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0528 RACE LANE - Health
528 Race Lane A= 126-463 —_. Marstons Mills NMI ■■■m■m■Q ■■■■■■■■■■■■■■■■■■■■■■i e■0.4 KNOWN■_ ■■■■■■■■■■■■■■■■■■■■■■■i ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■i ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■i ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■I ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■i ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ .■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■� ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■e ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■� ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ Commonwealth of Massachusetts �` O— �0a" �v Title 5 Official Inspection Form Ib Subsurface Sewage Disposal System Form Not for Voluntary Assessments V 528 Race Ln Property Address Owner Spell information is Owner's Name required for Marstons Mills ✓ Ma 02648 3-17-2020 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. Inspector Information ( N(e(e S� forms on the computer, use Douglas A Brown only the tab key Name of Inspector to move your D.A.Brown Inc cursor-do not Company Name use the return key. P.o Box 145 Company Address V`Rr� Centerville Ma 02632 City/Town State Zip Code 508-420-4534 S14297 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete.as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes < 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 3-17-2020 pector'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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. i Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 528 Race Ln Property Address Owner Spell information is Owner's Name required for Marstons Mills Ma 02648 3-17-2020 every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: System met or exceeded all passing requirements at time of inspection. This report can not predict the future performance under the same or increased usage. 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 528 Race Ln Property Address Owner Spell information is Owner's Name required for Marstons Mills Ma 02648 3-17-2020 every page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 i Commonwealth of Massachusetts ,/,p Title 5 Official Inspection Form III Subsurface Sewage Disposal System Form Not for Voluntary Assessments 528 Race Ln t.- Property Address Spell Owner Owner's Name information is required for Marstons Mills Ma 02648 3-17-2020 every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts �v lF Title 5 Official Inspection Form I' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 528 Race Ln Property Address Owner Spell information is Owner's Name required for Marstons Mills Ma 02648 3-17-2020 every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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. ❑ ® 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 water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts �v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 528 Race Ln Property Address Owner Spell information is Owner's Name required for Marstons Mills Ma 02648 3-17-2020 every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes" to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: 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? E ❑ 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? Z ❑ 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 528 Race Ln Property Address Owner Spell information is Owner's Name required for Marstons Mills Ma 02648 3-17-2020 every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 2 assessors DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: Not available at time of inspection Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts �n l Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 528 Race Ln Property Address Owner Spell information is Owner's Name required for Marstons Mills Ma 02648 3-17-2020 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owner stated pumping in june of 2020 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: 1500 gallons How was quantity pumped determined? tank truck Reason for pumping: maintenance t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I° Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 528 Race Ln Property Address Owner Spell information is Owner's Name required for Marstons Mills Ma 02648 3-17-2020 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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: 11-25-13 per as-built Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts �d I Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 528 Race Ln Property Address Owner Spell information is Owner's Name required for Marstons Mills Ma 02648 3-17-2020 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 2 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: 1500 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was clean (just pumped in June of 2020 ) t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts �m lR Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments u 528 Race Ln Property Address Owner Spell information is Owner's Name required for Marstons Mills Ma 02648 3-17-2020 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ' 41� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 528 Race Ln Property Address Owner Spell information is Owner's Name required for Marstons Mills Ma 02648 3-17-2020 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. 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.): Box was functioning properly at time of inspection. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts �n lg Title 5 Official Inspection Form III Subsurface Sewage Disposal System Form Not for Voluntary Assessments 528 Race Ln Property Address Owner Spell information is Owner's Name required for Marstons Mills Ma 02648 3-17-2020 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. 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 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 528 Race Ln V Property Address Owner Spell information is Owner's Name required for Marstons Mills Ma 02648 3-17-2020 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): One Chamber was opened and had only about 6 inches in the bottom. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts r Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form Not for Voluntary Assessments V 528 Race Ln Property Address Owner Spell information is Owner's Name required for Marstons Mills Ma 02648 3-17-2020 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 528 Race Ln Property Address Owner Spell information is Owner's Name required for Marstons Mills Ma 02648 3-17-2020 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 .� Commonwealth of Massachusetts �v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 528 Race Ln Property Address Owner Spell information is Owner's Name required for Marstons Mills Ma 02648 3-17-2020 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: greater than 5feet 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: 3-2020Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: design plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts IP Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form Not for Voluntary Assessments 528 Race Ln Property Address Owner Spell information is Owner's Name required for Marstons Mills Ma 02648 3-17-2020 every page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Assessing As-Built Cards Page 1 of 2 TOWN OF MONSTABLE LOCATION -,A Sf 14 C L= LA" SEWAGE# 00// VILLAGER,r,5t"o A-S M/c, c ASSESSOR'S MAP&PARCEL �O l -66 INSTALLER'S NAME&PHONE NO. (?a SEPTIC TANK CAPACITY / se o LEACHING FAC1T ITY:(type) he (size) 13 NO.OF BEDROOMS OWNER c = 7 S PERMIT DATE: fV v'Z/ J 3 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY A 1 t 500 A 3-s 1 r33- 0 0 13 . � I https://town.bamstable.ma.us/Departments/Assessing/Property_Values/HMdisplay.asp?ma... 3/18/2020 r Assessing As-Built Cards Page 2 of 2 https://town.bamstable.ma.us/Departments/Assessing/Property_Values/HMdisplay.asp?ma... 3/18/2020 lA Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments C-5 wM z 528 RACE LN Property Address u, HAYES I- .a Owner Owner's Name / information is required for MARSTONS MILLS I MA 02648 7-25-15 `1; every page. City/Town State Zip Code Date of Inspection .r, 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. Important:When filling out A. General Information forms on the 0qycomputer,use 1. Inspector: �, only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. D.A.BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE MA 02632 �d01 City(rown State Zip Code 508-420-4534 S14297 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: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 7-25-15 Ins ecto gnatu 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 conditiomO.use. l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 528 RAG--_ LN Property Address HAYES Owner Owner's Name information.is required for MARSTCNS MILLS MA 02648 7-25-15 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section U' 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 cGileria not evaluated are indicated below. Comments: HOUSE HAS BEEN VACANT SINCE THE SYSTEM WAS INSTALLED 142013 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. Chec<the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 528 RACE LN Property Address HAYES Owner Owner's Name information is required for MARSTONS MILLS MA 02648 7-25-15 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 528 RACE LN Property Address HAYES Owner Owner's Name information is required for MARSTONS MILLS MA 02648 7-25-15 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS_is.withiri 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded ❑ ® or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,. 528 RACE LN Property Address HAYES Owner Owner's Name information is required for MARSTONS MILLS MA 02648 7-25-15 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No El ® Required pumping more than 4 times in the,Iast.year,NUT 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 Zqne 1 ofa 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 abset*a :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 II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 528 RACE LN Property Address HAYES Owner Owner's Name information is required for MARSTONS MILLS MA 02648 7-25-15 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ ® Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 per owner DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 5 528 RACE LN Property Address HAYES Owner Owner's Name information is required for MARSTONS MILLS MA 02648 7-25-15 every page. Cityfrown State Zip Code Date of Inspection D. System Information Description: ACCORDING TO AS BUILT CARD SYSTEM CONSISTS OF A 1500 GALLON SEPTIC TANK D- BOX AND 2 500 GALLON CHAMBERS WITH 4 FT OF STONE Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection Yes No information in this report.) El Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: HOUSE VACANT Sump pump? ❑ Yes ❑ No Last date of occupancy: 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 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page'7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G M 5 528 RACE LN Property Address HAYES Owner Owner's Name information is required for MARSTONS MILLS MA 02648 7-25-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 528 RACE LN Property Address HAYES Owner Owner's Name information is required for MARSTONS MILLS MA 02648 7-25-15 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: SYSTEM INSTALLED IN NOV OF 2013 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 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.): J 9 9 ) Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) r If tank is metal, list age: years is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Sludge depth: 0 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 528 RACE LN Property Address HAYES j Owner Owner's Name information is required for MARSTONS MILLS MA 02648 7-25-15 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 0 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): SYSTEM WAS INSTALLED IN NOV 2013 AND THE HOUSE HAS NOT BEEN OCCUPIED Grease Traplocate on site plan): ( P ) Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 528 RACE LN Property Address HAYES Owner Owner's Name information is required for MARSTONS MILLS MA 02648 7-25-15 every page. Citylrown 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.): TANK WAS CLEAN AT TIME OF INSPECTION Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 528 RACE LN Property Address HAYES Owner Owner's Name information is required for MARSTONS MILLS MA 02648 7-25-15 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence df solids carryover, any evidence of leakage into or out of box, etc.): BOX LEVEL NO SIGNS OF LEAKAGE OR CARRY OVER Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑-1No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 528 RACE LN Property Address HAYES Owner Owner's Name information is required for MARSTONS MILLS MA 02648 7-25-15 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 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.): CHAMBERS WERE DRY AT TIME OF INSPECTION Cess pools (cesspool must be pumped as part of Inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 528 RACE LN Property Address HAYES Owner Owner's Name information is required for MARSTONS MILLS MA 02648 7-25-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 528 RACE LN Property Address HAYES Owner Owner's Name information is required for MARSTONS MILLS MA 02648 7-25-15 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 528 RACE LN Property Address HAYES Owner Owner's Name information is required for MARSTONS MILLS MA 02648 7-25-15 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: GREATER THAN 5 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: 7-2015Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: I Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 528 RACE LN Property Address HAYES Owner Owner's Name information is required for MARSTONS MILLS MA 02648 7-25-15 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 i . Assessing As-Built Cards Page 1 of 2 TOWN OF BMINSTABLE LOCATION gAcL- LA,VL-- SEWAGE# �� 3 �� VHI AGE,�o A —M is r ASSESSOR'S MAP.&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY ��p LEACHING FACILITY:(type) G(c 6,g bcr(size) 13 a NO.OF BEDROOMS owNER 7 =s PERMIT DATE: j COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility Of any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility Of any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY ' A� I 35' 1 A 3-3 1 133 f o a i3 3 http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=126002&seq=1 7/27/2015 1 -3-10 cmr�: DEPARTNIENT OF ENVIRONNENTAL PROTECTION aI 15.301'. continued �1f , (h) Bankntptcy. Inspection of the system must occur within two years prior to transfer by . , bankruptcy trustee to.buyer or within six months after.the.transfer,'provided that the.debtor ;,€ :• notifies the buyer in writing of the`requirements contained at 310 CIvIR•15.300 through ' 15,305 for inspection and upgrade,if necessary. An inspection conducted up to three}'ears -before the time of transfer may be used if the inspection report is accompanied by system pumping records demonstrating that the system has been pumped at least once a year during that time. (i) Change in Ownership or the Form or Ownership Where NeNv Parties are Introduced(e.g., ram, introduction of new beneficiarylies in a nominee trust;introduction of new jointtenant(s)or, new tenant(s).in common; introduction of.new parties where properly is transferring from •. • joint ownership to nominee or business trust,or.where a new general partner is introduced; . . creation of a legal life estate or an interest for life or fora term of years in trust for a party . other X. than the creator or his or her spouse;a m ch urge in the controlling ownership interest of . ! I a corporation, etc.). Inspection of the syste must occur within two years prior to transfer or if weather conditions prevent inspection at the time of transfer,the inspection must occur �., as soon as weather pert, ,but in no event.later than six'months after the transfer,provided. that the new party is notified in writing of the requirements contained at 310 CIvIR 15.300 through 15.305 for inspection and upgrade, if necessary... In.a nominee trust situation, whoever has authority to add a new beneficiary is responsible for the-inspection. An inspection conducted up to three years before the time of transfer may,be used if the. inspection report is accompanied by system pumping records demonstrating that the system has been pumped at least once a year during that time.' (4) Exclusions. Inspection of a system is not required at the time of transfer of title of the facility served by the system in the following circumstances: (a) a certificate of compliance for a new system has been issued by the Approving Authority within three years prior to the time of transfer and system pumping records demonstrate that the system was pumped at least once during the third year;or (b) the owner of the facility or the person acquiring title has signed an enforceable agreement with the Approving Authority to upgrade the system or to connect the facility to a sanitary sewer or a shared system within the next two years following the transfer of tide, provided that such agreement has been disclosed to and is binding on the-subsequent . owner(s);or (c) the facility is subject to a comprehensive local plan of on-site septic system inspection approved in writing by the Department and adnunistercd by a local or regional governmental entity,and the system has been inspected at the most recent time required by the plan. A comprehensive local plan may prioritize systems to be inspected on the basis of proximity . . 1 to water resources,. soil or'geological conditions, age•or size of systems, history *of • performance;frequency of pumping or other routine maintenance activity,or other relevant. factors, and may establish different schedules and-frequency of inspection on the basis of such criteria, provided that all systems are inspected at least once every seven years by a ' ' I System Inspector approved by the Department;or ' d the transfer is of residential real property between the following relationships: s i O. P P Y b !' 1. between current spouses; }' 2. between parents and their children; ` 3. be full siblings;and .4. where the grantor transfers the real property to be held in a revocable or irrevocable trust, where at least one of_the designated beneficiaries is of the first degree of ' relationship to the grantor. aI (5) A system shall be inspected prior to any change in the type of establishment,or increase in ., design flow,or prior to any expansion of use of the facility served for which a building permit or occupancy permit from the local building inspector is required. If the system is a cesspool, or if the system is failing as set forth in 310 CNIR 15.303 or 15.304(1)or is a significant threat j I ; to public health,safety,welfare and the environment as set forth in 310 CMR 15.304(2),then the system shall be upgraded prior to the change in the type of establishment,increase in design j flow or expansion of use of the facility. Prior to an increase in the design flow to any cesspool, ! or to any system above the existing approved capacity, the cesspool or the system shall be ! upgraded in accordance with the standards applicable to new construction. Whenever an 1,I addition to an existing structure which changes the footprint of a building with no increase in - . (. 9122/06 (Effective 4/21/06) corrected 310 CIVIR-550 No. Fee U THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. Y PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2ipfication for disposal 16pstem Construction 3permit Application for a Permit to Construct( ) Repair N Upgrade(/No Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. 5-`07&Rf<C I-A- Zi Owner's Name,Address,and Tel.No. ,f a�3�7-�13 Assessor's Map/Parcel �� ?j �B�r 7". 7 f X i Installer's Name,Address,and Tel.No. S -Z GU� Designer's Name'Address,and Tel.No. fow 57�i'T c>TJ �I/[:'`� ��, F/d✓t°� Qrl, d !7Z Ott �✓!G UL 67 Type of Building: Dwelling No.of Bedrooms �^ Lot Size 7i , sq.R Garbage Grinder( ) Other Type of Building No.of Persons 7— Showers( ) Cafeteria( ) Other Fixtures /�.a,o•�Ly Design Flow(min.required) ZZO gpd _ Design flow provided gpd Plan- Date do V // Z-01 Number of sheets Revision Date Title :: P . S 1 V Pe-4 Size of Septic Tank G-7 Cp Type of S.A.S. 2 C $ Description of Soil a<f VI GOF3Y /�o dti° Nature of Repairs or Alteration (Ans)''er when applicable) !s w S. a - B �j Al 6 Z_ �'7U�Zv -�1a*zD.eil 4- o1Vo.,. / 2� 2 - 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 ace the system in operation until a Certificate of Compliance has been issued by this Board of Health. Sign Date l Z 3 Application Approved by Date Application Disapproved by Date for the following reasons Permit No. >i �y�z Date Issued t -- ---------------------------------------------------- -------•-------•--------------- - ---- ------ ------ ---- ----- --- - --- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,N[ASSACHUSETTS -- Certificate of tompuance THIS IS TO CER ,�tha�tthe On-site Sewage Disposal system Constructed( ) Repaired( -r Upgraded( ) Abandoned( ),by at has been constructed in accordance with the provisio f Title 5 and th for Disposal System Construction Permit No. Q 13' dated i / Installer , M /- P.Gt - Designer v #bedrooms Z Approved esip 8\w, 3 gpd The issuance of this permit not�i construed as a guarantee that the system will functi esi d Date � � �/ Inspector CONCRETE� BOUND LOCUS DATA `°U _P u HELD N. OF F CURRENT OWNER JOSEPFI P. HOGAN ` EDWARO PLAN REFERENCE 298/12 STOtaE Al l� 5867-096 DEED REFERENCE c, -•� _ }1 VgV2'p0 z ZONING DISTRICT RF /f �x 11 lI" -- �• l BENCHMARK: COR FLOOD ZONE C OF CONCRETE WALK ELEV. 74.00 N- -�t _ r ASSESSORS HAP126 PARCEL 002 ( unuTr OVERLAY DISTRICT NOT A ZONE II POLE LOT AREA 26.427 S.F. o. _- EXISTING CESSPOOL TO BE Ot•cn 11. PUMPED. CRUSHED AND I rC�r7 �__ —` GARAGE ABA,JDONEp IN ACCOROA:_,CE (,J WTH TITLE 5 �� EXISTING —� SITE & SEWAGE _ — __ DRIVEWAY REPAIR PLAN -11528 � °o f— RA CE L A NE frJ O I IN / _o f .. �• I MARSTONS MILLS � Eti ST°,G �- --� � D.T.H. nl DATE: OV i1, 2013 DECK 2 BEDROOM / pprL•LLItJG DECK REMOVED AV' J OWNER/APPLICANT: Mr. ROBERT HAGGYES o ERs BOXR'n P.O. 0X 7t>7 I �' »5'= / / \,- _ POSED tt - MARSTONS Iv11LLS LEACHING 1_ . , LEACHING C �15 /'. r� PRO?OSED CHAMBER MA 0 26 4 8 1 ( SEPT GALLON' S.A.S. JL 'It' SEPTIC TArdFj / ` SHEET 1 OF 2 11 � j � I LOCUS 1 1 P� r •100 O� v rYrt PREPARED BY: 1 / 6 LOT RACE LArJ- EAS SURVEY, INC. •2e.427� S.F. 1 VI S R T. 6 A / o zo so 40 P.O. BOX 1729 11 — —� - t SANDWICH MA 02563 —1 �'� �� � — � \� y �(_< �, 1 / 4!��` l�' GRAPHIC SCALE: , LOCUS 1, PI-I. (508) 888-3619 7 1 �'� L' G�r 't'h t1{ �( 1 INr.0 = �n Fcr.r t /Gno\ �•>>_ zr_nn �'>1,r rn L •I I' 1 i TOWN OF BARNSTABLE LOCATION 3722 /a A cL L A AILE SEWAGE# 00/ VILLAGE/yM el,Tro LLS ASSESSOR'S MAP&PARCEL �Q ^0 INSTALLER'S NAME&PHONE NO. 00�� �u u /,-1 s Gi e,t— SEPTIC TANK CAPACITY / SU O LEACHING FACILITY:(type) S c u bcf,(size) 1 3 NO.OF BEDROOMS OWNER a O t A =5 hh PERMIT DATE: COMPLIANCE DATE: ✓ Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on` site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY t--iA C 71no 1 S O6 s o i A 3 - Ti 133- -4y4„ O o i3 No. �63 Fee U THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ii// PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 9ppliLAtion for bisposal *pstrm Const union 3pPrmit Application for a Permit to Construct( ) Repair¢(} Upgrade(� Abandon( ) Complete System ❑Individual Components ZF Location Address or Lot No. G7 ICJ � l L A-412:57' Owner's Name,Address,and Tel.No. ,��/�i� QS Pv4r 7G 7 _Assessor's Map/Parcel f�p—dD 7i M'lM!/ e. Installer's Name,Address,and Tel.No. —y GO Designer's Name,Address,and Tel.No. �w-5�7;6cz Type of Building: of Q�en 'ZOn2 )A Ipl-GQlvlG/� � r1Lt�67 Dwelling No.of Bedrooms Z^ Lot Size _7 Z- sq.ft. Garbage Grinder( ) Other Type of Building h2&?A- No.of Persons Showers( ) Cafeteria( ) Other Fixtures [Z._t,,q Design Flow(min.required) gpd Design flow provided gpd Plan Date /Vo 1/ Number of sheets 7i' Revision Date Title K ®L Size of Septic Tank l G �l Type of S.A.S. 2 C $ Description of Soil (:f Aeo,2 o !2V/e z� "��tiJ� V Nature of Repairs or Alterations(Ans(y✓er when applicable) ���0 �- - ✓�U/-f2c� G�d�LFle�l ¢ .�p c7VOn -1 3?C 2- Date Past 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 t. ace the system in operation until a Certificate of Compliance has been issued by this Board of Health. Sign Date Z 3 Application Approved by A Date Application Disapproved by Date for the following reasons Permit No. J z Date Issued )-t - W----- e No. 13 -6'26) Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer f PUBLIC HEALTH DIVISION--TOWN OF BARNSTABLE, MASSACHUSETTS Yes tl�ltat l for_ Isposak*,stein (to ttstruttlou Vermit Application for a Permit to Construct( ). Repair Upgrade( j("Abandon( ) Complete System ❑Individual Components Location Address or Lot No. c--- A4/4;F- Owner's Name,Address,and Tel.No. Assessor's Map/Parcel �� bG Z M'W /( ��' �� (i Pj 6/4X 7,17 Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. x✓z, S//�'d /� n is/ f SU 2 t/c:� �w���d✓��G/1J art �4 Type of Building: �f��•,n 7 /�k I L Dwelling No..&Be rooms _of Size - Z sq.ft. Garbage Grinder( ) I Other Type of Building Si4�e. � No.of Persons Showers( ) Cafeteria( ) Other F,.tunes U,4 Design Flow(min.required) ZZO gpd Design flow_ ro 'ded '- SSr gpd Plan Date Number of sheets 1/ Revision Date Title �, Size of Septic Tank SSG �,C/' Type of S.A.S. Description of Soil e 1 V l�3V aG ;-a ve /G Nature of Repairs or Alterations(Ans�`er when applicable) S vv S- `>�j 71,- 6 Z eI r 't/�4 /S oh( �V�� I i Date last inspected: Agreement: hThe 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 t lace the system in operation until a Certificate of Compliance-has been issued by this Board of Health. Signer " 4 ' 1 Date / Z AY3 Application Approved by l % Date Application Disapproved by Date for the following reasons Permit No. 201 3 Date Issued a ! / P - THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTI Y,that the On-site Sewage Disposal system Constructed( ) Repaired( -1--Upgraded( ) Abandoned( )by P a T`- at S � �•'/« LH has been constructed in accordance l with the provisions f�TTitle 5 and the for Disposal System Construction Permit No. -6(3'`/L3dated �� ! / Installer Designer E_ v � #bedrooms 2 Approved design fl f. S 3 gpd The issuance of this permit shall not a construed as a guarantee that the system will fiu►o n as designed. Date ! �� - Inspector ----------------!-------/-/----------------------------------------------------------------------------------------------Gv------------ k No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS B1stlOsal bpSte onstruttion Permit Permission is hereby granted to Construct( )�1 Repair( ) Upgrade( ) Abandon( ) System located at Sr�t'/� Z" 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:Constructi mutt be completed within three years of the date of this permit. Date t f I Approved by J �f TOWN OF BARNSTABLE LOCATION l �GL L L sl � SEWAGE# / yG VILLLAGE./yj a 41 5E0 y S ,y/4.1c ASSESSOR'S MAP.&PARCEL_�0 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY / o p LEACHING FACILITY:(type) - S a o r_4 c G,n nt b-r(size) j 3 NO.OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE: c 5 �� Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on, site.or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY I � qC 0 1506 I A 3-s:j 133--�Y�', L Town.of Barnstable SINE r� Regulatory Services ti 0;6 Thomas F. Geiler,Director BARN3IABLE. » Public Health Division , n39- Ikk Thomas McKean,Director ' 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 �&i3- �63, Date: -Z.fnc Sewage Permit I Assessor's Map/Parcel /Z4o — GoZ Installer & Designer Certification Form Designer: Installer: %?OPAI&' }o FIVI C R Address: �y/�d `�2� Address: �;Wbo✓ic/J, M4 02 S4 3 g )(On l _ ? - /3 ��urJ�✓�� f'1Slf�/Z was issued a permit to install a (date) (installer) septic system at �"26 �(, � � 4111AIS'elS based on a design drawn by (address) ql( dated !/—/l /-3 (designer) xI certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Stripout (if requ' ® ected and the soils were ound satisfactory. o� DAVID y�N D. �-A / G f FLAHERTY, JR. I staller's ST r No. 1211 R��rsTE��`o (Designer's Signa (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. gAoffice forms\designercertification form.doc Town of Barnstable P# Department of Regulatory Services ., Public Health Division Date l 1659. , 200 Main Street,Hyannis MA 026 . lFD AAA A r Date Scheduled ime . Fee d O _ � . ID Soil S di ility Assessmentfor S Dis Performed B : y Witnessed By: (/ LOCATION& GENERAL INFORMATION Location AddressFjr Owner's Name Address C�S,s Assessor's Map/Parcel: t f L o0 Z. Engineer's Name NEW CONSTRUCTION REPAIR ne L�� _564z � Telepho # 2 3 GOiC� Land Us6 l 1��� Slopes('90) l alb Surface StoStlt�t/ (�0.0 CC.'yy nes Distances from: Open Water Bodyft Possible Wet Area _ft Drinking Water Well __4�6ift Drainage Wayft Property Line f[ Other ft ftd AL 5 DD SKETCH:(Street name dimensions of lot exact � locations of test holes&Pere tests,locate wetlands in proxinuty to holes) / w ZE �uQ'i3��r� tom► I z8K M �✓ s2? G f ! � Parent material(geologic) /C�bd/ Depth to Bedrock IU/4- Depth to Groundwater. Standing Water in Hole: ti (3 Weeping from Pit trace A/04A� Estimated Seasonal High Groundwater DEErvrd E ATIO FOR SEASONAL BIIGH WATER TABLE, Method Used: — pDepth O standin in obs.hole: w In, Depth to soil mottles: In, Depth to weeping from side ofAo`bs,A hole: In, Groundwater ustment t1a^,U Index Well# Reading Date: Index Well level .ti Adj.factor 6 A Jj.Oroundwater Level PERCOLATdON TEST Date Time /?�f Observation Hole# Z Time at 9" Z`/Z_ Depth of Pere �¢ Time at 6" a Z� Start Pre-soak Time @ Time(9"-6") �'// /�l End Pre-soak Rate Min./Inch � G Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(YIN) Originai: Public Health Division Observation Hole Data To Be Completed on Back------= ***Tf percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one (1) week prior to beginning. Q:�s E rr[c�rERcroRM.DOc DEEP OBSEIIVAT'ION HOLE LOG -Hole# / Y ( 74- 5' Depth from Soil Horizon Soil Texture Sdil Color Soil . Other Stufaee(in.) (USDA) (Munsell) Mottling (Stnuchtre,Stones;Boulders. onsistency %T3ravel) 2e- ,L`� DEEP OBSERVATION HOLE LOG dole# 2 x , 7W- Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. onsisten % ravel 26 DEEP OBSERVATION DOLE LOG hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling, (Structure,Stones,Boulders. Consistency. Gravel) i i ' DEEP OBSERVATION BOLE LOG hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders, Consistency, 6 a Flood Insurance hate Map: / T Above 500 year flood boundary No_ Yes ✓ Within 500 year boundary No_ Yes Within 100 year flood boundary No,. Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring perviou aterial exist in all areas observed throughout the area proposed for the soil absorption system? QS If not,what is the depth of naturally occurring pervious material? Certification I certify that on P+ 9f (date)I have passed the soil evaluator examination approved by the Department of Env ronmental Protection and that the above analysis was performed by me consistent with the required trai ' ,e ertise a e per' ce escriW in 10 CMR 15.017. Signatu Date Q:W EPT1C\PBRCPORM.DOC L i 5.-8 Race Lane, MM Page 2 of 2 Subject: 528 Race Lane, MM Hi Bob, The records I have show a visit to the subject property to meet with you during December 2013. This visit was to address some of the questions you had about the property and the extent of the work you may be involved with. On the first floor we discussed a floor repair and the front bedroom. You then showed me the unpermitted second floor areas that existed. It appeared that that area was finished some time ago and needed to be addressed. This house shows a construction date of 1945 and the work that had been done could have dated back to the 1960's but could not be determined. I agreed that removing the ceiling finish, re-insulating the rafter bays and reapplying sheetrock was the only was to proceed. This work was done along with the first floor and it passed the required inspections. This should clear up any confusion. Robert McKechnie Local Inspector Building Department Town of Barnstable 200 Main Street Hyannis, MA 02601 508-862-4033 Diane Wurzburg - For me, it's all about you! 585-259-0455 Licensed Real Estate Agent, Accredited Buyers Agent Keller Williams Realty 7/14/2015 w28 Race Lane, MM Page 1 of 2 Crocker, Sharon From: Mark Spell [markspell@hotmail.com] Sent: Tuesday, July 14, 2015 11:21 AM To: Crocker,,Sharon Subject: Fwd: 528 Race Lane, MM Mark Spell Begin forwarded message: From: cbyrne100 <cbyrnel00gaol.com> Date: June 29, 2015 at 14:32:34 EDT To: Mark Spell <markspell@hotmail.com> Subject: Fw: Fwd: 528 Race Lane, MM Mark, Please see the email to the seller from the town inspector! I suggest we print it out and have it placed in the file at town hall. I will see you tomorrow at 3:30. Cheers Chris Sent born my P-Mobile dG I:I..Device -------- Original message -------- From: Diane Wurzburg Date:06/29/2015 12:33 PM (GMT-05:00) To: Chris Byrne Subject: Fw: Fwd: 528 Race Lane, MM -----Forwarded Message----- From: Robert Sent: Jun 29, 2015 12:03 PM To: "dwurzburg(c earthlink.net" Cc: bobhayesco(@comcast.net Subject: Fwd: 528 Race Lane, MM Sent from my iPhone Begin forwarded message: From: "Mckechnie, Robert" <Robert.McKechnie(a.town.barnstable.ma.us> Date: June 29, 2015, 11:27:33 AM EDT To: <bobhayesco .comcast.net> 7/14/2015 t A No.---z ........ Fl�g..l�.. ........ THE COMMONWEALTH OF MASSACHUSETTS OZ BOARD PF HE L H _. ....---- --.OF....... .. ... ..... ..... - '.............- ......... Appliration -for BiBpoottl Workii Tomitrurtion Vrrm t ,. Application is hereby made for a Permit to Construct (V�or Repair ( ) an Individual Sewage Disposal System at: .......4�1--•y-..... kv.................... Location-Address or Lot No. -- iti-Uw.....co e---------•---•-----•------------------- ...7.............................................................................................. O"caper ----------------------------•--•---•--------Address Installer Address Q Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.... '-----------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons_.-__-_.---.----.--_----_- Showers ( /) — Cafeteria ( ) a' Other fixtures ---------------------------- P4 Desgc T loik-----Li t-ca acity. .�00 gallons allons p r pens n per day. Ta lal%daily flow............. 0_ ...............gallons. 1 L q P / g" a ->-------_---- Diameter---------------- Depth--------------- Dis osal Trench—No..................... Width-_---____---_-._-_-- To al�en th_-_-_:_ x p ` �� g ............. Total leaching area..._._-..._...___.Sq. ft. Seepage Pit No..... ------------- Diameter....p q®A..."eptti below 'nlet_.... _._._ :._ -Total acliin area..---------------- it. Z Other Distribution box (✓S Dosing tank ( a 7 ~" Percolation Test Results Performed by-7 -- -- _ - •--•----------------•------•--------- Date--- '_J�.' 7�--------.-. a Test Pit No. 1................minutes per inch D pth of l'es lt_-._______________-. Depth to ground water----------._--.--.-__._. fX4 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water.-.-.-._-_-__---.-_--._. O Description of Soil-----------Q.`_ .r.... ------ F � ` VW ------------------------------------ --------------------------------------------------------------------------------------------------------------------------------------------- ------------------- Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ ----------------------------- ------------------------------------------------------------------------------------------------------------- -----------------------------------------------------------. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issue by the bo d of alth. Signed-- ----- �j Date Application Approved By.----- /��(�---- /A44 ---------------------------- _S D.7-- ------ Date Application Disapproved for the following reasons:----••..........................••-•----•--•---••-----••--------------•-.........-------------------•••--......- ...........................................................-------------••-•-------------•-------------•----------------•-------•----••---•-------•------------.-------------------------------------•- Date Permit No......................................................... Issued----../4)..�'/Z- - Z Date A�- No.... .. ........ FEE.. �..."�`J......... THE COMMONWEALTH OF MASSACHUSETTS BOARD 9F HE LTH OF....... - Appliration -for Ui,ipoiittl Mirkfi Totti#rurtiott Urrutit Application is hereby made for a Permit to Construct (✓�or Repair ( ) an Individual Sewage Disposal System at: - , 1 y^ Locationn'-Address or Lot No. Owner Address a /�; l rya/Z� . L -----•---•---•--------••-----------•---- -•--•------••----•-•---••-----•---------•-. Installer Address Q Type of Building. Size Lot............................Sq. feet U Dwelling—No. of Bedrooms--------c—................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons---------------------------- Showers ( /) — Cafeteria ( ) a d Other fixtures ......................................................-----------•--------------------------•--------•--•--•-•------•-------•-------------•---------- w Design Flow......... ()...........................gallons per person per day: Total daily flow.................�G. .._......._..._gallons. 9 Septic Tank L Liquid capacity._ -i-e�gallons Length___-_________ Width------.......... Diameter................ Depth---------------- xDisposal Trench—No- --------------------- Width-------------------- Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No----- ______________ Diameter____ �Stx__-:-- Depthfbelow inlet.... __,_... Total leaching area-------------.___ 1._sc ft. z Other Distribution box (4 Dosing tank Percolation Test Results Performed by.7 _:_., .. 1��1.................................... Date_-_cCf_'. _'. _5_-_______.. Test Pit No. I................minutes per inch Depth of Test/Pit--._-_______--____-. Depth to ground water..-._.__---__-._-.-..._. w Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------------ ------------------------------------------------------------------------------------------------------------------•----------------•-----•------------------- 0 Description of Soil------------------------------------------------------------------------------------------------------------------------ ----•-------------------------------••-•----- x U --------------•-•---------•--------------------------•--------•••-•--••-------------•--•----------•--•--------••-------•--......-------•--•----•---------------- -------------------------------------- w VNature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ ------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sig ned__ J_/�!.�1/ ----�-�- %G- � ---------------'---- - --- _- Date r � C7------------------------ 5 --- Application Approved BY _ -- _- - ... - -'------ Date Application Disapproved for the following reasons:................................................................................................................ ----------•------------•--•-----•---•-----------------------•-----•-----------------•--------------- Date PermitNo------------_------------------------------------------ Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH o-4V1_............OF........... /i�L/L................................................ Q.T.Pr#ifirate of Tnmplitturr TH�S IS TO CFxRTI�%1Y, TXthndividual Sewage Disposal System constructed (� or Repaired ( ) by ........................... �' Install r / at...Keen ` �....11 �G G/ = 1� �.�_.�411i1� �_._-------- ��/-�tA `� �'r�Z �- has installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No._._z_.7.j........................ dated. . ............. THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUE© AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. -- - s. -- DATE .... Inspector -•--•--•--•3---.....-- ------------•------------------------- THE COMMONWEALTH OF MASSACHUSETTS 75• BOARD OF HEALTH ....... . (fl�l............OF.......... ..CC -L % ✓ wd a73 — No......................... FEE-•---f.............. note#rttr�' tt �rrutif Permission is hereby granted!....... °'l - t f� "�1 -----....-•---•-------------------- to Construct ' or Re it ( ) an Individual- Sewa e Disposal Sy, em at No.- = r'` � ! {��' �!.a...__ �"►. .�`f_v---------------------------t—/...'� �. Street as shown on the application for Disposal Works Construction 1titNN,o G / — __ Dated---.-�E --'--G----------'...-------•- >---------------------------------------- Board o ealth DATE----0 ( ----------- ............... FORM 1255 HOSES & WARREN. INC.. PUBLISHERS L I- -�-r' .- - .- , �.-- � -7- I , .. , , -- --.'�'.��-' -- -o�f..' . -t� �, ;. . --. �I -, �% '- -ow,I..I'. 11., - , ---' ,--� '. , .,. , .- - , - " -�%�'i.-*"-ia'�",'i�--.-�:-';:�:�''--- -'�;'�.�-'-----t'*71 i� -, �.�� . , . ' ` ,1 37� ��: 1 -. M". ,�- - . , � I '. I.- "I -..'.'�- --�" , - , � I tl� .- . 1, � .-- . . - -�-- , -� -- - I -� ',- -----,.� -, �.' I . . , � '. . 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'�It 1 - t es , - i �' -' -.... WW ..'l 7 6-8 —-9C,oWA1,F. o ,r� � .I - ..� .- - - 1. 4�-- � . -.� � t.r1 1_ 74 _. _ _ _ __'- 7a.V1 I t 4 F - Ii � � Al"rC - ?CC E—XS I, d-9—SClEA. -.i� -I e-I ' -- I -�- . 1 I - , 1. % — * _ . � e Aa3 =� ?5 V //&. 5o' V . i I. - '. cE. R-T 1 FI EID -P-L 0T ' P L A N 4 ,L 0 T,I 0W. ''W qZ$ -=: '" Mle es $t kL.E. /'-- I b T E' '7 "I7 - A E E.N ✓ :� ,,/ 'z g: - �'�A"I-1 . . %I V,'A7.,; 7am.19Ay _ P'jeeCZ ,r.14? 7 7 -/ E H R E 8.Y CERTIFY, r H AT THE 8 U' I L D I N G R E G L_ A D 5"U-IIP4rE.1 : ' q' 4 6 N1I r H I- P-L. A N 1 S: L,0._ A T E D'-..'q.'N . , . j �;t E G . oV-ND ASr:SHOWN HEREON A' ND . HAT , I - . I c.0 N F .0RM _ r o Tk E jo Id 8y LAWS 6 � THE TOWN 0F ���p�tNUFMgfgy - r ' - WHE N C0NS�T CT E D ` o ! , - E. R ; 'i - I , -4 o' QW_JR 9m� J' - 7� A- -S L E S pVE" c NI S AJ L T'A I-NrTS-# I 'NZ p IM-it 0 y WE3T ,YAAM0UT� ��AA4S 0R7 * -- ' I - l I I II �- ,- I ' � -. 1 . l ��I I- : 1 LOCUS DATA CONCRETE BOUND FOUND & HELD N �ZN OF Mass CURRENT OWNER JOSEPH P. HOGAN o`'� EDWARD9cyG�, A PLAN REFERENCE 298/12 STONE o No. 28 DEED REFERENCE 8867-096 �ts e0 '� N 1812 00„ E 199 51 ZONING DISTRICT RF �� � � ��✓ P BENCHMARK: CORNER �-- FLOOD ZONE C J OF CONCRETE WALK " `74` ELEV. 74.00 N ASSESSORS MAP 126 I PARCEL 002 S UTILITY ' OVERLAY DISTRICT NOT A ZONE II POLE � f LOT AREA 26,427t S.F. 0 EXISTING CESSPOOL TO BE cA Rh'F _ — PUMPED, CRUSHED AND o ,4D GARAGE ABANDONED IN ACCORDANCE EXISTING WITH TITLE 5 r^ SITE & SEWAGE _ - - DRIVEWAY N REPAIR PLAN _ - - - - - - - - - - 1 ' '"- _ #528 CO RACE L A NE ����' H AD 13 IN MARSTONS MILLS #528 EXISTING D.T.H. #1 DATE: NOV 11 , 2013 2 BEDROOM DECK/ DECK o DWELLING o TO BE ;.:. OWNER/APPLICANT: / REMOVED 41 D.T.H. #2 Mr. ROBERT HAYES o � P. O. BOX 767 MARSTONS MILLS 45�t / PROPOSED H-20 PROPOSED LEACHING MA 02648 15UU GALLON CHAMBER SHEET 1 OF 2 1 -� kIr SEPTIC TANK 25.0' x 13.0' LOCUS PREPARED BY: 11 vPS L Q T 1 700.00il\ E A S SURVEY, INC. 1 �P5 26,427t S.F. I S 13 5���0„ w o RACE LANE N 141 RT. 6A 1 ''� W P . O. BOX 1729 1 0 20 30 40 SANDWICH , MA 02563 1 Li 28 PH. 508 888-3619 2 1 / GRAPHIC SCALE: LOCUS MAP CELL (508) 527-3600 f�i� 1 INCH = 20 FEET NOT TO SCALE: i SYSTEM DESIGN RAISE COVERS TO WITHIN 6" OF FINISH GRADE ONE RISER DESIGN FLOW TCF = 75.22 FINISH GRADE ' RAISE TO WITHIN 6" 2 BEDROOMS AT 110 GPB/D 220 GPD GRADE 74.5 ELEV. 74.4 FINISH GRADE OF FINISH GRADE ELEV. 74.3 2 BEDROOM EXISTING TO REMAIN ELEV. 74.2 GROUND ELEVATION 74.0 REQUIRED SEPTIC TANK 2.2' COVER 2' COVER TOP ELEV 72.0 2" MIN 1/8"-1/4" ___22_0x_2___ - _ _ 440 GAL. .1 22' OF 4" PVC ® 0. 3 10'®S=0.057 DOUBLE WASHED SEPTIC TANK PROVIDED = _1500 _GAL. C.O. SCH 40 4" PVC SCH 40 5' CADS= 0.02 O O 0 0 0 00000 o PEA STONE INV.= 2 MIS x T :v INV•= 72.70 O O 0 O O O OR FILTER FABRIC 72.04 10"TEE 14"TEE INV.= O 0 O 0 i� SIZE OF LEACHING FACILITY REQUIRED � '«�. EXISTING 71.84 O OO OO o o O OO OO 3 4" DOUBLE TO REMAIN 5�_7�� INSTALL 7INV.I= 0. O O 0 0 / 1 " GAS BAFFLE OUTLET TWO 5'-0"x8'-6"x3'-O" CHAMBERS WASHED STONE DESIGN PERC RATE - 3 -----MIN./INCH 4'-6 /2 4'-1" LIQUID LEVEL 0 D83 INV.=71.00 H-20 / 4' OF STONE ALL AROUND > LONG TERM APPL. RATE_2•74_GPD/S.F. 71.27 Ci S.A.S. (13.0' x 25.0') a SIZE OF LEACHING SYSTEM PROVIDED: INV.=71.10 DATUM: BOT. \jN OF A 69.0 220 _ 0.74 SF/GPD = 298 S.F. MIN. REQ. a o a o 67.5 cs v VERTICAL DATUM: PROPOSED 1,500 GALLON , MSL± / BARNSTABLE GIS H-10 SEPTIC TANK SET ON D I G DEEP TH #1 BOTTOM 61.5 USING 2 CHAMBERS WITH 4 STONE AROUND BENCH MARK USED: LEVEL STABLE BASE NO GROUNDWATER ENCOUNTERED CORNER OF CONCRETE J SIDEWALL = 2(13.0+25.0') x 2 = 152 S.F. WALK ELEVATION 74.00 • 12 BOTTOM = 13.0' x 25.0' = 325 S.F. CONSTRUCTION NOTES: PF �p_ TOTAL LEACHING AREA = 477S.F. 13-0139 ��STf-R 477 S.F x 0.74 = 353 GPD 1. CONTRACTORS / INSTALLERS SHALL VERIFY GRADES AND S"NIT W, ELEVATIONS AND SITE CONDITIONS PRIOR TO COMMENCING 353 GPD PROVIDED > 220 GPD REQUIRED = SITE & SEWAGE WORK ON THE SITE. ` 133 GPD RESERVE 2. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE REPAIR PLAN WITH DEEDED OR ZONING REGULATIONS. OWNER / APPLICANT NO (GARBAGE DISPOSAL / GRINDER ALLOWED) IS TO OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. , 528 3. VEHICULAR TRAFFIC, PARKING OF VEHICLES AND PLACING MATERIALS OVER THE SEPTIC TANK, DISTRIBUTION BOX AND D.T.H. #1 ib D.T.H. #2 0 S.A.S. AREA IS PROHIBITED DATE: OCT. 30, 2013 DATE: OCT. 30, 2013 RA CE LANE GROUND ELEV. 74.5 GROUND ELEV. 74.5 GENERAL NOTES: NO GROUNDWATER NO GROUNDWATER IN 1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. TITLE V AND THE TOWN OF BARNSTABLE RULES AND REGULATIONS i CERTIFY THAT I AM CURRENTLY APPROVED BY THE A A M A R S TO N S MILLS FOR SUBSURFACE DISPOSAL OF SEWERAGE. DEPARTMENT OF ENVIRONMENTAL PROTECTION TO CONDUCT LOAMY SAND LOAMY SAND 2. AT LEAST ONE ACCESS POINT OVER TANK TEES SHALL BE SOIL EVALUATIONS AND THAT THE RESULTS OF MY SOIL 10YR 5/6 10YR 5/6 DATE: NOV 11 , 2013 ACCESSIBLE WITHIN 3" OF FINISH GRADE, WITH ANY REMAINING' EVALUATION ARE ACCURATE AND IN ACCORDANCE WITH 310 g" 8" ACCESS PORTS BROUGHT TO WITHIN 12" OF FINISH GRADE. CMR 1 0-THRO VG 1 107 B B 3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE LOAMY SAND LOAMY SAND CAPABLE OF WITHSTANDING H-10 LOADING UNLESS --- ------------- 10YR 6/6 10YR 6/6 OWNER/APPLICANT: OTHERWISE SPECIFIED. RDA STONE, CERT IED SOIL EVALUATOR „ „ Mr. ROBERT HAYES 4. THE EXCAVATION CONTRACTOR SHALL VERIFY THE LOCATION EL. = 72.2 28 EL. = 72.3 26 OF ALL UTILITIES PRIOR TO ANY EXCAVATION. P.O. BOX 767 5. ANY MASONRY UNITS USED TO BRING COVERS TO GRADE INDICATES DEEP OR WITHIN 6" OF GRADE SHALL BE MORTARED IN PLACE. I' DTH #1 ib TEST HOLE 6. FINISH GRADE SHALL HAVE A MINIMUM OF 0.02 FEET PER 1' 64" M AR S TON S MILLS FOOT OVER THE S.A.S. AND DISTRIBUTION BOX. MA 02648 7. SEPTIC TANK SANITARY TEE'S SHALL BE CONSTRUCTED OF t, INDICATES COARSE SAND COARSE SAND SCHEDULE 40 PVC AND SHALL EXTEND A MINIMUM OF 6" ABOVE P-1 64" PERC TEST THE FLOW LINE AND SHALL BE ON THE CENTERLINE AND ' 2.5Y 7/4 2.5Y 7/4 SHEET 2 OF 2 �� 10% GRAVEL 10% GRAVEL LOCATED DIRECTLY UNDER THE CLEAN OUT MANHOLES. I NO MOTTLING 10% STONE 10% STONE 8. THE INLET PIPE INVERT ELEVATION SHALL BE NO LESS THAN PREPARED BY: 2 INCHES NOR MORE THAN 3 INCHES ABOVE THE INVERT NO WEEPING NO G.WATER NO G.WATER ELEVATION OF THE OUTLET PIPE. 156" INDICATES ADJ. GROUNDWATER EL. = 61.5 156" EL. = 62.5 144 E A S SURVEY INC. 9• THE SEPTIC TANK SHALL HAVE A MINIMUM COVER OF 9 INCHES 10. THE OUTLET SANITARY TEE SHALL BE EQUIPPED WITH A GAS NO OBS. GROUNDWATER B.O.H. P#14181 141 R T. 6 A 11.BAFFLE, PIPES INCHES SHALL BE SCHEDULEI A40 PVND OC SEWER PIPE NSTRUCTED FAND PVC DONNA MIORANDI S SHALL BE SLOPED 1/4 INCH PER FOOT MIN. EXCEPT FOR THEM NO OBSERVED GROUNDWATER SOIL EVALUATOR P. O. B 0 X 1729 FIRST TWO FEET OUT OF THE DISTRIBUTION BOX WHICH SHALL` ED. STONE BE LEVEL I DEPTH TO BOTTOM OF HOLE 13.0' BACKHOE OPERATOR. SANDWICH MA 02563 12. CHANGES OR REVISIONS TO SEPTIC DESIGN REQUIRE NOTIFICATION VARIANCES REQUESTED RODNEY FISHER SOIL TYPE: 1 TO EAS SURVEY INC. FOR B.O.H. AND DESIGN ENGINEERS REVIEW PERC RATE: 3 MIN. PER INCH PH. (508) 888-3619 13.AND MAGNETICOVAL.TAPE ON ALL COMPONENTS. 1 NONE LOADING RATE: 0_74 GAL/SF/MIN CELL (508) 527-3600 P i� 01