HomeMy WebLinkAbout1341 RACE LANE - Health 1341 RACE LANE,MARSTONS MILLS
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TOWN OF BARNSTABLE - UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION
4 OWNER AND INSTALLER INFORMATION - -
ADDRESS: Y A G!� /E - MAP NO. tl7 PARCEL NO. t/
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OWNER NAME: R46, 2,4l1'VILLAGE:
INSTALLATION DATE: � li,►/ LIJ BY:
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ADDRESS: CERT. NO.
co o PAUL CA SM X o ,
TANK INFORMATION
LOCATION OF TANK:
CAPACITY (/l TYPE `l ( 4.. AGE FUEL/CHEMICAL O I L
TESTING CERTIFICATION C I PASS C I FAIL DATE
LEAK DETECTION C ] CHECK IF N/A TYPE/BRAND
ZONE OF CONTRIBUTION [A YES C I NO DATE TO BE REMOVED
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FIRE DEPT. PERMIT ISSUED 1� YES C I NO DATE
CONSERVATION C� CHECK I N/A DATE
BOARD OF HEALTH TAG NO. C ]C 3[ ]C ]C ] DATE d 4
PLEASE PROVIDE A SKETCH �- HOWING THE TANK LOCATION ON THE BACK OF THIS CARD
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KEEPING YOU ORGANIZED
No.10334
24536
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CET ORGANIZED AT SMEAD.COM
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. LOCATION ?j�/ ��C� (..d7 SEh4frE#X0 $/
VILLAGE ,`I�S ASSESSOR'S MAP&PARCEL
T r NAME&PHONE NO. n arc IL vLLt✓� -17�
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) r'TS (size) /600
NO.OF BEDROOMS . `T
OWNER Wt i Ct.M
PERMIT DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching fac' ' Feet
FURNISHED BY C, /t'�V
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INSTALLER'S NAMESz PHONE NO. 575 WILLOW STREET �
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SEPTIC TANK CAPACITY / )II, `�
LEACHING FACILITY:(tyPe) /000 � �_(size)_ �
NO. OF BEDROOMS PRIVATE WELL Olk UIiLI WATER
BUILDER OR OWNER __ r
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED:
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Doc: 1Y1871P342 03-26-2012 9:32
` BARNSTABLE LAND. COURT REGISTRY
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NOTICE: The Town of Barnstable
recommends that the annl;rnn+
seek legal advice to prepare a
properly worded deed
restriction document
DEED RESTRICTION
WHEREAS, of
Q (owners name)
�0 \ �C11t").nm�,C— �ItP �� MA
(address) r
is the owner of l 3 LI L, tl AC.4-'` ts`4 located
(address)
at �5�
MA (hereinafter referred to.as
and being shown on a plan entitled "Subdivision of Land in
Mg$�,-rnH A%UL-S MA, Property of_ A um-)a4-1. ,
et al, duly recorded in Barnstable County Registry
of
Deeds in Plan Book , Page ��, ' `' ��• -� �1 ��-
Or on Land Court Plan Number 1(p4al ,' I 2. t,.o-r I
WHEREAS, uTt, q.' ,e21�m�r.� as the owner of said lot has
(owner's name)
agreed with the Town of Barnstable Board of Health to a restriction as to the
number.of bedrooms which can be included in any home built on said lot as a
pre-condition to obtaining a disposal works construction permit in compliance
with 310 CMR 15..000 State Environmental Code, Title V, Minimum '
Requirements for the Subsurface Disposal of Sanitary Sewage;
WHEREAS, the Town of Barnstable Board of Health, as a pre-condition-to
granting a disposal works construction permit for a septic system in compliance
with 310 CMR 15.200, State Environmental Code, Title V, Minimum
.Requireme0t 4brithe Subsurface Disposal of Sanitary Sewage, and authorizing
the issuggPs'of-a•:�'uild",ing permit.for the construction of a•single family home on
this prc pert(,s'-,rOgi4. ngg..that the agreement for the,restriction on the number of
bedrooms in= ny-�ou�.§a.-"constructed on the lot be put on record with the
BarnssaE Ctt`�i-Registry of Deeds by recording this document,. -
d=dr
S As-
JJ
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NOW, THEREFORE;- r tn�}� C,� rrn does hereby place the
P7 (owner's name)
4
following restriction on his above-referenced land in accordance with his
aare ementwith theIMULof Ramefahfa Rnorrl of uc-,l4h . .t-:..s:,... }
r~
run with the-land and be binding upon all.successors in title:
*� 1. �3 1 AGE L.�1 N., �A��5rbn1 A►w..s �g may have constructed
,.� (address)
' u on the lot a house containing no more than Y,c (�} bedrooms.
U
a agrees that this shall be.permanenf deed
d (owneress namee))
restriction affecting located on 13yt 9kq Lt��, 41)dUma► ILLt.MA, and .
being shown on the plan r corded in Plan Book , Paged
Or on Land Court Plan
For title of seethe following deed: Book , Page..
. Or Land Court Certificate of Title Numbe4iI Z5'g"ao e j -r4�{
Executed as a sealed instrument a160 day of -.X� 7—
Owner's signature
Owner's signature
Owner's signature
COMMONWEALTH OF MASSACHUSETTS
_ �W4 ss
20 -_-
Then personally ap eared the(bove-n ed
known to me to be the person who executed the foregoing. instrument-and
acknowle ged
the same to be free act and dee before me,
14
�tS
Public BARNSTPAN
ABLE COUNTY9SaN EYp�4•,� •
REGISTRY OF DEEDS
A TRUE COPY,ATTEST My commission xp'r
JOHN F.MEADE,REGISTER j (date
�*TA10
BARNSTABLE REGISTRY OF DEEDS
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1341 Race Lane
Property Address
Mark Williams
Owner Owner's Name
information is Mar tons Mills MA 02648 August 18, 2009
required for
every page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important: A. General Information
When filling out 7 �
forms on the
computer,use 1. Inspector:
only the tab key
to move your Patrick M. O'Connell
cursor-do not Name of Inspector
use the return
key. Septic Inspection Services Co.
Company Name
rab 189 Cammett Road
Company Address
Marstons Mills MA 02648
m Cityf'rown State Zip Code
508-428-1779 SI 12855
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
3 `i sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
co
Title (310 CMR 15.000). The system:
L
Passes ❑ Conditionally Passes ❑ Fails
N
CID
_ ❑,Needs Further Evaluation by th Local Approving Authority
dray !
�s
F-' ``" _ f August 18, 2009
Ins ctor's Signatu 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. D
09.160 VAlliams.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Dis sal System•Page 1 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1341 Race Lane
Property Address
Mark Williams
Owner Owner's Name
information is required for Marstons Mills MA 02648 August 18, 2009
every page. Cityrrown 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:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CM 15.303 or in 310 CM 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Recommend pumping tank, one leaching pit has 2-Y of effective leaching and other is full.
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
09-160 williams.doc•08106 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 2 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1341 Race Lane
Property Address
Mark Williams
Owner Owner's Name
information is g
required for Marstons Mills MA 02648 August 18, 2009
every page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
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.
09-160 williams.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w„ 1341 Race Lane
Property Address
Mark Williams
Owner Owner's Name
information is required for Marstons Mills MA 02648 August 18, 2009
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
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
❑ ® 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.
09-160 Williams.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w,. 1341 Race Lane
Property Address
Mark Williams
Owner Owner's Name
information is Marstons Mills MA 02648 August 18, 2009
required for 9
every page. CityrTown State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® 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.
09-160 Williams.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 1341 Race Lane
Property Address
Mark Williams
Owner Owner's Name
information is Marstons Mills MA 02648 August 18, 2009
required for g
every page. City/Town 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)]
09-160 wlliams.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
�<L Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1341 Race Lane
Property Address
Mark Williams
Owner Owner's Name
information is Marstons Mills MA 02648 August 18 2009
required for 9
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents:
Unknown
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: Currently
Occupied
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
09-160 williams.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w,. 1341 Race Lane
Property Address
Mark Williams
Owner Owner's Name
information is Marstons Mills MA 02648 August 18 2009
required for g ,
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: None
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)
❑ linnovative/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:
Compliance date: 9/11/90
Were sewage odors detected when arriving at the site? ❑ Yes ® No
09-160 Williams.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15
TOWN OF BARNSTABLE
LOCATION _// . �_`. _ SEWAGElP��
VILLAGE� r T
��-03 �
IZW 1
INSTALLER'S NAME & PHONE NO. 575 W`IU,OW MffT
' ABLE, 1MSS, d2 469
SEPTIC TANK CAPACITYI �`�
LEACHING FACILITY:(type)1106t) '�lG (Size)—l-
NO. OF BEDROOMS PRIVATE WELL OR UBLI WATER
I
BUILDER OR OWNER
DATE PERMIT ISSUED:_ L
DATE COMPLIANCE ISSUED=
VARIANCE GRANTED: Yes a
f
V/1
f
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Dept. of Environmental Protection
•Jitl
One winter Street' D.E.P..E. 'Titlee V Septic Boston Ma. 02108 epti
c Inspector
P.O. Box 2119
Teaticket, MA 02536
wlluann F.wELD (508)564-6813
Governor F
ARGEO PAUL CELLUCCI A* t
Lt.Governor
d
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, vG
PART A
/ CERTIFICATION 0107
f
Property Address: 1341 Race Lane Marstons Mill Map 064 Lot 37 Address of Owner:
Date of Inspection: 6118/98 (If different) o G 19
Name of Inspector: n/a Donaldson:327 Regency Dr.Ma t Mills c
ewe 9
I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) f F
Company Name,Address and Telephone Number: t s
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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
x Passes This Inspection Is based on criteria defined In Title V
Condition II Passes code 310 CMR 16.303.My findings are of how the system is
y performing at the time of the inspection.My inspection does
_ Needs F rther Evaluation By the Local Approving Authority not Imply any warranty or guarantee ofthelongevityofthe
Fails septic system and any of Its components useful Ilfe.
Inspector's Signature: Date: 6118/98
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. 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 Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C,or D:
A] SYSTEM PASSES:
x I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
B] SYSTEM CONDITIONALLY PASSES:
_One or more system components need to be replaced or repaired. The system, upon completion
of the replacement or repair,passes inspection.
Indicate yes,no, or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined",explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Co7hpliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or
the septic tank,whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent.The system will pass inspection If the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised DQI)97)
One Winter Street . Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 1341 Race Lane Marstons Mill Map 064 Lot37
Owner: Donaldson:327 Regency Dr.Marstons Mills
Date of Inspection:6118198
_ Sewage backup or.breakout or hiah.static water level observed.in.the distrOution box is due to a broken,
or obstructed pipe(s)or due to broken, settled or uneven distribution box.The system will pass inspection if
(with approval of the Board of Health). Describe observations:
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
—The system required pumping more than four 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
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 the public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
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 APPROPRIATE) DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method usedto determine distance (approximation not valid)
3)Other
D] SYSTEM FAILS:
You must Indicate either"Yes"or"No"as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in
310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be
contacted to determine what will be necessary to correct the failure.
Yes No
_ — Backup of sewage in facility or system component due to an 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 cloggerl
cesspool.
SAS is in hydraulic failure.
(reyleed 0412797)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 1341 Race Lane Marstons Mill Map 064 Lot37
Owner: Donaldson:327 Regency Dr.Marstons Mills
Date of Inspection:6119199
Dj SYSTEM FAILS(continued)
Yes No
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 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition.to the criteria:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 0427197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 1341 Race Lane Marstons Mill Map 064 Lot 37
Owner: Donaldson:327 Regency Dr.Marstons Mills
Date of Inspection:ellafss
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
_c_ — Pumping information was requested of the owner, occupant,and Board of Health.
x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal
— — flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
— x As built plans have been obtained and examined. Note if they are not available with N/A.
x — The facility or dwelling was inspected for signs of sewage back-up.
x — The system does not receive non-sanitary or industrial waste flow.
X — The site was inspected for signs of breakout.
x All system components, excluding the Soil Absorption System, have been located on the site.
x The septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected
— — for condition of baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge,depth of scum.
x _ The size and location of the Soil Absorption System on the site has been determined based on
The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of
Sub-Surface Disposal Systens.
x Existing information. Ex. Plan at B.O.H.
x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is
— — unacceptable)[15.302(3)(b)]
(revised 04127)971
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 1341 Race Lane Marstons Mill Map 064 Lot 37
Owner: Donaldson:327 Regency Dr.Marstons Mills
Date of Inspection:e118198
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 440 g•p•d./bedroom for S.A.S.
Number of bedrooms: 4
Number of current residents: 4
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings,if available:(last two(2)year usage(gpd):
rda
Sump Pump(yes or no): No
Last date of occupancy: nla
COMMERCIAL/INDUSTRIAL:
Type of establishment: nla
Design flow:0 gallons/day
Grease trap present: (yes or no) No
Industrial Waste Holding Tank present:(yes or no) No
Non-sanitary waste discharged to the Title 5 system:(yes or no) No
Water meter readings,if available: nra
Last date of occupancy: nra
OTHER:(Describe) Ma
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
n!a
System pumped as part of inspection:(yes or no)Yes
If yes,volume pumped: 15w gallons
Reason for pumping: Maintenance
TYPE OF SYSTEM
x Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) ( if yes, attach previous inspection records, if any)
I/A Technology etc.Copy of up to date contract?
Other.
APPROXIMATE AGE of all components, date installed(if known)and source information:
7 years
Sewage odors detected when arriving at the site: (yes or no) No
(revised 04117)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1341 Race Lane Marstons Mill Map 064 Lot37
Owner: Donaldson:327 Regency Dr.Marstons Mills
Date of Inspection:6118f98
SEPTIC TANK: x
(locate on site plan)
Depth below grade:-I'
Material of construction:x concreate metal FRP_Polyethylene—other(explain)
If tank is metal, list age nla . Is age confirmed by Certificate of Compliance No (YeslNo)
Dimensions: L10'6"H5'7^we'8"
Sludge depth:e"
Distance from top of sludge to bottom of outlet tee or baffle: 29"
Scum thickness:t'
Distance from top of scum to top of outlet tee or baffle:6"
Distance form bottom of scum to bottom of outlet tee or baffle: ts"
How dimensions were determined: Measured
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
Septic tank and ell components are structurally sound.Recommend pumping system every two years.
GREASE TRAP:
(locate on site plan)
Depth below grade: rda
Material of construction: _concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: Wa
Scum thickness:n1a
Distance from top of scum to top of outlet tee or baffle:rda
Distance from bottom of scum to bottom of outlet tee or baffle: nla
Date of last pumpingn*1,
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
rda
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 1-6"
Material of construction:_cast iron x 40 PVC_other(explain)
Distance from private water supply well or suction line?own
Diameter: nla
goimments: (conditions of joints,venting,evidence of leakage,etc.)
(revlssd 04127)97J
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1341 Race Lane Marstons Mill Map 004 Lot 37
Owner: Donaldson:327 Regency Dr.Marstons Mills
Date of Inspection:e118199
SOIL ABSORPTION SYSTEM (SAS):x
(locate on site plan, if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
Na
Type.
leaching pits, number: 2.1o00gallon leach pit
leaching chambers, number:Na
leaching galleries, number: rda
leaching trenches, number,length: rda
leaching.fields,number, dimensions:Na
overflow cesspool, number:Na
Alternate system: Na Name of Technology:_Na
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
The leach pits are structurally sound and functioning properly.
CESSPOOLS:
(locate on site plan)
Number and configuration: Na
Depth-top of liquid to inlet invert: Na
Depth of solids layer: Na
Depth of scum layer: Na
Dimensions of cesspool: rda
Materials of construction: Na
Indication of groundwater: Na
inflow(cesspool must be pumped as part of inspection)
Na
Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
Na
PRIVY:_
(locate on site plan)
Materials of construction: rda Dimensions: Na
Depth of solids: Na
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
Ne
(revised 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1341 Race Lane Marstons Mill Map 064 Lot 37
Owner: Donaldson:327 Regency Dr.Marstons Mills
Date of Inspection:6118198
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: nla
Material of construction:_concrete_met:al_FRP_Polyethylene_other(explain)
Dimensions: nfa
Capacity: rda gallons
Design flow: n1a gallonstday
Alarm level:_nfa Alarm in working order2_Yes_No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
No
DISTRIBUTION BOX: x
(locate on site plan)
Depth of liquid level above outlet invert: Liquid levelwithbottomofpipe
Comments:
(note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.)
The distribution box is structurelty sound.
PUMP CHAMBER:
(locate on site plan)
Pumps in working order.(yes or no)No
Alarms in working order(yes or no)_ves
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
We
(revised 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
1341 Race Lane Marstons Mill Map 064 Lot 37
Donaldson:321 Regency Dr.Marstons Mills
6118l98
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references, landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
H�.
CD c
4A
Rn l�l
g� �q
CC7
Page ! of 20
(revised 00f1719T)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
1341 Race Lane Marstons Mill Map 054 Lot 37
Donaldson:327 Regency Dr.Marstons Mills
6118199
Depth of groundwater 12
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from design plans on record.
Observation of Site(Abutting property,observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of Health
Check FEMA Maps
Check pumping records
Check local excavators, installers
X Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
USCS Maps and Charts _
(revlsed6427197) page 10 of 10
THE COMMONWEALTH'OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABG�E��o� �#� _ 6SS
�F-
ApphratioU for Dispnsa1 Works Toustrnrtion thrmit
IApplication is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal
System at:
............... -------•----------------- --•---•-----.Zoef!!!//.............................................................
Lo tion- sss or Lot No.
- Al.r_ .. ../f i� o
a ner Address
.......................... ...... -----•----....--------------------••-------------.....-----•------•••.............--•---•--•----•-
Installer Address Type of Building Size Lot._.",/.7�1....Sq.feet
t-, Dwelling—No. of Bedrooms--_--- .......•........................Expansion Attic A10) Garbage Grinder
P4 Other—Type of Building ......................:..... No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures ..---•---------••••----•---•••••......•-•---
W Design Flow............... g P P P y ............................................gal - s.
�.`�___________________ allons er erson er da Total da� flow gallons.
W Septic Tank—Liquid capacity/X_ gallons Length._./a.i_.._. Width.�.......... Diameter................ Depth..¢.-•A:��p P/-
Disposal Trench—No..................... Width......... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No_____ ___________ Diameter.•_...&..____.__. Depth below)nlet-__�o........_.._.. Total leaching area8.�`Z... ._sq. ft
"Z Other Distribution box ( ) Dosing tank ( ) / : ip t lrOAJE
~" Percolation Test Results Performed by........................... .......................... _. Date........................................
,aa Test Pit No. 1_2-------minutes per inch Depth of Test Pit..._Z_��__.._. Depth to ground water..'54 .4461
G%, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
C4 -----------------------------------------••••.-••-•---•-•••-••••-•--•-----•----••-----•--•--.............................................................
O Description of Soil l .7—a _-. ......... --........ Si-----J,D
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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by e board of ea /
.
Signed .. . --- ./. -
Q Date
Application Approved BY ... -----1.-'. . ...!7
Dace
Application Disapproved for the following reasons- ------------.................................. -----------------------------------------........................-----------------
---.....................................
C� y Date
PermitNo. -------- ------ 1 13...�... _-------------_- Issued .................................................
Date
ltfo.. 9/1;. JVra/ FEs....../..:!� .....µ—
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
A ItxMt>NYt firt Attu urk Cn�atrr#iun rrmt
jJf p F
i Application is hereby made for a Permit to Construct 4 or Repair ( ) an Individual Sewage Disposal
System at:
.......... ... ..... ..--
Location-Address or Lot No.
i .t2L SSA G 1� 6�taYS�u�s 1 S
.................. ._.... ._. ...... ......._.. ..._._...-----......-•--- ......---- -
- f( 2 .....°"1......... -..
Uwner n .............................•---•----•-•---Address
Installer Address
Type of Building Size Lot.-.�
... f-?...Sq.teet
., Dwelling—No. of Bedrooms............
..................................Expansion Attic (� Garbage Grinder ( �
a Other=`TypeYP� of Building -----------------------------No. of persons............................ Showers Cafeteria- ( ..� ...
Otherfixtures ...........•..-------------•-••........•--.•-•••--------•--•--•-••-----•-••----•-•--•--•... . ..............................
W Design Flow..................5 7_...._._.�__-_gallons per person per day. Total daily flow............................................gallons.
f i�=/ !�
W Septic Tank—Liquid capacity_ gallons Length---/'14._...._ Width._ _____.._. Diameter................ Depth_.-�.._-_.-..�i'
x Disposal Trench—No_____________________ Width___., .:._.-...... Total Length......: ......... Total Total leaching area....................sq. ft.
Seepage Pit No.....-_C----------- Diameter.......14.1...... Depth below inlet---/_ ...... Total leaching area.j!Z......sq—ft-
Z Other Distribution box ( ) Dosing tank ( ) / �j� 5?vvE �,pt.//)�4r•
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I....S._ ._.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.......................
a --•----------------------------- ...................................................................................................
O Description of Soil----.--• "--�.1107---����'-�----------3/.`a.'r✓, .....!5 ��=� ....--
c.� ---------------------------------------------------•.__-•-------•------•-•--••-------------•---- \
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 TITLE 5 of the-State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by the board of Health.
Signed. .- -,, '" ."- ' ' ..... .......... ....1���L?A...
e I _
. � ; Date .....
Application Approved BY .<<sr�'�k ts -J ... ( "
Application Disapproved for the following reasons- ------------------------------------------ --- ----------------------_....................................................
---------------------------......................................-------------------------- ................................ .......---------------------------......---------- ---- ........................................
- Dare
PermitNo. -----------!!--'---..y&I........................ Issued ..------------..--...----------------------------- -- --------..
Dare
THE COMMONWEALTH OF MASSACHUSETTS�}
BOARD OF HEALTH "[
TOWN OF BARNSTABLE
CITer#tftrate of Compltnnre
THIS IS-TO CERTIFY,That the Individual Sewage Disposal System constructed or Repaired,( )
by ---- INS, . s- ^��- ------------- --- ------------------------ --------------------------------------------------------------.-.-.-.-.-.-.-.-..-.--..-.-.--.-..-.--..--.-.-.-.-.-.
0 Installer
at -----------------------I../..........!-4.,Q .......-.--.+ A,-..........f�� ..r...........................-........ ..................
has been installed in accordance wA the provisions of TITLE 5 of The State Environmental Code as 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. {K ,
DATE------------- " '/. r''.... .......---------------.(----------- Inspector ... t ' ...; ....................................... zt
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�� , � TOWN OF BARNSTABLE
No........... ........A. FEE....
y..!;2.n.
Disposal Works Tonstruction Vvrmit
Permission is hereby granted. --- ±..............�.............. ...... .......................................
to Construct (\e)' or Repair ( ) an Indidual Sewage Disposal System
atNo..•••••---•-•-••......_11........1 .. A e ........-� et............ ....- --.------------------------------------------------..-.--•--•----•----------.-----•--•-------
Street
as shown on the application for Disposal Works Construction Permit No. ?0� Dated..........................................
...................... U . :� ---.---.-
DATE.................�''.._ .._��f,
..'.............................•. Board of Health
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WITNESSED BY PRECAST SEPTIC TANK ITH 0 CAST IN PLACE INLET AND BOARD EALTH '_;z f`1 4r OF H T'S PER - TITLE Y OUTLET Q DATE:SIZE so c; c I.0 N A'SEWAGE SYSTEM PROFILE ' OF ,: , PROP05E D OF SYSTEM DES IGNEO BY, THE TOWN REGULATIONS AND ,SCALE 1/4 4�- 0 FOR SUBSURFACE DISPOSAL STATE , JITLE V I7�N B PES SHALL BE SCHEDULE 40 'P.V.C. SEWER PIPE I ALL PI PER FOOT EXCEPT fOR 4 )A 7o 2. ALL PIPES SHALL B E SLOPED I/ WHICH SHALL , BE ' LEVEL ,THE THE F.1 RST '2 FEET OUT OF BEDROOMS AT 110 GALDAY PER BR. :��c GAL/DAY 3. DESIGN FLOW SEPTIC TANK S I Z E -4:4-0 X 1, GAL.GARBAGE DISPOSAL USE, GA T tA L 40 1, E ............LEACHING SYSTEM: � USE r- -T n t63 —7-7/5V 3�7&AREA: _3 ,5,z 4 i-1) .5-0 BOTTOM -2, A L I;b 4, C SOT TOTAL FLOW IREQ'O FLOW. Q- X !4:A-0 .W/.QLJ'T- GARBAGE DISPOSAL TLOT.A L LA 4 4�q, Y RESERVE FLOW- - SALIDA 14-�K f A�REFERENCE PLANS : tA,D,I 00' 11 AN Top A e 7A 8 e-45 APPROVED BY BOAR O.,�, OU -HEALTH r10�,j DATE : SITE ND .ozp'X,ZAAJDA2 &IJA Fo tgHj 7 A ...........PRO-PEITY OWNER ,� L -4- 1 ilm a A tiN-1 o f,),b 1-t L�i A,DAT&," 4 I- i r- t IR r'\AN WILL I A.T\&2-3 5 'T%MIGE I, A-Tot j5 1-4 ILL �,AA ;Ap L I