HomeMy WebLinkAbout1567 RACE LANE - Health 1567 RACE; LANE
MARS'TONS MILLS 047-137
.ro -
No. � Fee 7J
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: l---
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
R.pphration for Disposal 6pstrm (Cunstruttion i9ermIt
Application for a Permit to Construct( ) Repair(� Upgrade( ) Abandon( ) ❑Complete System Individual Components
Location Address or Lot No. (1569°7 (, Owner's Name Address and T 1.N .
p DMA S M rt t
Assessor's Ma /Parcel
Installer's Name,Ac1d ress,and Tel.No. 600-4 17—`217 Designer's Name,Address,and Tel.No.
to�/�.
�(� t
Type of Building: J
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date N j Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) pis
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Healt
Signpk Date
Application Approved by 12 IA Date Z — — ZV _
Application Disapproved by Date
for the following reasons
Permit No. _ Lfr(p Date Issued
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yew.
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
4pliCatlon for Disposal 6pstem Construrtion Permit
Application for a Permit to Construct( ) Repair(� Upgrade( ) Abandon( ) ❑Complete System Xlndividual Components
Location Address or Lot No. (5(P-7 LA 0"r Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel M" � ILLS
Installer's Name,Address,and Tel.No. 5cg_d Y 7_72 7 7 Designer's Name,Address,and Tel.No.
d 01V14 nGS /az-P(A�-z- 3 ou cLd pi14
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures `
Design Flow(min.required) n/ I� gpd Design flow provided J�l,��_ gpd
Plan Date iJ�/} Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date 1:�, _(L_ c71 9
Application Approved by Date ; _ �-
Application Disapproved by Date
for the.following reasons
Permit No. d/C)- q X 2 Date Issued
---------------------------------------------------------------------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( )
Abandoned( )by CA QiqAx.)1 r)ZL C-Q .
at 4 56a i & M i m has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.. Rated )-) - y-
a�
Installer Designer ,t{
#bedrooms Approved design flow AZIA gpd
The issuance of this permit hall not�e construed as a guarantee that the system will f n'c o—K/19,designed.
Date j Inspector/ 4 \
i t 1.
No. 2 0 `yT& Fee�J
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Disposal *pstrm Construction permit
Permission is hereby granted to Construct( ) Repair(X) Upgrade( ) Abandon( )
System located at 1,56"7
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must a completed within three years of the date of this permit. r
Date Approved by l) 1
12/4/2019 ShowAsbui It(1700X 2800)
��+ c
. TOWN OF BARNSTABLE
LOCATION �I,tS�D ,/R Ln SEWAGE 0
VILLAGE !s'I IZ d iV n S ,M 1 Ar ASSESSOR'S MAP k LOT
INSTA4ER'S NAME A PHONE NO,
SEPTIC TANK CAPACITY 7C
LEACHINO'PACHMT:(tYPe) t (sin) torn 6"/
NO.OFBEDROOMS a
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE
Separation Distance Between tbe:
Maximum Adjusted OtoumlwaterTablc to the Baton ofleadting Facility Feet
P&Ate Water Supply Well and Leaching Facility(If any aeU,all.
on site or witldn 200 feet of kxhiag facility) t
Edge of Wetland and Leadting Facility(U any wetlands exist
within-lw fcc}y1ling lsciliry)
Ftmdshed by J[Seacb4,n„ M�E(r,�y ( kPPer Cc �gP t
r 1
gunk
fF 6
p0
A,L'lay a-F-Z V
https:/fitsg ldb.town.barnstable.ma.us:8431/Home/ShowAsbuilt?mp=047137&sq=1 1/1
Dec 12 2019 15:30 HP Fax page 20
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
i
1567 Race Lane
Property Address r"
Ben Canavan
Owner Owner's Name information is
required for every Marstons Mills/
MA 02648 12-11-19
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.
tl h i llll I I ll ur.,�ir''
Important:When o.`y��
A Inspector Information l4r /,q 3 00
fining out forms p .4,o?;• "• ti
on the computer, ,A NI F u'
use only the tab James D.Sears
key to move your Name of Inspector
cursor-do not
Capewide Enterprisesuse
�• ��. o =�- c
key the return Company Name
153 Commercial Street
Company Address
Mashpee MA 02649
City/Town State Zip Code
rmmn 508-477-8877 S1623
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 C M R 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
12-11-19
In Actor's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: 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.
15insp.doc-rev.712812018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
I
Dec 12 2019 15:30 HP Fax page 21
Commonwealth of Massachusetts
fn Title 5 Official Inspection Form
i jr Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1567 Race Lane
Property Address
Ben Canavan
Owner Owner's Name
information s Marstons Mills MA 02648 12-11-19
required for every
page, CltylTown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary:Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
gl I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The system is a 1000 Gal.Tank D Box and pit. 12-2019 New D Box.
2) 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 ❑ NO (Explain below):
t5insp.doc-rev.7/2812018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 10
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Dec 12 2019 15:30 'HP Fax page 22
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1567 Race Lane
V Property Address
Ben Canavan
Owner Owners Name
information is
requiredd for every Marstons Mills MA 02648 12-11-19
page, CitylTown State Zip Code Date of Inspection
C. Inspection Summary (cant.)
2) System Conditionally Passes(cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) 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.
a. 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:
151nsp.dac•rev.7126/2018 Title E Official Inspection Form Subsurface Sewage Disposal System•Page 3 of 10
Dec 12 2019 15:31 HP Fax page 23
Commonwealth of Massachusetts
Title 5 Official Inspection Form
subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1567 Race Lane
Property Address
Ben Canavan
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 12-11-19
page. Ci;y/Town State Zip Code Date of Inspection
C. Inspection Summary (cons.)
❑ 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
b. 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.
c. Other:
4) 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 pending of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev,T1281,'01a Title 6 Official Inspection Form:Subsuftce Sewage Disposal System-Page 4 of 18
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form • Not for Voluntary Assessments
1567 Race Lane
Property Address
Ben Canavan
Owner Owner's Name
information
equir do re Marstons Mills MA 02648 12-11-19
required far every
page. Citylrown State Zip Code Date of Inspedcn
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in smaNg is less than 6" below invert or available volume is less
than day flow 01,r—
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
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 otherfailure 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 2000 gpd-
10,000 gpd.
❑ ® The system fai s. I have determined that one or more of the above failure
criteria exist as described in 310 CM 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.
5) 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 CA.
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
15insp.doc•rev.712612010 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18
Dec 12 2019 15:32 HP Fax page 25
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1567 Race Lane
Property Address
Ben Canavan
Owner Owner's Name
Informrequiratlfo Is Marstons Mills MA D2648 12-11-19
requires for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cant.)
If you have answered"yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section GA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes"or"no"for each of the following for all inspections:
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 NIA)
® ❑ 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)]
t5insp.doc•rev.H2812018 Titie 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 6 of 18
IDec 12 2019 15:32 HP Fax page 26
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1567 Race Lane
Property Address
Ben Canavan
Owner Owner's Name
information Is Marstons Mills MA 02648 12-11-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
1. 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
Description:
1000 Gal Tank D Box and pit.
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage(gpd)): 2017-26,000GaIs
2018-27,000 Gal's
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Present
Date
151nsp.doc•rev.7126f2016 Title 5 Official Inspection FDrm Subsurface Sewage Disposal System•Page 7 of 10
Dec 12 2019 15:32 HP Fax page 27
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
v` 1567 Race Lane
Property Address
Ben Canavan
Owner Owners Name
information is Marstons Mills MA 02648 12-11-19
required for every
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
2. 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/sci t.,etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
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 below):
3. 'Pumping Records:
Source of information: NA
Was system pumped as part of the inspection? ❑ Yes ® No
If yes,volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc-rev.7t262018 Title 5 OKidal Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Dec 12 2019 15:33 HP Fax page 28
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1567 Race Lane
'J Property Address
Ben Canavan
Owner Owner's Name
information is Marstons Mills MA 02648 12-11-19
required for every
page, City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. 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).
Approximate age of all components, date installed (if known)and source of information:
NA 12-2019 New D Box,
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 28"
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.):
Pipeing is 4" PVC SCH -40.
t5insp.doc rev.TIM2018 Title 5 OtUcial Inspection Form:Subsurlace Sewage 01sposai System-Page 9 of Is
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Dec 12 2019 15:33 HP Fax page 29
Commonwealth of Massachusetts
Title 5 Official Inspection Form
System Form - Not for Voluntary Assessments
Subsurface Sewage Disposal Y Subsu gy
1567 Race Lane
Properly Address
Ben Canavan
Owner Owner's Name
information Is required for every Marstons Mills MA 02648 12-11-19
page. City/Town State Zip code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
18"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 Gal. Precast H-10
1"
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
29"
0"
Scum thickness
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 181.
How were dimensions determined? Asbuilt-Tape
Sludge Judge
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.Tank at 18" below grade. In cover at 2"and outlet at 6". In Tee w/outlet
baffle No sign of leakage or over loading
Mnsp.doc-rev.7/26IM18 T tla 5 Official Irtspecdon Form:Subsurface Sewage Disposal System-Page 10 of 18
Dec 12 2019 15:33 HP Fax page 30
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1y Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1567 Race Lane
Property Address
Ben Canavan
Owner Owner's Name
information s Marstons Mills MA 02648 12-11-19
required for every
Page, City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. 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
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
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Dec 12 2019 15:34 HP Fax page 31
Commonwealth of Massachusetts
Title 5 Official Inspection Form
b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1567 Race Lane
Property Address
Ben Canavan
Owner Owner's Name
information Is required for every Marstons Mills MA 02648 12-11-19
page. CitylTown State Zip Code Date of Inspection
D. System Information (cunt.)
8. Tight or Holding Tank(cont.)
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
9. 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"x16"-32" below grade wlone line out. Box is New 12-2019 wlcover at 6".
t6inap.coe•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Dec 12 2019 15:34 HP Fax page 32
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
h
1567 Race Lane
Property Address
Ben Canavan
Owner Owner's Name
information is Marstons Mills MA 02648 12-11-19
required for every
paw. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
10. 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.
11. 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:
t5insp.doc•rev.7126P018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
f
Dec 12 2019 15:34 HP Fax page 33
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
>` 1567 Race Lane
Property Address
Ben Canavan
Owner Owner's Name
informaUr
required fo for every Marstons Mills MA 02648 12-11-19
e
page. City[Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS)(cont,)
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of
vegetation, etc.):
Leaching is a 1000 Gal. Precast pit. Camera out to pit. Clean w/1'water. No sign of over loading
or solid carry over.
12. 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
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
15in5p.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Dec 12 2019 15:34 HP Fax page 34
Commonwealth of Massachusetts
Title 5 Official Inspection Form
r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�. 1567 Race Lane
Property Address
Ben Canavan
Owner Owner's Name
information is required For every Marstons Mills MA 02648 12-11-19
paw. City/Town State Zip Code Date of inspection
D. System Information (cont.)
13. 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.):
t8insp.doc•rev.7/2612018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 18
Dec 12 2019 15:34 HP Fax page 35
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
1567 Race Lane
`J Property Address
Ben Canavan
Owner Owner's Name
information is required far every Marslons Mills MA 02648 12-11-19
page. CitylTown State Zip Code Date of Inspection
D. 'System Information (cont.)
14. 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
the building. Check one of the boxes below:
hand-sketch in the area below
❑ drawing attached separately
I
Jz?
A 1ISE
-DEc k
j
a Y
15insp.doc•rev.712&2018 Title 5 Official bspection Form:Subsurface Sewage olsposal System•Page 16 of 18
7
Dec 12 2019 15:34 H? Fax page 36
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1567 Race Lane
Property Address
Ben Canavan
Owner Owner's Name
information is required for every Marstons Mills MA 02648 12-11-19
page, City/Town State Zip Cade Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to Mpground water: 20'+
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked,date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
G.W. Maps.
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
20'+to G.W..Bottom of pit at 9' below grade. Bottom of pit at 1 V+above G.W. Depth.
Before filing this Inspection Report,please see Report Completeness Checklist on next page,
t6insp.doc-rev.7/262016 Title 6 Otfic al Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
Dec 12 2019 15:34 HP Fax page 37
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1567 Race Lane
Propety Address
Ben Canavan
Owner Owner's Name
informatlon is Marstons Mills MA 02648 12-11-19
required for every
page. CitylTown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information:Complete all fields in this section.
® B.Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1,2,3, or 5 completed as appropriate
4(Failure Criteria) and 6(Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank —Pumping contract attached
For 14:Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
� l __
i
I
li
P,r- , r
t5insp.doc•rev.W2612018 Title 5 Official Inspection Forn Subsurface Sewage Disposal System•PKU 18 of 18
t TOWN Or BARNSTABLE
Lo6an N DIY 7 .L�a Ce L`I SEWAGE
VILLAGE /t✓`41' -All /S ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY `0" f
LF.ACfiING PACII.ITY:(typs) `'� fsize) ��C� �c,�f
NO.OF BEDROOMS a
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE;
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Teaching Facility .-. ,Feet
Private Water Supply Well and Leaching Facility many wells exist
on site or vAthin 200 feet of leashing facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet €teaching facility) best
Furnished by_SCmki /�S-�lra Gt P 1 . L'/-
---
{
p L
q Vy
L /�-�
"7 9 0p STA?3LE Q G
?,O:�ATION AY 4 �� /lJ SEWAGE
VT :LAGS Adk&LOV ASSESSOR'S M P &PLOT
INSTALLER'S NAME & PHONE NO. QV-.0 l e 0
ck SEPTIC TANK CAPACITY /0 o� ..
LEACHING FACILITY:(tVpe) (size) 6 0
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC" WAT R
BUILDER OR OWNER -T�eo CyA,5 6—
DATE PERMIT ISSUED: `i �*"
DATE .COZIPLIANCE ISSUED:__ �� ��•�' �` --
VAVZIANCE GRANTED: Yes No
Y✓
xo� zs-9
r
�No
THE COMMONWEALTH OF MASSACHUS �'�C � lJ
BOARD OF HEALTI-S �
� ...............OF........�:g.� ............
Appliration for Disposal Works Tonstrwtinn rumit
Application is hereby made for a Permit to Construct (�or Repair ( ) an Individual Sewage Disposal
Systemat:_—'C -.7... ......................................................... ............................. 1._. ..._. ........ ..-
Lo tion- d. ess r�I,Lt No.
\ Address
C
W !r i.2..__...�......... ............................ ....•-----•..............•-------------------....:........................._........_.........----
,4
go Installer Address }
Type of Buildin Size Lot_ 2 �- -Sq. feet
Dwelling—No. of Bedrooms......................._.........._.__..._.•Expansion Attic ( ) Garbage Grinder ( )
P4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
WaOther fixtures .••••-••-•-•--•••••--••-•-•••••-••-•••--••-•--•--••••-'•••----•--------•-•--•--------•...................:
Design Flow............. ....................gallons per person per day. Total daily flow... ` 7._.....•.........gallons.
W Septic Tank—Liquid'capacity!PO.O.gallons Length-=� . Width................ Diamete; ''_ _" p `.. .
fv De th- ' �-•f•--
Disposal Trench—No.................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No......I------------- Diameter.. .�.�. .i._. Depth below inlet.61.... ...... Total leachingarea..4 ...
Other Distribution box (� Dosin tank ( )
Percolation Test Results Performed by ��r'�o .._ ��1;�__._ J6...kmate...._ _
Test Pit No. 1.._Z...._.__minutes per inch Depth of Test Pit..... Z_._....... Depth to ground water_-�)7_.__.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a •- ' ........... t --•---•--------..•..--------•--.................-----
l �0 Description of Soil............... t � � ---- ----•j..... -•---••........................•--_..z %
W -••---•-•••••--•-• ------. lam :-..�Z i _ 1�'� ..� e.l.� ............................................................
UNature of Repairs or Alterations—Answer when applicable.._____. fi
-- t.
--••-•-------------------------•...................-----•--•-------------------------...---•--•----.....--•-•-•----------------.--•-=-......;.-----------------•--------•------------••----•••--•---......
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLi� 5 of the State Sanitary ode—The undersigned further agrees not to"place the system in
oper on until a ti to of�Compliance has b en is ed the b and of health.
Signed : ... ..............•---
Date
licatio Approved BY `_ vr�/ �c.� _
Date/
Application Disapproved for the following reasons:..............................................................................................................
.....-•----•--.......---••-•-------------•----------------..............-----------.....--•--•-------------•-.......................--••---•----...---•--•.........................................
..
Date
Permit No....... --� -------------- ---.-------._.. Issued._.�x ._ '�' L_.
90
t A ll
No..l ..... ... 4..T................
9� !� THE COMMONWEALTH OF MASSACHUSETTS
`j/ (� BOARD OF HEALTH
1W_..... .oF......... . --- � ....� ..................
Appfiration for IliopooFaf Works Tonstrurtion ramit
Application is hereby made for a Permit to Construct ( A/or Repair ( ) an Individual Sewage Disposal
System at I
7,
......... `Y 11 ✓`
.��...
-�.a�- --•.r,�+ •�-�•Location Address o Ift
........................ .. ...................... ...............................
......._........
o" Address
r f ? ! fie �Yr) ` �� r
....
Installer Address _.
y .,
U Type of Buildin ;�> Size Lot... °:_.. =:'_'t.Sq. feet
Dwelling—No. of Bedrooms..:.........................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building a Other—Type g ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
_ Other fixturgs .•------•---••---•-•---•-----------•-•---•--•••---•--••............•....
5'». y ,/.% _'aJ---•-----•---•------------•-
WDesign Flow..............y�_E.__........................gallons per person#per day. Total daily flow..._._.._.__._4_ ._.................gallons.
WSeptic Tank—Liquid .capacity ( gallons Length. x>_::.`�_':= Width................ Diameter_+' .FU". Depth.. <._".=''
x Disposal Trench—No..................... Width.................... Total Length................... Total leaching area...... ------------sq. ft.
Seepage Pit No.......I------------ - iameter.___!.=`.. .__. Depth below inlet-. .c-,.. Total leaching area........_4�..._sq^f�'��1 t
z Other Distribution box ( Dosingltank ( ) i
t
'-' Percolation Test Results Performed b �A=f -- " f :�,. � . - d
Y . •------• --- .:.. Date ...........,.--•--
Test Pit No. I...... :......minutes per inch Depth of Test Pit....... `._.._. Depth to ground water.._`? `'-�'`° __.
(X, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
;1.d
D Description of Soil........ &r v ......
----
Vw. 1 r P ................t-------- ----•----------------------------
W -•-•--•----- - • ---•------ �>....................... `�- -�c:.' C t t .. - L
•••.
V Nature of Repairs or Alterations—Answer when applicable......... ....................................................................................
-------•--------------•-----•------••-------------------•--•-----------------------••--------.-----•••---•--...•---•••------•----•--------•-••----•-•-----•- -----•-•---•---•---•-••-----....--•--.----•
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIZ 5 of the State Sanitary ode— The undersigned further agrees not to place the system in
opera 'on until a , rtifi toloff*Compliance has b n issued b t e bo rd Qf health.
Signed._'. ----------
..........................
j
-
licatio Approved BY .. : ��aG'
Date
PPlication Disapproved for'the following reasons-----------------------------------------•---------------------------------------
-----------•••--•-----•----••-••----. ---------------------
Permit No...... :--•--.-:- �.�.
�^ , Datd �` ---Date......
� �--•'g-----•-...-------•--• Issued.----"w-'�-- --.:'�r�
THE COMMONWEALTH OF MASSACHUSETTS
-w BOARD OF HEALTH
OF.........1...'' ''. i.l ( l
:. ............ ......................................................
C9rrtifirFatr of Tootlrfianrr
THIS IS T CERTIFY, That.the Individual Sewage Disposal System constructed ( ) or Repaired ( )
Y ..... -�„ . ----------------------------------------------------------------------------------------•-----....----------
(; �� Installer
at ... / "" 4" y -
has been installed in accordance with the provisions of TITgr5 of The State SanitaryCode as escrlb d in the
ib
application for Disposal Works Construction Permit No_______ ________________ .__ dated_:...___ _��-_ ...� ,1S'____.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
�-� _ h
DATE...... ........... ....... ............................ Inspector...----- _y I� - ----- ---•-----•---•••---•--•-•--
THE COMMONWEALTH OF MASSACHUSETTS
.,,-_•..
BOARD F HEALTH
.�- o p
No.. ...... I...........••--•••--•
�io�ro� orko �onotrttr$ion rrutit -
Permission is hereby granted..... ._1.�._(>.._.. 0 L i c,i
-- ............. ._...
to Construct ( for Repair ( ) an Indivi ual Sewage Disposal System
Street
as shown on the application for Disposal Works Construction Permit .�.1��No.. '- " Dated.....
............
._. h.....
�^
-------------
� .,� /.
7 z oll�'7 ......................... Board of Health
DATE. �-
vv •----............................... ,
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
Barnstable
Town of Barnstable
/O'pTHE t0\ -
//,?� \o\`` m EI2LiS2 Ctiy
w. Board of Health a
•., ARM ABLE 1 a i t� f_i
H
MASS. ''a/1 200 Main Street Hyannis MA 026013; .l
200 i -
Office: 508-862-4644 Wayne Miller,M.D.
FAX: 508-790-6304 Paul Canniff,D.M.D.
JUIlidll Sawayanagi
October 24, 2011 -
Mr. Benjamin J. Canavan --
1567 Race Lane —
Marstons Mills, MA 02648 —
RE: 1567 Race Lane, Marstons Mills, MA Map/Parcel 047 - 137
Dear Mr. Canavan:
At the Board of Health meeting held on October 11, 2011, The Board voted to grant you
permission to obtain two additional septic system inspections: the first one within 60 days
and the second to be 12 months later. If both septic inspection reports indicate the system
has passed. If one or both of the septic system reports show that the system failed, the
system must be repaired or replaced within 60 days of the date of the report.
On August 5, 2008, the septic system failed according to Sean McElroy of East
Falmouth, a DEP certified septic system inspector. The system failed based upon the
observance of a stain line above the outlet invert of the distribution box and stains above the inlet invert in the leaching pit. In 2008, the owner was ordered to repair the system ---
within 60 days. To date, the system has not been repaired. ----
The reason for this decision to allow additional evaluation of the septic system is because _
the owner testified the septic system is functioning properly at this time. In the past, it
has been shown that stain lines make it difficult to make a determination as to whether a
septic. system actually passed or failed. -
PER RDER OF HE BOARD OF HEALTH -
ayn iller, M.D. _
Chaff n
Q:\WPFILES\1567 Race Ln MM BOH Oct201 Ldoc
-
Town of Barnstable Barnstable
Op THE TO
Board of Health asa,,;er;cacitv
rWR'ASS, E,Q I` 200 Main Street, Hyannis MA 02601 y' 9
Tq. `gym
Tf0 M, a 2007
Office: 508-862-4644 Wayne Miller,M.D.
FAX: 508-790-6304 Paul Canniff,D.M.D.
Junichi Sawayanagi
CERTIFIED.MAIL # 7011 0470 0001 4525 5280
September 30, 2011
Mr. Benjamin J. Canavan
1567 Race Lane
Marstons Mills, MA 02648
YOU ARE SCHEDULED TO APPEAR BEFORE THE BOARD OF HEALTH on
Tuesday, October 11, 2011 at 3pm in the Town Hall, Hearing Room, 2nd Floor,
367 Main Street, Hyannis, MA due to your failure to repair or replace the failed
septic system at 1567 Race Lane, Marstons Mills, MA 02648.
The State Environmental Code Title V requires all failed septic systems to be repaired or
replaced within two years. The Town of Barnstable Board of Health has more stringent
deadlines dependent upon the type of failure identified. In this case, the septic system
has been in failure beyond the established deadline.
You will be given the opportunity to testify, present witnesses, documentary evidence,
and other official information regarding this case.
PER ORDER OF THE BOARD OF HEALTH 4"
'r c q
Wayne Miller, M.D. ,(V ��v�
Chairman ,-
Q:\SEPTIC\Letters Septic Inspection Failures\1567 Race Ln MM BOH Oct201 l.doc
COMPLETE •
■ Complete items 1,2,and 3.Also complete A item 4 if Restricted Delivery is desired. ZR�
❑Agent
■ Print your name and address on the reverse ❑Addressee
so that we can return the card to you. Q Received by(Printed Name) C. Date of Delivery
■ Attach this card to the back of the mailpiece, _
rL Cli/lJL/GL�--
or on the front if space permits. " d'
D. Is delivery address different from item 1? ❑Yes
1. Article Addressed to: If YES,enter delivery address below: ❑ No
Mr. Benjamin J. Canavan
1567 Race Lane
Marstons Millss, MA 02648 3. Service Type
! ❑Certified Mail ❑Express Mail '
❑Registered ❑Return Receipt for Marc ndiii
❑ Insured Mail ❑C.O.D. C
4. Restricted Delivery?(Extra Fee) d YeA
2. Article Number ,I
7011 2470 0221 4525 5282
(transfer from service Iabeo I
PS Form 3811,February 2004 Domestic,Return Receipt 102595-02-M-1540
UNITED STATE,�,<� � `4 t •R x
h?ostage, es1 'ald
.�1sPs
.No.Y ,.
• Sender: Please print your name, address, and ZJP+4 in this boxly
a Town of Barnstable
? Public Health Division
a 200 Main Street
Hyannis,MA 02601
1l „►,�I,1:1l::li,,,+:,,'11:I.,=1i! t:lll,�:il,,,,l.�,
P SHE Town of Barnstable Barnstable
�p rp�y
Board of Health ;sieaC'y
rSA MASS.MASS.3LE,7+ 200 Main Street, Hyannis MA 02601 O D
9 m
iDrFb MAy a. 2007
Office: 508-862-4644 Wayne Miller,M.D.
FAX: 508-790-6304 Paul Canniff,D.M.D.
Junichi Sawayanagi
CERTIFIED MAIL# 7011 0470 0001 5280
September 30, 2011
Benjamin J. Canavan
1567 Race Lane
Marstons Mills, MA 02648
i
YOU ARE SCHEDULED TO APPEAR BEFORE THE BOARD OF HEALTH on
Tuesday, October 11, 2011 at 3 pm in the Town Hall, Hearing Room, 2nd Floor,
367 Main Street, Hyannis, MA due to your failure to repair or replace the failed
septic system at 1567 Race Lane, Marstons Mills, MA.
The State Environmental Code Title V requires all failed septic systems to be
repaired or replaced within two years. The Town of Barnstable Board of Health
has more stringent deadlines dependent upon the type of failure identified. In
this case, the septic system has been in failure beyond the established deadline.
You will be given the opportunity to testify, present witnesses, documentary
evidence, and other official information regarding this case.
PER ORDER OF THE BOARD OF HEALTH
Wayne Miller, M.D.
Chairman
Q:\Order letters\Sewage Violations\Request to Appear at BOH\1567 Race Lane Oct201 I.doc.
�oF 19KE raw
Town of Barnstable Barnstable
Board of Health AgAmedcaC'
• BARNS-TABLEMA%S ,
9 .
i639gq. 200 Main Street, Hyannis MA 02601 D
�e m
'°jeo MAC° 2007
Office: 508-862-4644 Wayne Miller,M.D.
FAX: 508-790-6304 Paul Canniff,D.M.D.
Junichi Sawayanagi
CERTIFIED MAIL # 7011 0470 0001 4525 5341
September 30, 2011
Mr. Benjamin J. Canavan
1567 Race Lane
Marstons Mills, MA 02648
YOU ARE SCHEDULED TO APPEAR BEFORE THE BOARD OF HEALTH on
Tuesday, October 11, 2011 at 3pm in the Town Hall, Hearing Room, 2nd Floor,
367 Main Street, Hyannis, MA due to your failure to repair or replace the failed
septic system at 1567 Race Lane, Marstons Mills, MA 02648
The State Environmental Code Title V requires all failed septic systems to be repaired or
• replaced within two years. The Town of Barnstable Board of Health has more Stringent
deadlines dependent upon the type of failure identified. In this case, the septic system
has been in failure beyond the established deadline.
You will be given the opportunity to testify, present witnesses, documentary evidence,
and other official information regarding this case.
PER ORDER OF THE BOARD OF HEALTH
Wayne Miller, M.D.
Chairman
•
Q:\SEPTIC\Letters Septic Inspection Failures\1567 Race Ln.,MM.doc
Town of Barnstable Barn
OFfNE T
P Regulatory Services Department i q a 1.1�
nARN5TA6LE, �* '
N^ Public Health Division
-Op .lbg9• 1m
rfb MPt a 200 Main Street, Hyannis MA 02601 2e07
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A. McKean,CHO
CERTIFIED MAIL # 7011 0470 0001 4525 5594 /
February 13, 2012 /� f
Mr Benjamin J. Canavan
1567 Race Lane
Marstons Mills, MA 02648
The septic system located at 1567 Race Lane,Marstons Mills, MA,was last inspected
on 8/05/2008, by Scan McElroy, a certified septic inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Failed"under the guidelines
of the 1995 TITLE 5 (310 CMR 15.00). On 11/08/ 2011, you were asked to appear
before the Board of Health to explain why the septic system had not been repaired.
At the discussion with the Board of Health it was agreed that we would like two further
inspections, in order to consider reversing the inspection on 5/10/ 2005. Two passing
inspections would need to be done; one in the near future and the second twelve months
after the first one.
It has been three months since the Board of Health meeting and, as of today, no
additional inspections have been filed. If you can show us any documentary evidence
that the first inspection has been done, we would appreciate your submitting such
documentation to this office.
F
Failure to comply with the Board of Health's request may result in future enforcement
action.
X�l
PER ORDER OF THE BOARD OF HEALTH
Thomas McKean, R.S. CHO \ ��
Agent of the Board of Health
Q:\SEPTIC\L.etters Septic Inspection Failures or Future Eval\Town of Barnstable.doc
e
Q: _
i Town of Barnstable Barnstable
/pf H p�40
: iw',Ii7Eriso G y --
�.'�`; Board of Health e � _r -
IIi,(nARVSTA6LE: -li -,._.y
9
nA55. Qi 200 Main Street Hyannis MA 02601 '
200 7
Office: 508-862-4644 Wayne Miller,M.D.
FAX: 508-790-6304 Paul Cannif,,D.M.D.
Junichi Sawayanagi
October 24, 2011 -
Mr. Benjamin J. Canavan
1567 Race Lane
Marstons Mills, MA 02648
RE: 1567 Race Lane, Marstons Mills, MA Map/Parcel 047 - 137
Dear Mr. Canavan:
At the Board of Health meeting held on October 11, 2011, The Board voted to grant you
permission to obtain two additional septic system inspections: the first one within 60 days
and the second to be 12 months later. If both septic inspection reports indicate the system
has passed. If one or both of the septic system reports show that the system failed, the
system must be repaired or replaced within 60 days of the date of the report.
On August 5, 2008, the septic system failed according to Sean McElroy of East
Falmouth, a DEP certified septic system inspector. The system failed based upon the
observance of a stain line above the outlet invert of the distribution box and stains above -the inlet invert in the leaching pit. In 2008, the owner was ordered to repair the system --
within 60 days. To date, the system has not been repaired. --.
The reason for this decision to allow additional evaluation of the septic system is because
the owner testified the septiasystem is fiinctioning properly at this time. In the past, it
has been shown that stain lines make it difficult to make a determination as to whether a
septic system.actually passed or failed. A
PEiller,
OF HE BOARD OF HEALTH -
M.D.
-
Q:\WPFILES\1567 Race Ln MM BOH Oct201 l.doc
.r 0
ti
� , t
LJUcw
LO C%
n
THE Town of Barnstable Earnstable
Op TO;y
Board of Health " "'�'caC'
T BARNSTABL£, 00 Main Street, Hyannis MA 02601
fI= A 2 �m
\DOA i639• Q,e i t .
FD MAt 2007
Office: 508-862-4644
Wayne Miller,M.D.
FAX 508-790-6304 Paul Canniff,D.M.D.
Junichi SawayanaPi
CERTIFIED.MAIL # 7011 0470 0001 4525 5280
September 30, 2011
Mr. Benjamin J. Canavan
1567 Race Lane
Marstons Mills, MA 02648
• YOU ARE SCHEDULED TO APPEAR BEFORE THE BOARD OF HEALTH on
Tuesday, October 11, 2011 at 3pm in the Town Hall, Hearing Room, 2nd Floor,
367 Main Street, Hyannis, MA due to your failure to repair or replace the failed
septic system at 1567 Race Lane, Marstons Mills MA 02648.
The State Environmental Code Title V requires all failed septic systems to be repaired or
replaced within two years. The Town of Barnstable Board of Health has more stringent
deadlines dependent upon the type of failure identified. In this case, the septic system
has been in failure beyond the established deadline.
You will be given the opportunity to testify,present witnesses, documentary evidence,
and other official information regarding this case.
PER ORDER OF THE BOARD OF HEALTHa' � jC',�
Wayne Miller, M.D. Oh (1 VA �= ,�c��-^ c/ -t—, �
Chairman
C
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Q:\SEPTIC\Letters Septic Inspection Failures\1567 Race Ln MM 130H Oct2011.doc
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r
r' OF THE Tp�
Town of Barnstable Barnstable
Alll fl1itedcaCIIy
. Board of Health r
nARNSCABLE,
MASS. m 200 Main Street, Hyannis MA 02601
i63q
ArFp MAt a 2007
Office: 508-862-4644 Wayne Miller,M.D.
FAX: 508-790-6304 Paul Canniff,D.M.D.
Junichi Sawayanagi
CERTIFIED MAIL # 7011 0470 0001 4525 5341
September 30, 2011
Mr. Benjamin J. Canavan
1567 Race Lane
Marstons Mills, MA 02648
YOU ARE SCHEDULED TO APPEAR BEFORE THE BOARD OF HEALTH on
Tuesday, October.11, 2011 at 3pm in the Town Hall, Hearing Room, 2°d Floor, -
367 Main Street, Hyannis, MA due to your failure to repair or replace the failed
septic system at 1567 Race Lane, Marstons Mills,MA 02648
The State Environmental Code Title V requires all failed septic systems to be repaired or
replaced within two years. The Town of Barnstable Board of Health has more Stringent
deadlines dependent upon the type of failure identified. In this case, the septic system
has been in failure beyond the established deadline.
You will be given the opportunity to testify, present witnesses, documentary evidence,
and other official information regarding this case.
PER ORDER OF THE BOARD OF HEALTH
Wayne Miller,M.D.
Chairman
Q:\SEPTIC\Letters Septic Inspection Failures\1567 Race Ln.,MM.doc
t
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
y 1567 Race Lane
�M
Property Address
Ben Canavan
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 11/8/2011
page. C4/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer, I /� •�
use only the tab 1. Inspector:
key to move your
cursor-do not Sean M. Jones
use the return Name of Inspector
key.
Capewide Enterprises
Company Name
153 Commercial St.
Company Address
Mashpee Ma. 02649
Cityrrown State Zip Code
508-477-8877 SI 4522
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
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
11/8/2011 =
Inspector's Signature Date
Via$
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 66
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. y 5
a .
`'J e
****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.
l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
li
,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 1567 Race Lane
Property Address
Ben Canavan
Owner Owner's Name
information is required for Marstons Mills Ma 02648 11/8/2011
every page. City/Town 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 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):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 1567 Race Lane
Property Address
Ben Canavan
Owner Owner's Name
information is required for Marstons Mills Ma 02648 11/8/2011
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
t ❑ 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-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
L
Commonwealth of Massachusetts
H Title 5 Official Inspection Form
<� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 1567 Race Lane
Property Address
Ben Canavan
Owner Owner's Name
information is required for Marstons Mills Ma 02648 11/8/2011
every page. CityjTown 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
El ® 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 1/2 day flow
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1567 Race Lane
Property Address
Ben Canavan
Owner Owner's Name
information is required for Marstons Mills Ma 02648 11/8/2011
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:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 1567 Race Lane
Property Address
Ben Canavan
Owner Owner's Name
information is required for Marstons Mills Ma 02648 11/8/2011
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): 330gpd
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 1567 Race Lane
Property Address
Ben Canavan
Owner Owner's Name
information is required for Marstons Mills Ma 02648 11/8/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
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)):
Detail:
2009 = 32,000 total = 88 gpd 2010= 35,000 total = 96 gpd
Sump pump? ❑ Yes ® No
Last date of occupancy: current
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
c�
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M e' 1567 Race Lane
Property Address
Ben Canavan
Owner Owner's Name
information is required for Marstons Mills Ma 02648 11/8/2011
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
` Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 1567 Race Lane
Property Address
Ben Canavan
Owner Owner's Name
information is required for Marstons Mills Ma 02648 11/8/2011
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
original system
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 10+feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints ok, no leakage, vented through roof
Septic Tank (locate on site plan):
Depth below grade: 1
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If hank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gallons
Sludge depth: 51,
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1567 Race Lane
Property Address
Ben Canavan
Owner Owner's Name
information is required for Marstons Mills Ma 02648 11/8/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle 3.5'
Scum thickness
2"
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
10"
How were dimensions determined? opened covers and took
measurements
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 does not need to be cleaned now but should be done soon and again every 2 years as
maintenance. Water level was ok, tank was not leaking and was structurally sound. Outlet baffle was
intact and in good condition.
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 1567 Race Lane
Property Address
Ben Canavan
Owner Owner's Name
information is required for Marstons Mills Ma 02648 11/8/2011
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 1567 Race Lane
Property Address
Ben Canavan
Owner Owner's Name
information is required for Marstons Mills Ma 02648 11/8/2011
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.):
Box was functioning as intended. D-box was video inspected and found to be soild with no rot, no
signs of past hydraulic overloading
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.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 1567 Race Lane
Property Address
Ben Canavan
Owner Owner's Name
information is required for Marstons Mills Ma 02648 11/8/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Pit was video inspected and found to have 5' of available leaching with no signs of past failure
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•11/10 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
�M 1567 Race Lane
Property Address
Ben Canavan
Owner Owner's Name
information is required for Marstons Mills Ma 02648 11/8/2011
every page. CitylTown 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
y 1567 Race Lane
Property Address
Ben Canavan
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 11/8/2011
page. CityTrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
i3
� t
O
t_i 2 26°
f3-+ ytt
O
3 ya°
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1567 Race Lane
Property Address
Ben Canavan
Owner Owner's Name
information is required for Marstons Mills Ma 02648 11/8/2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 20+
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Groundwater elevation was established by accessing Town of Barnstable groundwater contour maps
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1567 Race Lane
Property Address
Ben Canavan
Owner Owner's Name
information is required for Marstons Mills Ma 02648 11/8/2011
every page. CityFrown 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
COMPLETE •N COMPLETE THIS SECTION ON DELIVERY
■ Complete items 1,2,and 3.Also complete A. Signature
item 4 if Restricted Delivery Is desired. ❑Agent
I ■ Print your name and address on the reverse X ❑Addressee
so that we can return the card to you, B. Received by(Printed Name) C. Date of Delivery
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
D. Is delivery address different from Item 1? ❑Yes
1. Article Addressed to: If YES,enter delivery address below: ❑No
I"�QYY1�� rQ 'P%* �zv�CQS
Cf0 -TD( �\C t1ak
���5��33p� ulrYloc -h � od io
I.SL�` `"' V l\kjL f 0 C�U-da 3. Service Type
❑Certified Mail ❑Express Mail
❑Registered ❑Return Receipt for Merchandise
❑Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
2. article Number : 7 O`O 6 2150' �E 0 2' 10`41 16 3 7` '' i I
(transfer from service label) �
PS Form 3811,February 2004 ` Domestic Return Receipt 102595-02-M-1540
UNITED STATES POSTAL SERVICE ;�Y'f First-Class Mail
Postage&Fees Paid
.� USPS
' Permit No.G-10
I
Sender:Please.print your riame, address, and ZIP+4 in this box •
-7Zogcm
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Town of Barnstable Barnstable
ain
Regulatory Services Department i 1
9� 1639. ,m� Public Health Division
f°N4D�A 200 Main Street, Hyannis MA 02601 2007
Office: 508-8624644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
August 7,2008
Premiere Asset Services
c/o David Holt
1533 Falmouth Road
Centerville,MA 02632
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5
The septic system located at 1567 Race Lane,Marstons Mills, MA was last inspected
on August 5,2008,by Shawn Mcelroy, a certified septic inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Failed"under the guidelines
of 1995 TITLE 5 (310 CMR 15.00) due to the following:
Leach pit had signs of failure with stain lines above the inlet invert.
You are ordered to repair or replace the septic system within sixty (60) days from the
date you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
ER ORDER OF THE BOARD OF HEALTH
Donald R. Desmarais, R.S.
Agent of the Board of Health
CERTIFIED MAIL 47006 2150 0002 1041 7637
Q:\SEPTIC\Letters Septic Inspection Failures\1567 Race Lane.doc
Commonwealth of Massachusetts
Title 5 official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
I
1567 Race Ln
Property Address
Premiere Asset Services
Owner Owner's Name
information is required for Marstons Mills MA 02648 8-5-08 .
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.
A. General Information
1. Inspector:
Shawn Mcelroy
Name of Inspector ,
Upper Cape Septic Services
Company Name
29 Atwater Dr ci
Company Address Z 'yp
E. Falmouth MA 2536
City/Town State ip Code`.'
1-508-495-0905 S13971
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
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 C M R 15.000).The system:
❑ Passes ❑ Conditionally Passes ® Fails
❑ Needs Further Evaluation by the Local Approving Authority
z�w 8-5-08
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP.The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 1567 Race Ln
Property Address
Premiere Asset Services
Owner Owner's Name
information is required for Marstons Mills MA 02648 8-5-08
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.) l
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:
r
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
t5insp•03/08 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
1567 Race Ln
Property Address
Premiere Asset Services
Owner Owner's Name
information is required for Marstons Mills MA 02648 8-5-08
every page. City/Town 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.
t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
40 1567 Race Ln
Property Address
Premiere Asset Services
Owner Owner's Name
information is required for Marstons Mills MA 02648 8-5-08
every page. City/Town 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
El Discharge or ponding of effluent to the surface of the ground or surface waters
® due to an overloaded or clogged SAS or cesspool
® ElStatic 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.
t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 1567 Race Ln
Property Address
Premiere Asset Services
Owner Owner's Name
information is required for Marstons Mills MA 02648 8-5-08
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No - r `
❑ ® 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"non 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.
w
t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 1567 Race Ln
Property Address
Premiere Asset Services
Owner Owner's Name
information is required for Marstons Mills MA 02648 8-5-08
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 CM 15.302(5)]
t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 1567 Race Ln
Property Address
Premiere Asset Services
Owner Owner's Name
information is required for Marstons Mills MA 02648 8-5-08
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
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): 330
Number of current residents: 0
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: 6-08
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CM 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):
t5insp-03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
u v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 1567 Race Ln
Property Address
Premiere Asset Services
Owner Owner's Name
information is required for Marstons Mills MA 02648 8-5-08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information:
N/A
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):
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
t5insp•03/08 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 1567 Race Ln
Property Address
Premiere Asset Services
Owner Owner's Name
information is required for Marstons Mills MA 02648 8-5-08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 24
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.):
Good condition.
Septic Tank(locate on site plan):
Depth below grade: 16"feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
--------------------------------------------------------------------------------------------------------------------------
Dimensions: 1000 gal
Sludge depth:
15"
Distance from top of sludge to bottom of outlet tee or baffle, 17"
Scum thickness
6"
5"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle 13
How were dimensions determined? Tape
t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1567 Race Ln
Property Address
Premiere Asset Services
Owner Owner's Name
information is required for Marstons Mills MA 02648 8-5-08
every page. City/Town 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.):
Tank in good condition with baffles installed. Recommended pumping for solids.
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
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 grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary ryAssessments
1567 Race Ln
Property Address
Premiere Asset Services
Owner Owner's Name
information is required for Marstons Mills MA 02648 8-5-08
every page. City[Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank(cont.)
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in worldng 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
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
2"
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Box in good condition with stains above outlet invert.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1567 Race Ln
Property Address
Premiere Asset Services
Owner Owner's Name
information is required for Marstons Mills MA 02648 8-5-08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number:
❑ 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.):
Leach pit had clear signs of failure with stains above the inlet invert.
t5insp•03/08. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 P Y rY
`wM 1567 Race Ln
Property Address
Premiere Asset Services
Owner Owner's Name
information is required for Marstons Mills MA 02648 8-5-08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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
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.):
t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1567 Race Ln
Property Address
Premiere Asset Services
Owner Owner's Name
information is required for Marstons Mills MA 02648 8-5-08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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 wafter supply enters the building.
�?G G
< qV
t5insp•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1567 Race Ln
Property Address
Premiere Asset Services
Owner Owner's Name
information is required for Marstons Mills MA 02648 8-5-08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
Check cellar
❑ Shallow wells
Estimated depth to high ground water: 20'+
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health -explain:
® Checked with local excavators, installers- (attach documentation)
® Accessed USGS database- explain:
You must describe how you established the high ground water elevation:
Original design plans show no water at12'.
t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15
. . Town of Barnstable
�F THE T�
P� Regulatory Services
saxxsrnsie Thomas F. Geiler,Director
�$ MASS.
63 S. ,�$
A,Ep39�A Public Health Division
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS
DISCLAIMER
This septic system inspection report was completed by a private inspector who is certified by
the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original or copy of the report;
this Division does not warranty the functionality of the septic system in the future nor does
this Division agree with any technical observations and interpretations contained within this
report.
In addition, by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual number
of bedrooms approved at a particular property would be listed on the "Disposal Works
Construction Permit".
If you should have any questions regarding this roport, please contact the certified Septic
System Inspector who conducted the inspection.
QASEPTIC\Disclaimer Private Septic lnspections.DOC
n2`�
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
[ R
DEC 2 2003
L
N OF BARNSTABLE
TITLE 5 HEALTH DEPT.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: MAP
Owner's Name: PARCEL '
Owner's Addr �i-0- LOT
Date of Inspection:
'-�` I D
Name of Inspector• please print , COW
Company Name F76 .
Mailing Address: ��� 0 12003
L TOWN O t�A^iNS'rABLE
Telephone Number: `7'71. HEALTH DEPT.
CERTIFICATION STATEMENT.
1 certify that I have personally inspected the sewage disposal system at this address and that the information rtported
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 ection 15.340 of Title 5(310 CMR 15.000). The system:
Passes ,
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
ails
Inspector's Signature: '-- Date: 7 c/3
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will.perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page I
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 7
Owner:
Date of spection:
Inspection.Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
JI have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in,31 Q CIAR 15.304 exist.Any failure criteria not-evaluated-are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system, upon completion of the replacement or repair;as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a_complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with.
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is.leveled or.replaced
ND explain:
The system required pumping more than'4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):.
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 1'1
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: t
Owner:
Date of ection: o�U�
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the
system is not functioning in a manner which.will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100,feet but 50 feet or more from a
private water supply well**.Method used to determine distance
**This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A-copy of the analysis must be attached to this form.
3. Other:
3
Y
Page 4 of 11
OFFICIAL,INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner:
Date of pection:
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes N
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
J clogged SAS or cesspool
_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
/ cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/Z day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed.pipe(s).Number
/ of times pumped
i° 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 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.]
(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large'system the system must serve a facility with a'design flow of 10,000 gpd to.15,000
gpd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
� 4
r
Page 5 of.I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE'DISPOSAL SYSTEM INSPECTION'FORM
CHECKLIST
Property Address: -- wa'e--e liha'
Owner:
Date o spection: ap
3
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
Pumping.inforina'tion.was'provided by the owner, occupant,or.Board of Health
(�Were.any of the system components pumped out in the previous two weeks
Has the system received normal flows in the previous two week period?
f/ Have large.volumes of water been introduced to the system recently or as part of this inspection?
V Were as built plans of the system obtained and examined?(If they were not available note as N/A)
c/ 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?
V _ 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?
r/ 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:
Ye no
Existing information. =or 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)]
5
Page of l l
OFFICIAL INSPECTION•FORM_NOT FOR VOLUNTARY°ASSESSMENTS
SUBSURFACE SEWAGE`DISPOSAL SYSTEM INSPECTION.FORM
PART C
SYSTEM INFORMATION
Property Address:
Own '
Date nspection ZZQ
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 11:0 gpd x# of bedrooms):
Number of current residents: 0 d
Does residence,have.a garbage grinder(yes or no):
Is laundry on a separate sewage system'(yes or no �.[if yes separate inspection required]
Laundry system inspected(yes or noW�
Seasonal use: (yes or no):,�JQ ..
Water meter readings, if available(last 2 years usage(gpd)): 02- 7y&eo 0/ J�,,j®0, P
Sump pump(yes or no):
i Last date of occupancy:
COMMERCIAL/INDUSTRIAL
Type of establishment:.
Design flow(based on 310 CMR_15.203): gpd '
Basis of design flow(seats✓persons/s(ift,eic.): . .. „
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Tittle 5 system (yes or no):_
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:_
Was system.pumped as part of the in pection(yes no):
� _
: I,fyes,volume pumped: `gallons--How was quantity'puinped determined? `
'Reason Torpumping:
TYP T SYSTEM
rsSeptic tank, distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
Privy
_Shared system(yes or no)(if yes, attach previous inspection records, if any)
_Innovative/Alternative technology.Attach.a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy'of the DEP,approval
_Other`(describe):
roxii,ate age of all co ,po nts, ate 'nstal d if nown)an sourc f information:
Were sewage o r do s detected when arriving.
bat the site Yes'or no :
)
6
Page 7 of I 1
` OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: `7 `
Owner:
Date of I ection: ';)00 3
BUILDING SEWER(locate on site plan) A"
Depth below grade:
Materials of construction:_cast iron _40 PVC_other(explain):
Distance from private water supply well or suction liner
Comments(on condition of joints, venting, evidence of leakage, etc.):
SEPTIC TANK: locate o plan) Q�
�
grade:
below •
Depth l• /" go -
P �
Material of construction:_ oncrete_meta]_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: •S ` k 69' yc
Sludge depth: =
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: y ��
Distance from bottom of scum to bottom 9f outlet tee or baffle'
How were dimensions determined:
Comments (on pumping recommeriMations, Inlet and outlet tee or baffle condition,structural integrity, liquid levels
related to outlet invert vidgilce of leakage, etc.):
�.
3"
GREASE TR�: c'ate on site plan) 1
Depth below grade:_
Material of construction:_concrete_metal_fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping.
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Propert Address: 7
Owner: r
Date o spection: c;Qj Q00 3
TIGHT or HOLDING TAN<K;/ (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 outlevinvert:,
Comments(note if box is level and distribution to outlets equal,'any evidence of solids carryover, any evidence of
, �,e into,or ut o bqx et
14dOf
PUMP CHAMBER:/(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.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: S p /1j
d�
Owner:
Date of n ection: .,'-)do3
SOIL ABSORPTION SYSTEM (SAS): ,ram (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching,pits,number:
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 pondinb, damp soil;condition of vegetation,
/0(" ig';6 4-ez'�
CESSPOOLS: cesspool must be pumped as part of inspect ion)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.):
PRIVY pr(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.):
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:
Owner:
Date of spection: 0Qi Q0613
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
1
On
l0dD
10
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: e
Owner:
Date of section:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 2? feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators, installers-(attach documentation)
—/Accessed USGS database-explain:
You must describe how you established the high ground water elevation-.A o
/`>o a. s
11
Permit Numbe.1-
� / Date:
Completed by. -- �1'ci�[
HIGH GROUND-WATER LIEVEL COMPUTATION
Site Location: 15 ,17
C�
Lot No.
:Owner: �1jVj B'� - Address:
Contractor: /?` ' Address: 5 C
Notes.-
STEP 1 Measure depth to water table
to nearest 1!1 G . ......... /
Date /�z )F
month/day/Year
STEP 2 Using Water-Level Range Zone
and,lndex Weli'fPap locate l
site and determine:
A Appropr,ate index
O Water-level ranae zone ......_..
i
STEP 3 Using monthly report "Curent
Water Resources conditions" I
determine Curren-depth to
water level-for index well .......::.... /��0� ' V J• / i
i'
- month/year
STEP 4 Using Table of plater-level Ad* Istments
for index well (STEP 2A), cun:ent depth I
i
to water level for Index.well ('STEP 3)., i
'and water-level,zo-ie (STEP 213)
determine wafer-level adjcrstment .......,. —1
S bP b • Estimate depth to high water
by subtracting the water-
Ievel adiastment (ST EP 4)
f rom"me.asured'deFth to water
level at site (STEP 1) ......__.._
Figure 11--Reproducible conIpuiuiiori form.
15
,ill.,gr'i
/21mi<
BORTOLOTTI . CONSTRUCTION, INC.
SUBSURFACE STAGE DISPOSAL SYSTEM INSPECTION FORM
Address Of.Property . � (�1� /)S M/A,
Owner's Name 10 �Xe
Date Of Inspection
QCC��O�D
PART A J U N 9 1995
3-ST HEALTH DEPT.
Ilf TOWN OF BARNBTABLE
aYeck if the following have been done:
(/ Pumping information was requested of the owner, occupant, and Board of Health.
�ne of..the system. components have been pumped for at least two weeks and the
system has been receiving normal flow rates during that period. Large columes
of water.have'not been introduced into the system recently or as part of this
inspection.
As-Built, plans have been obtained and examined, Note if they are not avail-
able with N/A.
_ The facility or dd lling was.inspected for sighs of sewage back-up.
1 _ ,/The site was. inspected for signs of breakout.
i
1% A11 systern components, excluding the SAS,, have been located on the site.
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,
'di.mensions, depth of.:.li quid, depth of sludge, depth of scum.
_ The size and location of the SAS on ,the site has been determined based on erist-
ing. information or approximated by non-intrusive methods.
The facility owner ,(and occu
pants, if different from owner) were provided with
i nfoiriation on the proper 'maintenance of SSDS.
A.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLAW OONDITICNS
If residential
number of bedrooms
�- number of current residents
garbage grinder; yes or no
/G� laundry connected to system, yes or no
seasonal use, ryes or no
If nonresidential. r 1cilla<*ed flow-
Water meter readings, if available: N/,d
Last date of occupancy
G'ETIE RAL INFORMATION
Pumping records and source of information:
_
System pumped as t of inspection,Pam' yes or no
if yes,' volume pumped
Reason for pumping:
Type oo� system
tic tank/distribution box/soil absorption' system
Single cesspool
Overflow cesspool
Privy
Sharedtisystem (yes or no) (if yes, attach previous inspection records,
` if any)
Other (explain)
Approximate age of all components. Date installed, if kno
informati n: wn. Source of
IYO011)
/vv_ Sewage odors detected when arriving at the site, yes or no
_ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM I NFC RMATION CONTINUED
TI'INUED
SEPTIC TANK:_
(locate on site plan)
depth below grade: .l
material of construction: L,----concrete metal FRP other(explain
dimensions• `� S G,r S�,/ X6/f --
& sludge depth ------ -
3 z distance from top of sludge to bottom of outlet tee or baffle
y 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
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,
depth of;.liquid level in relation to outlet invert, structural integrity,
ev'dence;of .leakage, recommendations for repairs, etc. )
UISIRIBUi ION :BOX: ..1/ --
(locate on site plan)
- ve. depth of liquid level above outlet invert
Comments:
(note if, level and distribution is equal, evidence of solids carryover, evidence
of .leakage into or o t of box, recommendation fro repairs, tc. )
PUMP CHAMBER: CJ ---
(locate on site plan)
Pumps .in working order, yes or no
Comments
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs, etc. )
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSEDC'PION FORM
PART B
SYSTEM I U)M4ATICN OaTnNUED
SOIL ABSORPTICN SYSTEM (SAS) :
(locate on site plan, if possible; excavation not required, but may be
approximated by non-intrusive methods)
If not determined to be present, explain:
Type -
leaching pits and number �.
leaching chambers and number
leaching :galleries and number
leaching: ,trenches, number, length
leaching:. fields,. number, dimensions
overflow-cesspool, number
C omients:
(note, condition of soil, signs of hydraulic failure, level of ponding,
condition.of.vegetation, recommendations for maintenance or repairs, etc. )
CESSPOOLS :{Locate on site plan) :/U6 v
number and configuration
depth:taP of liquid to inlet invert
depth of:solds layer
depth of .sctm:-layer
dimensions of cesspool
materials. of construction
indication,of groundwater
inflow. (cesspool must be pumped as
part.of inspection)
Ccmnents:
('rote condition of soil, signs of hydraulic failure, level of
condition. of vegetation, recommendations for maintenance or rending,
pairs, 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, recommendations for maintenance or repairs, etc. )
A
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFO 2MATICN CONTINUED
D
SKETCH OF SEWAGE DISPOSAL SYSTEM;
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
--------------
,i
L-",
i
b
DEPTH T GROUNDWATER
3O ! depth to groundwater
method ofdetermination or approximation:
}
i }R
y • c
+S
SUBSURFACE .SEWAGE:DISPOSAL.SYSTEM INSPECTION FORM
PART 'C
FAILURE,CRITERIA
Indicate yes, no, or not determined (Y, N, or ND ). Describe basis of
determination in all instances.. If "not determined", explain why not.
t Backup of sewage into facility?
w Discharge or pondin of effluent to the su
rface urface of the ground or
surface waters?
/V Static liquid level in the districution box above outlet invert?
Liquid depth in cesspool, 6" below .invert or available volume, 112 day
flow?
i Requ red pumping 4 times or more in the last year?
number of times pumped
Septic tank is metal? cracked? structurally unsound. substantial
infiltration? substantial exfiltration? tank failure imminent?
Is any portion of the SAS, cesspool or privy,
below, the high groundwater elevation?
Within 50 feet of a surface water?
A. Within 100 feet of a surface water supply or tributary to a surface
water supply?
Within a Zone I of a public well?
Within 50 feet of a private water supply well?
Within 50. feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, riet the SAS)?
/V 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, amonia nitrogen
and nitrate nitrogen,
-- —= -
M39WACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
Name of Inspector: Ul "v—
Company Name
Company Address .
Certification Statement
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true, accurate and
complete as of ','--he time of inspection. The inspection was performed and
&^-s' .-�*ga3' ng upgrade, friiz�i.;"C;enance azd .r_q�'it are
consistent with W training and experience in the proper function and
maintenance of on-site sewage disposal systems.
Check e: 'I
I have not. found any information which indicates that the system fails
to adequately protect public health or the environment as defined in
310 d4z 15.303. Any failure criteria not evaluated are as stated in
the FAIIME .CRITERIA section of this form.
I have determined that the system fails to protect public health and
the environment as. defined in 310 CMR 15.303. The basis for this
detelZClillimatiOn .s provided in the FAILURE cRITERIA SeCtion of this
form.
Inspector's Signature -
f
Date
Original to System Owner
Copies to:
Buyer (If applicable)
Approving authority
w Bedroom a
A d Beroom
_ o
Smoke
Detector
Smoke
Detector
co SmokelCo
Bathroom Stairwell
�
Detector
Bathroom
-T 6"-
-T-
-10'6"-
Dining Living
o�
Wood
Deck
N
J
O)
Kitchen
Open
Porch
Garage
W
01
1567 Race Ln
Marstons Mills MA
02648
First floor layout -22'-
-10'6"- -12'6"-
o Bedroom
N
F..
W
Smoke
Detector
Closet/Office
Smoke/CO
0o detector
Stairwell
Bathroom
w
-8'-
New fram Unfinished
ing
Basement
1567 Race Ln Marstons Mills MA 02648
Finished Basement layout
1 r
,r
. ..._.,x.. .. 571 .1
p
IT
it
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t1 fY�•C»fJ4s� 4.1J GRYY/'x^'E Vd��6r�1'�/�Y
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F E > ALL PIPES TOX
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/ ,� B. Crc r wLr v cl -FREE
_ ! + Y
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,
_ r-
'd- _ S�l/✓f-'.ANG' F�i�e:9l/4�'I- `h1AYlNC.4 PERCC7,�" ION-
T PIS' I�, 5 Y Tf I T �N R,47W Or Z WINareS P41f INCH 4 1
4 �� _ .
.. � Ess
��o ►.u.�. �►� �>��� ,var 7`0 C��,E T�'}�I G'�',L �C.,EAC�/�ilG P/T � �% o�' ,�tEAk rt� r�sr
�3
NO �l LI7 N OX :4Nt�l �G,4l. B� N JTIF/ 'Ii' t�YflEN TJff YSTE / -/V r� STD'/9 to B NOT TD SCgGF , .vim E,41?:
tl,4T PI7`
���E� /�1�1 S ��rrvFo�CE•c� S�r�7Rr� r,�Nx �} co.�rP�rET`aN.4Nv PR1o� r�AActFf4�.InIG.
- T YPICAI,/0o 0 ,44 SEPTIC TANK
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