HomeMy WebLinkAbout0254 RACE LANE - Health 254 Race Lane
Marstons Mills P
A = 126 0.19
TOWN /OF BARNSTABLE
tOCATION 045Y r (,9- t SEWAGE #
VILLAGE ` S ASSESSOR'S MAP & LOT-lotto
INSTALLER'S NAME&PHONE NO. /I
SEPTIC TANK CAPACITY l M Gi41.
LEACHING FACILITY: (type) C2S5,060) "'1' Pi (size) CPX(,` MM 641
NO. OF BEDROOMS 3
BUILDER OR OWNER 01f t A TOSS
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leachyng facility) Feet
Furnished b � o
Y
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COMMONWEALTH OF MASSACHUSETTS
_ EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: S y Rd-Et
s FV
Owner's Name: � � � - r
Owner's Address:
Ir
Date of Inspection: (� t
Name of Inspector:jpleaje print)
Company Name: rl Ir tYIY�,�L (vtSPer-ito NS
Mailing Address: O X
ougl
Telephone Number:_ SUS-jgs 7t;US
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:,
rX Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority,
Fails10
y
Inspector's Signature: Date: O6 r-
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or:
DEP)within 30 g days of completing this inspection.
Y P b p ion. If the system is a shared system or has Y y s a design flow of 10,00 0
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of l l
OFFICIAL INSPECTION FORM'—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSALSYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 07 Sy QGL
Owner•_Carr"/'
Date of Inspection: p
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
QL I have-not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditi al Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or rep ' ;as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the or the following statements.If"not determined"please
explain.
The septic tank is metal and over 20 ye old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or ltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complyin septic tank as approved by the Board of Health.
*A metal septic tank will pass inspecti if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 2 years old is available.
ND explain:
Observation of sew e backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due a broken,settled or uneven distribution box. System will pass inspection if(with.
approval of Board of H th):
broken pipe(s)az,e.zeplaced
obstruction is.zemoved
distribution box is leveled or replaced
ND explain:
The stem required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspe ion if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 1 1
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: J5,z(
Owner: ih
Date of Inspection: �06
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in er to determine if the system
is failing to protect public health,safety or the environment.
I. System will pass unless Board of Health determines in accords a with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect pub c 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 v etated wetland or a salt marsh
2. System will m
y fail unless the Board of Heal (and Public Water Supplier,if any)determines that the
system is functioning in a manner that pro cts the public health,safety and environment:
_ The system has a septic tank an oil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to surface water supply.
— The system has aseptic and SAS and the SAS is within a Zone I of a public water supply.
The system has a septi and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a se tic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply w 1**. Method used to determine distance
**This system pass if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volat' a organic compounds indicates that the well is free from pollution from that facility and
the presence of monia nitrogen and nitrate nitrogen is equal to or less than 5 ppm;provided that no other
failure criteria e triggered. A copy of the analysis must be attached to this form.
3. Ot r:
3
r
Page 4 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DIkSPOSAL'SYSTEM INSPECTION FORM
PART:A-
CERTIFICATION(continued)
Property Address: 0311 �AGc' GA�f
r yt
Owner.=
Date of Inspection: _
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
` cesspool
1 Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis.-[This system passes if the well water..-analysis,
performed at a DEP certified laboratory;for coftrm bacteria and volatile organic.compmmds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is.equal to-or less than 5.ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 6a 15.303,therefore the system fails.The system owner should contact the Board of
Heal
th to determine what will be necessary to correct the failure:
E. Large Systems:
To be considered a large system the system must serve-a fa ' with a design flow of 10,000 gpd to 15,000
gpd• t
You must indicate either"yes"or"no"to each'of the owing:
(The following criteria apply to large systems in. ition to the criteria above)
yes no
the system is within 400 feet a surface drinking water supply
— — the system is within 200 eet of a tributary to a surface drinking water supply
— _ the system is locate in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a pub ' water supply well
If you have answered" s"to any question in Section E the system is considered a significant threat,or answered
"Yes"in Section D ab ve the large system has failed.The owner or operator of any large system considered a,
significant threat er Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The syste owner should contact the appropriate regional office of the Department.
n
f
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: a S-cr Rtce -av- c-c
a 4ks o
Owner:
Date of Inspection: _P(,Z6t0o
Check if the following have been done.You must indicate`yes"or"no"as to each of the following:
Yes No
oC _ Pumping information was provided by the owner,occupant,or Board of Health
Were any of the system components pumped out in the previous two weeks? .
Has the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of this inspection?
G1' _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
Were all system components,excluding the SAS,located on site?
Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
A _ Was the facility owner(and occupants if different from owner)provided with information on the proper
e of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
Existing information.For example,a plan at the Board of Health.
4 _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)]
5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: C f 1,4,-A.
Owner: �i rri
Date of Inspection: yb
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x# of bedrooms): i;,3C7
Number of current residents:
Does residence have a garbage grinder(yes or no): A#
Is laundry on a separate sewage system(yes or no): NJ [if yes separate inspection required]
Laundry system inspected(yes or no):AV
Seasonal use: (yes or no):
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no):
Last date of occupancy:f�_04
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.
Grease trap present(yes or no):—
Industrial waste holding tank se yes or no):—
Non-sanitary waste discharge the Title 5 system(yes or no):
Water meter readings,if a able:
Last date of occupanc se:
OTHER(des e):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no):_JU
If yes;volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank,distribution box,soil absorption system
_Single cesspool
Overflow cesspool
Privy
_Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no): wv
6
Page 7ofII
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: S7 Ct Lev..q
«s
Owner: '
Date of Inspection:
BUILDING SEWER(locate on site plan) ,
i
Depth below grade: (� a
Materials of construction: cast iron _40 PVC PCother(explain): CoH ye A5 ` U
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK(locate on site plan)
Depth below grade:
Material of construction: .or concrete metal fiberglass_polyethylene
—other(explain) —
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: testy
Sludge depth: y
Distance from top of sludge to bottom of outlet tee or baffle: _.
Scum thickness: 'D%
Distance from top of scum to top of outlet tee or baffle:.2
Distance from bottom of scum to bottom of outlet tee offl ae: ��
How were dimensions determined: Mfe46urea
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):wle-
4p
GREASE TRAP:_(locate on site plan)
Depth below grade:—
Material of construction:_concrete_meta fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top o outlet tee or baffle:
Distance from bottom of scum t ottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping re mmendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: a$ C C t4'a
A 4s ' t
Owner: r _
Date of Inspection:
TIGHT or HOLDING TANK: (tank must be pumped at ' e of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete I fiberglass_polyethylene other(explain):
Dimensions:
Capacity: ons
Design Flow: allons/day
Alarm present(yes or no):
Alarm level: Al in working order(yes or no):
Date of last pumping:
Comments(condition alarm and float switches,etc.):
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 )
Pumps in working order(yes or no :.
Alarms in working order(yes.o o):
Comments(note condition o ump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: 01
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): /f (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,
etc.).
S'as'` we �f wAiC-� w4�
a VC- w ec co led",a► •Pz WIti�E� wc.5 c INc� lic�k,t s4,errgti�,j
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 constructio .
Indication of groundw er inflow(yes or no):
Comments(note co ition 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 co ition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
9
Page 10 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SE
WAGE DIS
POSAL
O SAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: C e
Owner:
Date of Inspection:
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.
ww �V�49 tP ZA-P
6792
Page I I of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner
Date of Inspection: )6
SITE EXAM
Slope VV
Surface watevo
Check cellar q46
Shallow wells IHO
Estimated depth to ground water 00 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators, installers-(attach documentation)
OC Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
C&{ k,e oa-+� .10 P-2k
11
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL S
PART A RE = D
CERTIFICATION
JUL 2 5 2002
Property Address: 254 Race Lane
Marstons Mills, MA 02648 TOWN OF BARNSTABLE
Owner's Name: Anita Foss HEALTH DEPT.
Owner's Address: 1
Date of Inspection: July 11, 2002 J
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P.O. Box 49 Map: 126
Osterville,MA 02655-0049 Parcel. 019
Telephone Number: (508) 862-9400 Lot: 5
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
✓ Passes
Conditionally Passes
Need Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: July 14, 2002
The system inspector shall subm a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS "
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 254 Race Lane
Marston Mills, MA
Owner: Anita Foss
Date of Inspection: July 11, 2002
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes, no or not determined(Y,N,ND) in the for the following statements. If"not determined",please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 254 Race Lane
Marstons Mills, MA
Owner: Anita Foss
Date of Inspection: July 11, 2002
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 254 Race Lane
Marstons Mills, MA
Owner: Anita Foss
Date of Inspection: July 11, 2002
D. System Failure Criteria applicable to all systems:
You must indicate either`yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than % day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped_.
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ Any portion of a cesspool or privy is within a Zone 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 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either`yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA)or a mapped
Zone II of a public water supply well
If you have answered`yes"to any question in Section E the system is considered a significant threat, or answered
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.3-04. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 254 Race Lane
Marston Mills, MA
Owner: Anita Foss
Date of Inspection: July 11, 2002
Check if the following have been done: You must indicate`yes"or"no"as to each of the following:
Yes No
✓ Pumping information was provided by the owner,occupant, or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection ?
✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ Was the site inspected for signs of break out?
✓ Were all system components,excluding the SAS, located on site?
✓ Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ?
✓ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
✓ Existing information. For example,a plan at the Board of Health.
✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)].
5
Page 6 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 254 Race Lane
Marstons Mills, MA
Owner: Anita Foss
Date of Inspection: July 11, 2002
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: 0
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): Yes
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Unknown
COM MERC IAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Pumped approximately 2 years ago-per owner
Was system pumped as part of the inspection (yes or no): No
If yes,volume pumped: _gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank, distribution box, soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components, date installed(if known)and source of information:
The original system in the 1970s and a newer pit added in 1985
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 254 Race Lane
Marstons Mills, MA
Owner: Anita Foss
Date of Inspection: July 11, 2002
BU1 LDING SEWER(locate on site plan)
Depth below grade: Approx. 20"
Materials of construction: _cast iron 40 PVC ✓ other(explain): Orangeburg
Distance from private water supply well or suction line:
Comments(on condition of joints, venting,evidence of leakage, etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: Approx. 8"
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 gal.
Sludge depth: I"
Distance from top of sludge to bottom of outlet tee or baffle: 31"
Scum thickness: 0"
Distance from top of scum to top of outlet tee or baffle: 10'r
Distance from bottom of scum to bottom of outlet tee or baffle: 14"
Hoag were dimensions determined: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert, evidence of leakage,etc.):
Tees were present. The liquid level was even with the outlet invert. There were no signs of leakage. Scum/sludge were
minimal.
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 254 Race Lane
Marston Mills, MA
Owner: Anita Foss
Date of Inspection: July 11, 2002
TIGHT or HOLDING TANK: None. (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches, etc.):
DISTRIBUTION BOX: None (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: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 254 Race Lane
Marston Mills, MA
Owner: Anita Foss
Date of Inspection: July 11, 2002
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits, number: 6'x 6'(1000 gal.)
leaching chambers,number:
leaching galleries,number:
leaching trenches, number, length:
leaching fields, number,dimensions:
✓ overflow cesspool,number: I
Innovative/alternative system Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.):
The overflow cesspool was 5'W x 5'T x 9'bottom to grade and had Y of water on the bottom The cover was to grade The
leaching pit was dry. The scum line was approximately ]'up from the bottom. There were no signs of failure The bottom to
grade was approximately 10'. The cover was approximately 15"below grade
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth -top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
indication of groundwater inflow(yes or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
PRIVY: None (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
9
Page 10 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 254 Race Lane
Marstons Mills, MA
Owner: Anita Foss
Date of Inspection: July 11, 2002
Map: 126
Parcel. 019
SKETCH OF SEWAGE DISPOSAL SYSTEM Lot: 5
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.
i
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10
Page 1 1 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 254 Race Lane
Marston Mills, AM
Owner: Anita Foss
Date of Inspection: July 11, 2002
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 40' +/- feet
Please indicate (check) all methods used to determine the high ground water elevation:
Obtained from system design plans on record- If checked, date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours maps
Checked with 'local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
The bottom of the leach pit to grade was approximately 10'. Using the Barnstable topographic map and the Cape Cod
Commission water contours maps the maps were showing approximately 40'+/-to ground water at this site
This report has keen prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
11
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1 h S T A L L E R'S N A M E A EP k- MEDE-IROS
142 Corporation Street
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OWNER —s7-�y -7
DATE PERAlIT ISSUED__
RAT E GDMPLiAt1I� E IS5ULD
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
- .^.............OF....
A1111 tratiou for Eliipnaal Works Towit:7an
' n rrnttt
Application is hereby made for a Permit to Construct ( ) or Repairndividual Sewage Disposal
System at:
................__ ��_"� . �: �`.. -----------------........... ----•..._...._.------.
o .r� �?.. �or
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..... ............................................................ L
............----------------------------------- .--. 5. .. ................._.....
Owne � s
�... .----..... l- ••_... -- _....
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( _ ) — Cafeteria ( )
Q' Other fixtures .....................
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Tottal leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.....................Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water-___-.---_-..._________-
f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water____----------•_---_-._.
a - ... ---•----------------•--------.-.--------•-----------------•----•-------------
O Description of Soil................ ............
V = _. .._.. ----------------------------------------------------------
--------------- - ---- - -
VNature of Repairs or . _rations—Answer when applicable.. _.................................
�?___..
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
.I
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b
een issued the board of health.
Signed `.. v ----•-•••• ----
ate
Application Approved B rZ _-
' late
Application Disapproved for the f oll ing reasons:.----••-------••-------•-----•------ .............................
-
..................................................................•--•----•-••--•-----....•••..........._....•---••-•••-•••-••-•-•••••••---•--_..••-•-••••••----••-------••-------- ...............Date
PermitNo......................................................... Issued........................................................
Date
No................_....... Fps............. ............._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..................0 F.....
ApplirFation for Disposal Works Tonstru ton rrntit
Application is hereby made for a Permit to Construct ( ) or Repair r an Individual Sewage Disposal
System at
................-•- � . .... _:''__�_........-----............... --------•------------
Loo tion Address
a • 1....{ / ,'.. 1 i / 4i ....• ...... ..........................
Ad8 e s
Installer Address
d Type of Building Size Lot............................Sq. feet
aU DwellingNo. of Bedrooms______________________________ _..__Ex Expansion Attic
— --•------ p ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No, of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures .....................................................................................................................................................
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No_____________________ Width.................... Total Length..................... Total leaching area.....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I________________minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to-ground water........................
P
-----------..-----••--••----------•----•----------------•-----------._..._._.........................................................
Description of Soil
................ ________a___+ks' ^f�=_
U ----•----------------------•------------------------
U Natur of Repairs or rations Answer when applicable - -- ------" .................---,.. ....+..
------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE; 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beef issued y the board of hea th.
'
Signed._ = M........................................ _..
Application Approved By................... -•-- ----• ---- ••.-----•. _— •----- ------------- I _. -
ate
Application Disapproved for the f ollo -ng reasons---------------•-------------------------------------------------------------•-----------._...--•-----•-•••-----
---• -------------•-------....-------•-•--.......•-----------------------------------------------------------
Date
PermitNo......................................................... Issued.........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
^. .........OF.............�•'.....................................................................
(Inrtifirate of TontpliFanrr
TH S IS T, O-EERTIFY hat t e Ind,vidual Se e Dim s' al System constructed ( ) or Repaired ( )
--------------
by l ' " . `gg
at......(~.....................- Z..... �_ all / " + ' -'
-a- -------- •------- -------------••------•-----
has been installed in accordance with the provisions of TITLE, '5 of The State Sanitary Code as described in the
application for Disposal,Works Construction Permit No.......................................... dated.__.._---_.-.--_-_.__----_____--____--__________
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CO STRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE._..... .... .. --�. ----•-----•____________________ Inspector....-- - ---....-=----- ------- wu:�_ ............................
COMMONWEALTH OF MASSACHUSETTS
BOARQ__QF HEALTH
<2.a ! I1 D<:):...`..1..... .....OF.... l`w ....................wry -__....._.. '
No......................... F .......................
Disposal 1VVyhs In
Permission is hereby
- granted- d -----_.... --•----------S-------
•..
•---- --.....-----._...------.....................
r � nvldual evs) a Disposalyste , 'to Construct R
at No. &" -- ----
; l ---------------- --
Street. -� ;;
as shown on the application for Disposal Works Construction Permit No____ _____ _ ____ PAted__._______ __.___..___.....____._._....
................................... --------- -- - r •---- -•-----•-•-•---- rF ;
DATE_ �' _ Board of Health
FORM 1255' A. M. SU'L'KIN, INC., BOSTON