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HomeMy WebLinkAbout0765 RACE LANE - Health 765 Race Lane Marstons Mills P S / A = 103 020001 Ir ,r LOZAiIO�N 1Z� n � � SEWAGE PERMIT NO. `T K t VILLAGE I N S T A LLER'S NAME i ADDRESS BUILDER OR OWNER Ry4ej eJ EA- v►ti� DATE PERMIT ISSUED 6-- 3a - p8- DATE COMPLIANCE ISSUED! -�,S� ,_ r. � : 4/ �, ���° o �` O �, ��V y �Y O � __ No............:2 ...... Fps.. ... ........ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Appliration for Disposal Mork Tonstrurtion, ruti# Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: ...........v. Location-Ad ess Owner �, Address Type of Buililing� W Size Lot._ f._ ...Sq. feet UDwelling—No. of Bedrooms.......... ............................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—Type e of Building No. of persons............................ Showers — Cafeteria c_, YP g P ( ) ( ) a Other fixtures -------------------------------- -. W Design Flow............................................gallons per person per day. Total daily flow..------. ...................gallons. WSeptic Tank—Liquid capacitylgallons Length................ Width---------------- Diameter---------------- Depth................ x Disposal Trench—No. .................... Wi th_................_.. Total Length__________ ---•---- Total leaching area........ __...sq. ft. Seepage Pit No......I------------- Diameter:- __.. Depth below inlet..... Total leaching are . ,� .__._sq. ft. z Other Distribution box Dosing tank Percolation Test Results Performed by.. .+. _•MSWAJ.�_ Date........ r` "�� `- Test Pit No. I...... -__minutes per inch Depth of Test Pit-___-kr�...... Depth to ground water.._.. �i, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ............................................................................................................................................................ O Description of Soil---. t ..... " -----•-------••--•--------------•••--•-----•--•---•••------•----------- V ._._ �-- ---------- Y 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 iITI:;j. 5 of the State Sanitary Code— The undersigned fyrther agrees not to place the system in operation until a Certificate of Compliance has bee i,5s eby the b rd of fealth. -_�F Sig d.-•--- 1 :_®.. =--• ._.. - Date Application Approved By...... •..... .^. Date Application Disapproved for the following ollowin reasons----- --------------- -------------------------------••-------------•--•......................... ---------------------------------------------•-----------------------------...---'-----------------------I---•--•--•-•--•------••••••-------------•-•----------------•---•-••------------•----••...._..._ p� Date PermitNo......................................................... Issued_...Q:::.t!��---� -- ---- ------ ` Date No............... : ... Fps.,, ..................... ti* THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . OF...... .. ." ' ............... • ... Appliration for Btipniia,I _IVorko Tontxnrtinn ruts E a Application°'is"fiereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at Loc�ion-Address or - - -- A. _-T fit. - ..moo. ►.N r.. ''�t Owner ss 1i • i Address C� aefG e"o % ing Size Lot. 'i ---- er aOther—Type of Building ._:_............................ No. of persons............................ Showers ( ) Cafeteria ( ) d ,.,Other fixtures =......................................................-------- --------....'.....................•-•-- W Design Flow............................................gallons per person per day. Total daily flow :. gallons. WSeptic Tank—Liquid capacij690iallo'ns Length __. _.... Width v............. Diameter .._........... Depth................ x Disposal Trench No Wi f :: Tota `L:ength Total leaching area... sq. ft. Seepage Pit No. Diameter De th-below inlet.... :.. Total leachingar sq. ft. z Other Distribution box Y, Dosin ank '-' Percolation Test Resu ts'< 711 = n► .•. { a Performed�by+ _ j'��A�+- Date. Test Pit No 1 a �s m>nutes pe�mch Depiliof Test Pit 4 Depth to ground water , . Gz, Test Pit No 2 .' s._nuriutes pertlnch Depth'o, 'Test Pity ................. Depth to ground water_................ D Description of Soil... ,w ...........`-- . = .. .. .......... ..U"..b- ------ -a0't ' UNature of Repairs or Alterations Answer when applicable ------------------------------------- --_-•---.---. � + �+ +. ... ::. Agreemehi. a The .undersigned agrees Jtotinstall the aforedescrlbed Individual Sewaget Disposal,,,.ystem in accordance with the provisions of I T! 5 of the State Sanitary Code=:The undersigned f flier agrees::,iiot to place the system,in q rw, operation until'a Certificate of&'Coinpiiance has,. ee by the rd of ral+t'h c�.......... wh Dia-te '` --��.Application Approved By .... - - Date for th eas, g -, ... ..... i•.._ ....,-_. ............................_..:_. __._..._. .............•..--....-•.....Application Disapproved �,.,. _ Date Permit No.........................................................' Issued.............................. .......................... Date THE COMMONWEALTH OF MASSACHUSETTS •'.` {=1X ar , ; BOARD ' OF ALTI-I- ,t .OF.. .. . ....... ..... Trrtif irair"of Tomplianr "TH 1 TO CER IFY, T he•.Ind�igv' ewage Disposal System constructed' , or Repaired ( ) by.--- Q ------- .. � �1 . Inst er A;,ee"'". has been installed in accordance with the provisions o T:IKE 5 of The State Sanitary Code as descri d • the �i application for Disposal Works Construction Permit No.__ _- r►_ dated--. "`. ...... . ........ CON'THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE TRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE-------------------------------------------------------------------------------- Inspector................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD _ 1'1EALTH No...................... Y 4 1:r:7 h EIS'✓ laisp,a 1 nrk (gn #radian ` irMtit Permission is,hereby granted... _ ` .. '.... ---- `1�"` T .,F .......... to Construct or air'(-. n ndivid al Sewage'Disposal System at No..... �CIc .... .. .. V ----•---••------..--------- ------c----- = .:._.... Street as shown on the application for Disposal Works ConstructionrPit N Dated......Al r -- ------------------------------ Board of Healthy10 DATE------ `"3d-.71. FORM 1255 HOBBS & WARREN, INC., PUBLISHERS l f. ;NAll t.-, - � ,a`.� i"�tg�'v• . . ;5 . j r � � e 7 9 / F " SO 4 Q or (' GAL, a 000 O p N c. 5'--pre c r `- HOLE Q D ID;)' s 1- 2 V) ti .n f c t J 2- ( 0 D ✓^,ram r"t b _.•t' .i - - f f �N 0FM l' 9c ' ROBERT BUNIKIS ` No.22162 r a .o P LEGENO, EXISTING SPOT ''ELEVATIO,N': OxO CERTIFIED PLOT PLANM ` EXISTING CONTOUR -._ 0 LOT /z0 Wit{ cep �-A"NE p FINISHED SPOT ELEVATION 0.0 FINISHED CONTOUR 0- APPROVED BOARD OF . HEALTH AAJI NS fA2 L 9,,AAS!* DATE ----AGENT- -- " ' SCALE: J "_- 40 DATES « 5 Z 78' --- Ti �h/•4 7&(Z r L DREDGE ENGINEERING C— O ING�' ------ ----� CLIENTt-e�.�xt- I CERTIFY THAT THE PROPOSED EGISTERE REGISTERED JOB N0. 79nzy_ BUILDING SHOWN ON THIS PLA1� CIVIL LAND CONFORMS TO ,THE,. ZONING- LAWS''.J' ENGINEERS SURVEYOR DR. BY �4•A_n'I_ OF BARPISTA E ASS. �y 4 33 NO MAIN ST. 712 MAIN ST CH- BY: SO. -YARMOUTH, MASS. HYANNIS, MASS. SHEET Z OF DATE REG. LA;NID SURVEYOR 20 FT. M//V. IV07',c %F E/TNER TN,E SEPT/C TAN/< OR k AAre MORE. rHA,.V /Z"EELOW "/e7 FT: m/M. 24"O/Alm/ET,ER .CO,,yCJFETE CONE& SidALL. �E .l9J�®tJ��T T® G1�.4®.E.�.AN EXTRA CO NCRCTE f- 0 Pt p. Jy E,4 YY C�9 S T o r ELC--V,./00. MJN. P/TCN'- CO{�E/�S IB n PhW A7 /F/N OR/VA=- WA Y i p' /r9iN. CO/VCA- -- 7 A — ORADCL EA/V SA NO eA 4, :�. LIl�[//O LEVEL .� _ " _;• - • • - y� - . 4"CAST "LAYER IRON P/PE a v v • o qF /�$ -'3�B •:;b Mm.P/TcN 40 O rjAL. . f • • • • • _e • • • " 0 040 ::::`I %9"P�rc rT SEPTIC TANfC D/sT a r► o e • • • • • • • e o WASHED ST2�NE. I ;I �. BOX p • e � e • • • 1 • o•p °a Q o 0 • ee E DF H�VC D 0 o P7- v —JV.9SHE0 STOME e s+ a • • • • e +• • • • • p eo y PREC,45T SEEPAGE _ !Nli�l�T �LEVAT/0/!/S fl s •p - e e • . a o 0 • • e ' Q� o P/T OR EQUIV. /AIYE,R7 AT BUILDING 176 yFT. INLE-'T. SEPT/C TANK S, S FT, -/O F-T: OIA4m, �I C(SEE TABULATION O(J7LET SEPT/C TANK 95.3 FT. ET D/STR/1S!/7'/DN BOX 9 5'° )�T SECT/ON OF G)?©LNrD W,,47-EIC TABLE O UTLET D/57RIBUT/ON BOX 9 4•9 FT /NLETSEEPAC,E o�T 9¢.-s Fr. SEWAGE O/•SPOSA Z SYST.,E/►9 TAOUE.ATIDN LEACH/NG -=/T SCALE % _ /= O" D/MENS/ON A —FT. DESIGN CRITERIA _ O/NRNS/aN $ 6 FT. A14ofW8ER OF BEDROOMS _. DIMENSION 0- 4 I=T . GA.RQAGED/S�OSAL UN/r` - :• SO/L LOG. TOTAL E3T/MA7"Eb =LOAN �C G,�4t.1AoAv SOIL TEST /4t/ SOIL, TEST�•2 •�®/L TE$T+ J1(UMB,ER OF SEEtiD4GE PITS f`E[EY. ��•� d"ELEY_ -,e>A.TF OF SOIL TEST S Z • S/OE LEACH//VG PER P/T 6 713 SQ, FT. � RESULTS J•d/TNESSED BY ®OTTOM Lr4CN/NG PER PIT so. PT. 5,v/35, 4 /',6RC0LAT/Oro AATE A'! Z•2 M14—V/I.NCLY_ TOTAL LEACH//YG AREA y� 6 SQ. FT. ._3 PEVCO L.AT/ON RATE j*2, NJlN.�/w' RESER1iE L&aCHlNG AREA Z� b SQ. F T. C-4-A y N OF titA ss .�: r f= - o�' ROBERT: �� /✓S Al/[_ P. COA-R sE _ r x lZ S Tc� LS ti o BUNIKIS No. O �.� ��� - -.. • � _ r . • _ �.�� �:�.-.� � f z �- `�,� EL®RIDGE ENI�/N.�R/IVG CO,l/VG. •Po GISTS �FS`SrOPlAI �N .NO crmo4f v® vc�.Are R �/VCOI�A/TL�RSUP f NYANN/3_,::M,aSS. . .510. T,4RMOUTK Ii7.at�,s_ �.. adgifo lvo yai-4 raw AT,.IsLE� � ,� � ` �90 Z� � . .r 7 SHEET-OF TOWN OF BARNSTABLE LOCATION SEWAGE #0O— Q VILLAGE_ I^�t/� STONS rrt%r� S ASSESSOR'S MAP &LOT j INSTALLER'S NAME&PHONE NO. B I&A 017K SEPTIC TANK CAPACITY /OU D LEACHING'FACILITY: (type) -,5b06/xWG &5 (size) 13 xQ4 4'`STo///= j NO.OF BEDROOMS BUILDER OR OWNER. Q TO PERMITDATE: ! COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist. on site or within MO feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist i within 300 feet of leaching facility) Feet . Furnished by I f3Nh a s a-5cioC, 53 , cr��zs b, box TOWN OF BARNSTABLE �-�io ✓ LOCATION' 7�r SOCZ LAl. SEWAGE # 00— 052 VLF LAGS A/-Z!5-rONS 02 U—S n ASSESSOR'S �`MAP & LOT D � � I INSTALLER'S NAME&PHONE NO. BSI A/S/ 20171: 20-�� SEPTIC TANK CAPACITY ` UO 0 LEACHING FACILITY: (type)R'50y69kY6 (size) 13�24' VS2012—C NO.OF BEDROOMS_ BUILDER OR OWNE ,TDH14 MffML PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �S - o AOM19 . vao/ A Noy �y� 57 l� 1J Fee THE COMMONWEALTH OF MASStHUS'ETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Tippr[cation for Mopozat 6p5tem Construction Permit Application for a Permit to Construct( )Repair(v)Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. 765 � LW 1,26 Owner's Name,Address and Tel.No. Assessor'sMap/Parcel � / � `s awff �`���FIDAI `�' -��Po /o - 0_6 . oo L Installer's Name,Address,and Tel.No. � rT Designer's Name,Address and Tel.No. PC `+/error 01A r).,ksrW?:5, /",tL5 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 2RO 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 Nature of Repairs or Alterations(Answer when applicable) Z/wr-/Wz ca� �l�9 0&611 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 f the FavironmentaLZode and not to place the system in operation until a Certifi- cate of Compliance has been issued b i o o e Signed Date —,Z1-0 Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued , +`s tih ,1 , Fee — _ THE COMMONWEALTH OF MASSA HUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 5pplication for Mgogar *pgtem Construction permit Application for a Permit to Construct( )Repair( V)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 76� !`�C_ L IaO Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. �f�tA/Y R y��-� Designer's Name,Address and Tel.No. C(A rAi0r61,5 /y114,1 5 Type of Building: Dwelling No.of Bedrooms 2 Lot Size sq.ft. Garbage Grinder( ) # Other Type of Building 1QE S No.of Persons Showers( ) Cafeteria( ) Other Fixtures < Design Flow ,ZF6 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 t ?Nature of Repairs or Alterations(Answer when applicable) , IKE44L oCz— W s 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 f the Fiw' onmental Eode and not to place the system in operation until a Certifi- cate of Compliance has been issued b o o 'ea Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. 0411� , ' 'd Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERT��jj Y,that tg4e On-site Sewage Disposal System Constructed( )Repaired( !/)Upgraded( ) Abandoned( )by at IQ&Z has been constructed in accordance with the provisi Milk of Title 5 and the for Disposal System Construction Permit No*F0A0—,P,5e dated /�' �a Installer lt�il &Wl _ Designer n The issuance of this permit shall no be co r strued as a guarantee that the system.will function adesigne D Date 11 7'7/� Inspector ` ,' 11./ a' 1 / ., yl , J --------------------------------------- No. a'r Fee o Gc THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS ]Digogar 6potem Construction 30ermit Permission is hereby granted to Construct( )Repair( Upgrade( )Abandon( ) System located at 641 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 e"t'ir-tit. Date: l 3/c7 Approved b V 'L 1/6199 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, /(! A10 - hereby certify that the application for disposal works construction permit signed by me dated 173E 06 concerning the property located at �`'r Rk-1- meets all of the following criteria: �• The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. 1• The soil is classified as CLASS I and the percolation rate is less than ore equal to 5 minute per inch.Pe q s p ,• There are no wetlands within 100 feet of the proposed septic system There are no private wells within 150 feet of the proposed septic system y There is no increase in flow and/or change in use proposed J• There are no variances requested or needed. et• The bottom of the proposed leaching facility will not be located less than five feet above the ma.,dmum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor ` method when applicable] a• If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14) feet above the maximum adjusted groundwater table elevation, Please complete the following: e A) Top of Ground Surface Elevation(using GIS information) B) G.W. Elevation +the 1A4 (. High G.W. Adjustment DIFFERENCE BETWEEN A and B �' I SIGNED : DATE: I-Od (Sketch proposed plan of system on backjer q:health folder.cen L b 1 i TROY WILLIAMS 1_ - 12-° SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection (508) 385-1300 19 Hummed Drive South Dennis,,, MBA 02660 -\ COMMONWEALTH OF MASSACHUSETI'S EXECUTIVE, OFFICE OF ENVIRONMENTAI.AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SY PART A 6� C ED CERTIFICATION Property Address: 765 Race Lane JUN 1. 2 2002 Marstons Mills, MA TOWN OF BA STABLE f Owner's Name: John Krafton HEAL PT. Owner's Addres,. 765 Race Lane Q Marstons Mills,MA 02648 Date of Inspection: June 10,2002 �- Name of Inspector: Troy M. Williams 5 I Company Name: Troy Williams Septic Inspections Mailing Address: 19 Hummel Drive South Dennis,MA 02660 Telephone Number: (568)385-1300 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP appro,ed system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The sv-len v/ Passes Conditionally Passes Needs I urther 1:valuation by the Local Approving Authortt) ails Inspector's.Signature: � Date: (o/10 /02 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of i lealth or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the 'inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments Although system meets the minimum requirements set forth by the Massachusetts Department of Environmental Protection,certification Is not to be construed as a guarantee of future working condition of system,piping or components. This inspection represents the conditions of the system on the Date of Inspection noted above. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 dace I Page 2 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A' CERTIFICATION (continued) Property Address: 765 Race Lane Owner: Marston Mills,MA Date of Inspection: John Krafton June 10,2002 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _v/—/- I have not found any information which indicates that any of the failure criteria described in 310 CN4R 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 replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Boar of Health, will pass. Answer yes.no of not determined(Y,N,ND)in the_ for the following statements f"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(wh ler metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is i inent. Svstem will pass inspection if the existing tank is replaced with a complying septic tank as approved by t Board of health. *A metal septic tank will pass inspection if it is structurally sound, leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or tgh static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or tut en distribution box. System will pass inspection if(with approval of Board of Health): broken pe(s)are replaced obs tion is removed di ibution box is leveled or replaced ND explain: The system require pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with proval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART A CERTIFICATION(continued) Property Address: 765 Race Lane Owner: Marstons Mills,MA Date of fnspection: John Krafton June 10,2002 C. Further Evaluation is Required by the Board of Health: Conditions exist which require fdnher 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) at the system is not functioning in a manner which will protect public health,safety and the envir ment: 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 mar 2. System will fail unless the Board of Health(and Public Water upplier, if any)determines that the system is functioning in a manner that protects the public heal ,safety and environment: _ The system has a septic tank and soil absorption s em(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water pply. _ The system has a septic tank and SAS the SAS is within a Zone I of a public water supply. The system has a septic tank an AS and the SAS is within 50 feet of a private water supply well. _ The system has a septic t- - and SAS and the SAS is less than 100 feet but 50 feet or more front a private water supply well". ethod used to determine distance "This system pass if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and vo tle organic compounds indicates that the well is free from pollution from that facility and the presenc f ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure feria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 765 Race Lane Marstons Mills,MA Owner: John Krafton Date of Inspection: June 10,2002 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than %:day flow _Z 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. /j�j_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Hiq Any portion of a cesspool or privy is within a Zone 1 of a public well. ,i,, Any portion of a cesspool or privy is within 50 feet of a private water supply well. ,vla Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) ,vo(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303. therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a sign flow of 10,000 gpd to 15,000 gpd- You must indicate either"yes"or"no"to each of the following: (The following criteria.apply to large systems in addition to the cri is above) yes no _ the system is within 400 feet of a surface drinki water supply the system is within 200 feet of a tributary a surface drinking water supply the system is located in a nitrogen s sitive area(Interim Wellhead Protection Area—IWPA)Ora mapped Zone 11 of a public water supply ell 1f you have answered"yes"to any q stion in Section E the system is considered a significant threat,or answered "yes"in Section D above the larg ystem has failed.The owner or operator of any large system considered a significant threat under Sectio or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owners uld contact the appropriate regional office of the Department. 4 f Page 5 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 765 Race Lane Owner: Marstons Mills,MA Date of Inspection: John Krafton June 10,2002. Check if the followinc have been done. You must indicate"yes"or"no"as to each of the followine Yes No information was provided by the owner. occupant, or Board of l ield, __. -vl Were any of the system components pumped out in the previous two wecks _ 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) _,1_ Was the facility or dwelling inspected for signs of sewage back up Was the site inspected for signs of break out v1 _ Were all system components,excluding the SAS, located on site Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition of the baffles or tees, material of construction,dimensions,depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems'.' The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no Existing information. For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)(310 CMR 15.302(3)(b)j 5 Page 6 of 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 765 Race Lane Owner: Marstons Mills,MA Date of inspection: John Krafton June 10,2002 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): C2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x k of bedrooms): 33-0 Number of current residents:c Does residence have a garbage grinder(yes or no): /vo Is laundn on a scparate sewage system(),es or no):/vu (if yes separate inspection required] Laundry system inspected(yes or no): iv/q Seasonal use: (yes or no): iv& Water meter readings, if available(last 2 yearshsage(gpd)): _D► ���voti s oo= Id Sump pump(yes or no): ivo Last date of occupancy:_ 0 f.L,C., a,' e-J.. COMM ERCIAUINDUSTRIAL Type of establislunent. Design flow(based on 310 CMR 15.203): __gpd Basis of design flow(seats/persons/sgft,etc.): _ Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): _ Non-sanitary waste discharged to the Title 5 system (y or no): Water meter readings, if available: _ Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:pn Was system pumped as pa of the in pecS` tion(yes or no): 1f yes, volume pumped: gallons-- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _ZSeptic 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: a..k was 1h S47kI/,. mot -7- aS-�, Were sewage odors detected when arriving at the site(yes or no): a- 6 Page 7 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 765 Race Lane Owner: Marstons Mills,MA Date of Inspection: John Krafton June 10,2002 BUILDING SEWER(locate on site plan) Depth bclu%� grade: /B"f Materials of construction: cast iron Z40 PVC__other(explain): Distanc:• fion. pr,\atc water supply well or suction line: ,v/,g Comments(on condition of joints, venting,evidence of leakage,etc.): _1r�"S G,�.d _�-.n�s o.•...c �v�..dt �l f- '1 Z.._ -fi .�...� o ,�' , a � �'-a. SEPTIC TANK: (locate on site plan) Depth below grade: I_ Material of construction: concrete_metal_fiberglass_polyethylene —other(explain) If I", is metal list age: _ is age confirmed by a Certificate of Compliance(yes or no)'_{attach a copy of certificate) Dimensions: Sludge depth: ___y Distance from top of sludge to bottom of outlet tee or baffle: 02' 8'' Scum thickness: 07'' Distance from top of scum to top of outlet tee or baffle: C '' Distance from bottom of scum to bottom of outlet tee or baffle: /.2 ' Mow 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.): lc k L'- s�;- --- GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_p ethylene_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 to or baffle: Date of last pumping: Comments(on pumping recommendations, ' t and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of le e,etc.): 7 Page 8 of 1 I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 765 Race Lane Owner: Marstons Mills,MA Date of Inspection:John Krafton June 10,2002 TIGHT or MOLDING TANK: (tank must be pumped at timXofr* ction)(locate on site plan) Depth below grade: Material of construction: concrete metal fiber ss_polyethylene other(explain): Dimensions: Capacity: gallons Design Floe. gallons/day Alarm present(yes or no): Alarm level:_ Alarm in workin rder(yes or no): Date of last pumping: Comments(condition of alarm a float switches,etc.): DISTRIBUTION BOX:Z(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box,etc.): /l -=>✓�.. [ts /t ►. cra.J U i.., :. 6✓c�c.� .+ 4 0 ��o (../ /[n✓o✓y PUMP CHAMBER: __(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber ondition of pumps and appurtenances,etc.): 8 Page 9 of 1 I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 765 Race Lane Owner: Marstons Mills,MA Date of Inspection: John Krafton June 10,2002 SOIL ABSORPTION SYSTEM(SAS): v/ (locate on site plan,excavation not required) If SAS not located explain why Type _ leaching pits. number:_ leaching chambers,number: - ,$GU y a//� 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.): C-,r rti — r.ii n. w o.1/ - +-- -- Pi✓.O-th e..t o%�' Gay c�v'c. f�L .I..re d ,/ �,o yo bt-e.✓w�1 �. '/5.� �OU-f r 1�e✓� �-D.J�..,k, CESSPOOLS: (cesspool must be pumped as paZinspecuon)(locon site plan) Number and configuration:Depth--top of liquid to inlet invert: Depth of solids layer:Depth of scum Ia.er: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of raulic 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 hydrauli ailure, level of ponding,condition of vegetation,etc.): 9 Page 10 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 765 Race Lane P Y Marstons Mills,MA Owner: John Krafton Date of Inspection: June 10,2002 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. i I WOO 7 4,"" t = 27 ' F A r .2 c z— Sou 3P _ 31 yZ F O I IU Page 1 I of 1 I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 765 Race Lane Owner: Marstons Mills,MA Date of Inspection: John Krafton June 10,2002 SITE EXAM Slope Surface water Check cellar ✓ Shallow wells Estimated depth to ground water_j-'feet Adjusted high ground water elevation=_feet Please indicate(check)all methods used to determine the high ground %%ater elevation: ✓Obtained from system design plans on record- If checked,date of design plan reviewed: Its _Observed site(abutting property/observation hole within ISO feet of SAS) —Checked with local Board of Health-explain: _ Checked with local excavators, installers-(attach documentation) _/Accessed USGS database-explain: fy�25-3 _Lww..=,3 .53. 3' 5- You must describe how you established the high ground water elevation: US vs 1�—k2Y-- �-_i3 �._.�c...�-.,J a•L__lt.Ls_...—_ai.u.ti._-�—•_�-- _. ru r_.s.L_w�-+� i r_ /1..4 .,..1 cry✓<a:• _ S7. Y G.. . � + �1A, . YL 0.E Sly Gw_-g `~ c I_ r ti ti.✓cacti __�1r L �C_....f_3_J`_.! .�ti.-_�.e�.�._.t�...e.1�./�_t../�....t'e-/. t, ti✓_�.�L. c77 L7 - - - - - - 7• Sr of 4;-4- 11 '