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HomeMy WebLinkAbout0885 RACE LANE - Health 885 Race. Lane..uu Marstons Mills 'A`.= 104 - 005 001' 11 i 1 I �!I lI 1 A la�, UP012934 Town of BA-nstable. P#� Department of Regulatory Services PuBEA blic Health Division Date 6 Fie$ 200 Main Stree• Hyannis MA 02601iEL Date Scheduled � ' f� ± Time Fee Pd.l i . it/Suitability Assessment fop Se isposal/ Performed By. ' `I ! Witnessed By: i � LOCATION & GENE_ 41,INFORMATION Location Address �mC Owner's Name' ,.�6N01V1 r i 1 5 � Address (? j Assessor's Map/P4teel: /tQv�� b1, /�'�--� I Engineer's Name O S t llC - 1 vv�' ' o - s��l NEW CONSTRU�'I;ION REPAIR Telephone# sv�j 3 6 i Land Use ()e�1_�.i Slopes(9'0) �`� •I Surface Stones ��0 >,>� Distances from: Open Water Body.-::* ft Possible Wet Area ft Drinking Water Well�0 ft I ' brainage Way 1 b� ft Property Lincft Other ft SKETCH:($treet name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes) - S�e� �141V-� y rn i i i i Parent material(geologic) �1 I Depth to Bedrock Depth to Groundwater. Standing Water in Hole:' Weeping from Plt Face Estimated Seasonal i iigh Groundwater ! D �)`TION FOR SF,ASONAL HIGH WATER T.0LE Method Used: ! Jn, Depth Ob erved standing in obs.hole: __in. Depth to sall mottles: p i in. Ordundwntt r Adjustment ft. Depth toiweeping from side of obs.hole: ! ! _ A .faetor � AdJ.Oraundwnterlevel.,,,e Index Well#_ Reading Date: Index Well level --- i PERCOLATION TEST . Dale __ Time Observation Tulle at V Hole# Time at 6" Depth of Pere . d� Time(V-6n) Start Pre-soak Time-0 -- i End Pre-soak � � •;� 'Rate MinJlnch Site Suitability Assessment: Site Passed Site Failed;- Additional Testing Needed(Y/N) Original:.Public k olth Division Observation Hole Data To Be Completed on Back— ***If percolal�ibn testis to be conducted within 1-00' of wetland,you must first notify the Barnstable C40servation Di*ision at least one (I wedk prior to beginning. DEEP OBSERVATION.HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color` Soil Other. Surface(in.) (USDA) (Munsell); Mottling (Structure,Stones,Boulders.. Consistent %Gravel t- 7 j DEEP OBSERVATION HOLE LOG Hole#. / Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistent %Gravel) tj tip- Zl C✓ i'�t-e 2 sy 1A DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in. (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistent %Gravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) '"` (USDA) (Munsell) Mottling (Structure,Stones.Boulders. Consistency, ra I Flood Insurance Rate Map: Above 500 year flood boundary No „Yes _V 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 pervious material exist.in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? Certification I certify that on �� (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required tr ` 'ng, xpertise and experience.described in all CMR 15.017. Signature V Date b Q:\SEPTICTERCFORM.DOC TOWN OF BARNSTABLE LOCATION �. C;2 CA rk CSEWAGE# . �(` -2o z.. t. (:�VILLAGE (/V( ASSESSOR'S MAP&PARCEL 10 y/0015-001 t' INSTALLER'S NAME&PHONE NO. Q� "E(<<5 'FfP Lei yU SEPTIC TANK CAPACITY -e—V-C Si 1f✓t q 1000 LEACHING FACILITY:(type) � l�Sf U7c N�'y((size),2-5 5e 1(•3ZWO NO.OF BEDROOMS OWNER 66Vt00A,1 PERMIT DATE: 1��L.J�1 COMPLIANCE DATE: v/--/ 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 AZ-2, A3-- 6; Qpa - 2 ,,q �P,t�� 83, )5'� L � N ParT No. q 0 0� Fee G"o / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: V PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftpliCation for Disposal *pstrm Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade(K) Abandon( ) ❑Complete System XIndividual Components Location Address or Lot No. eF-S �� ^� /►�/��� Owner's Name,Address,and Tel.No. Kt.-n 10A,.-/1 6arl v Assessor's Map/Parcel / 0 O 5 —00 Jles 4.4 de— Installer's Name,Address,and Tel.No.50���� 29� Designer's Name,Address,and Tel.No.50 8 360 331 ,lox are_ -10tj,c4iA140Z)"b3 oak R/8 -�a OZS37 Type of Building: pp// Dwelling No.of Bedrooms Lot Size 7_/ 72o fi sq.ft. Garbage Grinder( ) Other Type of Building 5C �-444y1h diy No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 3 t) gpd Design flow provided 350 gpd Plan Date 1�0 ' 0 (� Number of sheets 2— Revision Date Title Size of Septic Tank `--X t 'It/t e, I00 D Type of S.A.S.Sh/114 S Y 49*° '0 7rnfV j VZp Description of Soil S-e_e_AAV% Nature of Repairs or Alterations(Answer when applicable) Pow(.4c-e— --Vo'6-2& 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 to place the system in operation until a Certificate of Compliance has been issued by this Boar f Health. Signed Date /���� Application Approved by Date (0 Application Disapproved by Date for the following reasons Permit No. �2_ Date Issued f --------------------------------------------------------------------------------------------------------------------------------------- 40— No. t •.� Fee I V TAE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION --TOWN OF BARNSTABLE, MASSACHUSETTS 01ppl.tatlon for Misposal 6pstem ConstrUttion Permit Application for a Permit to Construct( ) Repair( ) Upgrade K) Abandon( ) ❑Complete System XIndividual Components Location Address or Lot No. S R A C-t-LA ,e /h/" • Owner Name,Address and Tel. JrMhe.e 0,1 Assessor's Map/Parcel f O y U O 5 —pc) i i P6- R<1 CQ (.An A-_ Installer's Name,Address,and Tel.No.���� De igner's Name Address,and Tel.No.SU 8 36 v � I /-4e � t7//s +eyerK 30,175 OX �4PCl 1y4p4,,,c1,M4OZ)13 box 981 L S �c6,/L1A OZ.S�-7 Type of Building: .3 � DwellingNo.of Bedrooms fLot Si 7�0 / sq.ft. Garbage Grinder( ) Other Type of Building Sc'1 4 �r No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) Q gpd Design flow provided �U gpd Plan Date (o " 1 Number of sheets 2' Revision Date Title t Size of Septic Tank ko X ' 1 1,i' 000 Type of S.A.S.Sh/l I-e S j /-I L/1 '�n VZO Description of Soil S-Ce �P(40 Nature of Repairs or Alterations(Answer when applicable) t?e �0 A c,e- i -e& L� (-e S S t -A 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 Certificate of Compliance has been issued by this Board- Health. Signed Date 7 �f Application Approved by Date Application Disapproved by Date for the following reasons IqPermit No. D Date Issued ------------- -------------------- - -- - - •----------- ------------------ ----------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded(X) Abandoned( )by C� ( < S �S�A 4 at d C, Q L A•n-e-- Q I M> has been constructed in acco dance with the provisions of Title 5 and the for Disposal System Construction Permit No. " dated / Installer /-e �'� (_ l 5 Designer Sow S #bedrooms Approved de!signflow 3 o I .At gpd The issuance of this pernAs 17/g:strued as a guarantee that the system dei&i d. f/ Date Inspector ---- ----- - ----------) - No. 120 Fee l ^✓ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction 30ermit Permission is hereby granted to Construct( ) Repair( ) Upgrade(Y) Abandon( ) System located at �Q A( e- L Ali-P_ ,Mq/_S`(OAJS 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:Con/structi ust b coo'pleted within three years of the date of this permit.�1 Date C3 l - Approved by Town of Barnstable .,�IHME � Regulatory Services Richard V. Scali, Interim Director BARNsrnaLE. MASS. 1� Public Health Division 'Eor�u►+°i Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 A Installer & Designer Certification Form Date: . i (ILI Sewage Permit# /��AgAssessor's Map�Parcel d y �r,0O1 Designer: Va g Installer: Afi —►U5 e�,(IAX&I h4-) Address: yo Address: �G VVIA mp , OZ57 3 O -S3_� On (a �� r l y �%S eV EQ�. h was issued a permit to install a (date) (insta er) septic system at �j VAm L*� 04, 1{U based on a design drawn by _[ (address) dated iki (designer) re M I 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. Strip out (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. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed.in compliance with the terms of the IAA approval letters (if applicable) OF_ o DARRE�! �. (Installer's Signature) M �. /STEM esigner's SignaNGiAR�a� CC„ PLEASE RETURN TO ARNSTABLE 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. Q:\Septic\Designer Certification Form Rev 8-14-13.doc � T Town of Barnstable Regulatory Services Richard V. Scali, Interim Director * BA.NFrABLE, » Public Health Division 9 MASS. g Thomas McKean, Director FO MA'S 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Homeowner Certification Form for Alternative Systems y Property Address: �h ICAC/t-, j, T-- M . M I u, Assessor's Map\Parcel: 'vl-� OM - PC)1 Property Owners Name: In accordance with Massachusetts DEP alternative system approval letters, the following certification information is required by the Owner of record. The Owner of record must place an '`x" in the applicable box next to each line certifying the information. Yes N\A ❑ I have been provided a copy of the Title 5 I/A technology Approval letters. (15 page Standard Conditions letter and the specific technology letter) ❑ I have been provided with the Owner's Manual !� ❑ II have been provided with the Operation and Maintenance Manual ❑ DYFor Systems installed under a Remedial Use Approval, I agree to fulfill my responsibilities to provide a Deed Notice as required by 310 CMR 15.287(10) ElFnd the Approval For Systems installed under a Remedial Use Approval, I agree to fulfill my responsibilities to provide written notification of the Approval to any new Owner, as required by 310 CMR 15.287(5) i� ❑ If the design does not provide for the use of garbage grinders, the restriction is understood and accepted D /❑ Whether or not covered by a warranty, I understand the requirement to repair, replace, modify or take any other action as required by the Department or the LAA, if the Department or the LAA determines the ',System to be failing to protect public health and safety and the environment, as defined in 310 CMR 15.303 I , cif"0£2c Y o N 0Y" i agree to comply with all terms and conditions above. Property Owners printed name /d Pro pe Owners Signature ate Note: This form must be submitted along with the septic system disposal works permit application for all I\A systems including new construction, repairs\upgrades, with and without aggregate (stone) and with conventional design criteria or credited design criteria. Q:\Septic\IA homeowner certifcation.doc . ErCO • ,-, I OFFICIAL USE go Postage $ ru O Certified Fee Is R,� � Return Receipt Fee `/ ,�( a M (Endorsement Required) Hem O ON Restricted Delivery Fee ��` 0 (Endorsement Required) r� 0 Total Postage&Fees ra r Kimberly S. Bonomi 885 Race Lane Marstons Mills, MA 02648 Certified Mail Provides: n A mailing receipt e A unique identifier for your mailpiece a A record of delivery kept by the Postal Service for two years Important Reminders: o. Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail®. InCertified Mail is not available for any class of international mail. 'a NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. n For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. e For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". n If a postmark on the Certified Mail receipt is desired,please present the arti-, cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. I IMPORTANT:Save this receipt and present it when making an inquiry.- PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 SECTIONSENDER: COMPLETE THIS I .MPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. signature item 4 if Restricted Delivery is desired. X ❑Agent ■ Print your name and address on the reverse ❑Addrossee so that we can return the card to you. B.Receivedby(Printed Name) C.-Daf o li ■ Attach this card to the back of.the mailpiece., or on the front if space permits. D. Is delivery�add ss- 'fferent from item 1? ❑Yet i 1, Article Addressed.to: If YES, r4fer�d�Fver ss below: I].No �PrMp,026g8<<cP J 6 Kimb'&1Y S. Bonomi j JUN 2 4 2014 I + 885 Race Lane s: se icerype Mar9tons Mills, MA 02648 ! ❑Cb0fled Mail ❑Exp�`N1m . r ! 0 Insu re�Jj P Detum Receipt for Merchandise -"� ---- --, — ❑Insured ll- - TI C.O.D. 4. Restricted Delivery?(Extra Fee) p Yes ' 2. Article Number 6 (rransfer from service labeq 7 012, 1, 010 00 0 0 2851 3689 PS Form 3811:February 2004 Domestic Return Receipt 102595-02W-1540 I i UNITED STATES POSTAL SERVICE First-Class Mail I Postage&Fees Paid LISPS Permit No.G-10 Sender: Please print your name, address, and ZIP+4 in this box • I I Town of Barnstable Public Health Division 200 Main Street Hyannis, MA 02601 :•• ;tiMµ:„ ff IE, �ft:t:�tif" fl� �: 1"1 f; f'fflt`"iii �. . ... t Town of Barnstable Barnstable Regulatory Services Department ;wWa j Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL # 7012 1010 0000 2851 3689 June 20, 2014 Kimberly S. Bonomi 885 Race Lane Marston Mills, MA 02648 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 • The septic system located at 885 Race Lane, Marstons Mills,MA, was last inspected on 4/11/2014, by Michael DiBuono, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system" Fails" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: • The Septic system is in hydraulic failure. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thomas cKean, R.S. CHO Agent of the Board of Health QASEPTIC\Letters Septic Inspection Failures or Future Evl\26 Helmsman Dr Cent Jun 2014 doc.doc 1 I � I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 885 Race In Property Address John.Theriault Owner Owner's Name information is required for every Marstons Mills MA 02648 4/11/14 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 forms A• General Information n on the computer, use only the tab 1 Inspector: I I n key to move your . cursor-do not Michael DiBuono use the return Name of Inspector key. NEIGHBORHOOD WASTE WATER SERVICES �n Company Name 350 MAIN STREET Company Address r W. YARMOUTH MA 02673 City/Town State p Zi Code,., 508-775-2820 S113522 Telephone Number License Number , "= B. Certification certify that I have personally inspected the sewage disposal system at this addre s and that-the -r+ information reported below is true, accurate and complete as of the time of the inspection. T e 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 04/11/2014 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official In wtiorm: urface Sewage Disposa System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 885 Race In Property Address John Theriault Owner Owner's Name information is required for every Marstons Mills MA 02648 4/11/14 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This system consists of a 1000 gallon concrete septic tank. And one 6x6 concrete leach pit in Hydralic failure. It is my recommendation that the system be replaced. 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. 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): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 885 Race In Property Address John Theriault Owner Owner's Name information is required for every Marstons Mills MA 02648 4/11/14 page. City/Town 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 �F Title 5 Official Inspection Form I�o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 885 Race In Property Address John Theriault Owner Owner's Name information is required for every Marstons Mills MA 02648 4/11/14 page. City/Town 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 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. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded ® or clogged SAS or cesspool ❑ ® Liquid depth in 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 885 Race In Property Address John Theriault Owner Owner's Name information is required for every Marstons Mills MA 02648 4/11/14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to 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 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 885 Race In Property Address John Theriault Owner Owner's Name information is required for every Marstons Mills MA 02648 4/11/14 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 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 f Commonwealth of Massachusetts iw Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 885 Race In M Property Address John Theriault Owner Owner's Name information is required for every Marstons Mills MA 02648 4/11/14 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: This system consists of a 1000 gallon concrete septic tank. And one 6x6 concrete leach pit in Hydralic failure. It is my recommendation that the system be replaced. Number of current residents: occupied 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.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 2013 80,000 2012 122,000 Detail 280 GPD over the last two years. 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 reacings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 885 Race In Property Address John Theriault Owner Owner's Name information is required for every Marstons Mills MA 02648 4/11/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: CURRENT Date Other(describe below): This system consists of a 1000 gallon concrete septic tank.And one 6x6 concrete leach pit in Hydralic failure. It is my recommendation that the system be replaced. 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 w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °wM Syey'�� 885 Race In Property Address John Theriault Owner Owner's Name information is required for every Marstons Mills MA 02648 4/11/14 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 20 + years Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 24"s 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.): This system consists of a 1000 gallon concrete septic tank. And one 6x6 concrete leach pit in Hydralic failure. It is my recommendation that the system be replaced. Septic Tank(locate on site plan): Depth below grade: 17"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) This system consists of a 1000 gallon concrete septic tank. And one 6x6 concrete leach pit in Hydralic failure. It is my recommendation that the system be replaced. If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gallon Sludge depth: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 885 Race In Property Address John Theriault Owner Owner's Name information is required for every Marstons Mills MA 02648 4/11/14 page. Cityrrown 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 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 3" Distance from bottom of scum to bottom of outlet tee or baffle 36" How were dimensions determined? TAPE + ESTIMATED Comments on pumping recommendations inlet and outlet tee or baffle condition structural integrity, ( p P 9 9 Y, liquid levels as related to outlet invert, evidence of leakage, etc.): This system consists of a 1000 gallon concrete septic tank. And one 6x6 concrete leach pit in Hydralic failure. It is my recommendation that the system be replaced. 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 885 Race In Property Address John Theriault Owner Owner's Name information is required for every Marstons Mills MA 02648 4/11/14 page. Cityrrown 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.): This system consists of a 1000 gallon concrete septic tank. And one 6x6 concrete leach pit in Hydralic failure. It is my recommendation that the system be replaced. 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �^M 885 Race In Property Address John Theriault Owner Owner's Name information is required for every Marstons Mills MA 02648 4/11/14 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 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.): This system consists of a 1000 gallon concrete septic tank. And one 6x6 concrete leach pit in Hydralic failure. It is my recommendation that the system be replaced. 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. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: This system consists of a 1000 gallon concrete septic tank. And one 6x6 concrete leach pit in Hydralic failure. It is my recommendation that the system be replaced. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 885 Race In Property Address John Theriault Owner Owner's Name information is required for every Marstons Mills MA 02648 4/11/14 page. CityTTown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): This system consists of a 1000 gallon concrete septic tank. And one 6x6 concrete leach pit in Hydralic failure. It is my recommendation that the system be replaced. 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 l i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 885 Race In Property Address John Theriault Owner Owner's Name information is required for every Marstons Mills MA 02648 4/11/14 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.): This system consists of a 1000 gallon concrete septic tank. And one 6x6 concrete leach pit in Hydralic failure. It is my recommendation that the system be replaced. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Ul Iq [ol +� i Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 885 Race In M Property Address John Theriault Owner Owner's Name information is Marstons Mills MA 02648 4/11/14 required for every page. Cityrrown 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 pernnanent 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 885 Race In Property Address John Theriault Owner Owner's Name information is Marstons Mills MA 02648 4/11/14 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 25+ ft feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Prior inspection report from 2003 Indicated ground water is below 50 ft per Inspector Patrick O'Connell ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Prior inspection report from 2003 Indicated ground water is below 50 ft per Inspector Patrick O'Connell Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 ` Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �^M 885 Race In Property Address John Theriault Owner Owner's Name information is required for every Marstons Mills MA 02648 4/11/14 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked E Inspection Summary D (System Failure Criteria Applicable to All Systems)completed E System Information—Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 L (YaaQu,t l TOWN OF BAR NSTABLE V LOCATION 865 V4<& Lpo:_ SEWAGE # LAt4 V-+yow4 VE.LAGE IW; It S ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. k- Ot, SEPTIC TANK CAPACITY 10.00 a AAWW41 Assv"A2 LEACHING FACILITY: (type) Lt_r-^,A, ga fi (size) `I$e�-I i 11 , S+n6 NO. OF BEDROOMS Z BUILDER OR OWNER fbonz N A wi R aowie z (®t^rNIM 4,4 7-081 PERMIT DATE: L-4-7 3 COMPLIANCE DATE: L A kiyaW N Separation Distance Between the- ,. Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist A site or within 200 feet of leaching facility) 1J1A Feet j Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) 0.1 A Feet Furnished by W!ll i q...i 14 kx sail J.P , . SsptL I, i c,+ J Septic System Sketch Cross Section Ground Surface 16" Steel Chimney Vent \' Septic Tank AS 1l Burled Portion Underground House of House �\ Below Ground Courtyard Concrete Walkway Please note that they house Is located below ground. No structural projections occur above ground. Septic Tank Vent 2 25' ~--Cedar Trees S. 22 Utility SAS Pole Solar Panels Gravel Parking Area ��z RACE LANE William E.Robinson,Jr. Site:885 Race Lane Septic System Inspections Marston Mills,MA. Not to scale 43 Tomahawk Drive Centerville,MA 02632 hate:June 7,2001 (508)775-7986 r .al AsBuilt Page 1 of 1 TOWN OF BARNSTABLE rIL CATION 8815 Q.� LPdJ-G- SEWAGE# lA,4km n ,4 LAGE Ma2s(ows lv(I its ASSESSOR'S MAP&LOT o4 00 STALLER'S NAME&PHONE NO. tAv► SEPTIC TANK CAPACITY o 0 s LEACHING FACILITY: (type)_Lts-*,e.L. pi-r (size) SLI6,(J 11I s}uaJ6 NO.OF BEDROOMS Z BUILDER OR OWNER 1cc,ZEN A W EGL W I A clowl r.Z (04rMbV i,j 20o t) PERMITDATE: L-1 7 3 COMPLIANCE DATE: LAA l gid N Separation Distance Between the: ► I Ma4mum Adjusted Groundwater Table to the Bottom of Leaching Facility 37.® _ Feet Priv�te Water Supply Well and Leaching Facility (If any wells exist o site or within 200 feet of leaching facility) N Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) N A Feet v Furnishedby UgiWat QoLsK$W I* IN Lhy� d r ' Cross Section r Grand Sutaae - ftr * steel cMn.ey vew Sapm Taws ■ Wclerwound Haunt Burted Patlon of Hasa ` IBelow Grand cm"rd 1) Conenk Pfaase nob that the Vyallnaay Ihoune Is located below waww. No stnuWral po►e rctlore oCas above Sdoc Tank vaw Cedar Trap 2S utlotY Pals ' SOW Panels Gravel Parking Am ' RACE LANE WNlael E f+oeseoar Jr. Slb:W fop Lure . septic Sys"M bepeedene Merlons NFA,MA. Not lo ask p TCMW%Mk OIL. • - CWWWW,MA. 0=2 G.te:June T,toot (une)775-7M I http://issgl2/intranet/propdata/prebuilt.aspx?mappar=104005001&seq=1 5/5/2014 COMMONWEALTH OF MASSACHUSETTS u EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION MAP PARCEL. ' O o 5 v v TITLE 5 LOT OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION RECEIVED Property Address: 885 Race Lane Marstons Mills Ma.02648 APR 2 9 2003 Owner's Name: Gregory and Kathryn Varjian Owner's Address: SAME TOWN OF BARNSTABLE Date of Inspection: April 18,2003 HEALTH DEPT. Name of Inspector: PATRICK M.O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: (508)428-1779 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: _X_ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: nA Date: D� 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. Notes and Comments: Tank in good condition. 14"Effective leaching in pit.System has had annual pumping by current owners.Recommend keeping system pumped annually. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 885 Race Lane,Marstons Mills Owner: Gregory and Kathryn Varjian Date of Inspection: April 18,2003 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _X_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 885 Race Lane,Marstons Mills Owner: Gregory and Kathryn Varjian Date of Inspection: April 18,2003 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 885 Race Lane,Marstons Mills Owner: Gregory and Kathryn Varjian Date of Inspection: April 18,2003 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool —X— Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool —X— Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow —X— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. —X— Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _X_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X— Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] _No_(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large 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• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. A Page 5 of l 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 885 Race Lane,Marstons Mills Owner: Gregory and Kathryn Varjian Date of Inspection: April 18,2003 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No _X_ _ Pumping information was provided by the owner,occupant,or Board of Health _X_ Were any of the system components pumped out in the previous two weeks? _X_ _ Has the system received normal flows in the previous two week period? _X_ Have large volumes of water been introduced to the system recently or as part of this inspection? N/A Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ Was the facility or dwelling inspected for signs of sewage back up? _X_ _ Was the site inspected for signs of break out? _X_ _ Were all system components,excluding the SAS,located on site? _X_ _ 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? _X 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 _X_ _ Existing information.For example,a plan at the Board of Health. _X_ _ 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)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 885 Race Lane,Marstons Mills Owner: Gregory and Kathryn Varjian Date of Inspection: April 18,2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 Number of current residents:3 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no):No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): 2001-16,000 gal. 2002—118,000 gal=161 gpd. Sump pump(yes or no): Ejector pump for basement bathroom. Last date of occupancy: Currently Occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Pumped annually Source of information: Homeowner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped:___gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X_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: All system components same age as original house which was built in 1973 per town records. Were sewage odors detected when arriving at the site(yes or no): No Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 885 Race Lane,Marstons Mills Owner: Gregory and Kathryn Varjian Date of Inspection: April 18,2003 BUILDING SEWER: X (locate on site plan) Depth below grade: 1' Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line: 10' Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: X (locate on site plan) Depth below grade: 1' Material of construction:_X_concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 8' long x 5.2'wide—1000 gal. Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: 29" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 13" How were dimensions determined: STICK WITH HINGE FLAP. 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 in good condition baffles are intact.Liquid level at bottom of outlet pipe no evidence of leaks. GREASE TRAP: No (locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 885 Race Lane,Marstons Mills Owner: Gregory and Kathryn Varjian Date of Inspection: April 18,2003 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: No (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 885 Race Lane,Marstons Mills Owner: Gregory and Kathryn Varjian Date of Inspection: April 18,2003 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type _X_leaching pits,number: One 6x6(1000 gal.)pit leaching chambers,number: leaching galleries,number; leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): Leaching pit has W-10"of standing water leaving14"effective leaching available.No high water stains above current level.No ponding,breakout,or excessive vegetation in area of leaching pit. CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: No (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.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 885 Race Lane,Marstons Mills Owner: Gregory and Kathryn Varjian Date of Inspection: April 18,2003 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. z� Lol Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 885 Race Lane,Marstons Mills Owner: Gregory and Kathryn Varjian Date of Inspection: April 18,2003 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 50 feet from ground level on property. Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system des=gn plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) _X_Accessed USGS database-explain: USGS topo map(Sandwich Quad)and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map indicates groundwater below el.45.USGS topographic map shows property to be at el. 100.Bottom of leaching pit 8' below grade leaving more than 42'of separation between groundwater and bottom of leaching. '{ ` t Y. F L 't..` � 4t` - ; is - v / �.J' ' V - '1 •�( Septic `System Inspection;Report r 'Y 885 Race Lane , Marstons mats ,Massachusetts Y ; tr F, h +Ar •d n'4 , ty.; � + ✓ •n i I , June 7, 200 ' G �} preparec For +Y • ' t r 4 t� '{ .,#*Bozena Niechwiadowicz.- J ; 885 Race Lane ; 1Vlarstgns,Mills 14assachusetts,r02648 Prepared by 3e Lb f 1' ti r . Y y c t William E. Robinson Jr Septtc Inspections 43 Tomahawk Drive . ` _ r Centerville,Massachusetts`0263�2 . r J t1: s ' n'G• '. . Providin .Innovative r'lu i nY F r ' t l g So t o s or. Solid WasteHealth &.Safety„ '� r �t. / � � r. x '�� +' ;q .r4 Y ,,`� k �. 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COMMONWEALTH OF MASSACHUSETTS ' ID EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION 09M 5�6 TITLE 5 ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM ' PART A CERTIFICATION ' Property Address: 885 Race Lane,Marstons Mills Owner's Name:Bozena Niechwiadowicz Owner's Address: Same as above ' Date of Inspection: June 7,2001 Name of Inspector:(please print) William E.Robinson,Jr. ' Company Name: William E.Robinson,Jr.Septic Inspections Mailing Address: 43 Tomahawk Drive Centerville,MA. 2632 Telephone Number: (508)775-7986 ' CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported ' below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ' X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ' Fails w&sk Inspector's Signature. Date: 0 ' 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. Notes and Comments ' The septic system appeared to be in good functioning condition on the day of inspection. Please note that the leach pit was not directly inspected due to its depth below the surface(41). Also note that the system serves 2 ' bedrooms and one person has occupied the house for the last 2 years with minimal water usage. The system was judged to be functioning normally for the use it is getting on the day of inspection. Please note that this house is an"underground"house with no structural projections above the ground suface. ' ****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. Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) ' Property Address: 885 Race Lane,Marston Mills Owner:Bozena Niechwiadowicz Date of Inspection: June 7,2001 ' Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ' X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The septic system was found to be in good working condition on the day of inspection. ' B. System Conditionally Passes: N/A One or more system components as described in the"Conditional Pass"section need to be replaced or ' repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. ' Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally ' unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: ' Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ' broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ' ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 I ' OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 885 Race Lane,Marston Mills Owner:Bozena Niechwiadowicz Date of Inspection: June 7,2001 ' C. Further Evaluation is Required by the Board of Health: N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system ' is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh ' 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ' _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance ' "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. I ' 3. Other: 1 I Page 4 of 11 ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY OLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 885 Race Lane,Marstons Mills Owner:Bozena Niechwiadowicz Date of Inspection: June 7,2001 D. System Failure Criteria applicable to all systems: You must indicate`yes"or"no"to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or — clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than'/s day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. ' _ X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds ' indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] ' No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. ' E. Large stems: N/A � 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. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) ' yes no the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a ' significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. ' Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART B CHECKLIST Property Address: 885 Race Lane,Marstons Mills Owner:Bozena Niechwiadowicz Date of Inspection: June 7,2001 ' Check if the following have been done.You must indicate"yes"or"no"as to each of the following: ' Yes No X Pumping information was provided by the owner,occupant,or Board of Health(None Available) X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? ' _ X Have large volumes of water been introduced to the system recently or as part of this inspection? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) (N/A) ' X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS,located on site? X _ 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? X _ 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 ' _ X Existing information.For example,a plan at the Board of Health. X _ 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)] i ' Page 6 of 11 F O FICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 885 Race Lane,Marstons Mills ' Owner:Bozena Niechwiadowicz Date of Inspection: June 7,2001 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Unknown Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd(assumed) ' Number of current residents: 1 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] ' Laundry system inspected(yes or no): N/A Seasonal use:(yes or no): No Water meter readings,if available(last 2 years usage(go): 1999—3K gals.(8.2 gals/day).2000—4K gals.(11 gals./day) ' Sump pump(yes or no): No Last date of occupancy: Currently occupied. COMMERCIAL/INDUSTRIAL N/A Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sq k etc.): ' Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: ' Last date of occupancy/use: OTHER(describe): ' GENERAL INFORMATION Pumping Records Source of information: None available ' Was system pumped as part of the inspection(yes or no): No If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: ' TYPE OF SYSTEM _Septic tank,distribution box,soil absorption system _Single cesspool ' =Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval X Other(describe):Septic Tank and leaching pit. No"D"box. Sewage eiector pump from house to system. Approximate age of all components,date installed(if known)and source of information: Assessor's records indicate that house was built in 1973. Therefore,system is 28 years old. tWere sewage odors detected when arriving at the site(yes or no): No ' Page 7 of 11 ' OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION(continued) ' Property Address: 885 Race Lane,Marston Mills Owner:Bozena Niechwiadowicz Date of Inspection: June 7,2001 ' BUILDING SEWER(locate on site plan) Depth below grade: 7' Materials of construction:_cast iron X 40 PVC_other(explain): Distance from private water supply well or suction line: N/A Comments(on condition of joints,venting,evidence of leakage,etc.): ' Sewer exits into a sump where a sewage elector pump directs effluent into septic tank. No evidence of 1_eakaze,all joints appear to be in good condition on the day of inspection. Eiector pump operating normally. SEPTIC TANK: X (locate on site plan) Depth below grade: 16"(inlet side to outlet side) Material of construction: X concrete_metal_fiberglass_polyethylene ' _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 8.5'x 5'x 4' ' Sludge depth: 7" Distance from top of sludge to bottom of outlet tee or baffle: 219" Scum thickness: None present ' Distance from top of scum to top of outlet tee or baffle: N/A Distance from bottom of scum to bottom of outlet tee or baffle: N/A How were dimensions determined: Direct measurement Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels ' as related to outlet invert,evidence of leakage,etc.): Inlet and outlet baffles in good condition. No signs of leakage,liquid level at outlet invert. Recommend Pumping at this time due to depth of sludge. ' GREASE TRAP: N/A (locate on site plan) Depth below grade:_ ' Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: ' Scum thickness:Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): ' Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION(continued) Property Address: 885 Race.Lane,Marstons Mills Owner:Bozena Niechwiadowicz Date of Inspection: June 7,2001 ' TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: ' Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons ' Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): ' Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: N/A(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.): PUMP CHAMBER: N/A (locate on site plan) ' Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): ' Page 9 of I 1 ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION(continued) ' Property Address: 885 Race Lane,Marston Mills Owner:Bozena Niechwiadowicz Date of Inspection: June 7,2001 tSOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) ' If SAS not located explain why: ' Type X leaching pits,number:One 6'x 6'leaching pit(inspec(orassum)es2stone all around) leaching chambers,number: ' leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: ' innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): tSoil dry,no signs of hydraulic failure,no ponding,no lush vegetation. CESSPOOLS: N/A (cesspool must be pumped as part of inspection)(locate on site plan) ' Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: ' Depth of scum layer: Dimensions of cesspool: Materials of construction: ' Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: N/A (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.): i ' Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION(continued) ' Property Address: 885 Race Lane,Marston Mills Owner:Bozena Niechwiadowicz Date of Inspection: June 7,2001 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. 1 Please see attached sketch 1 1 1 1 1 i ' i� ' Page 11 of 11 ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION(continued) ' Property Address: 885 Race Lane,Marstons Mills Owner:Bozena Niechwiadowicz Date of Inspection: June 7,2001 ' SITE EXAM Slope: Flat in SAS area Surface water: None in area Check cellar: No cellar Shallow wells: None in area Estimated depth to ground water 54.8 feet(below the ground surface at the SAS) Please indicate(check)all methods used to determine the high ground water elevation: ' Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) ' X Accessed USGS database-explain: You must describe how you established the high ground water elevation: ' Seasonal high groundwater was determined by comparing USGS/Cape Cod Commission groundwater data and Town of Barnstable GIS data to field measurements. ' The surface of the ground at the SAS was estimated from the Barnstable GIS map (June 1992) to be at elevation 97.8. The bottom of the SAS was assumed to be approximately 10' below the surface(based on the ' location of it's top approximately 4' below the surface); therefore,the of the bottom of the SAS is at elevation 87.8. The groundwater elevation beneath the site was estimated from the Barnstable Ground Water Contour and ' Road Index Map (June 1992) and found to be at elevation 43. Using the Cape Cod Commission method to estimate the seasonal high groundwater elevation, the site was found to be within the area of groundwater indicator well SDW-253(Zone B). According to the data available from the Cape Cod Commission the June 1992 adjustment for that well is 7' upward. Therefore, the adjusted groundwater is at elevation 50. When ' subtracted from the SAS bottom (elevation 87.8) the resultant separation is 37.8' between seasonal high groundwater and the SAS bottom. 1 ' LOCUS MAP & SEPTIC SYSTEM SKETCH 1 1 o� �� �°'�"' � ,�� fit; ah�E�o a �• x L'1�'e'; y� 4.r+� ��., �, ~Q� �_ fit' �'L�`'� i •y �� .y sw •tt � ��,-� �rspaali y�;0,� gy'�,..f`'� �, �. /`�✓�„ c����� ` � �.e '� y .n°h �o' .. �agg(A:�r,. "fir 4•r-`^^`�,ds � i a �l •O ~^•r ',s wn A t �,ri ("} + �s:' � `'^us� ,�3 •i•� tl�s tk � \�S O �a�•' �4 �e r � � 'Aye,. �Q$ ,.a I 1� w��s/1� � ^��'.a +� �Y� -4� �, � •� Q'" Q"Qr.Is,� 'an a �#� �`+ �•• s t!4 I �� �� o� ao,:s � d w:^�.0�� �° �i.S"J � � ,y� ty sr •r i`S'. '�.,_� t L��,,°��`A t� �' Gs y 0.,t3�:o ���to � •.C � � s ..3� %•• + �yJ.J � .��©r �... / 1 .`�'p . � P •v0 Vb 'fir ' `�. Lj VF ��Y.r✓ - aF '` +fib` (r ♦ 00 � 4 =�� f FE00 r a C aeber r << a Y . s Cade it 53 _ v r q � r )� trgrvu _ -,�'^+....-.- / � l � �. • :�� tip%� F .� . �" !� 8 •� ,.G�. 5,+\ ram•• � ! ° • ,- �� ( ©o � • � ••• { y• gym• i Lake • .. Uj . + •� .' • p • E" .• { .--�! asA. f �•1 •ae, i , 4 •� l� Y i w*' 43 16"W Hamblin s,.• ° r Name:SANDWICH Location: 0410 41'44.9" N 0700 24'28.4" W Date:6/7/2001 Caption: Locus Map Scale: 1 inch equals 2000 feet 885 Race Lane Marstons Mills,MPS ' Copyright(C)1997,KUptech,Inc. f Septic System Sketch CirOSS S6Ct1O11 Ground Surface ' 16" 4' Steel Chimney Vent ' Septic Tank SAS Buried Portion Underground House of House ' Below Ground Courtyard Concrete ' Walkway Please note that the house is located P�,I ' below ground. No structural projections ' occur above ground. Septic Tank Vent #885 25' -- Cedar Trees ' 25' 22' Utility ' SAS Pole Solar Panels ' Gravel Parking Area — RACE LANE William E. Robinson, Jr. Site: 885 Race Lane ' Septic System Inspections Marstons Mills, MA. Not to scale 43 Tomahawk Drive ' Centerville, MA. 02632 Date: June 7, 2001 (508) 775-7986 � I ' Inspectors Certificate 1 1 1 ��� •°•t�� S jCr V) � . r THE COMMONWEALTH OF MASSACIHIJSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT William E. Robinson, . Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR ° as provided in 310 CMR 15.340 and Section 13 of. Chapter 21A of the General Laws. Issued by The Department of Environmental Protection.- April 20, 1995 Acting Director of the ' ton of Water Pollution Control 1 1 1 1 1 1 1 1 1 1 II. 1 1 1 1 1 1 1 FROM GREGORY C VARJIAN BUILDER FAX NO. : 15084282370 Oct. 23 2001 07:43PM P1 TOWN (.)F BAt{NS'fAf11,E 13[1!1LVI,'\(; Map—..�. Parcel CL'.� z 1 Permit Health Division �c� „�c• : '' J 7l - �/ Date Issued "C 1 Conservation Division _. f�S ' Fee {'_ IDS Tax CollectorJ ro Treasurer 1`� l vlsv� Planning Dept.���1i1 4 �.��� • Date Definitive Plan Approved by Planning Board ENVIROMMAL WIDE AM 'TOWN RMUL_ATIONS Historic-Ol(H-144%�7/ __ Preservation!Hyannis a9W Project Street Address S �f U tr llage l A '/t n S C A e S '- Owner C-7r pf�' �,� .• • �j( ;2t1n R i t^c.� w ---�—�- Address Telephones Permit Request_ '� L✓llc �, �, f -�- , •;tom - :dGquare feet: [ft�oo�r�:hex, <ipro0osed t 2nd floor:existing Proposed _ Total new Valuation ..'Y . -'�---i ti, c l� Flood Plain - - Groundwater Overlay Construction Type WL � Lot Size e Grandtalhered: Q Yes CIAO If.yes,attach supporting documentation_ Dwelling Type: Single Family Zk,"� Two Family CI Mufti-Family{;units)) Age of Existing Structure — Histori ' c House: ❑Yes t�to On Old Kings Highway: -3 Yes 4hrrb Basement Type: - full Q Crawl J�Ti�W�allJk)out Q Other _ Basement Finished Area(sq_ft.) / (J VL/ ` � '�f- Basement unfinished Area(sq.ft) Number of Baths: Full:existing 01 e- new 0A t -- 10. new Number of Bedrooms: existing neyr _ Total Room Count(not including baths}:existing {ir new First Floor Room Count �'�� Heat Type and Fu Q No: idGas U Oil U Electric ?Other 'Y � Central Air: Yes o Fir places:Existing NL'�� New 0'� -' Existing woodlcoal stove: & es--/--0 No0 �'t� k^ Detached garage:v existing i Pool:�existing O new size Bam:1 existing i1 new size Attached garage:,J existing anew size _ Shed`0existing J new size_ _Other: size ­­ Attached !c �, - Zoning Board of Appeals A rion ❑ Appeal# ��_ Recorded J t�� a0S-00 NO. s ©�� --------- Fee---- -------------- BOARD OF HEALTH TOWN OF BARNSTABLE ApplicationArlVell Congtruction Permit Appl' i i h e made for a,permit to Construct ( ), Alter ( ), Repair ( )an individual Well at: ^� ocation — Ad ress I %? rl/1i� Assessors Map and Parcel ws1 ----- -- -- — Owner Address Installer — Driller Address Type of Building Dwelling------- -- — —---- Other - Type of Building-------- `------- No. of Persons------------------------------------ Type of Well— � `-�-mod--- Capacity----X --`�,-yyoo-- - ----- Purpose of Well---7A�-L— ��------ F i Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Heal&WProtn Regulation - The undersigned further agrees not to place the well in operation unt' e has been issued by the Board of Health. Sign dacApplication Approved B - --_---— —�--- date Application Disapproved for the following reasons:--------- - - - ------- ----- --------------------------------------------------------- -- ----— — — date �_1�_ Permit No. "�-s7=" --- Issued---— ----- ate —— BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate Of Compliance THIS IS T�ERTIFY � ndi dual Well Constructed (Altered ( ), or Repaired ( ) y Installer at----���� -��___------------------------------- ----------------------- has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. ----—------------Dated------ -------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE-------------- -- - —-- Inspector--------------------------------—----___---- 44 No. a�_ Fee-----21 �----- BOARD OF HEALTH TOWN OF BARNSTABLE • ' 01POricat on for Veil CongtructionVermit Appli do is hereb made for a permit to Construct (1\), Alter ( ), or Repair ( )an individual Well at: fin/ . Alm.s4 `/_/- _00 5 -_o© 1 oration — Address, P -- —-- A Ma and Parcel -- .--� �� S Assessors Owner Address Installer — Driller Address Type of Building + Dwelling - ------------------------- Other - Type of Building-----'=------- - - No. of 4 Type of Well Capacity yp - Y----L-- --- ,�—-- Purpose of Well �i •�'1-`` ----- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The - Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until-a Certificate pl/l'ce has been issued by the Board of Health. Signe - — ------- — — jt�a ) S Application Approved By _ ------- -------- - date Application Disapproved for the following reasons:-------------- —--- -— I . ----------- — date Permit No: 1�1 _©�- _�_------- Issued---— - -- d — -- --- — ate BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of COMPliante THIS IS TO ERTIFY, That the Indio-dual Well Constructed (4 'rAltered ( ), or Repaired ( ) f —Installer -------------------- has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. --------- -Dated----- ------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE----- ----- -- - -- Inspector------ - - --- - —------- BOARD OF HEALTH TOWN OF BARNSTABLE ]Veil Con!9truct ion Permit No. C� 0_-) 0-C�' Fee- J — Permission is hereby grantedto Construct (44 "Alter ( ), or Repair. ( ) an Individual Well at: No. -- �~ .46c_P Z/ -- -------- - -- - - - - - - street as shown on the application for a Well Construction Permit L' 1 No.__— c �Ca Q l — ed— - �— `3---------------------------- - -- — — — —--—-------------------------------- �l Board of Health DATE— FROM GREGORY C VARJIAN BUILDER FAX NO. 15084282370 Oct. 23 2001 07:42PM P1 f1ii•�•�'A •.1~l!- ] PIP j j4 C. Aj.l.l ..» �� ...S;i� ( �`r r_I f .l.f .J ii t�..�tr l:'. L.}�l.s- 1��.7 f.'St.:i,/1,n 2! 14/•J w�G. ;r�'I: -yt�r, SA'1:-• I . , .:�; {rI T:t.'�1r �s::141'I' A" I'P.10N ' i�2'} Department of Health, Safety ((� p __ ({ and Environmental Services (^fT/fir r 2 1r. lr 8. 00 4 3,1 RE ;D A)D/ALT/'(70 I4T WAM ibf9. By THIS PERMIT CONVEYS NO QIGNT TO OCCUPY ANY STREET.ALLEY OR SIDEWALK OR ANY PART THEREOF,EITHER TEMPORARILY OR PERMANENTLY.EN- CROACHMENTS ON PUBLIC PROPERTY.NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE,MUST BE APPROVED BY THE JURISDICTION.STREET OR ALLEY GRADES AS WELL AS DEPTH AND 1_OCATION OF PUBLIC SEWERS MAY BE OBTAINED FROM THE OEPARTMENT OF PUBLIC WORKS.THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. MINIMUM Of POUR CALL INSPECTIONS REQUIRED FOR ALL CONSTRUCTION WORK: APPROVED PLANS MUST BE RETAINED ON JOB AND I.FOUNDATIONS OR FOOTINGS THIS CARD KEPT POSTED UNTIL FINAL INSPECTION WHERE APPLICABLE, SEPARATE 2.PRIOR TO COVERING STRUCTURAL MEMBERS HAS BEEN MADE.WHERF A CERTIFICATE OF OCCU• PERMITS ARE REQUIRED FOR (READY TO LATH). PANCY IS REQUIRED.SUCH BUILDING SHALL NOT BE ELECTRICAL.PLUMBING AND MECh- 3,INSULATION. OCCUPIED UNTIL FINAL INSPECTION HAS BEEN MADE, ANICAL INSTALLATIONS. a.FINAL INSPECTION BEFORE OCCUPANCY BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS T T i 1�31v� ?tip 2 ; 2 2 f 3 T HEATING INSPECTION APPROVALS ENGINEERING DEPARTMENT BOARD OF HEALTH OTHER: ,... SITE PLAN REVIEW APPROVAL _ T WORK SHALL NOT PROCEED UNTIL PERMIT WILL BECOME NULL AND VOID IF CON• INSPECTIONS INDICATED ON THIS THE iNSPECTOR HAS APPROVE011HE STRUCTION WORK IS NOT STARTED WITHIN SIX CARD CAN BE ARRANGED FOR 8Y VARIOUS STAGES OF CONSTRUC MONTHS OF DATE THE PERMIT IS ISSUED AS T>`LEPHONE OR WRITTEN NO7IFICA- TAN �1/Mrcn weA oc r�� THE COMMONWEALTH OF MASSACHUSETTS b� J.. .-BOARD OF HEALTH ®�.. - --- ..................... A firat vn for i-qpaval Marks 6ustrurtion Vrrmit Application is hereby made for a Permit to.Construct ( ) or Repair ( ) an Individual Sewage Disposal Syst at #'! ,/ ... Ln.A dres or Lot No. ..... � ... R..................... .............. O r Address ............... Installer .............. ....Address... }� g� -.........__. UType of Buildg� , Size Lot.../_.: :..Sq. feet �-4 Dwelling of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures -•__________ ___ __________ ::. W Desi Flow........................... allons er erson er da Total dail flow._____.. - __ gallons. lmP P P Y Y �.............••• WSeptic Tank—Liquid capacity.J_.......gallons Length................ Width................ Diameter................ Depth................ %x Disposal Trench—No..................... Width.................... Total Length............._.._.__ Total leaching area....................sq. ft. �:j. Seepage Pit No--------------------- Diameter------__............ Depth below inlet.................... Total leaching area..................sq. ft. Y •............................•••--•._....-•---•-----.. Date----._............. Percolation Pit Results Performed b .............. ��.:_-.__.__.__.__._. _Other Distribution box Dosing tan aTest Pit No. 1......_t......minutes per inch Depth of Test Pit.................... Depth to ground water....I________________- G%, Test Pit No. 2................minutes per inch Depth of Test Pit............ ._ Depth to ground water__. .................. ------ -- ........................................ 0 Description of Soil ------------------------------- U .-----------•--------------------------------------------� -'------•---------------------------------------------------------------------------------------------------•--------•---------- W V Nature of Repairs or Alterations—Answer when applicable..... ::;_ •-------•----=----------------------------"•----------------.......---...._......................._......--•••-•---------- ` ------------------------------------------------- ........................ Agreement: `1 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 uje ,..,n,d rther agrees not to place the system in operation until a Certificate of Compliance h`s een issued thef lth. Sid-- .._... . . -••- ....•• • ............••----•..... •_•••••......-• ......•••_-••.. D Application Approved By..... .- --- "= Da e Application Disapproved for the following red _----------------_-- ............................................................. .......... .....--•-•---•--•--------------------•-------------------------------------------......-•------------------•--••••-•-......•-------•-••......•.... .... --------------......._� ,'� � Date Permit No......................................................... Issued..- ..... ...... i Date - ----------- THE COMMONWEALTH, OF MASSACHUSETTS BOARD OF HEALTH , N Applirathm for 15isposa1 Wore Tonstrurtion Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Syst at 41 fi � -.. fd/ ................... a Location•A/re. ,,� ror Lot No.i .. .................... 4-1 -w . �, Addreas.... .............................. .... ...,, ........ .......................................... r . .. .. .. ..tt .. Installer Address l• Type of Build1�o. Size Lot__�._l ____Sq. feet Dwelling of Bedrooms......................:.....................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—Type of Building No. of persons____________________________ Showers — Cafeteria Other fixtures ........................ _ ___ _ _ ________ W Design Flow............................____° ...._ allons per person per day. Total daily flow... .l�`" ... W Septic Tank.---Liquid capacity_ allons Length Width Diameter Depth xDisposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter_.._._._.___....____ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1.......Z......minutes.per inch Depth of Test Pit..................:..Depth to ground water__________________.--_- (, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_______________________- ----------•------------------------••t----•---•---•--•--•------- ODescription of Soil-----------------••• » . ----------------------------------------•----•--•--•-----•------ 14-14 U ............................=•--••-------•--•••-•-•----- ------------------------------------•--------------------------=-----._.__._._.._.------------------------------------------------------------------ ................................................... U 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 XI of the State Sanitary Code—The undersi ned rtIler agrees not to place the system in operation until a Certificate of Compliance h s*been issued the boar of h lth. - fi Application Approved BY ar"' ;_, :.r fit. .� -` '!; ' _ ..= ------------ =� /D. Application Disapproved for the following red •------------•--••---..__....-•-------•--•-••---•--••------••-•-......... ................•-------------•------._._...---...--•---------...._..__.-•-----.__---•--•-- •-- .........•--------------------------------------- --------•-•-------•------- ---------- Permit No......................................................... Issued--.7 !T 1 Date --------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OFF HEALTH �: -�_............... T.erttf ua#P of Toutphattr.e TH it CE IFFY; h Individual Sewage Disposal System constructed ( ) or Repaired ( ) by....... _ + - ---- =••••-•----.............. ...........---- ............................................................. I:,stalt¢k at....... _W4 . ------------- ....... has been installed in accordance'with the provisions of Article XI of The State Sanitary Code a described in the application for Disposal Works Construction Permit No_ ____________________ °_ _ dated..--- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. �. DATE---........••••••---••---•••--•--•---•--••-•--•-••••-•••-•-••--•--••-••-----•_.. inspector................................................. . .......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD .OF HEALT , ...... .................. er No.... � F-EE._ Permission, > ereby granted...... ..................r........................... R " an vO idua isoto or sat st atN D _.. ...•---- -_...•- ` a Street as shown on the application r Disp�al Works Construction 1t NOr/,y� ated----- � X.4 - Board of I-Iealth DATE....... ------------------ - .,.,_._..:............. FORM 1255 HOBBS & w RRFN. INC... PUBLISHERS Jc)N N o Jw, Ocl 4 T) 2 /67't .�S 3 -F 20 W 1- Z d ` F.2• , 0.26SS October 4, 1972 .. M AI G Qa v_r-- _E_L F_v. _1 o-cn. o Board of Health Town of Barnstable Hyannis, Mass. 02601 Gentlemen: ���-CLA-Y - At the request of Mr. Murray we are sub- mitting the results of a test pit taken this date by Alfred Fuller. Location of pit is on Lot F near the corner of Wheeler Road and Race Lane - (see enclosed plan. ) The accompanying sand sample is typical of all material found below the 30 level. 7=G Ce- -125:F1� e truly yo r , Joh Barnard, Jr. JB:FE enc. \VA YE e TA a E-E--LE-V-44-ca AM /lata�eleG� //�, �ad� 68/d/ 6/7-f3S-7#,V a NOTE: TO PREVENT BREAKOUT, THE PROPOSED DESIGN CRITERIA NOTE: MAGNETIC TAPE TO BE PLACED OVER ALL COVERS FINISH GRADE SHALL NOT BE < EL:94.21 FOR A DISTANCE OF 15' AROUND THE PERIMETER OF THE S.A.S. NUMBER OF BEDROOMS: EXISTING 3 BEDROOM DESIGN TOF: EL.=97.0t SEPTIC TANK PROPOSED D-BOX PROPOSED S.A.S. _SOIL TEXTURAL CLASS: CLASS i DESIGN PERCOLATION RATE: <2 MIN/IN INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & COVER INSTALL A 4" DIAMETER INSPECTION PORT OVER DAILY FLOW: 110 G.P.D/BR. DESIGN FLOW: 330 G.P.D. OUTLET AND SET TO 6" OF FINISH GRADE SET TO 6" OF GRADE ONE CHAMBER (MIN.) AND SET TO 3" OF F.G. ' F.G. EL.=96.4t F.G. EL.=96.6t /-F.G. EL: 96.6t F.G. EL: 96.8(MAX.) GARBAGE GRINDER: NO (NOT DESIGNED FOR GARBAGE GRINDER) fJ SEPTIC TANK: 330 gpd x 200% = 660 gpd RE-USE EXISTING 1,000 GAL SEPT. TANK r LEACHING AREA REQUIRED: (330)/0.74 = 445.94 S.F. 9" MIN COVER/ ® S=1% (MIN. 36" MAX COVER L = 10' L = 15'(MAX) INSTALL TWO INSPECTION PORTS (MIN.) DISTRIBUTION BOX: 4 OUTLETS (MINIMUM)(H20) EL. =95.66 0 S=1% (MIN.) ® S=1% (MIN.) TO WITHIN 3" OF FINISH GRADE 4"SCH40 PVC 4"SCH40 PVC 4"SCH40 PVC ell s: _ PRIMARY S.A.S. 10"I s• 11" TO USE 4 ROWS OF 4 - INFILTRATOR HI-CAPACITY H-20 UNITS-NO STONE .� 14" 48" L/OU/0 INVERT INV.=94.60 LEVELINV.=94.35 INV.=93.80 BOTTOM AREA: (GENERAL USE APPROVAL FOR 4.73 SF/LF OF BIODIFFUSER) GAS BAFFLE PROPOSED 4 ROWS OF 4 UNITS AT 6.25'/UNIT = 25'/Row (BIODIFFUSERS) 16 UNITS x 6.25 LF x 4.73 SF/LF = 473.0 SF D-BOX INV.=94.05 INV.=94.25 DB-5 SOIL ABSORPTION' SYSTEM (PROFILE) TOTAL AREA = 473.0 SF EXISTING 1,000 GALLON SEPTIC TANK H 0 RESTORE VEGETATIVE COVER DESIGN FLOW PROVIDED: 0.74GPD/SF(473.OSF)= 350.0 GPD > 330 GPD req'd EXISTING SEWER OUTLET BACKFILL WITH CLEAN PERC SAND 75" TO TOP OF CHAMBERS NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING , PIPE INVERTS PRIOR TO CONSTRUCTION BREAKOUT=TOP ELEV.=94.21 2) D-BOX SHALL BE SET LEVEL AND TRUE TO INV. ELEV.=93.80 GRADE ON A MECHANICALLY COMPACTED SIX BOTTOM ELEV.=92.88 EXISTING SUITABLE INCH CRUSHED STONE BASE, AS SPECIFIED IN 2.83' MATERIAL 310 CMR 15.221(2) 5' MIN. ABOVE BOTTOM OF 3) REPLACE EXISTING 1,000 GALLON SEPTIC TANK T.P. EXCAVATION OR G.W. EFFECTIVE WIDTH = 4 x 2.83' =11.32' WITH 1500 GALLON SEPTIC TANK IF FAILED, (7.38' PROVIDED) USE 4 ROWS OF 4-HIGH CAPACITY DAMAGED, OR UNDERSIZED. BOTTOM OF TESTHOLE EL.=85.5 = INFILTRATOR UNITS (H20) - NO STONE 4) INSTALL INLET & OUTLET TEES W/ GAS BAFFLE AS REQUIRED - SEPTIC SYSTEM PROFILE TYPICAL SECTION 16" N.T.S. N.T.S. GENERAL NOTES: SOIL LOGS a 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL SECTION 11" j I BOARD OF HEALTH AND THE DESIGN ENGINEER. DATE: JUNE 3, 2014 INVERT HEIGHT END CAP 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS SOIL EVALUATOR: DARREN MEYER, CSE 1614 OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE LOCAL RULES AND REGULATIONS. P��� �F MAS, WITNESS: DONNA MIORANDI, BARNSTABLE HEALTH INFILTRATOR - HI CAPACITY (H20) CHAMBER 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE D y� I DESIGN ENGINEER. Elev. TP-q 1 Depth Elev. TP-2 Depth MODEL 16' HICAP 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING c� " FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN o. 1140 "' 96.8 0" 96.5 0" LENGTH 76 NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT ENGINEER BEFORE CONSTRUCTION CONTINUES. A LOAMY SAND A LOAMY SAND TO CHANGE WITHOUT NOTICE. PRODUCT DETAIL MAY 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. �c��STERE4 1OYR 4/2 1OYR 4/2 EFFECTIVE LENGTH 75' DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE. 95.97 10" 95.58 11" SIDE WALL HEIGHT 11" 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF S�NITAR�a� B i B THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF OVERALL HEIGHT 16" HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. �L/i LOAMY SAND LOAMY SAND 1 IOYR 6/8 10YR 6/8 OVERALL WIDTH 34" 7. DWELLING IS SERVICED BY MUNICIPAL WATER SUPPLY. j34" 93 83 ,C 32" 13.6 CF 8. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED 93.97 C CAPACITY TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. (101.7 GAL) 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE PERC 0 EL. 92.60 MEDIUM LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO STARTING WORK. SAND MAAND PROPOSED SEPTIC SYSTEM/SITE P LA N 10. EXISTING LEACHING TO BE PUMPED, CRUSHED AND FILLED PER TITLE 5. 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION 2.SY 7/3 I� 2.SY 7/3 885 RACE LANE, MAR STO N S MILLS, MA 1 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY 85.8 ti 132" 85.5 132" Prepared for: Bonomi 13. NO KNOWN PRIVATE WELLS WITHIN 150 FT. OF PROPOSED LEACHING PERC RATE<2 MIN/IN. ("Cl" HORIZON) 14. ALL PIPING TO BE 4" SCH 40 0 1/8-/FT (UNLESS SPEC. ) NO GROUNDWATER OBSERVED System Design and Site Plan by: SCALE 0 15. THE DESIGN OF THIS SYSTEM DOES NOT ALLOW MEYER&SONS, INC. NTS D.M.M. 06/ 8/14 ` 1, Darren M. Meyer, R.S., CSE, hereby certify that I am currently approved by MADEP pursuant to 310 CMR 15.017 PO BOX981 CHECKED to conduct soil evaluations and that the above analysis has been performed by me consistent with the SHEET N0. FOR THE USE OF A GARBAGE GRINDER. 16. NO WETLANDS WITHIN 150 FT. OF PROPOSED LEACHING requirements y uirements of 310 CMR 15.017. 1 further certify that I hove passed the Soil Eval. Exam in October, 1999. EASTSANDWlCH,MA02537 508-362-2922 D.M.M. 2 of 2 r; MARSTONS MILLS s LEGEND } CAPE COD PROPOSED CONTOUR AIRPORT ® PROPOSED SPOT GRADE -- gg -- EXISTING CONTOUR �pJ� + 96.52 EXISTING SPOT GRADE LOCUS PARCEL ID: ,tk ii W— EXISTING WATER SERVICE Rqc� 83/007 TEST PIT tX � OAF LOCUS MAP LOCUS INFORMATION PARCEL ID: TOOPP PA T PATIO BLOCK 96.7 PLAN REF: 446/57 / 005-001 TITLE REF: 27254/187 104 AREA/ 4 5-0 S.F. W -k PARCEL ID: MAP 104 PAR. 005-001 ZONING: "RF" FLOOD ZONE: "C" O� SS COMMUNITY PANEL: 250001-0015—C DATED:08/19/85 96.4 G �O #885 W G SEPTIC SYSTEM TOF=97.00 G� (SAVE) 96.9 REPAIR PLAN SPRUCE LOCATED AT: EAST. 1000G 96.9 r 1 SEP. TANK 885 RACE LAN E TP APPROX. Loc. MARSTONS MILLS MA. BUS _ EXIST. LEACH �� PIT (NOTE 10) PREPARED FOR S APPROX. 96.4 ?sue e ,ry --v � PATIO w �;'UNDEERGROur ,r 97 0 411 K I M B E R L E Y S. B O N O M UTILS OQ' _ JUNE 8, 2014 F 0 W ` 12"MAP 0 ; 972 OF 44S s� DA N y� irri tion %' c E — PARCEL ID: well '96 �� o. 14 104/006 W ---- ,�11 'PEGI E Si 96.7 � SgNITAR�a� N 6°°0 , �q ,•�, 4 MEYER & SONS INC. �� .�o°� 104/005 1002 P. 0. Box 981 E. SANDWICH , MA 02537 PH. (508)360-3311 fax (774)413-9468 meyerandsonsinc@gmail.com SCALE: 1"=30' 11 SHEET 1 OF 2 ' i r, fi Y�1 .( r..,. ?'�" a s- -..: :4..,.� .... .. _fha_. ._ .,...- .�.4;��.. .t d .Y:C•`�'V�. 'i':"a '�.'t-W�.t .�'T'. y� ,�sc �' rY;.;-a, a�,` .: •y ...�,,. •hy.- _.. G ,:..,.. .. .r ... ..r .�q°,�.a• f$� -.i°S .�-- .' i Al, •a _K - 4ti 1 Y tC r i• > h :S. v�'•�„y .-�C f..�. � �•�,"�,i+,E^�''^ra �'. 'S. 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