ° �p`1µ OF M4.p ro To P(ac��✓6 iir ✓Nk�fY �Jo�� y , OB �1 �dT, ,010. . . . . . . . . . . . . . 14 H. '8 t 4 \A� '' PETITIONER : ,/� , H/_,� �,�/ ST . . , , . ?���rnT++`+ n V I THE COMMONWEALTH OF MASSA.CHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the_.Department's qualifications'. as required and-is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection. • June 8. 1995 r Acting Director.of the • ion of Water Pollution Control r..:ntl -rt...—�':-r.-•.�s�r-rr..r...-.r.::—rrc:>rr..•�.-rrr--�*—rr.-r.__ ._. ..._ .__.. _ ._.. .__...._. __. ...._._.. .-_.-�-r.rr --r. '..- ..- k". TOWN OF Barnstable BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION �� .-• .... r••.-•.••--.:vr•'.--�.rn>:•r.:-r:-rr..m-.--.-• r--•e--s:.---r-r..-rnrc-rr rs�rsrer..rx ssrrsrr ._. rnr.•mri-nrcrsrr.rr-n•.-rrr•r.•-:r -TYPE OR PRINT C1.EARLY- PROPERTY INSPECTED STREET ADDRESS 86 T,anri Pc T.anP Marst.anc Mi1`1 c Ma2,c ASSESSORS MAP, BLOCK AND PARCEL # a, 1D d �e • OWNER' S NAME Rnhert, A - Finnigan _r_ PA117' D - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber Jr, COMPANY NAME J.P.Macomber & Son Inc. COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 Street Town or City State LIP COMPANY TELEPHONE ( 508 ) 775 3338 FAX (790 508 1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate, and complete as of the time of �inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one: Y,XXX Syste6 PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15. 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have conducted has found that .the system fails to Protect the public health and the environment in accordance with Title 5 , 3.10 CMR 15 . 30.3 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signatur Date 2/19/96 �. One copy of this Urtification must be provided to the OWNER, the BUYER (.where applicable-) and the BOARD OF HEALTH. * If the inspection FAILED, th-e owner ors ` erator shall up grade pgrade ' the system within one year of the date of the inspection, unless allowed or requi,,red otherwise as provided in 310 CMR 15 . 305 . ASSESSOR'S MAP NO. a� PARCEL LO-C,AT -ION SEWAGE PERMIT NO. V I L L A G E """" Imo` �3L INSTALLER'S, _ NAME & ADDRESS B U I L D E R OR OWNER DATE PERMIT ISSUED �J ,z �gu DATE COMPLIANCE ISSUED_ a ' , / V e No..... G.���..�b FFs.................................. THE COMMONWEALTH OF MASSACHUSETTT BOARD F HEAL71 H ('f.i.'V..............OF.... .0. 3/ may. -... ,� lirtt#ion for 'Uhipwial ork Tomitrnrtion Frrutit Application is hereby made for a Permit to Construct (�or Repair ( ) an Individual Sewage Disposal System at: --- -------------------• --•.... y Add, dd ress Loca on �' •— ���' ' f or Lo J Oj nerj �I�' �dG'�• � ! .. Ad 1 r t Installer Add ess d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms..._..__....._ .............Expansion Attic Garbage Grinder 4m6&�,, '4 Other—Type of Building No. of persons............................ Showers i a YP g --------------=-----------• _.._...P ( ) — Cafeteria dOther fixtures ------•---------------------------------- ••.............------.........-•-•--• ............................................................. w Design Flow........r-).... .......................gallons per person per day. Total daily flow........3 j_--Lt.-..................._gallons. WSeptic Tank—Liquid capacity/���gallons Length. _.�.... Width.-e1-:..0.--.. Diameter..._.'61..... Depth.. ........ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area.... ___....sq. ft. Seepage Pit No....elf..... Diameter..... 2......... Depth below inlet.._l?............. Total leaching area.. ____sq. ft. Z Other Distribution box Dosi � t ) Percolation Test Results Performed by............. .c .Ct: __._.__....__......._.___......... Date.... _. Test Pit No. I................minutes per me D th 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..-•----•---•-•..............•..-----••--•-----•----.....--•-•-•--•--........--••-•-•-------------------------...-•---------..........-•-••-•-------....--------------•- x U ....--••-•..................... w U Nature of Repairs or Alterations—Answer when applicable............................................................................................... • -•----•-----•-----•-••••--•••-•---•................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions/artificate fTI'''LL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in op at o til of Compliance has bee d the board of h lth. Signed---- • ...... ........ s>iur.• . '�e.---- --------------! late cation Approved BY .._.. I Application Disapproved for the following real n :-------•-••----•........................••--•---••••-----•---•--•-••--••-•------••--......--••••-----••......-- .........-•---------------••-----•-----•-•--•---........-•---------......-•----................••-•...................---------•------•----•-----...-•--•-•-------------•--••-••--••-----•---•----------- Date PermitNo....................................................... Issued....................................................... Date — --------------------- ----- r No......................... FEa............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....................OF............................................ Appliration for Uiipuuttl Workii Tomitrnrtiun ami# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Systemm at: ...-� 7 .... ...... ............... ........ CocynAddress or L No.oy')"e­ _........�y6ne 3-A......;;, -C............ ................. Installer Add ess UType of Building ? Size Lot............................Sq. feet Dwelling—No. of Bedrooms........s.7................................Expansion Attic (�� Garbage Grinder k(/ Other—Type T e of Building r J ....._..... No. of persons............................ Showers C4 YP g ------•-•---•-= P ( ) — Cafeteria ( ) a, Other fixtures .........--•---•---------------------------•-. W Design Flow........ .��..........................gallons per person er day. Total daily flow_.......3-3-..0......................gallons. WSeptic Tank—Liquid capacity/��gallons Length._..y.... Width..t... Diameter-_._'�..... Depth... Ix Disposal Trench—No. _•.................. Width.................... Total Length.................... Total leaching area............__ sq. ft. Seepage Pit No.___�% =r_-_-- Diameter.....-.._..... Depth below inlet.... Total leaching area__ ...sq. ft. Z Other Distribution box Dosi t k ) ~' Percolation Test Results Performed by..... ........ ................................... Date....1/._.' t a Test Pit No. I................minutes per inc D th of Test Pit..................._ Depth to ground water......................... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ---------------------------------------------------•-----------•---------•--.-_-•----------------•-------- ••------------------------ -..... •-------------- _._. 0 Description of Soil................................................................................-•-•----•----------•-•--------------•---•------------ V ..•----••••-•••---•----...--•---•-----....•-•--•-•-•••-------•--------------------------•-••••------•---•••---•-••---------------------••-•-----------•..................__•-------••.....-•------------ W ------------------•----•••••••----•-••---••---••-•--------•-----------------•-•----•------------•-----•------------•-•----------•----•---•------------•-----------••-••-••-------••••-••_----- V Nature of Repairs or Alterations—Answer when applicable...._........................................................................................... Agreement: The undersigne agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the o i`oi s of 5 of the State Sanitary Code— The undersigned further agrees not to place the system in opera ertificate of Compliance has bF' dthe board of h lth. Signed..._ ''`. •------------------.. Z '( �U_. DeApplication Approved BY--•-----------•------------•--------- ••-•---•---........--••----••--_.. _.._._........----- . --•........_.... Date Application Disapproved for the following reaso .........._.__....__......__......._..___._.._........_.........._-- .....................•-------•-•------•-----•-•----•------------------------•---•-•-----•------.............---•--.......•---•-••----•...•---------•-----------------••--------------•••---••------•-•--- Date PermitNo......................................................... Issued.--------...--•----•----...----•••--•--••-••-••---•••-- Date• THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH ....OF .ni .v//?. .......................... (Irrtif irate of Toutplittnrr T IS IS T E TIF T a the Indi, idual S zge Disposal System constructed ( ) or Repaired _( ) g-� I� /1 ..UGC //G �•`/J `.-� ------------•--•---•--....---- ._ .... t._..._ Installer has been installed in accordance with the provisions of TITLE r of The State Sanitary Co desc 'bed in the application for Disposal Works Construction Permit No-------- .-. dated............ . . . ........... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM �WILL FUNCTION TISFACTORY. �►-� DATE...l...' ....�....... JII'.- Inspector 1.__ . ...........................•--••--••----•--•--•...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �6- 3 76 ..... OF................. ./N,47el G- ..................................... No......... _............... F .92•......... �iu�ruu�tl orku �onu�rttt#ion rrbti� Permission is herebyranted...�.v&.,.................. .........._.... to Constru9t ( ) or Repair ( ) an Individual Sewage Disposal System 96-*3 T l 4, -k o � �, `........ treet as shown on the appl'catio, =for`Disposal `'Forks Construction Permit No.........:.... ..... Dated.......................................... rd of ea k� "�/"•` DATE................................................................................ FORM 1255 A. M. SULKIN, INC., BOSTON d ' J TOP OF FOUNDATION CONCRETE COVER •,` CONCRETE COVERS 4" Xn• ON �mn'r�r `/7XO OR SCHEDULE 40 12"MAX. • • P.V.C. PIPE 4 SCHEDULE 40 P.V.C.(ONLY) 'T � PITCH 1/4"PER.FT PIPE- MIN. LEACH e,e PITCH 1/4"PER.FT. PIT PRECAST o' INVERT io" �y ' a LEACHING e�a ELY.7.X ... SEPTIC TANK. INVERT DIST. INVERT p w e�;. PIT OR •e INVERT EL:Y7X�. . .. BOX ELyfi'`1... >_ EQUIV. / am.... GAL. EL.y? ' INVERT EL,'�'�Xl.. INVERT a w w �: ::�; 3/4"TO 11/; ,' • EL'/Y.:�.. �: WASHED W STONE ' yp '-- --W DIA. } DIA. v PROFILE OF — - } AfO GROUND WATER TABLE SEWAGE. . DISPOSAL SYSTEM NO SCALE p- sga� L/ S IL LOG WITNESSED BY DATE .7 �¢ `. .... TIME.. . .r7.(/�F�°✓ • . . . . ..BOARD OF HEALTH TEST HOLE I TEST HOLE 2 :7. TAc /3 ELEV..y.�.XO.. . . . ELEV. .`��XQ. .. . . . . . . . . . . . . ENGINEER 0 -3 oP �o ,, /s DESIGN DATA : NUMBER OF BEDROOMS TOTAL ESTIMATED FLOW , GALLONS/DAY BOTTOM LEACHING AREA �� . . . . SO.FT. /PIT SIDE LEACHING AREA . . �'� SQ.FT./ PIT GARBAGE .DISPOSAL . .��. ..(50% AREA INCREASE) TOTAL LEACHING AREA . .a6 3 . . . . SQ.FT IMAla 4 y) PERCOLATION RATE „C, s 5 2 . . . . . . MIN/INCH LEACHING AREA PER PERCOLATION RATE .. ... 'SQ,FT. AO—WATER ENCOUNTERED NUMBER OF LEACHI G PITS Q �l� 2 APPROVED . .. . . . . . . . . . BOARD OF HEALTH ? R • '• 3.iy �" = /a w. DATE. . . 6!6/ �.��� j0 6A9 ` AGENT OR INSPECTOR �. z R i o T o 1H 0 f 44sue P, ACiA/G R/r To ✓nR,fr Joy ,A7 60 1814 . �lSiE' �•, 0 PETITIONER gNATA?�\ /� M� /l/�/A/ 4e, i 73 SFPric I ' l 52 ' J-6/ ,3� w , 20• ` 20 zo b ( 1 1 00 000 � � �o ILI / Jp Oo ti c i 20, 003 °� w N i o n, n o �0 . \ ---�--� 3 s, 1 �� .FX T/n/4 If _ S270S8',39.. ZA vRIEJ ZAAIZ- 1 � 1 1 I I g3- 'S ' LP � C(P\_ 48 , oc) i 33- '139 ► 50 � � l o0 \ 20 2� PLAN OF �TJ GO, �,6, G8 — — — -� 80 . .0 o A UR I E.5 4A AI F A5AI�IUJ`7-4 BI- Z- PR EPA RED 6 y 1J�9/Pi,fAveE �r-q Fo,QSAA/lJt�/IC y FOR D�4 C, SCAG E ,DATF 7_L3O. vRAw� 8 y /4 Pb y sE� `.