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HomeMy WebLinkAbout1323 RACE LANE - Health 1323 Rake Lane neMarstons Mills A=064 038 y� 1 . � COMMONWEALTH OF MASSACHUSETTS f .EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION v v• ITLE 5 OFFICIAL INSPECTION FORM-rNOT FOR VOLUNTARY SUBSURFACE SEWAGE DISPOSAL SYSTEM FOB ASSESSMENTS PART A CERTIFICATION U 6 Y Property Address: Owner's Name: _ Owner's Address: GGU Date of Inspection:_ l 1 t4 b'7 do26ga Name of Inspector: (please print) 6 "� 7E" Company Name: ( � Mailing Address: 0 �'�SP toh$ t C� i... r L6'{ 4 Telephone Number: :14, CERTIFICATION STATEMENT s I certify that I have personally inspected the sewage disposal system at this address and that he informs on reported below is true,accurate and complete as of the time of the inspection.The inspection was perf6i mod based on rn 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 s stem: r-, -� Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: , Q, / " 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 r authority, n e approving ovmg 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 Page 2 of 1 i OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAUSYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 3a Ace- L-artz Owner: Date of Inspection:_1 1 191 p 7 Inspection Summary: Check A,B,C,D or E I ALWAYS complete all of Section D A. System Passes: I have mot found any information which indicates that any of the failure criteria described in 310 CMR 15.3 3 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" ection need to be replaced or repaired.The system,upon completion of the replacement or repair,as appro ed by the Board of Health,will pass. Answer yes;no or not determined(Y,N,ND)in the for the fol ing statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or th septic tank(whether metal or not)is structurally . unsound,exhibits substantial infiltration or enfiltration o failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic.tank 'approved by the Board of Health. *A metal septic tank will pass inspection if it is stru ly sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old' vailable. ND explain: Observation of sewage backup break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken ettled or uneven distribution box. System will pass inspection if(with, approval of Board of Health): broken pipe(s)=zeplaced obstruction is removed dist4ution box is leveled or replaced ND explain: The syste equired pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection i with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3ofil ` OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: _ Date of Inspection: C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in o er to determine if the syst is failing to protect public health,safety or the environment. em 1- System will pass unless Board of Health determines in accordanc ith 310 CMR 15.303 1 b that system is not functioning in a manner which will protect public ealth,safety and the environment:the Cesspool or privy is within 50 feet of a surface water ._ Cesspool or privy is within 50 feet of a bordering vege ed wetland or a salt marsh 2. System will fail unless the Board of Health( d Public Water Supplier,if any)determines th System is functioning in a manner that protec he public health,safety and environment: at the The system has a septic tank and soil bsorption system(SAS)and the SAS is within.100 feet of surface water supply or tributary to a s ace water su PP lY• a — The system has aseptic tank an SAS and the SAS is within a Zone 1 of a public water supply. — The system has a septic tank d SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well ethod used to determine distance "This system passes if t e well water analysis, EP certified laboratory, bacteria and volatile or is compounds indicates ha he�well i at a ns free from Pollution fromocoliforin thatt facility and the presence of amm is nitrogen and nitrate nitrogen is equal to or less khan 5 ppm,provided that no other failure criteria are ggered:A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of l l OFFICIAL INSPECTION FORM—NOTFOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL-SYSTEM INSPECTION FORM PART.A- CERTIFICATION(continued) Property Address: Owner:__SAlu,gttw �rZS r��] Date of Inspection: `1t0:2 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No �0 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''/z.day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped— . _ Any portion of the SAS,cesspool or privy is below high ground water elevation. _0L 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 calif"bacteria and volatile organic.co ' indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is.equaa:to•or less than 5.ppm;provided that no other,hWure criteria are triggered.A copy of the analysis must be attached to.this form.] (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 w'th a design now of 10,000 gpd to 15,000 gpd• You must indicate either`yes"or"no"to each of the followin (The following criteria apply to large systems in,addition t e criteria above) yes no the system is within 400 feet of a surf drinking water supply _ the system is within 200 feet of a 'butary to a surface drinking water supply _ the system is located in a n tr gen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water ply well If you have answered"yes"to y question in Section E the system is considered a significant threat,or answered "yes"in Section D above th arge system has failed.The owner or operator of any large system considered a. significant threat under Se on E or failed under Section D shall upgrade the system in accordance with 310 CNIR 15.304.The system owne should contact the appropriate regional office of the Department. A Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: �( Date of Inspection: Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No .lam — 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 f 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) . y ,___ Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? �o _ Were all system components,excluding the SAS, located on site? A _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition ofe7baffles 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 rn enance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no Existing information.For.example,a plan at the Board of Health. _ Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance is unacceptable)(310 CUR 15.302(3)(b)] S Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 3 Owner- Date of Inspection: I 1 t L7 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): .3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: 1 Does residence have a garbage grinder(yes or no): /VD 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): /oV Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): fW Last date of occupancy: C�r COMMERCIAIANDUSTRRIAL Type of establishment: Design flow(based on 310 CMR 15.203): d Basis of design flow(seats/persons/sgft,et Grease trap present(yes or no): Industrial waste holding tank pres (yes or no): Non-sanitarywaste disch arge the Title 5 system(yes or no):_ Water meter readings,if av ' able: Last date of occupancy/ OTHER(describ GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no):j If yes,volume pumped:______gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ( Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all componenA,date installed(if known)and source of information: tt `« ► SS' P/l �Ol� Were sewage odors detected when arriving at the site(yes or no): /t9D 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: ] Owner: Date of Inspection: i_i BUILDING SEWER(locate on site plan) Depth below grade: " Materials of construction:_cast iron X 40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): I SEPTIC TANK: (locate on site plan) —�- P ) Depth below grade: Material of construction: K —other(explain) ` concrete metal fiberglass_polyethylene If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no): certificate) __ (attach a copy of Dimensions: IOI�D Sludge depth_:— " Distance from top of sludge to bottom of outlet tee or baffle:_jp1 q Scum thickness: 410' Distance from top of scum to top of outlet tee or baffle: $ O Distance from bottom of scum to bottom of outlet tee baffle: How were dimensions determined: Comments(on pumping.recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage etc.): a (c. i -tvk l i4uit� GREASE TRAP:____(locate on site plan) Depth below grade:_ Material of construction:—concrete etal fiberglass___polyethylene other (explain):. " — Dimensions: Scum thickness: Distance from top of scum t op of outlet tee or baffle: Distance from bottom of s m to bottom of outlet tee or baffle: Date of last pumping: Comments(on pump' g recommendations, inlet and outlet tee or baffle condition,structural inteq i li uid levels as related to outlet ' vert,evidence of leakage,etc.): ty' q 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: Owner•. ' Date of Inspection: n.7 TIGHT or HOLDING TANK• (tank must be ped at time of inspection)(locate on site plan) Depth below grade:. Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: allons Design Flow: gallons/day Alarm present(yes or no . Alarm level: ]arm in working order Date of last pump' g (yes or no): Comments(cond' on of alarm and float switches,etc.): 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 f,any evidence o solids carryover,any evidence o leakage into or out of box,etc.): f -.Ckjj PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no):. Alarms in working order(yes.or Comments(note condition of p chamber,condition of pumps and appurtenances,etc.): . o Page 9 of 1 l OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: r 3 a3 Owner: �a.�._ f _ t( Date of inspection:—L ' iq 1 p"7 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type . 4 leaching pits,number: leaching chambers,number: teaching 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 etc.): ,damp soil, condition of vegetation, CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet in Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of constructi Indication of ground w ter inflow(yes or no): Comments(note co ition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on'site plan) Materials of construction: Dimensions: Depth of solids: Comments(note con ition of soil,signs of hydraulic failure,level of ponding,condition of vegetation;etc.): ------------------------------------ Page 10 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 13 .3 Owner: . u Date of Inspection: [ I Ig I m SKETCH OF SEWAGE DISPOSAL SYSTEM, Provide a sketch of the sewage disposal system including ties to at least two Per benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.landmarks or ,IV w� _ ag Page i l of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: , Owner: •A Date of Inspection: SITE EXAM Slope ves Surface water Nb Check cellar e43 Shallow wells lap Estimated depth to ground water feet 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 Iocal excavators,installers-(attach documentation) —X Accessed USGS database-explain: You must describe how you established the high ground water elevation: ^ I1 ' ' ^t .. +t •.{ x ,� r Tz fY r z+i. f �\, F.tT . Se tic `S: tem =Iris echon lie ort- ~� A Y P F P t ,f ^' i, 1323 Race Lane x . Marstons Mil1s;.Massachuset{s All . � `y bt• } ;'r� ' $t ` a t /; i t } -� (al t ' y�1 n Tl June ,20U t rf� yt E f }1t frt t l is lr f ,tr .�• ,. t Prepared For: ''' K '` •, , C 1 •d t i t '� �. �' .' ' Y Gary and Betty Anne Kurth t 4323 Race Lane } >IVlarsians mill's Massachusetts 0264,8; v L .I•d <�S _• ti _" S a .`'^ ! fe ! \ tt'.. 4 j, 1, °' ll' . Prepared by: 1 A.t r3•+/ { - • r µ e A •S. 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J 2 . . _ COMMONWEALTH OF MASSACHUSETTS ' z f EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION Q TITLE 5 ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM ' PART A CERTIFICATION Property Address: 1323 Race Lane,Marstons Mills Owner's Name: Gary&Betty Anne Kurth Owner's Address: Same as above ' Date of Inspection: May 31,2001 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 t 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 ' Fail 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. Notes and Comments ' The septic system appeared to be in good functioning condition on the day of inspection. ****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 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) ' Property Address: 1323 Race Lane,Marstons Mills Owner:Gary&Betty Anne Kurth ' Date of Inspection: May 31,2001 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 1 ND explain: t ' Page 3 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART A CERTIFICATION(continued) ' Property Address: 1323 Race Lane,Marstons Mills Owner: Gary&Betty Anne Kurth Date of Inspection: May 31,2001 ' 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. ' 3. Other: ' Page 4 of I I ' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART A CERTIFICATION(continued) ' Property Address: 1323 Race Lane,Marstons Mills Owner:Gary&Betty Anne Kurth Date of.Inspection: May 31,2001 1 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%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: N/A ' 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 11 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: 1323 Race Lane,Marstons Mills Owner:Gary&Betty Anne Kurth Date of Inspection: May 31,2001 ' 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(sewage Treatment Plant) 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) 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)( )] ' Page 6 of 11 ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION Property Address: 1353 Race Lane,Marstons Mills Owner:Gary&Betty Anne Kurth Date of Inspection: May 31,2001 FLOW CONDITIONS I� 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 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(gpd):1999-125K gals.(342 gals/day),2000—1QK gals.(444 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 ft,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: Barnstable Sewage Treatment Plant(1999-1K gals.) ' 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: ' Were sewage odors detected when arriving at the site(yes or no): No Page 7 of 11 j ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION(continued) ' Property Address: 1323 Race Lane,Marstons Mills Owner: Gary=&Batty Anne Kurth Date of Inspection: May 31,2001 tBUILDING SEWER(locate on site plan) Depth below grade: 6"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 exists building under basement slab in walkout area. No evidence of leakage,all joints appear to be in good condition on the day of inspection. ' SEPTIC TANK: X (locate on site plan) Depth below grade: 2"to 6"(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: 1" Distance from top of sludge to bottom of outlet tee or baffle: 3'4" Scum thickness: None present Distance from top of scum to top of outlet tee or baffle: N/A t 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 tees in good condition. Outlet baffle in good condition. No signs of leakage,liquid level at outlet invert. Do not recommend pumping at this time. ' 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: 1323 Race Lane,Marstons Mills Owner:Gary&Betty Anne Kurth Date of Inspection: May 31,2001 ' 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.): t DISTRIBUTION BOX: X (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.): "D"box level,no evidence of solids carryover,no evidence of leakage. ' 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.): t ' Page 9 of 11 ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION(continued) ' Property Address: 1323 Race Lane,Marstons Mills Owner:Gary&Betty Anne Kurth Date of Inspection: May 31,2001 ' SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: �I ' Type X leaching pits,number: 1 leaching pit(with 2 of stone all around) leaching chambers,number: ' leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system T.,pe/name of technology: Comments(note condition of soil, sign s of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): ' Soil dry,no signs of hydraulic failure,no yonding,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.): 1 ' Page 10 of 11 ' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) ' Property Address: 1323 Race Lane,Marstons Mills Owner:Gary&Betty Anne Kurth Date of Inspection: May 31,2001 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 1 1 1 ' Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION(continued) ' Property Address: 1323 Race Lane,Marstons Mills Owner:Gary&Betty Anne Kurth Date of Inspection: May 31,2001 ' SITE EXAM Slope: Mostly flat in SAS area Surface water: Little Pond is across Race Lane to the north ' Check cellar: No water Shallow wells: None in area Estimated depth to ground water 23 feet(below the ground surface at the SAS) ' Please indicate(check)all methods used to determine the high ground water elevation: 1 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 and installation as-built information.. ' The surface of the ground at the SAS was estimated from the Barnstable GIS map (June 1992) to be at elevation 76. The bottom of the SAS was measured to be approximately 10' below the surface;therefore,the ' of the bottom of the SAS is at elevation 66. 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 46. 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, the adjustment for that well is 7' upward. Therefore, the adjusted groundwater is at elevation 53. When subtracted from the SAS bottom (elevation 66) the resultant separation is 13' between seasonal high groundwater and the SAS bottom. I 1 ' Locus MAP & SEPTIC SvrrEm SKcrcx 1 1 1 1 1 1 v. Cft H •2, N Sco►ton Z / HN) Jr INIEur_NANCE 4 IV t•Q� tj.. / c4Ays �4'GPn�p h'armersrillc / v B AR S T. A B Litt lc t K\ 1'unrl d fj iANr' ' Fa rgro;. ds r s; La k c ,Meek 1 fJUbS - .. fir,••'•` ' I , A Ow t 1 160 W 4j Name: SANDWICH Location: 041°41'46.3" N 070°25' 13.1" W Date: 6/5/2001 Caption: Locus Map Scale: 1 inch equals 2000 feet 1323 Race Lane Marstons Mills, MA. Septic System Sketch Ground Surface ' 2.. 12" *4' 6" Foundation R Septic Tank SAS A "D" Box C ' Cross Section E SAS ' "D" Box Septic Tank ' Vz 22' 42' 24' 28' L ' ZO' 2 ' A N ' Walkout E Area of House 1 #1323 * = Estimated depth using ' an electronic locator 1 ' William E. Robinson, Jr. Site: 1323 Race Lane Septic System Inspections Marstons Mills, MA. Not to scale 43 Tomahawk Drive ' Centerville, MA. 02632 Date: May 31, 2001 (508) 775-7986 t 1 1 1 1 1 1 1 1 - W V) t THE COMMONWEALTH OF MASSACHUSETTS 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 i ; � I ' I � ; ' I � ' L7 � Z,.-7-�e- 3 S .� L0 -CATION SEWAGE PERMIT NO. VILLAGE t3a3 iM.h(Z5100 M j L L- INSTALLER'S NAME A ADDRESS D A dJ K msN a� r N e UILDER OR OWNER H.4 M DATE PERMIT ISSUED �S 25 DATE COINPLIANCE ISSUED r \y[� a8., 41 � ��� A � Y �. _�e .. ��� Nofy-- .Lv�j Fss.... ............:.. THE COMMONWEALTH OF MASSACHUSETLIS BOAR® OF HEALTH ..........................................OF.....................I.........._....... ............. Appliratiun for DiipuuFal Work.5 Tonstrurtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( Vj""'aan Individual Sewage Disposal System at: .... ll � .... . .��1la- rf -�dxg:' --•...........................................C.. ........................................... - Location-Address or Lot No. 9wner . ....... ........Address w /���11� ....1..c�_046ZA I------------------------- ------------------ Installer Address UType of Building Size Lot-----® ...............Aq. feet �-� Dwelling—No. of Bedrooms____...... ............................Expansion Attic ( ) Garbage Grinder ( ) p-, Other—Type of Building XA.5................. No. of persons.._...5_.._................ Showers (2) — Cafeteria ( ) Q' Other fixtures .................................. Design Flow..........._i" _ .._ --__gallons per person per day. Total daily flow__--__--._-�� d................gallons. w >m � �-------------- g P P P Y• Y ------ WSeptic Tank—Liquid"capacity-'gallons Length...... ..... Width---S .... Diameter=__R ___.._. Depth.--ram_......_.. x Disposal Trench—No. .................... Width.................... Total Length........ ...._//_._... Total leaching area....................sq. ft. 3 Seepage Pit No......../.......... Diameter..... .l2.... Depth below inlet...... .... Total leaching area... r_..sq. ft. Z Other Distribution box ( ) Dosing tank ( ) a Percolation Test Results Performed bY..........._.............................................................. Date........................................ Test.Pit No. I.-.,............. per inch Depth of Test Pit.................... Depth to ground water........................ rz, Test Pit No. 2.......:........minutes per inch Depth of Test Pit.................... Depth to ground water.....:.................. 0: .......................................----------------••----------------•-•---•------------•------........---•--------------------•----...........--------- 0 Description of Soil.................................................................•---------.....-------------•------...---------------------------------------------------......_..--•-- x w - UNature 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 iITLL 5 of the State Sanitary e— T undersi r er agrees not to place the system in operation until a Certificate of Compliance has been i sue the b t 0:�011 '71D Application Approved BY 7efollowing ----------------- - -•-------- ...----------------------------- ---•• Date ..... Application Disapproved or reasons: ...:_:... --------•........................•------......------------------------------...........•-•-•--------•--------•---•-----•-----•------------------------------------------------------------------------ Date PermitNo......................................................... Issued........................................................ Date -------------------- .F FE z.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........... . ..........................OF....................................... Appliration for Disposal Works Tonstrnrtinn "prrmi# Application is hereby made for a Permit to Construct ( ) or Repair (v<an Individual Sewage Disposal System at: ............�s L� .t ..._ 1.`�..../.:j%,t�:,�:.7 rit�r:.dr...L.l... ... .............. ° - .....• ................. Location-Address or Lot No. Owner Address a ........... .......................... ... .......... ....._...._........ Installer Address UType of Building Size Lot_-.y .--------- Jgq_. feet Dwelling—No. of Bedrooms.........._?.............................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building i < No. of persons . ................. Showers a YP g ��--=-r•-.---------------- P -- (Z) — Cafeteria ( ) Other fixtures W Design Flow..............S._.. ...................gallons per person per day. Total daily flow............—7 j._d.................gallons. WSeptic Tank—Liquid'capacity/lTV.gallons Length.....%...... Width.... Diameter--_f......... Depth_ 1. ......... x Disposal Trench—No..................... Width.................... Total Length......._............ Total leaching area....................sq. ft. Seepage Pit No-------/........... Diameter.._..,/_. _.... Depth below inlet.......6........ Total leaching area...-.S:J/.2..sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---------............... ix -••-------•----------------------------•-••-----•---------••------•--•--•---------.........-•-•---•..................................... ...--------- ••-- D Description of Soil----------------------------------------------------------------------------------------------------------------------------------------------------...... ----------------- x W UNature 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 TITU 5 of the State Sanitary Co undersign; ftriter agrees not to place the system in operation until a Certificate of Compliance has been is ued b he b of hu'dth. ..., ,►1 1 - IV ............... Application Approved By --- : .f......------------- ` Date Application Disapproved . --------------------------------------•- ore f ollowing reasons----------------------•-----------------------------.-----------------------------------.._......_.._........---- •...........................••-•---•-•----...------------•----------..........----••-•----....------...----....•••----------------•----•-•-------••. •--•---•..........I_.................... Date PermitNo......................................................... Issued-......................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .....................................OF..................................................................................... Tntifira r of Tiimplittnre THI, I CERTIFY, That the Individual Sewage F ` Sewa e Di=sr po.saS econst ructe (�r Repaired ... ••. ( ) .by. — Installer has been installed in accordance with the provisions of I_TI F 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No..�%_f.__//2- -" THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONS RUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. � I DATE......... �----1--"---•7�5. Inspector.......... = ---�. . ---� .............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH " / .............................OF.......... 1) E, " No.........0 ........ FEEDD.`.................. Disposal Permission is rib r -'! "� -------•--.- 2 3 Y g - ------.... .S_�----�'�'�--.m...Ad................. to Construct ) or epai ,(' ) an Ind�6idual Sewage oral System at No. 'c. Street Street � as shown on the application for Disposal Works Construction Permit No.......?r.41.:6/,2,Dated............:: � ,�f T�Soa'rd of• eaith~-�-------•-------••....:............._ DATE.............. -------- - --•------ ••�• - FORM 1255 A. M. LKLW, INC., BOSTON r 362-4541 926 main street yarmouth mass. 02675 down cope efi f4eehlIg civil engineers&land surveyors structural design Arne H.Ojala P.E.,R.L.S. land court Richard R.Fairbank P.E. surveys site planning sewage system October 28, 1985 designs Banrstable Boaxd of HeaZth inspections Banrstable Town HaZZ South Street permits Hyannis, MA 02601 On September 24, 1985, Dorm Cape Engineering inspected the sewage system construction of Zot 12 Race Lane in Marstons MiZZs and found thetsystem to be constructed according to the attached pZan, and was checked and found to be in new condition and ready for service. SincereZy, Arne H. O,jaZa P.E., R.L.S. WES/kmk enc. 4 II i I ev e� 32.W IJ E PAR Eo FOR 77 ��j� L O cATiO.v: t��CE 13aJ°�1 ,2 EFE.eC.VCE: Z NEe E BY CEeT"/F Y T.Ws�T' 7'!/E �C,//LD/•VG SNON/�/ OV Ti//S �L�i.V /S LOC�9T�� O.4/ YL✓E Iw�t� OF y.,eoc%c/D AS �'/•NO Wit/"HE�EOA./. �Q ARNE H. G� le OJALA w CIVIL y i No. 30792 ISTF. 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