HomeMy WebLinkAbout0737 RACE LANE - Health 737 RACE LANE, MARSTONS MILLS
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YOU WISH TO OPEN A BUSINESS?
For Your Information: Business Certificates COST $30.00 for 4 years. A Business Certificate ONLY REGISTERS YOUR NAME in the Town
(WHICH YOU MUST DO BY M.G.L. - it does not give you permission to operate). You must first obtain the necessary signatures on this form
at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1" FI., 367 Main St., Hyannis, MA 02601(Town Hall) and get
the Business Certificate that is required by law.
x s T DATE: t ll 10
`3 ` < Fill in please:
APPLICANT'S YOUR NAME:
VM "r. BUSINESS YOUR HOME ADDRESS:
73
e 1
TELEPHONE # Home Telephone Number: `i6 1 U t
NAME OF NEW BUSINESS �3acv s-, !,� \M$c_L,,.,� L 1I. -g% TYPE OF BUSINESS
IS THIS A HOME OCCUPATION? YES NO yes✓t'«S
Have you been given approval from the building division? YES NO
ADDRESS OF BUSINESS 737 Rc CL MAP/PARCEL NUMBER
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need.. You MUST GO TO .200 Main St. — (corner of
Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate'your business in this
town.
1. BUILDING COMMISSIONER'S OFFICE
This individual has been informed of any permit requirements that pertain to this type of business.
Authorized Signature**
COMMENTS:
2. BOARD OF HEALTH
This individual has ee informe f the ermi require ents that pertain to this type of business.
Authorized Sig ture**
COMMENTS:
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual ha en inforfi d ofthe licery�i'jg re,,(rG('! r�ryltents that pertain to this type of business.
`r ( i ,
Authorized Signature**
COMMENTS: .
WN OF BARNSTABLE C ✓
LOCATION �I yRA - 46 ` SEWAGE # Q E— �S
VILLAGE AZZ• l�/�// ASSESSOR'S MAP & LOT I d v D
INSTALLER'S NAME&PHONE NO. 264
SEPTIC TANK CAPACITY ZJr"
LEACHING FACILITY: (type) (size) °2
a.
NO.OF,13EDROOMS��
BUILDER OR OWNER S LA n�
PERMITDATE:,?— / "' COMPLIANCE`DATE: -Z9 1—
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 any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZIpplitation for Mizpooal *pgtem Cori.5truction i3ermit
Application for a Permit to Construct( )Repair( x)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 737 Race Lane Owner's Name,Address and Tel.No. 4 2 0—3 3 8 6
Marstons Mills Larry Mahan 163 Walnut St
Assessor's Map/ParcelMarstons Mills 0 2 6 4
Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No.
W E Robinson Septic Servicw
PO Box 1089, Centerville, MA 02632
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder(no)
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil sand
Nature of Repairs or Alterations(Answer when applicable) Title 5 Septic repair consisting
of 1500g septic tank, D-Box and 3 maximizers (stonepacked)
,
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 B d of Health.
Signed /iy I t � Date r
Application Approved by Date 3 ^
Application Disapproved for 64 follo ing reasons
Permit No. Date Issued
- --------- — ---------------------
7�WN OF BARNSTABLE
LOCATION SEWAGE # � /S
ASSESSOR'S MAP& LOTT
INSTALLER'S NAME&PHONE NO.
IT
SEPTIC TANK CAPACY r6-Q
:.LEACHING FACILITY: (hype)�- B 6 C / G�
(size) _aZ
NO.OF BEDROOMS.
A:U ER OR OWNER�
`PERMITDATE: - / ?" `j' COMPLIANCE DATE:
Separation Distance Between the:
Maxii'pum Adjusted Groundwater Table and Bottom of Leaching Facili Feet
Pri*e Water Supply Well and Leaching Facility (If any wells exist
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
zed
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YY,
No. / Fee $5 0.0 0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
ZIpplication for i$�l'O aY pgtelu Con5truction 3permit
Application for a Permit to Construct( )Repair( X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 737 Race Lane Owner's Name,Address and Tel.No. 4 2 0—3 3 8 6
Marstons Mills Larry Mahan 163 Walnut St
Assessor'sMap/Parcel Marstons Mills 02648
Yam:.
Installer's Name,Address,and Tel.No! 7 7 5—8 7 7 6''°,%. Designer's Name,Address and Tel.No.
W E Robinson Septic Services'`.
PO Box 1089, Centerville, MA 02632
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(no)
Other Type of Building No.of Persons Showers( ) Cafeteria( )
11
Other Fixtures — ` f) r
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title.
Size of Septic Tank Type of S.A.S.
Description of Soil sand
Nature of Repairs or Alterations(Answer when applicable) Title 5 Septic repair consisting
of 1500g septic tank, D-Box and 3 maximizews (stonepacked)
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 IN B d of Health.
Signed Ie�v i i — Date
Application Approved by Date Z
Application Disapproved fort following reasons
Permit No. Date Issued
.. THE COMMONWEALTH OF MASSACHUSETTS
Mahan ( . `BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( Xhj Upgraded F )
Abandoned( )by
at 737 Race Lane, Marstons Mills has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. �J�r�/ dated
Installer W E Robinson Sept Sry Designer
The issuance of this permit shall not be construed as a guarantee that the systemr ill function as designed.
Date r Inspector =>
---------------------------------------
No. ! b4 Fee $5 0.0 0
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE,, MASSACHUSETTS
Mahan 'Wtoo-gar *proem Con.5tructton Vermit
Permission is hereby granted to Construct( )Repair( X)Upgrade( )Abandon( )
System located at 737 Race Lane,
Marstons Mills
Installer: W E Robinson Septic Sre
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 permit.
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Date: 3 — 1 3—?b Approved by Q.�
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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
ENGINEERED PLANS)
1, William E. Robinson, Sr ,hereby certify that the application for disposal works
construction permit signed by me dated ~ "3_9 concerning the '
property located at 737 Race Lane, Marstons Mills, MA meets all of the
following criteria:
* There are no wetlands within 100 feet of the proposed leaching facility.
* There are no private wells within 150 feet of the proposed septic system.
* There is no increase in flow and/or change in use proposed.
* There are no variances requested or needed.
* If the proposed leaching facility will be located with 250 feet of any 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 Elevation(according to the Engineering Division G.I.S. map) C�
B)Observed Groundwater Table Evaluation(according to Health Division well map) L
SIGNED: DATE
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 20-1998
(Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted).
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
�.f. Svey,•
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
A. General Information
Important:
When filling out 1. Property Information:
forms on the
computer,use 737 Race Lane
only the tab key Property Address
to move your Scott Travis
cursor-do not Owner's Name
use the return
key. P.O. Box 212
Owner's Address
r� Eastville Va 23347
City/Town State Zip Code
11/28/06
Date of Inspection: Date
2. Inspector:
James Holler
Name of Inspector
Holler& Son Construction Co. LLC
Company Name
P.O. Box 702
Company Address
Marstons Mills Ma .02648
City/Town State Zip Code
508-420-0280
Telephone 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
❑ RVeds Further Ev I ation by the Local Approving Authority
11/28/06
1 spect 's Signature Date
The stem 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
Land 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.
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Page 1 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
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B. Certification (cont.)
737 Race Lane
Property Address
Marstons Mills Ma 02648
Cityrrown State Zip Code
Scott Travis 11/28/06
Owner's Name Date of Inspection
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 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:
Travis Ins ection.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
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C Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
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B. Certification (cont.)
737 Race Lane
Property Address
Marstons Mills Ma 02648
City/Town State Zip Code
Scott Travis 11/28/06
Owner's Name Date of Inspection
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
❑ 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:
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
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Page 3 of 16
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Certification (cont.)
737 Race Lane
Property Address
Marstons Mills Ma 02648
City/Town State Zip Code
Scott Travis 11/28/06
Owner's Name Date of Inspection
C) Further Evaluation is Required by the Board of Health (cont.):
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for 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:
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Page 4 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Certification (cont.)
737 Race Lane
Property Address
Marstons Mills Ma 02648
City/Town State ZipCode
Scott Travis 11/28/06
Owner's Name Date of Inspection
D)System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
® Discharge or ponding of effluent to the surface of the ground or surface waters
El 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
El ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped: None.
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or
❑ ® tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
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.
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Page 5 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
�M SVey`�
Subsurface Sewage Disposal System Form
B. Certification (cont.)
737 Race Lane
Property Address
Marstons Mills Ma 02648
Cityrrown State Zip Code
Scott Travis 11/28/06
Owner's Name Date of Inspection
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.
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
C. Checklist
737 Race Lane
Property Address
Marstons Mills MA 02648
City/Town State Zip Code
Scott Travis 11/28/06
Owner's Name Date of Inspection
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)]
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Page 7 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
y` Subsurface Sewage Disposal System Form
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D. System Information
737 Race Lane
Property Address
Marstons Mills Ma 02648
City/Town State Zip Code
Scott Travis 11/28/06
Owner's Name Date of Inspection
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
1
Number of current residents:
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
Seasonal use? ❑ Yes ® No
268
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump? ❑ Yes ® No
Current
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:
Last date of occupancy/use: Date
Other(describe):
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Page 8 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
737 Race Lane
Property Address
Marstons Mills Ma 02648
City/Town State Zip Code
Scott Travis 11/28/06
Owner's Name Date of Inspection
General Information
Pumping Records:
Source of information: Owner
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)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
1998, Owner
Were sewage odors detected when arriving at the site? ❑ Yes ® No
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Page 9 of 16
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
�M
D. System Information (cont.)
737 Race Lane
Property Address
Marstons Mills Ma 02648
City/Town State Zip Code
Scott Travis 11/28/06
Owner's Name Date of Inspection
Building Sewer(locate on site plan):
1.5
Depth below grade: feet
Material of construction:
® cast iron ❑ 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: N/Afeet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
1
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 ❑ Yes ❑ No
certificate)
--------------------------------------------------------------------------------------------------------------------------
1
Dimensions: 000 gallon
8 inches
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle Winches
1/2 inch
Scum thickness
Distance from top of scum to top of outlet tee or baffle 3 inches
Distance from bottom of scum to bottom of outlet tee or baffle 12 inches
How were dimensions determined? Sludge Judge
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Page 10 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
D. System Information (cont.)
737 Race Lane
Property Address
Marstons Mills Ma 02648
City/Town State Zip Code
Scott Travis 11/28/06
Owner's Name Date of Inspection
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping is not necessary at this time, should be reviewed in 2008
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.):
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):
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Page 11 of 16
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
737 Race Lane
Property Address
Marstons Mills Ma 02648
City/Town State Zip Code
Scott Travis 11/28/06
Owner's Name Date of Inspection
Tight or Holding Tank (cont.)
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
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert Zero
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 level and no evidence of solids carryover or leakage
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
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r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
737 Race Lane
Property Address
Marstons Mills Ma 02648
City/Town State Zip Code
Scott Travis 11/28/06
Owner's Name Date of Inspection
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 x 500 gallon
❑ 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.):
two 500 gallon chambers with about 8 inches of water in bottom, no hydraulic failure signs at all
Travis Inspection.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 13 of 16
Commonwealth of Massachusetts
Tithe 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
7M
D. System Information (cont.)
737 Race Lane
Property Address
Marstons Mills Ma 02648
CityfTown State Zip Code
Scott Travis 11/28/06
Owner's Name Date of Inspection
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.):
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.):
Travis Inspection.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 14 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
737 Race Lane
Property Address
Marstons Mills Ma 02648
City/Town State Zip Code
Scott Travis 11/28/06
Owner's Name Date of Inspection
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
Q i 2-41-4,
2 32 —p
-74- o
2 �s_3
3 14 -o
`f -f 8-L
S 7-7-4 �{ S
Travis Inspection.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 15 of 16
f �
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Not for Voluntary Assessments
` Subsurface Sewage Disposal System Form
wM
D. System Information (cont.)
737 Race Lane
Property Address
Marstons Mills Ma 02648
Cityrrown State Zip Code
Scott Travis 11/28/06
Owner's Name Date of Inspection
Site Exam:
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water:
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health explain:
❑ Checked with local excavators, installers - (attach documentation)
® Accessed USGS database-explain:
USGS elevation data, vs Wellhead data
You must describe how you established the high ground water elevation:
USGS contour maps indicate lot elevation of 56 feet MSL, with system bottom 6.5 feet down equates
to 49.5 feet MSL, A1W 230 Well at 23.8 feet MSL yields a 25.7 feet separation.
i
Travis Inspection.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
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