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HomeMy WebLinkAbout0516 RACE LANE - Health (� IZCA rylarS?dnS m; C i i 1 ck II@ dS a7Es COMMONWEALTH OF MASSACHUSETTS �, - EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS�� �HSTASLE DEPARTMENT OF ENVIRONMENTAL PROTEZR464,1 28 Am 9: 54 TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 516 Race Lane 30 Marstons Mills MA 02648 Owner's Name: Chris Heden Owner's Address: Date of Inspection: May 31. 2005 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 . Osterville.MA 02655-0049 Telephone Number: (508)862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Needs urther Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: June 6, 2005 The system inspector shalY'tcopy 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 p y 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 11 ' 9 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 516 Race Lane Marstons Mills MA Owner: Chris Heden Date of Inspection: Mav 31, 2005 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 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 516 Race Lane Marstons Mills MA Owner: Chris Heden Date of Inspection: May 31, 2005 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 s stem is failing to protect public health,safety or the environment. y I. 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 I Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 516 Race Lane Marston Mills MA Owner: Chris He den Date of Inspection: Mav 31, 2005 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'h 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 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 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: S16 Race Lane Marstons Mills MA Owner: Chris Heden Date of Inspection: May 31. 2005 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 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 516 Race Lane Marston Mills MA Owner: Chris Heden Date of Inspection: Mav 31, 2005 RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 4 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): n/a [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)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied 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 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): Pumping Records GENERAL INFORMATION Source of information: Pumped in 2004-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: Installed on 7131/00-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 516 Race Lane Marstons Mills MA Owner: Chris Heden Date of Inspection: Mav 31, 2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 14" 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):certificate) (attach a copy of Dimensions: 1500 Qal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 4" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measurin 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 li uid level was even with the outlet invert. There did not a ear to be an si ns o leaka e. 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 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 516 Race Lane Marston Mills MA Owner: Chris Heden Date of Inspection: Ma 31, 2005 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: allons/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: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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.): The D-box was level. No solids were resent. 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 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 516 Race Lane Marston Mills MA Owner: Chris Heden Date of Inspection: Mav 31. 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: 2-500 gal. each chambers- 12 5'x 25'x 2'(per as built card) 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.): The leach field was clean. There did not appear to be any signs offailure 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 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS S SUBSURFACE SEWAGE DISPOSAL SYST EM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 516 Race Lane Marston Mills MA Owner: Chris Heden Date of Inspection: Mav 31, 2005 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. A � p 3 y 1 s Dob y 3q6 y�� 10 ,v Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 516 Race Lane Marstons Mills MA Owner: Chris Heden Date of Inspection: _Mav 31, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25 +/- 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: Using Barnstable topographic and water contours mans the maps were showing approximately 25'+/ to ground water at this site. This report has been 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 I Commonwealth of Massachusetts Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 516 Race Lane Property Address Tina Lilly Owner Owner's Name Information is Marstons Mills required for every MA 02W 2-8_14 page. Cdyrrown State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Imng out tforms A. General Information filling out forms on the computer, �`�Lj"OF Or1q/s�'. u onlythalyab 1 Inspector. .``rya s9c, k to move our ` ge�tDitre�t returnnot James D.Sears = �: JAMES yN :m= key. Name of Inspector _ C y eEnterprises LLC „e Company Name ��••�0 ...TI 153 Commercial Street �''�i S I N SPE�'���`���` Company Address Mashpee MA 02649 Citylrown State Zip Code 508-477-8877 S 1623 Telephone Number license Number 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. 1 am a DEP approved system Inspector pursuant to Section 15.340 of Title 5(310 CHAR 15.000).The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority R 2-8-14 1 or's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. —**This report only describes conditions at the time of inspection and under the conditions of use at that time.This Inspection does not address how the system will perform In the future under the same or different conditions of use. �. 2 111I �I L51ne•3H 3 Tire 5 0lriciel Form:SuOmafaae Sewage Diepoael System-Pape I or t 7 CI I Ir,,I_ga Commonwealth of Massachusetts Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 516 Race Lane Property Address Tina Lilly Owner Owner's Name Information is every Marstons Mills required for eve MA 02648 2-8-14 page. Citylrown State Zip Code Date of Inspection B. Certification (cunt.) 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: 13) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Passe section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes","no"or"not determined" (Y. N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltrabon or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ms-3113 nW 5 DfcW sPedM Form:Subsurlaoe Se+vage Disposal System•Page 2 or 17 Zd d90:0Lt,L LLgaj Commonwealth of Massachusetts Not Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 516 Race lane Property Address Tina Lilly Owner Owners Name information is required for every Marstons Mills MA 02648 2-8-14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumpsfalarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont).- El Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed ptpe(s) or due to a.broken, settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment 1. System will pass unless Board of Health determines In accordance with 310 CMR 15.303(1)(b)that the system Is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh mns-3r13 Mtla g Official Inspection Fottn:Subsurface Sewage Dispose!System•Page 3 ar 17 £ d dL0:06 t,6 1,l qad Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 516 Race Lane Property Address Tina Lilly Owner Owner's Name i"toffnation is every Marston Mills required for eve MA 02648 2-8-1 4 page. CityfTown State Zip Code Date of inspection B. Certification (cons) 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. - El The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well"*. Method used to determine distance; '•This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other. D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ® Backup of sewage into facility,or system component due to overloaded or clogged SAS or cesspool ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® Liquid depth in am is less than 6°below invert or available volume is less Cl than %day flow". /�i�vG t5k=•3113 Me 5 official Impaction Forth:Subsurface S&&?Q9 Disposal System•PeQe.4 0117 ti d dL0:0l,t,l, l 1. qaj I . Commonwealth of Massachusetts Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 516 Race Lane Property Address Tina Lilly Owner Owne>'s Name InfiDrequired ition is Marston Mills MA 02648 2-8-14 required for every page. Eit—yrreown State Zip Code Date of inspection B. Certification (cunt.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or' obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than.50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal collform bacteria Indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.) ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either`yes"or°no"to each of the following, in addition to the. questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ 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 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. thins•3113 Tile 5 OWKW hapecdon rrotm Subsudace Sewage Disposal System-Page 5 of 17 g,d dLO:OI t,6 1 1, qaj I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 516 Race Lane Property Address Tina Lilly Owner Owner's Name requinform r on is Marstons Mills MA 02648 2-8-14 requiredd for every page. Cttyrrown State ZJp Code Date of Inspection C. Checklist Check if the following have been done.You must indicate'yes"or'no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? IR ❑ 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? 21 ❑ Were the septic tank manholes uncovered, opened, and the.interior of the tank inspected f+or the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined.based on: ❑ Existing information. For example, a plan at the Board of Health. ❑ IR Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)1310 CMR 15.302(5)) D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Us 5 OtBW tnVedUon Forth:Subsurface Sewage Disposal System•Page 6 of 17 9-d d9o:0l,t,6 l l qej Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 516 Race lane Property Address _Tina Lilly Owner Owners Name information is required for every Marston Mills MA 02648 2-6-14 page. Cityrrown State Zip Code Date of Ins pection D. System Information Description: The system is a 1500 Gal. Tank D Box and two 500 dry well chambers Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection information in this report) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasona.luse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 201245,000Gals Detail: 2013-53,000Gal's Sump pump? ❑ Yes .No Last date of occupancy: Present Date CommerciaWndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seatsipersonsisq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank-present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-B 3 Title 5 OliicW Inspeeeon Form:Subsurface Sewage Eh � 9 sposel 6ystam•Page 7.of 17 d d80:0 1 t,L l l qej f Commonwealth of Massachusetts Title 5 Official Inspection Form ? Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 616 Race Lane Property Address Tina Lilly &War Owner's Name inb d for every on is required for Marstons Mills MA 02646 2-8-14 page. Citylrovm State Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: Data Other(describe below): General Information Pumping Records: Source of information: 4-30-09 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/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 I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3M3 Mo 5 OWd Irmpeedw Form:Subwface Sewage 04owl System•Page 8 of 17 g d d90:0 i,t,l l•1, qaj Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Fon»-Not for Voluntary Assessments ' 516 Race Lane Property Address Tina Lilly Owner Owner's Name Infom required edon is required for every Marstons Mills MA 02648 2-8-14 page. CityJrown state Zip Code Date of Inspection D. System Information (cons) Approximate age of all components,date installed (if known)and source of information: Tank 1996/2000 Permit # 2000-372_ Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2'feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line:_ feet Comments(on condition of joints, venting,evidence of leakage,etc.): Pipeing is 4" PVC SCH 40. Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: ®concrete ❑metal ❑fiberglass ❑ polyethyiene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gal_ Precast Sludge depth: 2" t5irre.3M 3 We 5 Olbdal hspadion Fare Subwrlwe Sewage Disposal System-Page 9 of.17 6 d d60:O1,t,l. 1,6 qej Commonwealth of Massachusetts awwo Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 516 Race Lane Property Address Tina Lilly Owner Owner's Name required for is every Marstons Mills required for eve MA 02648 2-6-14 ' page. cityrrown state Zip Code Date of Inspecilon D. System Information (cont.) Septic Tank(cunt) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Asbuilt-Tape _Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tank at working level. Tank at T below grade w/both cover's at 2". In and outlet Tees. Note: Out)Let tee has a filter. 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: tie Sins•3r13 We 5 Of6dW hupeclon Form:SUneface Sewage Oiaposal System•Pap 10 of.17 06'd d60:O1 til 66 98j Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 516 Race Lane Property Address Tina Lilly Owner Owner's Name information is Marstons Mills MA 02W 2-8-14 required for eve ry page. Cdyfrown State Zip Code Date of Inspedion D. System information (cunt.) 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 constriction: ❑concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping:. Date Comments(conclition of alarm and float switches,etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5kV•3M 3 Tide 5 Official trspedlo Fornr Subsurface Sewage Disposal System•Page 11 or 17 i i'1 d d60:O 1 b l L L 9e i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 516 Race Lane Properly Address Tina Lilly Owner Owners Name information is required for every Marstons Mills MA 02648 page. Cttylrown State Zip Cock Date Date of of Ins pection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x16"-20"below grade w/cover at 4". One line out. Box is in bad shape,need to replace D Box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No` Alarms in working order. ❑ Yes ❑ No' Comments(note condition of pump dumber,condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: L TWO 5 OfEdal UmPa tlon Forth Sulu ffbW Savage Disposal SYSIMn•Page 12 or.17 d Zl' d06:O1 t,l t•6 qa,l I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 516 Race Lane Property Address Tina Lilly Owner Owners Name infennalion required fo a Marstons Mills MA 02648 2-8-14 reQuired for every page_ cityrrown State Zip Code Date of lnspedion D. System information (cant.) Type: . ❑ leaching pits number. ® leaching chambers number: 2 ❑ 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.): Leaching is two 500 Gal.dry well chamber's w/4'stone. 10'x37x2'chambers at 40"below grade w/cover at 26". Leaching is full,not leaching Need to replace leaching. 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 i Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No MM-3n3 TI6e 5 09bal Nsp&Ww Form:SLbaa we Sewage Disposal System•Page 13 or.17 £L'd d0L:06 tiL l,1, qej Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 516 Race Lane Property address Tina Lilly Owner Owner's Name information Is required for every Marstons Mills MA 02648 2-8-14 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Comments(note condition of soil,signs of hydraulic failure, level of ponding. condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.),. t5ins•3113 Title 5 Of6dd ftPectfon Form:.SuDsutfaw satraps olsposat system•Pape t,of 17 bL'd i doh:o1 t,l 6 6 9ej Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 516 Race Lane Property Address Tina Lilly Owner Owner's Name information is required for every Marstons Mills MA 02648 2-&14 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately Zv, = ;2rI o z r � y t5hs•3113 TiUa 5 OffieW Wpec6m Fmm:Subsa(aae Sewage Disposer System•Pepe 15 of 17 56'd dl•L:ol,tl, 66gej Commonwealth of Massach usetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 516 Race Lane Property Address Tina Lilly Owner Owner's Name Information is Marstons Mills required for every MA 02648 2-8-14 page. Cttyfrown State, Zip Code hate of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check.cellar ❑ Shallow wells NO Estimated depth t high,ground water. 70+' 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 propertylobsenration hole within 150 feet of SAS) ® Checked with local Board of Health-explain: GIS ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain.:.. You must describe how you established the high ground water elevation: GIS and past report 70+'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. thine-3113 rifle 5 Official trerpection Fam;Subswfaoa Sewage Dkposd System.Pap 78 of 17 96 d d6L�Ol•�6 Llga� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 516 Race Lane Property Address Tina Lilly Owner Owner's Name information is required for every Marstons Mills MA 02648 2-8-14 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins- Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 ..A ru # - .•. I O ru Ir-q OFFICIAL cc ti Postage $ \5 At? p Certified Fee �� �G, p Postmark O p Return Receipt Fee 1/ 1 p (Endorsement Required) I y MAR -,T7Vl4 Restricted Delivery Fee p (Endorsement Required) C3 Total Postage&Fees 9D p rq li r- Jason R & Tina MTina Lilly 516 Race Lane Marstons Mills, 02648 Certified Mail Provides: a A mailing receipt o A unique identifier for your mailpiece a A record of delivery kept by the Postal Service for two years Important Reminders: o Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail& o Certified Mail is not available for any class of international mail. o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. o For an additional fee,a Return Receipt may be requested to provide proof.of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To*receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. c For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". ■ If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. i PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 SOMPLETE THIS SECTIOMON DELIVERY ® .Complete items 1,2,and 3.Also complete A. Signature � it 4 if Restricted Delivery is desired. X a Agent ® Print your name and address on the reverse J4i 6 ❑° ddressee so that we can return the card to you. B. Received by(176ted Nwne C. Date f Del!' ®.Attach this card to the back of the mailpiece, LI or on the front if space permits. d D. Is delivery addre ifferent from item�l-? 1 Article Addressed to: If YES,enter delive��Oddress below: ` No Jason:R & Tina MTina Lilly 516 Race Lane ` I MarstosMills, 02648 3. Service Type I ❑Certified Mail ❑Express Mail ❑Registered ❑Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number( 7,2 1010 0000 2851 2 0 2 6 �' Transfer from service label) orm 3811.February 2004 Domestic Return Receipt 102595-02-M-1540 -UNITED•.STATE$POSTAL,SERVICE First-Gass Mail Postage&Fees Paid USPS Permit No.G-10 •Sender:Please print your name,address;and ZIP+4 in this box • Town of Barnstable Regulatory Services Department Public Health Division 1200 Main Street Hyannis, MA 02601 I Ili1`I�IfIIII-P!diliji;;lIM III!ity}III-III!Ili-ill'Id ill;ill I Town of Barnstable Barnstable BOARD OF HEALTH MA"BM ' 200 Main Street, Hyannis MA 02601 I �i639 A1� fp met 2007 Office: 508-862-4644 Richard Scali,Interim Director. FAX: 508-790-6304 Thomas A.McKean,CHO. CERTIFIED MAIL# 7012 1010 0000 2851 1890 March 5, 2014 Tina Lilly 516 Race Lane Marstons Mills, MA 02648 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE TITLE 5 The septic system located at 516 Race Lane,Marstons Mills,MA was last inspected on 2/08/2014,by James D. Sears, a certified septic inspector for the state of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of the 1995 TITLE 5(310 CMR 15.00). • Distribution box is in "bad shape" per the report. It needs to be replaced. • Leaching facility is full, not leaching. The leaching facility needs to be replaced. You are ordered to repair or replace the septic system within sixty(60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH T omas McKean, R.S. CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Eval\516 Race Ln MM Feb 2014.doc Town of Barnstable Barnstable BOARD OF HEALTH I •"W,,% 200 Main Street, Hyannis MA 02601 D 1°tFp0 39. s�0� 2007 Office: 508-862-4644 Richard Scali,Interim Director. FAX: 508-790-6304 Thomas A.McKean,CHO. CERTIFIED MAIL#7012 1010 0000 2851 1890 March 3, 2014 Tina Lilly 516 Race Lane Marstons Mills, MA 02648 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 516 Race Lane,Marstons Mills,MA was last inspected on 2/08/2014,by James D.Sears, a certified septic inspector for the state of Massachusetts. The inspection of the septic system showed that the system"Fails"under the guidelines of the 1995 TITLE 5(3 10 CMR 15.00). I 4 - • Need-to-rep am Distribution box. Is ,,, �'� Z sip` F`f'O% • Need-to-rel,}�ee-�:�Ig Lea C, ,-%-( Z(( A 2-A '--, repay ce l . You are ordered to repair or replace the septic system within sixty(60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S. CHO Agent of the Board of Health QASEPTICULetters Septic Inspection Failures or Future Eval\516 Race Ln MM Feb 2014.doc r Parcel Detail http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=8051 4tA5S. �� t? /. a Logged In As: Parcel Detail Wednesday, February 26 2014 Parcel Lookup Parcel Info Parcel 126-003 —��� Developer ILOT 2 ID Lot Pri Location 516 RACE LANE �� Frontage 1105 Sec Sec Road� � Frontage Fire -- _ ONS MILLS District IC-O-MM t Town sever exists at this Road _ _ ) 11344 No Index address; Asbuilt Septic Scan: 126003 1 Interactive s a I P 126003_2 , : ,� , Owner Info _ ) Co- Owner,LILLY,JASON R&TINA M Owner I Streetl PO BOX 858 J �� Street2 F -77' City IMARSTONS MILLS i� �) State[MA Zip 10 462 8 country! 1 Land Info Acres 10 57 ] Use jSingleFarn MDL-01 1 Zoning jRF Nghbd j0105 Topography Level Road I Paved Utilities I Septic,Gas,Public Water Location Construction Info Building 1 of 1 Year -- Roof '— -� Ext,--- Built�1996 Struct(Gable/Hip Nall`Wood Shingle Living 1906 Roof�ph/F GIs/Cmp AC INone � Area Cover= Type Style jColonial Int pastered Bed 13 Bedrooms Wall Rooms I Bath j Model Residential sPine/Soft Wood 2 Full ors Floor' Rooms 1 s�s Heat- ____ _ Total Grade jAverage Type 1Hot Water Rooms 16 Rooms Heat�- __ — Found-1 -- pr r, Stories 12 Stories Fuel Gas I ation iPoured Conc. Gross http://issgl2/intranet/propdata/ParcelDetaii.aspx?ID=8051 2/26/2014 T r • 1H� Town of Barnstable Barn BOARD OF HEALTH ' 200 Main Street, Hyannis MA 02601 D 2007 Office: 508-862-4644 Richard Scali,Interim Director. FAX: 508-790-6304 Thomas A.McKean,CHO. CERTIFIED MAIL# 7012 1010 0000 2851 2026 March 5, 2014 Tina Lilly 516 Race Lane Marstons Mills, MA 02648 • ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 • The septic system located at 516 Race Lane,Marstons Mills,MA was last inspected on 2/08/2014,by James D. Sears, a certified septic inspector for the state of Massachusetts. The inspection of the septic system showed that the system"Fails"under the guidelines of the 1995 TITLE 5(310 CMR 15.00). • Distribution box is in "bad shape" per the report. It needs to be replaced. • Leaching facility is full, not leaching. The leaching facility needs to be replaced. You are ordered to repair or replace the septic system within sixty(60)days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH s Kean, R.S. C Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Eval\516 Race Ln MM Feb 2014.doc , 4 https://tools,usps.com/go/TrackConfinnAction.action?tRef=fullpage&tLc=1&text28777=&tLabels=70121010000028512026 English Customer USPS Mobile Register/Sign In Service / , / f • S.C°oIi/l' Search USPS.com or Track Packac USP Quick Tools Track Ship a Package Send Mail Manage Your Mail Shop Business Solutions Enter up to 10 Tracking A Find Find USPS Locations Buy Stamps i Sc d tiQ�ff , TM Customer Service> Loo ul pXLIP o Tracking i Have questions?We're here to help. Hold Mail F—Y..... ........_........ Change of Address _ .... _ i Tracking Number:70121010000028512026 i i Product & Tracking Information Available Actions Postal Product: Features: Certified Mail" USPS Text Tracking- �k11 Email Updates ..... ...... — March 6,20114,2:14 Delive[ed MARSTONS Pin MILLS,MA 02648 March 6,2014,11:00 Available for MARSTONS am Pickup MILLS,MA 02648 March 6,2014,9:59 Sorting Complete MARSTONS 0 am MILLS,MA 02648 110 • March 6,2014,9:31 MARSTONS Arrival at Unit am MILLS,MA 02648 Depart USPS March 6,2014 Sort Facility PROVIDENCE,RI 02904 i March 6,2014,3:05 Processed am through USPS PROVIDENCE,RI 02904 Sort Facility (� March 5,2014,8:54 Processed v-i through USPS PROVIDENCE,RI 02904 pm Sort Facility i Track Another Package What's your tracking(or receipt)number? Track It ' I LEGAL ON USPS.COM ON ABOUT.USPS.COM OTHER USPS SITES Privacy Policy i Government Services> About USPS Home> Business Customer Gateway> Terms of Use> Buy Stamps&Shop, Newsroom, Postal Inspectors> FOIA> Print a Label with Postage> USPS Service Alerts> Inspector General, No FEAR Act EEO Data> Customer Service> Forms&Publications) Postal Explorer, Delivering Solutions to the Last Mile> Careers> Site Index) • �✓'. � ; Copyright0 2014 USPS.All Rights Reserved. https://tools.usps.com/go/TrackConfinnAction.action?tRef=fullpage&tLc=1&text28777=&tLabe1s=7012 10 1000... 4/1/2014 TOWN OF BARNSTABLE �, 1 LOCATION a w IfA- —L- L47VZ SEWAGE# c cW 41'a/U 'VILLAGE : 111J ASSESSOR'S MAP&PARCEL �2 INSTALLER'S NAME&PHONE NO. 2—-Va SEPTIC TANK CAPACITY 45� LEACHING FACILITY. (type) ,Mle-4 ,� CZ�(size)NO.OF BEDROOMS OWNER � � 71N3 Cam` l PERMIT DATE:3 L/-/ y COMPLIANCE DATE: C3 J7 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 J site or within 200 feet of leaching facility) �/� Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching fa Feet FURNISHED BY ,-Z -2 2 '� r�. 2,6 , a 63 -2-Y-1 �o 0 No. / Fee 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZIPPliLation for Nsposal 6pstem Construction Vermit Application for a Permit to Construct( ) Repair(k) Upgrade( ) Abandon( ) ❑Complete System ,Individual Components Location Address or Lot No. 6-1 Ad-Z Lam/' Owner's Name,Address,and Tel.No. Assessor's Map/Parcel /2,1, b CA,-5— ^1111'A r Installer's Nam/ee Addresss,and Tel No. / Designer's Name,Address,and Tel.No. /J,� 1 &7 ;5 /3 0�F��7 .4-1 04"C- ,019 /✓�.L��i d.-�d AY J' Aj Ak?el L .3A2,3 G+�/G4 3 2- 2-97_Z- v 37 Type of Building: (/ Dwelling No.of Bedrooms r Lot Size 2- ( / v sq.ft. Garbage Grinder( ) Other Type of Building J'Iit �-�. y/GI No.of Persons Showers( )Cafeteria( ) Other Fixtures Design Flow(min.required) �7�U gpd Design flow provided JZ12-' L 5 gpd Plan Date t Number of sheets 2 Revision Date Title Size of Septic Tank ��4 -9,,e(J'17AI4r Type of S.A.S. _ -e4AfT cZA.�� Description of Soil SQ 2_�1i4/✓ Nature of Repairs or Alterations(Answer when applicable) w S `l ti GG1 Zviy l-c' �'�r Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental C de and not to place the system in operation until a Certificate of Compliance has been issued by this Board of He t ? Si ed Date '.J — 7 , / 1 Application Approved by Date Application Disapproved by Date for the following reasons Permit No. d Date Issued �� No.. / Fee THE COMMONWEALTWOF MASSACHUSETTS Entered in computer: s; Yes ® PUBLIC HEALTH DIVISION - TOWN OR BARNSTABLE, MASSACHUSETTS application for Misra �rfpstem Construction permit Application for a Permit to Construct( ) Repair�k) Upgrade( ) YAbandon( ) ❑Complete System K Individual Components Location Address or Lot No. f 1(( Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Z/„ / dV_2 &Avz ��S Installer's Name Address,and Tel.No. Designer's Name,Address,and Tel.No. A,e 4 C (lt*J /3ox 46-I 14Apw,cG,/�'/4 /"_e.y_t d ro$4 .S 56Y7,pl [: 14,iowtc4 ?�i JUi 2-900 oZ � 3 5-b F 362- Z9ZZ ozs`37 Type of Building:Dwelling No.of Bedrooms Lot Size 2 /�/r d `--sq.ft. Garbage Grinder( ) Other Type of Building J_/ 4.4^/rr No.of Persons Showers( ) Cafeteria( ) Other Fixtures - Design Flow(min.required) d�& gpd Design flow provided yZ Z 5 gpd Plan Date 3- f Number of sheets Revision Date Title / Size of Septic Tank n/C� Type of S.A.S. Z e4;I7 L C 5 Do C 4,4.a 4�e_.r Description of Soil S-'C Nature of Repairs or Alterations(Answer when applicable) 04c Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental C de and not to place the system in operation until a Certificate of Compliance has been-issued by this Board of He t Si ed Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. J/� G (o d Date Issued L L --------------------------------------------------------------------------------------------------------------------------------------------- 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�D t)/V E f A+1 R!C/a,r/J 1� i o C G��{l �/i✓� at }�/!li R e C 44 N!L' M M has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No�/<< 060 dated J Installer T �/�.S Designer /lij ,� ,roiv S #bedrooms �� Approved design flow T' 1,7_, 2 S' gpd The issuance of this permit shall no be construed as a guarantee that the system will tion s- a igned. Datef Inspector No. n D Fee d THE COMMONWEALTH OF MASSACHUSETTS , PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *pstetn Construction i3ermit Permission is hereby granted to Construct( ) Repair(A Upgrade( ) Abandon( ) System located at ��(p g1l e 'e_ L../`q/V z/ 4 4 51-7d Al S Al , //f and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction mu t be ompleted within three years of the date of th's permit. Date _�_ Approved bey r Town of Barnstable op tiff ' .o Regulatory Services Richard V.Seali,Interim;Director • saai`sr►stae. •: MASS g Public Iealth.Dlvsion - � Thomas WKean,Director. 2008I1iin Stree�A annis MA.02601. Y: Office: 508-862-4644. Fax: 508-100-6304 Installer &-DesiQn`er Certification Form Date: .: �`� Sewage Permit# Assessor's MalParcei. Designer: l"lL' 8P �YI L Installer; b�v e*0-cec V�-� eRve Cr 1 l S Address-: 1'" Address:: 1�j y (�(v q On 3 was issued a permit to install a (date) (instaher) se tics stem at p y 6.4-1 N based:on a design drawn by Me (address) " dated l (.designer) I certify that the septic system referenced above was nst4iled.substantialiy according:to the design; which riayiclude minor approved changes such as lateral relocation of the . distribution box andlor septic tank. Step out: (if required) was inspected and the.soils were found satisfactory. I certify"that the septic system.referenced above was installed with major changes ( .e. greater than 1Q' lateral relocation of the;SAS or any verEicaI'relocation of ariy component of the septic system).;but in accordance yYith State &:Local Regulations. Plan.revision or certified as built by designer to follow, Strip out(if required) was inspected and the soils were found satisfactory. I certify that the system referenced above was:constructed_"in compliance with the terms of the I1A approval letters if applicable) 4F 46 DAR ' N (Install Signature) i 40 Desi er's Si afore SgN1iA41�� PLEASE RETURN`TO B' " TABLE. PUBLIC HEALTH DIVISION. CERTIFICATE OF CO MPLIAINCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS= BUILT CARD ARE RECEIVED BY`THE BARNSTABLE P-UBLIC'HEALTH.BIVISION, THANK YOU: ,, - Q\SepticlDesier Gemficacion.Form Rev 3-14-13:ioc TOWN OF BARNSTABLE LOCATION ,:5-ka Imo„`P SEWAGE# VT:,LAGE VA,r,rs a\ rs ',�k 1, ASSESSOR'S MAP&PARCEL O INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY S-OO p , LEACHING FACILITY:(type) 3 (size)-c-.%j/_Y NO.OF BEDROOMS OWNER PERMIT DATE: ��� Z J Q© )o COMPLIANCE DATE: t J ctn� 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 r within 300 feet of leaching facility) Feet FURNISHED BY R= zi y: I.A { R, 10 � 0 Via- �ac6« (a 3: Q`? . 3 7-1 j 1� y j TOWN OF BARNSTABLE VOCATION S 1(o RAU. SEWAGE # a M ' 3,-)- vTgLAGE YO M��IS ASSESSOR'S MAP & LOT �a6' 003 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY S� LEACHING FACILITY: (type) 560 CA"L61l Ca� (size) /a•S-X 2.S JC NO. OF BEDROOMS 3 BUILDER OR OWNER 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 leac ng facility) Feet Furnished by�r SpGon --S; �0., Ch b� � g Le ice e ti [00 � . � d a - i Town of BArnstable. pit Department of RekWatory Services PublicIealth Division Date a �ANNBlA8I8y •MAS i ,b ¢ tee$ 200 Main Street;Hyannis MA 02601 3 .l r f Date Scheduled 'TimeT_ Fee Pd. I ,I� oil' Suitabi ' Assessifaient for ,dew Disposal Performed By. 1 Y f��, G✓� Witnessed By: / LOCATION & GENERAL iNr,oRMATION LL Location Address"19-1 9O z L t � ! Owner's Name 'mil /)�S �'✓� ! t-l.S I Address 1K '.PAIILI-51 �9 Assessor's Map/P4rcel: l 26/ 00-3 I Engineer's Name fvlL. l°:l � a NEW CONSi1ZUt2ON REPAIR Telephone# 360 -33r► land Use Rec-IVC)JT t At-- Slopes(�o) O V, Surface Stones Distances from: Open Water Body ���'ft Possible Wee Area ft Drinking Water Well ?f ft Drainage Way j ft Property Line ft Other ft SKETCH:($treet name,dimensions of lot,exact locations of test holes&Pere tests,locate wetlands in proximity to holes) dAh-A 3 fal wF Parent material(geglOgic) 1 I Depth to Bedrock e Y . I Wee 1n from Plt Face � 1 ` F`-� <'rt Depth to Groundwater. Sta mg Water in Hole:' i p g Estimated SeasonaliHigh Groundwater DtTERMIN . TION FOR SEASONAL HIGH WATER T,�LE Method Used: io. Depth to sail tttottlrs: ln. Depth Observed standing in obs.hole: I in, Depth Adjustment tt- Depth to weeping from side of obs.hole: i _ A •AGfOctor ter A j Adf.drpundwnter Level Index We11# _ Reading Date: index Well level - I PERCOLATION TEST . Date Trote Al Observation ' , Time lit 9" -.�- —• Hole# �^ Time at 6" Depth of Pere -- P 1 i Time(V-0) Start Pre Time.0 -- y End Pre-soak Rate MinAnch Additional Testing Needed(YIN) Site Suitability Assessment: Site Passed — Site Failed: I Observation Hole Data To Be mpleted on Back Original:.Public.He$1th Division CO. ***If percolaAibn test is to be conducted within 100, of wetland,,you must first notify the Barnstable C4i<jservation Division at least one(1) wedk prior to beginning. DEEP OBSERVATION HOLE LOG Hole# _ Depth from Soil Horizon Soil Texture Soil Color Soil Other— Depth Surface(in.) (USDA) f (Munsell) Mottling (Structure;Stones,Boulders. Q Consistent %Gravel pel l L �. a; DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistenc y.%Gra el R. DEEP OBSERVATION HOLE LOG Hole# Depth from So orizon Soil Texture Soil Color Soil Other Moulin S tructure Stones Boulders. Surface(in.) (USDA) (Muosell) g Consistenc %Gravel I f I I i I EP OBSERVATION HOLE LOG Hole# Depth from Soil zon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consisten ra I i Flood Insurance Rate Map: Above 500 ear flood bounds No Yes Y boundary Within 500 year boundary No i✓ Yes Within 100 year flood boundary No Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist,in all areas observed throughout the area proposed for the soil absorption system? ' � If not,what is the depth of naturally occurring p rvious material? Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Envirc hmental Protection and that the above analysis was performed by me consistent with the required nri ,exp ise an ex erience described in 3:10 CMR 15.017. Si nature Date �J �✓ Q:\.SEPTIC\PERCFORM.DOC Commonwealth of Massachusetts Al Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments „ 516 Race Lane Marstons Mills, MA 02648 Property Address Tina and Jason Lilly P.O. Box 858 Owner Owner's Name information is Marstons Mills MA 02648 August 14, 2009 required for 9 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may Gnot �bee altered in any way l� ✓ll/'"c� Important: A. When filling out General Information forms on the computer,use 1. Inspector: only the tab key to move your Patrick T. Sullivan cursor-do not use the return Name of Inspector key. Ready Rooter, Inc. Company Name r� PO Box 371 -17 Jan Sebastian Dr. Company Address Sandwich MA 02563 t0 City/Town State Zip Code 508-888-2805 S112843 Telephone Number License Number 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 5 (310 CMR 15.000). The system: C? ® Passes Conditional) Passes❑ y ❑:Fails ❑ Needs Further Evaluation by the Local Approving Authority ata August 18, 2009 Inspector's Signature Date ICU The system inspector shall submit a copy of this inspection report to the Approving Auth`�ority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 516racela 03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .'' 516 Race Lane Marstons Mills, MA 02648 Property Address Tina and Jason Lilly P.O. Box 858 Owner Owner's Name information is Marstons Mills MA 02648 August 14, 2009 required for every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 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 describe in the"Conditional Pass" section need to be replaced or repaired. The system, upon co letion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and ove 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits bstantial infiltration or exfiltration or tank failure is imminent. System will pass inspection ' the existing tank is replaced with a complying septic tank as approved by the Board of ealth. *A metal septic tank ill pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indi ting that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or hig static water level in the distribution box due M to broken or obstructed pipe(s) or due to a brok settled or uneven distribution box. System will pass inspection if(with approval of Board of alth): ❑ broken pipe(s) are replaced ❑ obstruction is removed 516racela•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 516 Race Lane Marstons Mills, MA 02648 Property Address Tina and Jason Lim P.O. Box 858 Owner Owner's Name information is Marstons Mills MA 02648 August 14, 2009 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumpi/morn 4 times a year due to broken or obstructed pipe(s). The system will pass inspectionval of the Board of Health): broken pipe(s) are ❑ obstruction is r moved ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Boar of Health in order to determine if the system is failing to protect public health, safety or the a Ironment. 1. System will pass unless Board of Health determ' es in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in 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 f a bordering vegetated wetland or a salt marsh 2. System will fail unless the Boar of Health (and Public Water Supplier, if any) determines that the system is fun tioning in a manner that protects the public health, safety and environment: ❑ The system has a Sept' tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface ater supply or tributary to a surface water supply. ❑ The system has a s ptic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a eptic tank and SAS and the SAS is within 50 feet of a private water supply well. 516racela•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3 Commonwealth of Massachusetts Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 516 Race Lane Marstons Mills, MA 02648 Property Address Tina and Jason Lilly P.O. Box 858 Owner Owner's Name information is Marstons Mills MA 02648 August 14, 2009 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SA 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 nalysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the pre ence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no o er failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other. D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No El Backup of sewage into facility or system component due to overloaded or ® clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 5116racela•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 516 Race Lane Marstons Mills, MA 02648 Property Address Tina and Jason Lilly P.O. Box 858 Owner Owner's Name information is Marstons Mills MA 02648 August 14, 2009 required for every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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 eac of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of surface drinking water supply ❑ ❑ the syste/queon n 200 fe of a tributary to a surface drinking water supply ❑ ❑ the systeed i nitrogen sensitive area (Interim Wellhead Protection Area— IWpped Zone II of a public water supply well If you have answered "yes" to aon in Section E the system is considered a significant threat, or answered "yes" in Section D large system has failed. The owner or operator of any large system considered a significander Section E or failed under Section D shall upgrade the system in.accordance with 310304. The system owner should contact the appropriate regional office of the Departme 516racela•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 516 Race Lane Marstons Mills, MA 02648 Property Address Tina and Jason Lilly P.O. Box 858 Owner Owner's Name information is required for Marstons Mills MA 02648 August 14, 2009 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)) t 516racela-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 6 Commonwealth of Massachusetts w - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 516 Race Lane Marstons Mills, MA 02648 Property Address Tina and Jason Lilly P.O. Box 858 Owner Owner's Name information is required for Marstons Mills MA 02648 August 14 2009 - , every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3- Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 GPD Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 2007= 107 GPD 2008= 159 GPD Sump pump? ® Yes ❑ No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): % Grease trap present? /� ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 stem? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 516racela-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 7 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 516 Race Lane Marstons Mills, MA 02648 Property Address Tina and Jason Lilly P.O. Box 858 Owner Owner's Name information is g required for Marstons Mills MA 02648 August 14, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Ready Rooter records: Pumped 04/30/09 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: — Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Septic tank and D-Box installed approx 1996. SAS installed July 31, 2000. As-built and Certificate of Compliance on file at Board of Health. Were sewage odors detected when arriving at the site? ❑ Yes ® No 516racela 03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8 Commonwealth of Massachusetts ti Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 516 Race Lane Marstons Mills, MA 02648 Property Address Tina and Jason Lilly P.O. Box 858 Owner Owner's Name information is required for Marstons Mills MA 02648 August 14, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 1.5 Depth belowgrade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 11 X 5 X 4.5 1500 gallons Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle 36" Scum thickness 1 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 14" How were dimensions determined? Tape measure and dip tube. 516racela•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 516 Race Lane Marstons Mills, MA 02648 Property Address Tina and Jason Lilly P.O. Box 858 Owner Owner's Name information is g required for Marstons Mills MA 02648 August 14, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet PVC tees in place. Filter in outlet should be cleaned with maintenance pumping every two (2) years. Liquid level at outlet invert. Grease Trap (locate on site plan): Depth below grade: / feet Material of construction: ❑ concrete ❑ metal ❑�f erglass ❑ polyethylene ❑ other(explain): Dimensions: / Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last.pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of-inspection) (locate on site plan): Depth below grade: Material of construction: [] concrete ❑ metal fiberglass polyethylene ❑ other(explain): 516racela-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 10 4 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 516 Race Lane Marstons Mills, MA 02648 Property Address Tina and Jason Lilly P.O. Box 858 Owner Owner's Name information is Marstons Mills MA 02648 August 14, 2009 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gall Ins Design Flow: allons per day Alarm present: ❑ Yes ❑ No Alarm level: /wWitches, larm in working order: ❑ Yes ❑ No Date of last pumping: ate Comments (condition of alarm and flo ): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): One inlet, one outlet. Some corrosion on interior of D-Box. No sign of leakage at this time. No solids carryover. No sign of high water staining. Riser brings cover within 6"of grade. Pump Chamber(locate on site plan): Pumps in working order: '� ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No i 516racela•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 516 Race Lane Marstons Mills, MA 02648 Property Address Tina and Jason Lilly P.O. Box 858 Owner Owner's Name information is Marstons Mills MA 02648 August 14, 2009 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 2-500 gal ea w/ 4 of stone. ❑ 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.): Chambers located and inspected with camera. 3.5' below grade, not excavated. Liquid level 1.5' below invert. Clean stone visible though side walls. No sign of past hydraulic failure. 516racela•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 516 Race Lane Marstons Mills, MA 02648 Property Address Tina and Jason Lilly P.O. Box 858 Owner Owner's Name information is Marstons Mills MA 02648 August 14, 2009 required for every page. City(Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspectiory) (locate on site plan): Number and configuration / Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer r Dimensions of cesspool Materials of construction Indication of groundwater inflo El Yes ❑ No Comments (note condition f soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: l Dimensions Depth of solids Comments (note condition of soil, signs of/ydraulriic failure, level of ponding, condition of vegetation, etc.): 516racela•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 13 f • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 516 Race Lane Marstons Mills, MA 02648 Property Address Tina and Jason Lilly P.O. Box 858 Owner Owner's Name information is g required for Marstons Mills MA 02648 August 14 2009 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 4 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. ti 3y -2 ` i O 5'� r O J 1-�� .ti ( S�Y 516racela•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 14 Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 516 Race Lane Marstons Mills, MA 02648 Property Address Tina and Jason Lilly P.O. Box 858 Owner Owner's Name information is Marstons Mills 02648 August 14, 2009 required for every page. City/Town State Zip Code Date'of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 27 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: 06/21/00 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database-explain: ma.water.usgs.gov terraserver-usa.com You must describe how you established the high ground water elevation: Emergency Repair Form from 2000 shows property elv= 76.9. Adjusted ground water at elv=49. Accessed local ground water contours and topo mapping. 516racela•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 11 . - TOWN OF BARNSTABLE LP,CATION i 7d &Le- /ii. SEWAGE # Z�-37Z ' VIL AGE_/✓1aI51` E5 WI;11-.s ASSESSOR'S MAP & LOT _4e INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /SAD `AG LEACHING FACILITY: (type) SDO lar! Lew S 1 � )(�?, (size)A "".?f�W' NO. OF BEDROOMS 3 BUILDER ORIOWNER PERMITDATE: 6—Z Z 41 COMPLIANCE DATE: !%a°�,7f'��0��✓ Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility �� Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 6C Rea * I K } A � a TOWN OF BARNSTABLE 4 nn LOCATION SEWAGE # N 9--- Vt, LAGE ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACII.TTY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: 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 on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If an wetlands exist within 300 fee aching facili ) Feet Furnished by �+✓% s hOr�l . '✓-Yes•.,: l L No. `4�?40,t'T,6 `� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 4--' PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 0(ppficatfon for ;Dioponl *potem Construction permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Am Owner's Name,Address and Tel.No. Assessor',MapP el r5 y0s y / Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 77/�y3Q Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(-Ao!� Other Type of Building L�i1 No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow Z//9 gallons per day. Calculated daily flow J?'ye_), gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank D. � Ii Type of S.A.S. Description of Soil I D X% Z Nature of Repairs or Alterations(Answer when applicable) f/7 _iz: Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by t 's Boazd He h. Signed Date �?J Application Approved by Date gt. Z-Z-h`ts Application Disapproved for the following reasons Permit No. ' Date Issued ' ��� a f Fee 1.6 r ; THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Y� _ . PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS ZIpprication for ;Diopozar bpgtem Con!9truction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. �/1 ��1� l� Owner's Name,Address and Tel No. TJ ( Pao. "geG Dr�c�� Asse sor' Map��ce � Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(� Other Type of Building G l fei1 ' No.of Persons Showers( ) Cafeteria( ) Other Fixtures "Design Flow Al gallons per day.. Calculated daily,flow J�J7� gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 1j," �® fl"It V-1 Type of S.A.S. Description of Soil . Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site-sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by s Board He Ith. Signed~ Date Application Approved by Date go� "'�- i Application Disapproved for the following reasons „e , Permit No. � * a.:_. �` Date Issued �" X Z THE COMMONWEALTH OF MASSACHUSETTS �Z6 OD j BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CE TIFY,that the On-site Sewage Disposal System Constructed Repaired v )U raded *� g P Y ( ) P ( Pg ( ) Abandoned( )by at _4 �G'G d! Q'Ir��7�Dy19 sC1ip /S has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Pe dated '" t Installer Designer The issuance eooff this permit h .1 not be�strued as a guarantee that tJae 11 function a�.desi e . = Date Inspector,.- — ———— rg------------------------------- ' No. / �CJ aa3 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Iniopogal *pgtem on.5truction Permit Permission is hereby anted,,tgg Construct�+ )Repair( )Upgrade( )Abandon( ) �, System located at ?�� �°S�Ce- /yl• ��1$ 74�(''-S" '�'//��5 and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this t. Date: Approved by J r 7Y5 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(WITHOUT DESIGNED PLANS) 1 L ���erT L . ��/' 1� i, hereby certify that the application for disposal works construction permit signed by me dated ,�r�Z/�®D concerning the property located at 5_/6 ll�e�e 1#1 A,05AWrI Ai/!S meets all of the following criteria: a/The failed system is connected to a residentiai dwelling only. 1 here are no commercial or business uses associated with the dwelling. The soil is classified as GLASS I and the percoiation.ate is less than or ecuai :o ; minutes per inch. +� There are no wetlands within 100 feet of he ororosed smuc system • 1 here are no private weils within 1:0 feet of he propcsed septic system Y There is no incase in flow and/or change in lise oroposed There are no variances guested or needed. u The bottom of the proposed leaching facility will not be located less than five tee:above the mammum adjusted groundwater table e''eration. (Adjust the groundwater table using the=::raptor `method when applicable] c/ If the S.A.S. will be located with 2f0 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) � a _ B) G.W.Elevation `—1 Z i the MAX.High G.W.Adjustment. 7 = /V %. DIFFERENCE BETWEEN A and B SIGNED : DATE: i/ zIle,�' (Sketch proposed plan of system on back]. ¢namMW«n V w , p� 1 sg Vla r 1121r(—CF— �. TOWN OF BARNSTABLE LOCATION1� VILLAGE- /I/�D/S J'`D.i'S /LJi%/S SEWAGE # ASSESSOR'S MAP & LOT —ai s INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACa-ITY: (type) „ (size) NO. OF BEDROOMS i BUILDER O OWNER Ch� j PERMITDATE: COMPLIANCE DATE:I ! Separation Distance Between the: JMaximum 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) Edge of Wetland and Leaching Facility(if any wetlands exist D Feet within 300 feet of leaching facility) Furnished by 6L Feet I 9a O 0 ,4 9/� N 4 Commonwealth of Massachusetts gR �(1 Executive Office of Environmental Affairs 2 0 '7996 Bw Department of ��g Environmental Protection Ice Wllllam F.Weld 9$9 Gowmor '1 Trudy Cox + e d� S�entry, FA D3 David B.Struhs Comm"am SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 1 CERTIFICATION Property Address: 6/6 (see/aftc �a,'-170'r�1i"IIJ Address of Owner: Gr. Date of Inspection: ./�-q� (If different) /'�/R>sll v� // /V p 3 4 Name of Inspector: JO v. #a/2 � Company Name, Address andd Telephone Number: Jo4- rr ,)V4 l4, /sa wpI„Nt S11 1Y/ursfi�s IM"As A-14 o��yy 7-el. # �'o� y2g.9s 9S 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: _c/Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: —� c tom, / 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: AJ SYSTEM PASSES: 1� I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: 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) The septic tank is metal, 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 conforming septic tank as approved by the Board of Health. (revised 8/15/95) 1 One Winter StrW • Boston,Massachusetts 02108 • FAX(617)SWI049 • Telephone(617)202-MM 0 Printed an Raq ds P Vsr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: S/.G /?,qt4 Owner- ;!Z L.4.jc e./ 13 P 1'Al f Date of Inspection: Bj SYSTEM CONDITIONALLY PASSES (continued) 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 pi%nits ) are replaced obstructio removed distributioox is levelled or replaced The system required pumping more than\ r times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of ealth): broken pipe(s) are`replaced obstruction is rem ved C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEA TH: Conditions exist which require further evaluation by the Board f,-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 AT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAF AND THE ENVIRONMENT: i • Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a borderirig vegetated wgtland'or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC VN TER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THE T PROTECT THE P LIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil ab�sorpuon system and is withi i00 feel lu a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil#orption system and is within Zone I of a public water supply well. _ The system has a septic tank and soiV absorption system and is within 5 feet of a private water supply well. The system has a septic tank and sgii absorption system and is less than 00 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 faci,l'ity and the presence of ammonia nitroge and nitrate nitrogen is equal to or less than 5 ppm. D] SYSTEM FAILS: I have determined that the system vi 'laces one or more of the following failure criteria as fined in 310 CMR 15.103. The basis for this determination is identified low. The Board of Health should be contacted to let rmine what will be necessary to Correct the failure. Backup of sewage into/:.acility or system component due to an overloaded or dogged 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. (revised 8/15/05) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 4ya Owner: F%ZL A4, Date of Inspection: D] SYSTEM FAILS (continued): Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth i cesspool is less than 6" below invert or available volume.,is--less than 1/2 day flow. Required pumping ire than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Abss r�tion System, cesspool or privy'"is below the high groundwater elevation. Any portion of a cesspool or pri'\iswithin in 100 feet of'a surface water supply or tributary to a surface water supply. Any portion of a cesspool or pri a Zone I of.a public well. Any portion of a cesspool or pri 'n�50 feet of a private water supply well. Any portion of a cesspool or privy is less/tha' 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If tPe well been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, a\criteri en and nitrate nitrogen. E]LARGE SYSTEM FAILS: �` The following criteria apply to largg/systems in addition toove: The design flow of system is 10;000 gpd or greater (Large @@ system is a significant threat to public health and safety and the environment because one or more of the following conditions exit: the system is within feet of a surface drinking water supply the system is w�iithin 200 feet of a tributary to a surface drinking water s ply the syste is located in a nitrogen sensitive area (Interim Wellhead Protecti n Area (IWPA) or a mapped Zone II of a public w ter supply well) The owner or operator o any such system shall bring the system and facility into full compliance n�th the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the De;:mnentY�r further information. (revised 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: lice )ane Owner: �Z4z�ZAI A?02.;rim Date of Inspection: 3-- Check if the following have been done: r/ Pumping information was requested of the owner, occupant, and Board of Health. l,_ 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. As built plans have been obtained and examined. Note if they are not available with N/A.. /The facility or dwelling was inspected for signs of sewage back-up. i/The system does not receive non-sanitary or industrial waste flow j/The site was inspected for signs of breakout. ✓AII system components, ei cluding the Soil Absorption System, have been located on the site. NH 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. V The size 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 (dnd occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal Svstem. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION Property Address: /`ace L,*tx N� � Owner: /_,144AI /3R.•1"< Date of Inspection: 3_ FLOW CONDITIONS RESIDENTIAL: Design flow: 170 ¢allons Number of bedrooms: NgN �Q U ��v',,i� 'u S� t/Lo eu ti �0, Number of current residents:�N� Garbage grinder(yes or no): Mo Laundry connected to system (yes or no): No Seasonal use (yes or no): iva Water meter readings, if available: W04'e Last.date of occupancy: 2 YUpg <;rr fys1�� b��,use �oysr �cgrNa,� 2�eu,.s caef� COMMERCIAUIN DUSTRIAL: Type of establishment: Design flow:_gallons/day 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: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: 904O System pumped as pan of inspection: (yes or no) No If yes, volume pumped: ¢allons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system / Single cesspool __._._..__... ....... ..._.._......_...,.... .._ . .. f Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: 10 Sewage odors detected when arriving at the site: (yes or no) LVn (revised 8/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: f 1b /Q4ce Z4,,e N-4//, Owner: . . .G4 Z,rt IV /3R,',u., Date of Inspection: SEPTIC TANK:_ (locate on site plan) B Depth below rade: P Material of construction: \concret metal _FRP _other(explain) ' i Dimensions: /- Sludge depth: Distance from top of sludge to bottom of outlet t or baffle. Scum thickness: Distance from top of scum to top of outlet tee or baffles - Distance from bottom of scum to bottom of outlet tee or- of e: 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:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP _bthk<(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-Ifafile Comments: \' (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level lr•>,relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 6/15/95) 6 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: s/(, 1?,*C e A// Owner: .C,L et,yR.;ri� Date of Inspection: TIGHT OR HOLDING TANK:_\`��. (locate on site plan) Depth below grade: f Material of construction: _concrete_metal _FR _other(explain) / Dimensions: Capacity: gallons / \ Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of al, rri and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) . _1 Depth of liquid level above outlet invert: Comments: (note if level and distribution, is equ��idence of solids carryover, e�oento or out of box, etc) PUMP CHAMBER:_ (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, conoitiofi of pumps and appurte ces, etc.) (revised 8/15/95) 7 u , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 5-16 /lace 4".0 ./1ll A4j Owner: /sG�s1,r/ Qo.iti� Date of Inspection: -3 SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches; number,length: leaching fields, number, dimensions: overflow cesspool, number: I _ Comments: (note condition of soil, signs of hydraulic-failure, level of ponding, condition of vegetation,etc.) CESSPOOLS: _ (locate on site plan) Number and configuration: 2 ACia cd05J � �'�ob11v > w k,' Depth-top of liquid to inlet invert: Depth of solids layer: /1" o n�"„ ddssru-aL Depth of scum layer: Dimensions of cesspool: � X 2r Materials of construction: 01&ek Indication of groundwater: iVant inflow (cesspool must be pumped as part of inspection) A/v CO S5 av .r evar L r Comments: (note condition of soil, signs, of hydraulic failure, level of ponding, condition of vegetation, etc.) �1a►=• cefss7oyL- /,a� ��'' so%�s t Oytr /urfi u�as ry a'f �dL�lr 1�he s7ii-, Gtf r., 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.) (revised 8/15/95) 8' i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 911" Z1,A. M�� Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' I / s6 20 y 7 5 J I V DEPTH-TO GROUNDWATER Depth to groundwater. 255 'r I feet 1 method of determination or approximation: (revised 8/15/95) 9 Real Estate System - General Property inquiry Help Parcel Id' 126 003- - Account No! 68508 Parent: Location; 516 RACE LANE MM Neighborhoods 20AC Fire Dist: CO Bevel Lot: Lot Sizes . 57 Acres Current Own: ELDRIDGE, RACHEL M TV-'-'. State Class2 101 %MARK J ELDRIDGE No. Bidgs, 1 Area: 7 6 516 RACE LANE Year Addeds MARSTONS MILLS MA 2648 Deed Date! 030192 References 7901/28 .,`. january Ist: ELDRIDGE, RACHEL M TR Deed MMDD: 0392 Deed ReW 7901 /28:2 Comments: Values: Land! 31500 Buildings! 38600 Extra Features'. Road System: 516 index: 1344 (RACE LANE ) Frntgl 105' . 1ndexN ) Frntg; Control Infou Last Auto Upd: 050695 Statusc C Last TACS Update: 082991, Land Reviewed By! Date! 0000 Bldgs Reviewed By MI,.... Bates 0189 Tax Title: Account: 5147 Takeng 072094 Account Status: Hold Statum Cancel Press XMT for more data Next screen PAR Action Owners Nane Road Index Road Name Parcel Number 126 004 MARSTONS MILLS LOCUS - RgCE PARCEL ID: 126/002 O1 , SHUBAEL 200.00 4 ` POND �oJ i P�'p ; ------------- o�p SOP t 76.3 UPOLE; ---;------------------- UTILITY 76.2 r. -- G---__ ' LOCUS MAP I' o PLAN REF: 145/33 & 298/12 _' ! DEED REF: 20002/138 ------- � ASSESSORS MAP 126 PARCEL 3 ZONING: "RF"DECK FLOOD ZONE: "C" TOP FND --� 12.5' PANEL: 001-0015—C DATED 08/19/89 INSIDE DOOR w __ \ � TBM=79.00 SHED' Z _ ___ Q -�� w __ G�� ° 77.1 SEPTIC SYSTEM ° N 0 REPAIR PLAN 00 e 77.3 � TP-2 N N LOCATED AT: Q 22.44' �-' 516 RACE LANE #516 ,____------_---38 M A R S TO N S MILLS, MA. W ----------------- TOF=79.00 ,, EXIST. LEACHING PREPARED FOR Q -4° ° ° _-- ---=- _ JASON 8c TINA LILLY ������������� EXIST. 1,500G - - - 2014 ------------------� MARCH 3, 77 7 SEPTIC TANK ; SHED N OF yqs E ? 77.3 D � R M. Gr No. 1140 ---, PARCEL ID: 1► 126/003 HOLLY 4 ,� � STEM 0 t SANITAR0a ��� 0. AREA=24,930t S.F. -4-�. HOLLY 1 0 77.2 i 76.9 TOP CB EL=77.80 -' 200.13 MEYER AND SONS INC. GRAPHIC p:SCALE� PARCEL ID: P.O. BOX 981 126/060 so o 10 20 � ` 40 eo EAST SANDWICH, MA. 02537 (508)362- 2922 ( IN FEET ) 1 inch = 20 ft. JOB# 1630 _ f T.O.F. NOTE: MAGNETIC TAPE TO BE PLACED OVER ALL COVERS NOTE: PLACE RISERS OVER ALL COVERS W/IN 6" OF GRADE FINISHED GRADE (77.0) EL: 79.00 F.G,EL: 77.3 F.G.EL: 77.3 F.G. EL: 77.0 A MAINTAIN 2% MIN SLOPE OVER LEACHING AREA :a Q ` 2" OF 3/8" DOUBLE WASHED 3/4" - 1-1/2" TOP TANK=EL. 76.38 STONE OR FILTER FABRIC DOUBLE WASHED STONE a 6" 4" SCH 40 PVC 7 ;a 10"1 6" ®®®®- O ®®®® 14> © S- 1% MIN.) ®®®®®®®®®®® A: TEE'S ARE TO BE INV.74.30 ` ' ®02150 ®®®® 4' SCH 4o PVC 2 EFF. DEPTH E3E300 ®®®®® ::�: � INV.75.05 IN V.74.1 4' 2 X 8.5' 4' J EXIST. INVERT GAS PROPOSED DB-3 , BAFFLE EFFECTIVE LENGTH = 25 _ :..... . DISTRIBUTION BOX INV. 75.30 INV. ELEV.= 73.80 EXIST. 1 ,500 GALLON SEPTIC TANK , OF GAS BAFFLE TO BE INSTALLED ON ���` Mgs�9c BREAKOUT OUTLET TEE AS MANUFACTURED BY DA E M ELEV.= 74.80 TUF-TITE, ZABEL, OR EQUAL TOP CONC. ELEV.= 74.80 rE3 11 INV. ELEV.= 73.80 ®®®®®NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING ®®®PIPE INVERTS PRIOR TO CONSTRUCTION FG/S1ER�`� ®®®2) D-BOX SHALL BE SET LEVEL AND TRUE ANITAR� BOTTOM EL.= 71 .80 ®®®TO GRADE ON A MECHANICALLY COMPACTED SIX 3.75' FT. 3.75' INCH CRUSHED STONE BASE, AS SPECIFIED IN 310 CMR 15.221(2) SEPARATION 6.0 FT. EFFECTIVE WIDTH = 12.5' 3) INSTALL INLET & OUTLET TEES AS REQUIRED SEPTIC SYSTEM PROFILE ADJUST. GRNDWATER EL: 65.80 4 SOIL ABSORPTION SYSTEM (SECTION) (500 GALLON LEACH CHAMBER) GENERAL NOTES: DESIGN CRITERIA 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL SOIL LOGS P#: 14300 BOARD OF HEALTH AND THE DESIGN ENGINEER. NUMBER OF BEDROOMS: 3 BEDROOOM DESIGN 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS SOIL TEXTURAL CLASS: CLASS 1 (0.74 GPD/SF) OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE DATE: FEBRUARY 26, 2014 LOCAL RULES AND REGULATIONS. DESIGN PERCOLATION RATE: <2 MIN/IN SOIL EVALUATOR: DARREN MEYER, CSE 1614 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR DAILY FLOW: 110 G.P.D. X 3 BR = DESIGN FLOW: 330 G.P.D. TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE WITNESS: DONNA MIORANDI, BARNSTABLE HEALTH DESIGN ENGINEER. GARBAGE GRINDER: NO (not designed for garbage grinder) 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING SEPTIC TANK: 330 gpd x 200% = 660 gpd, USE EXIST. 1,500 GAL. SEPTIC TANK FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN Elev. TP- 1 Depth Elev. TP-2 Depth ENGINEER BEFORE CONSTRUCTION CONTINUES. 76.8 0" 76.8 0" 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. A. A LEACHING AREA REQUIRED: (330) = 445.94 S.F. 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF LOAMY SAND t LOAMY SAND 74 THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF 10YR 3/2 10YR 3/2 HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. 76.05 9" t 76.05 9" B e USE TWO (2) 500 GALLON PRECAST LEACH CHAMBERS W/ 4' 7. WATER SUPPLY PROVIDED BY PRIVATE DRINKING WATER WELL. LOAMY SAND LOAMY STONE ON ENDS & 3.75' STONE ON SIDES: 25' L X 12.5' W x 2'D 8. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED 10YR 6/6 10YR 6/6 TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. 73.8 36" 73.8 36" BOTTOM AREA: 25' x 12.5'= 312.50 SF 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE C C THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING MEDIUM MEDIUM SIDE AREA: (25 + 12.5) X 2 X 2 = 150 SF CONSTRUCTION. SAND SAND 10. EXISTING LEACHING TO BE PUMPED, CRUSHED AND FILLED PER TITLE 5. 2.5Y 6/6 TOTAL SQUARE FEET PROVIDED = 462.50 vs. 445.94 REQ'D 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION PERC ® EL. 72.0 2.SY 6/6 DESIGN FLOW PROVIDED: 0.74(462.50 S.F.) = 342.25 G.P.D. vs. 330 G.P.D. req'd _ _ THIS PLAN 12 AND IS NOT STOOBEECONSIDERED A PROPERTY MINE SURVEEIs ONLY PROPOSED SEPTIC SYSTEM UPGRADE PLAN 13. NO ABUTTING PRIVATE WELLS WITHIN 150' OF PROPOSED LEACHING. 65.80 J' 132" 65.80 132" 516 RACE LANE, MARSTONS MILLS, MA 14. NO WETLANDS WITHIN 100' OF PROPOSED LEACHING. 15. ALL PIPING TO BE 4" SCH 40 ® 1/8-/FT (UNLESS SPECIFIED) PERC RATE <2 MIN/IN. ("C" HORIZON) Prepared for: Lilly NO GROUNDWATER OBSERVED ` i System Design and Topography Plan by: SCALE DRAWN • 1, Darren M. Meyer, R.S., CSE, hereby certify that I am currently approved by MADEP pursuant to 310 CMR 15.017 MEYER&SONS,INC. N.T.S. DMM to conduct soil evaluations and that the above analysis has been performed by me consistent with the PO BOX981 DATE CHECKED SHEET NO. requirements of 310 CMR 15.017. 1 further certify that Ifi hove passed the Soil Evol. Exam in October. 1999. EAST SANDWICH,MA 02537 i c 508-362-2922 03/03/14 DMM 2 of 2