HomeMy WebLinkAbout1037 RACE LANE - Health [037 RACE LANE, MARSTONS MILLS
A=083.008 .
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I ,+4/J 00 8, 'TOWN OF BARNSTABLE
LOCi',T7,ON LI1I SEWA E #
VEU,'ALGE S v \S ASSESSOR'S MAP &LOT-A - 00-!R
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 1<66 Cry.
LEACHING FACILITY: (type) ize) X��It�,
NO.OF BEDROOMS �' -I
UII,DER ROWNER S4444 &SL6 6e-
PERMTTDATE: _COMPLIANCE DATE: = 99
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200,feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
C
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T^ A-3 .
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No. '_` a z Fee /
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MAS ACHUSETTS
for ]Di5pooaY 6p5tem Con5truction Permit
0(pprication
Application for a Permit to Construct(✓)Repair( )Upgrade( )Abandon( ) ,El Complete System El Individual Components
Location Address or Lot No. 103 7 kC&, 1,0ee Owner's Name,Address and Tel.No.
Assess r'gAap�cel
M
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
7/-
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( '
Other Type of Building G No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date / 17- Qg, Ntunbe of sheets / Revision Date
Title ew ��/!
Size of Septic Tank / ,5/�� �i�� Type of S.A.S. y —jj5 e_e;e lee 1B4k5%
Description of Soil e e049!
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by Bo f Hpulth.
Signed Date Zf
Application Approved by - Date
Application Disapproved for the following reasons
Permit No.
' f
N0 e r v t Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in cornp°ter: '
PUBLIC.HEALTH DIVISION =TOWN OF:BARNSTABLE MAS ACHUSETTS Yes
Y cation for tzpaa .- ipgtem ctConotruction 3perm�tt
Application for a Permit to Constrict(V)Repair( ;)Upgrade(._ )Abandon( ) Complete System O Individual Components
Location Addressor Lot No.' 7 "ec's N ,Address and Tel.No.
Assessor a ar
Installer's Name,Address,and Tel.No.' • Designer's Name,Address and Tel.No.
Type of Building:.
'Dwelling No.�of Bedrooms Lot Size' " sq.ft. Garbage Grinder
Other Type of Building E G No.of Persons Showers( ) Cafeteria( )�
.;
Other Fixtures
{ Design.Flow gallons per day Calculated daily flow 0�0 gallons
Plan: Date / /Z 9� Nurn of sheets / ` Revision Date
Title J'�2dli �!!
rl Size of Septic Tank Type of
Description of Soil'
Nature of Repairs or Alterations(Answer_when applicable) /'y�'w C'O l°sJ`1loc.� f�!1
Date:°last inspected +
r Agreement
* The undersigned,agrees to ensure the construction and'maintenance of the afore desenbed on-site sewage disposal system,
' in accordance`with theprovisions,of Title-5 of•the Environmental+Code'and not to place the system'in,operation until a Certif
cate of Compliance has been issued•by this Bo /f;He�fthh,
Signed ` / Date ��ZZ
�� •.
APPlication Approved,by.;{ Date. � ✓.�� '.
''Application Disapproved for the following reasons
Permit No. " + - -'y Date`Issued-
••THE COMMONWEALTH'OF'MASSACHUSETTS ,
° BARNSTABLE MASSACHUSETTS
certificate of Compliance
THIS IS TO CERTIFY, 4 th t the.On-site Sewa a bis osal System Constructed +�Re aired Upgraded,'(
Abandoned(° :)b d J: CDrJ.ST,
at 7 f51`4�5 S has been constructed inaccordance
with the provisions of Title 5 and-the for Disposal System ConstructionPermit No 1. 42 dated''
Installer D! � /f% G'D�i'S .:
r Designer
The.issuance of this.permit shall not be construed as a guarantee that the system will fu-nction_as designed:
Date j �-: I..iC' Inspector,• .
No �-- — — — — -- --- ---1,17
—.-- Fee . ``��,,
40
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION BARNSTABLEs MASSACHUSETTS
tg 05al_&Pgterri or�gtruction errnit
Permission is hereby granted to Construct(Repair( )Upgrade( )Abandon( ) r
System located at �W�� �C�. <9tl�'
and as described in the.above:Application for Disposal'_System Construction Permit:The applicant recognizes his/her duty to ,
comply with Title 5 and`the following local provisions or special conditions. ,
Provided-Construction must be completed within three years'of the date of this permit.
Date: Approved by
1
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TOWN OF BARNSTABLE
..00 ON A SEWAGE #
:VELLkGE 9"SIdIAS 6ISS ASSESSOR'S MAP & LOT A _3— 06A
INSTALLER'S NAME&PHONE NO. LO .
SEPTIC TANK CAPACITY I a0 �a
�
e:LEACHING FACILITY: (typ a l�
NO.:OF BEDROOMS 3
,,•• DER)OR OWNER spa S(v�D��
PERMUDATE: J "I 9'�COMPLIANCE DATE:
Separation Distance Between the:
Ivfaximum,Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
`.site or within 200 feet of leaching facility) Feet
,Edge of Wetland and Leaching Facility(If any wetlands exist
Vvithin 300 feet of leaching facility) Feet
Furnished by
T
Lam.}
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DATE 5/19/06
PROPERTY ADDRESS 1037 Race Lane
Marstons Mills
MA 02648 -
On the above date, the septic system at the address above was
Inspected.
This system consists of the following;.
�. 1-1500 ga.EPon ,ze/?t.ic .tank..
2., 1-Dizt2.igut.i.on Box..
3., 3-500 gaeeon .eeach.ing cham&ez,3
Based on inspection, I certify the following conditions: = y
4., 7h.i, :is a 7.it.ge T.ive zep.t.ic zy.6temo
5., Sepi-ic zyhtem .ins .in /22o/2e2 wolzking o2dea at the /?2esent
�"•`. 1,1 .—� ;ice
-i
SIGNATU a f
Name: Robert.A..Paoli nI
Company: Joseph P. Macomber & Son Inc .
Address: P. O. Box 66
Centerville, Mass 02632
Phone: 508-775-3338 or 508-775-6412
LP. .MACOMBER & SON, INC.Tanks-Cesspools-LeachfieldsPumped & InstalledTown Sewer Connectionsx 66 Centerville, MA 026.32-0066
775-3338 775-6412
•
\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
a
TITLE 5
OFFICIAL INSPECTION FORM—.NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: .. 1037 Race Lane
Marstons Mills MA 02648.
Owner's Name: Heinz' C of 7kin
Owner's Address: Po Rnx 1 1 ti
Marc't nnc 'Nf; l l MA' n2648
Date of Inspection: 5/1 9/0 6
Name of Inspectors(please print) Robert :A P.ao.l'ini
Company Name: �_. )..Nacomi~.,ea 9 S:o.n Inc..
Mailing Address:
Ce2 e2U.c e, ass.•02632
Telephone Number: 5 0 8-7 15 3 3 3 8
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 16:000). The system:
XXX Passes —
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signa . Date: o
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
****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
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Page 2 of 11
OFFICIAL INSPECTIONYORM—.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �
PART A
CERTIFICATION(continued)
Property Address: 1037 Race Lane
Marstons Mills MA 02648
Owner: Heinz Grotzke
Date of Inspection: 5/1 9/0 6
Inspection Summary: Check A,B,C,D or.E/ALWAI'S<eomplete all of Section.-D
A. System Passes: qES
NO I have not found any information which indieates`that any of the failure criteria described ih 3.10 CMR
15.303.or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comme ts:
Sel2tic zyztem .is ..in paope¢ wo2k.inggAdea at the j22e,6ent t.ime.-
B. System Conditionally Passes:
NO One or more system components as described in the"Conditional Pass"..section need wbe.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.
NO 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:
NO, 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:
NO The system required pumping more than 4 times a year due to broken or obstructed pipe(s)..The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2.
f
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1037 Race Lane
Marstons Mills MA 02648
Owner:. Heinz Grotzke
Date of Inspection: S J 1 4/0 6
C. Further Evaluation is Required by the Board of Health:
No 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(l)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
No Cesspool or privy is within 50 feet of a surface water
tLQ 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:
No The system has a septic tank and soil absorption system(SAS).and the SAS is within 100 feet.ofa
surface water supply or tributary to a surface water supply.
No The system has a.septic tank and SAS and the SAS is'within a Zone 1 of a public water supply.
No The system has a septic tank and.SAS and the SAS is within 50 feet of a private water supply well.
No The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more fron]a
private water supply well".Method used to determine distance visual
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5.ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 11
OFFICIAL-INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1037 Race Lane
Marstons Mills MA 02648
Owner: Heinz Grotzke
Date of Inspection: 5 f 1 q/o h
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 incesspool 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 l 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 greaterthan 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
iindicates 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 morefof 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 101000 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
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
_ X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered.a significant threat,or answered
"yes"in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
4
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Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFA
CE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 1037 Race Lane
Marstons Mills MA 02648
Owner: Heinz Grotzke
Date of Inspection: 5/1 9/0 6
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 pro vided'by the owner,occupant,or Board of Health
Were any of the system components pumped outin.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)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X Was the site inspected for signs of break out?
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)J
5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL:SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 1 037 .Race Lane
Marstons Mills MA 02648
Owner: Heinz Grotzke
Date of Inspection: 5/1 9/0 6
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: 2
Does residence have a garbage grinder(yes or no):n o
Is laundry on a separate sewage.system (yes or no)12 o [if yes separate inspection required]
Laundry system inspected(yes or no):n o
Seasonal use: (yes or no): no 2004=29, 000gaQ2on q1)D-79.45
Water meter readings,if available(last 2 years usage(gpd))z 0 0 5-1'1', 000 ga on G%17-3 0. 4
Sump pump(yes or no): no
Last date of occupancy: A e z e 2 t
P
COMMERCIAL/INDUSTRIAL
Type of establishttient: N1,4
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 —
Source of information: NIA
Was system pumped as part of the inspection(yes or no): e-')
If yes,volume pumped:)= gallons--How was quantl pumped determined? Mrcg3b r(Z0
Reason for pumping: k, L� S(Ayya
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:
8 yea/tz [3oao.tiott.i Corz.6t
Were sewage odors detected when arriving at the site(yes or no): n o
6
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1037 Race Lane
Marstons Mills MA 02648
Owner: Heinz Grotzke
Date of Inspection: 5/1 9/0 6
BUILDING SEWER(locate on si-e plan)
Depth below grade: 3 D"
Materials of construction:_cast iron X 40 PVC_other(explain):
Distance from private water supply well or suction line: 20t
Comments(on condition of joints,venting,evidence of leakage,etc.):
Jo.ini-z a/2Reaa t.icrht., No .eeakage., Vented th2ouah house. ven.t..
SEPTIC TANK:ES(locate on site plan)15 00 ga:V i o n a
Depth below grade: 2 4"
Material of construction:Xconcrete_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:. 10' 6"X5' 8"X5'' 8"
Sludge depth: 4"
Distance.from top of sludge to bottom of outlet tee or baffle: 1"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 0
Distance from bottom of scum to bottom of outlet tee or baffle: 0
How were dimensions determined: meazalLed
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of.leakage,etc.):
l umR .tank evelzy 2. ea/zz., Zn$etg .ou iet tees ate .in 12,9ace..,
an -i.a .-6 2uctuaa eiy .sound.,
GREASE TRAPfd(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 out tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
G,zea se tza/2 .i s not /.-aezeat
I
7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .--,
PART C
SYSTEM INFORMATION(continued)
Property Address: 1 037 Race Lane
Marstons Mills MA 02648
Owner: Heinz Grotzke
Date of Inspection: r 1 9/(l ti
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.):
7ight oa ho&iag tank -i not paezent
DISTRIBUTION BOX:y e (if present must be opened)(locate on site plan) ,
Depth of liquid level above outlet invert: 0
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
Box .iz . eeve o Kaz �.. iateaa,&3., No zo.P.id caaayovea.4o iekage. .in oa
out o� gox.!.'
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.):
luml2cham9ea i.6 not /2aezent
� I
8
Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1037 Race Lane
Marstons Mills MA 02648
Owner: Heinz Grotzke
Date of Inspection: 5 f 1 9 f o 6
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Located: zee 12age 70.,
Type
leaching pits,number:
X leaching chambers,number: 3
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.):
--� Loamy to medium zand.,No z.ignz o� �a.iivae..,Solt' 9,3 ate djzy., Ve.getat.ion
i-6 no2ma No /zoad.iag
CESSPOOLS:N0 (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(yeg%r no):.
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
Ce,6,312oo.ez ate not /2aesen,t
PRIVY:N0 (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.):
%2.iuy .i.3 not /22ezen.t
9
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Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1037 Race Lane
Mar.stons Mills MA 02648
Owner: Heinz Grotzke
Date of Inspection: 5/1 9/0 6
SITE EXAM .
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-If checked,date of design plan reviewed:
u e s Observed site(abutting property/observation hole within 150 feet of SAS)
r Checked with local Board.-of Health-explain:as Ru i Pt ca2d
no Checked:with local excavators,installers-(attach documentation)
e 6Accessed USGS database=explainAi_;/2: 0Wn.,&a2n,3;ta9 me.,uz
You must describe how you established the high ground water elevation: '
/lsed. : Cape Cod Comm•izion /date.¢ 7ag.Pe Coritouaz And Pugtic ldate2 Sup12•2y
0e,e.e head p2otect.io-n .a/teaz map. Sept 1995
Uatez 2e6ouaces o,,e,l.ice cape cod comm.izion.-
Leaching
Pit n feet
Groundwater. Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
Therefore,the vertical separation distance between the bottom
of the leaching pit and the adjusted groundwater table is 3,L
feet: .
� D
11
TOWN OF BARNSTART.F i30AtiD QF 118ALT11
-BUIISURPACK 9FHAGH DISPOSAL SYSTPM IVOPFCTION FORM PART D•• CERTIFICAT-10N
w•TI.1•'•1••L'Sf�Tlgl'R7R77A111R'R711f1'P�.�'�'��-R
-TYPE OR PRINT CLEARLY-
PROPERTY INSPFCmv
STREET ADDRESS 1037 Race Lane Marstons Mil l c; QZG4a
ASSESSORS MAP, BLWK AND 'PARCEL 0
OWNER's NAME Heinz :Gj otzke
PART'.'D 0ERTIFS0ATJI0N ;
NAME 'OF 'INSPECTOR R094ilt Pa.O"n.i
ose/5h :P.� Macomit "Son. Inc
COMPANY NAME � '•
COMPANY ADDRESS Box 6 6 ' 'Can�o_,Tvi to 17a.64'.02632 '
Stre �' Town-or City. 7 . U0. LIP
COMPANY TELEPHONE ( 508'. Y�7.5 - 3338 YAX . '.508',.V'90 1578
CERT-I'FICATION. STATEMENT
I certify that. I fiave personally .inspected ..the sewage 'dispogil. 8.70tem at
kleco)nmen0at
his nddress and that- ;the' information reported .is true,. aooUra•te•i and
omplete as of the time .qf, inspectiony The in�pevticrn was performed and any
ions regard.ing upgrade-, .malntenancel' abd repair •are• oon$is'tent
with my trainiljg and exP.erience in thq ppoper functi-on' and Me'
intenanoe of on-
site sewage d48posai systems.
Check one;
System PASD
The inspection wh ic.h 'I have .conducted has .,n.ct' found any information .
which indicates that the system' ,fails to ' adequately. protect .public
health or the env,i ropmen t as defined io. .310 CMR. -Any failure
criteria trot evaluated are as stated in the FAI'LUIM CRI'PRRIA .s+ee.tion o-f
this form.
System FAILED*
' The inspection which I have aon ted 'has '•found that the System fails to
protect the public health end the enVAronM' en•t • in aocordanee With Title
61 310 CMR 15 , 303, and as • specifically noted -on •PART' C �►. FAILURE
CRITERIA of this i ec'tion .form.
Inspector 8ignatu DatQ �
ne• copy of this certj f i.oat•iah must -be rovi'ded 'to : the .QWR9R., t�h� BUYER'•
where appliveble) and thii I39ARD OV HEA TII.
* rf the inspection FAIL'Lb,, 'thb .cwneV.or1"gpe'rator ehal� . uptr�ade'.the system.
within o'ne year oC the da't•e of the inspection, unless. A1.1 wed Qr regj.ui;red
nt.hprw4se as urovided iTi 1140 CMR 15 ,3061. ;
g l uwu ul 11"il.11st,alult
Department of Health,Safety,and Environmental Services
"ll Public Health Division Date
367 Main Street,Hyannis MA 02601
� uiwersets �
Date Scheduled �` - > 7 Time 10 A�^ Fee Pd.
Soil Suitability Assessment for Sewage Disposal t
Performed By:'LE'^14 Ck\AIA (�Owrj W-t E 00t*bl-W6)witnessed By: 3f7Ltp-J-DJ NN 10 C-U-CO
LOCATION&`CE1VEptAL:INFORMATIO
Location Address GnV Owner's Name !Mt 151614 Ojs3L\C,
/037 Address 6-71�t 1 R-D
M.M1�, A&/1 0-2-6
Assessor's Map/Parcel: /1A �J PGip Engineer's Name"Dow►� eh�E C—N6� 1
NEW CONSTRUCTION REPAIR Telephone 0
Land Use
vj�,e�,.f-1— Slopes(°/,) Surfhce Stones
Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well R
Drainage Way ft Property Line
ft Other 61ca—+C�, ft
L,
i
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands In proximity to holes)
LA-M
�28e7, 13
50
0-7 r
�x�
l� Co
/V
t
Parent material(geologic) CsLA(4 L Depth to Bedrock "7 Z�
Depth to Groundwater: Standing Water in Hole: Weeping from A Face CIA
Estimated Seasonal High Groundwater iJ(7
Wdt�(Z- CNC.tt�.�NT�,Y�EA
DETERMINATION FOR SEASONAL H16H WATER TABLE
Method Used: in. Depth to soil mottles: In.
Depth Observed standing in obs.hole: p ft.
Depth to weeping from side of obs.hole: In. Groundwater Adjustment
Index Well N___._._ •Reading Date:__ Index Well level Adj.factor Adj.Groundwater Level
PERCOLATION TEST*::
Observation -}�— 1 Time at 9"
Hole 0
Depth of Pere �— 71me at 6" •
Start Pre-soak Time® Time(9"-6")
End Pre-soak
?-4 dal 6:Q2
Pate Min./Inch t to
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) A
Original: Public Health Division Observation Hole Data To Be Completed on Back—�
Copy: Applicant ,
IIbiC# 1
1)I;r, It 011SERVA'1'ION IIULC LOG soil other
Snil Texture Soil Color
I)cpth from Soil I lorizon (USDA) (Munsell) Mottling (Slnrcturc,Sto'es,nouldercs.
Surface(in.)
�� t0 i1
A 2 9r
U a ccbki�-S �
V vAND�1' o� otiw•
t-PA/v- J io c�bb
36 �
20 G-1
llEEP 013SCItVA I ICiN it Soil
Solt Texture Soil Color
Soil other
Depth from Soil I lorizon (USDA) (Munsell) Mottling (Structure,Stones,bouldercs.
Surface(in.)
v to 3/z
54-
(��3� � asp •2._CI
Jrrc� U 6(, ` 7 0 % cs,•bbu S
DEEP OBSERVATION 110"' LOG soil Ter
Soil Texture Soil Color
Dcptir from Soil I lorizon (USDA) (Munsell) Mottling (Structure,Stogy es,bouldercs.
Surfnce(in.)
--------------
--------------
IIOIC� _
llCGI' 013SCIiVATION IIOLE LUG soil other
Soil Texture Soil Color
Dcpth from soil I lorizon (USDA) (Munsell) Mottling (Slnrclurc,Stones,bouldetes.
Surface(in.)
IFIoo lm!rance Rate Maw
Above 500 year flood boundary No—
within Yes
500 year boundary No_ Yes
Within 100 year flood boundary No— Yes
( ' turall Oc urrin Pervious MaterJ�l
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the.._
area proposed for tite soil absorption system?
—
If not,what is the depth of naturally occurring pervious material?
('prlification I certify that on �/0V (date)I�have r�p � ,assed tite soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was perfonned by me consistent will)
(lie required(raining,expertise and experience described in 310 CMR 15.017.