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Home My WebLink About1355 RACE LANE - Health 1355 RACE LANE Marstons Mills A = 064 - 015 - 001 TOWN OF BARNSTABLE LOCATION "CZ /` SEWAGE # VYLLAGE Al A! I L L S ASSESSOR'S MAP & LOT A` ms i R4694%ZMER'S NAME&PHONE NO. 119 n 46 PYO('0 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) -NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: C DATE: 3 1 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 33 �� s 39r �. . 0 13�� TOWN OF BARNSTABLE LOCATION \p�Ce �,.GN2 SEWAGE # 7 � �/ w VILLAGE(�q ASSESSOR'S MAP & LOT 66, INSTALLER'S NAME & PHONE NO.C'G SEPTIC TANK CAPACITY I 00 U LEACHING FACILITY:(type) 1.., , ; (size) I 0 y o �1'ova NO. OF BEDROOMS �J PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER , Q�V�IZ S err. oc�5 DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ,� �� \ � ��. .�� .S�' � P — D S �G No.. . - Fmc............._......0 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE P3� Vvftrafilan for Diivnsa1 Workii Tonstrnrttnn Famit Application is hereby made for a Permit to Construct ( ) :or Repair 3X� an Individual Sewage Disposal System at: l� .......-•---- `. ---- -................................................................ .................... -•-- ---------------------- ............... �^ _L ation-Address oCrt No. - ✓.n.r�.c� ....------•---•- -•---—------------•-----------------c`- . ---............ .......................... Owner .: Addres •- w l f� `��. l.S� m �- fi . �M s� S ....... ... -------•-•- Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) a'4 Other—T e of Building No. of persons............................ Showers Other—Type g ---------------------------- P ( )--- Cafeteria ( ) dOther fixtures --------------------------------------------------------------------------------------------------------•---••--•-- ......•--• w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter--.............. Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter....----.--......... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by................................-......................................... Date........................................ Test Pit No. I----------------minutes per inch Depth of Test Pit.................... Depth to ground water......--.--............. 0i4 Test Pit No. 2................minutes per inch Depth of.Test Pit---:................ Depth to ground water..--.................... .................................................................................................................... 0 Description of Soil................•_�vJ -- . •-•-•--•-•---•••--•-•••--•-------------••------•-------•---••---•---•------•---•-•-•-•---•-•-•-••-••••---•--•-----. x V -------------------------------- •--•------------ -----------------------------------------------------W ..........................-..... ......................... ........................ ..................................... e S ---------- S 1 CUSS �� U N e f epair`� Alterations—A saver when appli ble. S -------- - ............ ._. .._ .....3---------.........-. .................. ........... -T'�-fi ........ ....------------`� �- --- ---------....---------------------------------------.......------------ 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 Compl' n`c,��has been issued by the board of health. Signed aA �^'�' ) �xl - ---------------- ----- . -----....... -- . r. Date Application Approved By U .�Cc .v ,7------------------------------------------------------- �v. r Application Disapproved for the following reasons- --------- ------- ------------------------------- --------------------------------------- ---------------------------------- ----- ------ --------------.....................................----------------------------...................................... ----------------------------------------------------- ----- ................. ----------- Dare Permit No. Issued --. -- f.-. .9..I.... Date `--- No..��:...: ..�-. f Sr FEs.......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH c �,✓� TOWN OF BARNSTABLE _ �L,7 � rltrtt�iaan for Disposal lark, Tonstrurtiun Prrntit f Application is hereby made-for a Permit to Construct ( ) or Repair Y� an Individual Sewage Disposal System at: O. I (�^ /� ckc e .-�J 1" vl V� L ation-Address C� or Lot No. .... :•� .......... .............•-;-•`--�c---••••------ ...•••••--^ 1..,.fi.. ............----- owner Address•-••• 'r Installer Address UType of Building Size Lot............................Sq. feet I-•, Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) - a`L4 Other—T e of Building No. of ersons____________________________ Showers YP g ---------------------------- P (-•-->--- Cafeteria ( ) dOther fixtures ----------------'-------------------------------....-----------------"-"---'--'----------'---'-•-"•------__ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No----------------------Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.................... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ = '.............................................'•-'--•-••---•--•...--•••'-- O Description of Soil----_----•----- - .�_d__ ...:...........................:. ........................................... M •-------------------------------------------------------------------------------------------------------------------'---_____---------------------------______------_____-----------•----------------- W -------------------------------"----------------'--'---'--'------'---'-"'-'---------------"-'--"----'------------ ------ .._.._'-------- t x D i;:i X� S �� C'SS�dv U Nature of i2 airs or Alterations—Answer why applicable.______ ____________________________.)_..._.__.. .___...._.__�______............�.. ..................................................... t-'.�--------� ---------- `? ...... )...................................................................... Agreement: 4,_,._."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 Complia cn e has been issued by the board of health. _ q Signed ----L ----- - -------------------------------------------------------- --------------- .... 1 Da[e Application Approved By .. 0% .-J -�1 -,a--- ,J ......-.-... - f- ..... /... Application Disapproved for the following reasons- -------------- ----------------------------------------------------_----------- --...------------..._-.......................... .................................................................................................................-----------------------------------------------------------------------...................... --------------------------------------- Permit No. - ...------- Issued ....Gi...-- --� --�--J--------------Dale------ 4 Date 4 5 � THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Cfezttfirate• of Cfotttyliattce THIS TO CERTIFY That the Indi i ual Sewage Disposa System constructed ( ) or Repaired (� ) byL -----------------------------1 Installer at .................. ....� �------...._------- C---C-'e---------- - --------------.. 1G--` ------------- ---1�.........05..:.........✓ C . has been installed in accordance with the provisions of TITLE 5 of—The State Environmental Code as described in the application for Disposal Works Construction Permit No. --------- -.....v -(/fir/... dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION S TISFACTORY. DATE------- ---�.---------- ----------------------------------------------------------------- Inspector ..................-...........................•................................................... it P'1 D" THE COMMONWEALTH OF MASSACHUSETTS 1- BOARD OF HEALTH Qa / TOWN OF BARNSTABLE FEE.. Disposal Work Tonstrnr#ion Prrutit� Permission is hereby granted ....__.__._...__ ___________________ ..............................................•------- to Construct ( ) or Re ,air ( )�anC�IIV�,dividual Sewage Disposal System at No I P 3 Kec C-e 1„ �1 - -----------------------•_.._. __........-•-••••-•---L .....-....................................................----.............................. Street —,5 ^ 1 as shown on the application for Disposal Works Construction Permit Dated.......................................... DATE...... ...................................... Board of Health FORM 36508 H0138S Q WARREN,INC.,PUBLISHERS 1. 2� �q- RECEIVED MAY 3 12005 COivIONWEALTH OF MASSACHUSE11 STOWN OF BARNSTABLE".%`"•'°�-. HEALTH DEPT. z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION �4 K b� lO,9M NBy 350 MAIN SIREET WEST YARMOUTH,MA 508-775-2800 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM C A �� gC,,Fe-WART IFICATION MAP 064—PARC D15 Property Address: 1383 RACE LANE MARSTONS MILLS,MA 02648 Owner's Name: FITZSF\4MONS,ELVIRA Owner's Address: 1382 RACE LANE MARSTO?,7S MILLS,MA 02648 Date of Inspection MAY 13,2005 Name of Inspector:(please print) JAMES D. SEARS Company Name: A&B Canco Mailing Address: 350 Main Street West Yarmouth,MA 02673 Telephone Number: 508-775-2800 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage d!sposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails 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 thS::,3pection. If the system is a shared systeri or has a design flow of 10,000 gpd or greater,the inspector and the ays,em 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 tot he buyer,if apr4icable,and the approving authority. Notes and Comments ****This report only describe;conditions at the time of inspection and under the conditions of use at that time. This inspection does not addr.%s how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1383 RACE LANE MARSTONS MILLS,MA 02648 Owner: FITZSIMMONS,ELVIRA Date of Inspection: MAY 13,2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: .( _ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CUR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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 complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health)" broken pipe(s)are replaced obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 2 Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 1383 RACF,LANE MARSTONS MILLS,MA 02648 Owner: FITZSIMMONS,ELVIRA Date of Inspection: MAY 13,2005 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 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 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: Title 5 Inspection Form 6/15/2000 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 1383 RACE LANE MARSTONS MILLS,MA 02648 Owner: FITZSIMMONS,ELVIRA Date of Inspection: MAY 13,2005 D. System Failure Criteria applicable to all systems: N/A 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 pit is less than 6"below invert or available volwme 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 N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A 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 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 CUR 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 service 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 is 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 CUR 15.304. The system owner should contact the appropriate regional office of the Department. Title 5 Inspection Form 6/15/2000 4 i Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST. Property Address: 1383 RACE LANE MARSTONS MILLS,MA 02648 Owner: FITZSIMMONS,ELVIRA Date of Inspection: MAY 13,2005 Check if the following have been done. You must indicate"yes"or"no"as to each of the following Yes No if Pumping information was provided by the owner,occupant,or Board of Health If Were any of the system components pumped out in the previous two weeks? it 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? If Was the site inspected for signs of break out? ✓ Were all system components,including 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)has been determined based on: Yes No ✓ Existing information. For example,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Title 5 Inspection Form 6/15/2000 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1383 RACE LANE MARSTONS MILLS,MA 02648 Owner: FITZSIMMONS,ELVIRA Date of Inspection: MAY 13,2005 FLOW CONDITIONS �. RESIDENTIAL✓ Number of Bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 220 Number of current residents: 2 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] I Laundry system inspected(yes or no): YES Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no) NO Last date of occupancy: PRESENT COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: N/A—TO HAVE MAINTENANCE PUMP AFTER INSPECTION. Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any Irmovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 1991—PERMIT#91-241 Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1383 RACE LANE MARSTONS MILLS,MA 02648 Owner: FITZSB4MONS,ELVIRA Date of Inspection: MAS' 13,2005 BUILDING SEWER(locate on site plan): ✓ Depth below grade: 18 Materials of construction: Cast iron ✓ 40 PVC _ other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): ✓ Depth below grade: 3' Material of construction: 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: 1000-GALLON PRE CAST Sludge depth: 10" Distance from top of sludge to the bottom of outlet tee or baffle: 20" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 12" Distance from bottom of scum to bottom of outlet tee or baffle: 16" How were dimensions detern fined: ASBUILT&TAPE Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): TANK AT WORKING LEVEL,INLET BAFFLE—OUTLET BAFFLE. NO SIGN OF OVER LOADING OR LEAKAGE. GREASE TRAP(located on site plan) N/A 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: j Comments(on pumping recomtendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Title 5 Inspection Form 6/15/2000 7 Page 8 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1383 RACE LANE MARSTONS MILLS,MA 02648 Owner: FITZSIMMONS,ELVIRA Date of Inspection: MAY 13,2005 TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no) Alarm level: Alarm in working order(yes or no): Date of last pumping Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (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 IS 16"X 16"—4'BELOW GRADE,ONE LINE IN—ONE LINE OUT. BOX IS CLEAN&SOLID,NO SIGN OF OVER LOADING OR SOLID CARRY OVER. 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.): Title 5 hispection Form 6/15/2000 8 Page 9 of 11 t OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1383 RACE LANE MARSTONS MILLS,MA 02648 Owner: FITZSIMMONS,ELVIRA Date of Inspection: MAY 13,2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: _ 1 leaching chambers,number: leaching galleries,number leaching trenches,number,length leaching fields,number, dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) LEACHING IS ONE 1000-GALLON PRE CAST PIT,PIT IS 5'BELOW GRADE WITH COVER AT 2". 3'OF WATER IN PIT,STAIN LINE AT 38. NO SIGN OF OVER LOADING OR SOLID CARRY OVER. CESSPOOLS: N/A (cesspool must be pumped as part of inspectionXIocate 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.) Title 5 Inspection Form 6/15/2000 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1383 RACE LANE MARSTONS MILLS, MA 02648 Owner: FITZSIMMONS,ELVIRA Date of Inspection: MAY 13, 2005 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. 33* 3S ' 0 f 0 Title 5 Inspection Form 6/15/2000 10 p Page 11 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1383 RACE LANE MARSTONS MILLS. MA 02648 Owner: FITZSIMMONS. ELVIR4 Date of Inspection: MAY 13,2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to no groundwater l feet Please indicat.-(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: —7— Observation site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: . Checked with local excavators,installers-(attach documentation Accessed USGS database-explain: You must describe how you established the high ground water elevation: AREA HIGH, HOUSE UP ON HILL. NO SIGN OF GROUND WATER. f._. Title 5 Inspection Form 6/15/2000 I1 Commonwealth of Massachusetts . Title 5 Official Inspection Form ate' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments SLR M 1355 Race Lane Property Address Elvira Fitzsimmons Owner Owner's Name - - information is required for Marstons Mills Ma. 02648 11-5-14 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer, use 1. Inspector: only the tab key to move your Matthew F. Gilfoy cursor-do not Name of Inspector use the return key. B&B Excavation Company Name 14 Teaberry Lane Company Address Sandwich Ma. 02644 Ban Citylrown State Zip Code (508)477-0653 S113640 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the 0 information reported below is true, accurate and complete as of the.time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 11-5-14 Inspector's Sign ure f Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. / t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Ift Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1355 Race Lane Property Address Elvira Fitzsimmons Owner Owner's Name information is required for Marstons Mills Ma. 02648 11-5-14 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: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below_ Comments: B) System Conditionally Passes: ❑ one or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): i t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1355 Race Lane Property Address Elvira Fitzsimmons Owner Owner's Name information is required for Marstons Mills Ma. 02648 11-5-14 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): t ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is.within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17. Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 1355 Race Lane Property Address Elvira Fitzsimmons Owner Owner's Name information is required for Marstons Mills Ma. 02648 11-5-14 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and.SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to.overloaded or El ® 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 '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments s..°" 1355 Race Lane Property Address Elvira Fitzsimmons Owner Owner's Name information is required for Marstons Mills Ma. 02648 11-5-14 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Z Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or,less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1355 Race Lane Property Address Elvira Fitzsimmons Owner Owner's Name information is Marstons Mills Ma. 02648 11-5-14 required for 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)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1355 Race Lane Property Address Elvira Fitzsimmons Owner Owner's Name information is required for Marstons Mills Ma. 02648 11-5-14 every page. CitylTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) ... Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d see below 9 ( Y 9 (gP ))� Detail 2012-57,000 gallons 2013-134,000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: April-5-14 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 1355 Race Lane Property Address Elvira Fitzsimmons Owner Owner's Name information is required for Marstons Mills Ma 02648 11-5-14 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part:of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ' 1355 Race Lane Property Address Elvira Fitzsimmons Owner Owners Name information is Marstons Mills Ma. 02648 11-5-14 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1991 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 3,6„ Depth below grade: feet Material of construction: ® cast iron ❑40 PVC ❑ other(explain): Distance from private water,supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in good working order no sign of leakage. Septic Tank(lo:ate on site plan): 3' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, ist age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal. Sludge depth: 3" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1355 Race Lane Property Address Elvira Fitzsimmons Owner Owner's Name information is required for Marstons Mills Ma. 02648 11-5-14 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) 33" Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 0" Distance from top of scum to top of outlet tee or baffle NS Distance from bottom of scum to bottom of outlet tee or baffle NS How were dimensions determined? measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appeared to be in working order,Baffles present no sign of back- up.Liquid level equal with outlet invert. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection . Form II Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ,. 1355 Race Lane Property Address Elvira Fitzsimmons Owner Owner's Name information is required for Marstons Mills Ma. 02648 11-5-14 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grader Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: - gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1355 Race Lane Property Address Elvira Fitzsimmons Owner Owner's Name information is required for Marstons Mills Ma. 02648 11-5-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): At time of inspection d-box appears to in working order no sign of carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.)` * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1355 Race Lane Property Address Elvira Fitzsimmons Owner Owner's Name information is required for Marstons Mills Ma. 02648 11-5-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 6'x6' ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At time of inspection leaching appears to be in working order with no sign of hydraulic.failure. Water level 5' below invert at time of inspection. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert - - Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1355 Race Lane Property Address Elvira Fitzsimmons Owner Owner's Name information is required for Marstons Mills Ma. 02648 11-5-14 every page. Citylfown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsuilace Sewage Disposal System Form Not for Voluntary Assessments 1355 Race Lane Property Address Elvira.Fitzsimmons Owner. •Owner's-Name information.is. required for Marstons Mills Ma. 02648 11-5-14 every page. Cityrrown State Zip Code Date of Inspection D. System: Information (Pont.) Sketch Of Sewage Disposal System: Provide a.view 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 th e.building. Check one of the boxes below: hand=sketch in the area below drawing attached separately Ali a,_ao O O 3 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts G Title 5 Official Inspection Form i. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y` 1355 Race Lane Property Address Elvira Fitzsimmons Owner Owner's Name information is required for Marstons Mills Ma. 02648 11-5-14 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: No Gw 10' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: pate ® 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) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Previous inspection report showing ground water @ >10' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1355 Race Lane Property Address Elvira Fitzsimmons Owner Owner's Name information is required for Marstons Mills Ma. 02648 11-5-14 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17