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HomeMy WebLinkAbout1645 RACE LANE - Health 1645"Race Lane, Marstons_Mills A= O'4/7 0/0 �N I r c� Commonwealth of Massachusetts" 004 i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Race Lane L Property Address Michael Buckholz Owner Owner's Name information is Marstons Mills MA 02648 12/22/2020 required for every page. Cityrrown State Zip Code Date of Inspection,. Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information 61 4t- 15 013-- on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. 52 Rivers End Road red Company Address Teaticket Ma. 02536 City/Town State Zip Code 508-280-3356 S13938 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 CMR 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 i 12/23/2020 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 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 c Commonwealth of Massachusetts p Title 5 Official Inspection Form (� i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,(Y e / 1645 Race Lane v Property Address Michael Buckholz Owner Owner's Name information is required for every Marstons Mills MA 02648 12/22/2020 page. City/Town 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: ® 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. This 3 bedroom home has an H-10 1000 gallon septic tank with an H-10 D-Box feeding a precast leaching pit with apx. 2' of stone. At the time of the inspection no visible failure criteria was found. 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 ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �n 1645 Race Lane L., Property Address Michael Buckholz Owner Owner's Name information is required for every Marstons Mills MA 02648 12/22/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 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: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1645 Race Lane L Property Address Michael Buckholz Owner Owner's Name information is required for every Marstons Mills MA 02648 12/22/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool 99 P ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e / 1645 Race Lane Property Address Michael Buckholz Owner Owner's Name information is required for every Marstons Mills MA 02648 12/22/2020 page. City/Town State Zip Code Date of Inspection 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 cesspool is less than 6" below invert or available volume is less than 'h 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. ❑ ® 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. ❑ M 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 2000 gpd- 10,000 gpd. ❑ ® 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. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 c Commonwealth of Massachusetts - Title 5 Official Inspection Form 1' i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Race Lane v Property Address Michael Buckholz Owner Owner's Name information is required for every Marstons Mills MA 02648 12/22/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 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 CA 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 ® El 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 I c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1645 Race Lane v Property Address Michael Buckholz Owner Owner's Name information is required for every Marstons Mills MA 02648 12/22/2020 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): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 plus GPD Description: Number f current residents: 2 o cu 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): town water Detail In 2020-40,000 gallons were used and in 2019 - 18,000 gallons were used. Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form nl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1645 Race Lane Property Address Michael Buckholz Owner Owner's Name information is required for every Marstons Mills MA 02648 12/22/2020 page. City/Town 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/sq.ft., 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: 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form (- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1645 Race Lane v Property Address Michael Buckholz Owner Owner's Name information is required for every Marstons Mills MA 02648 12/22/2020 page. Cityrrown 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: Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 22"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: town water feet Comments (on condition of joints, venting, evidence of leakage, etc.): Water was flushed and came freely. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Race Lane Property Address Michael Buckholz Owner Owner's Name information is required for every Marstons Mills MA 02648 12/22/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 14"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: H-10 1000 gallon Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle 35" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? 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.): I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of inspection the liquid level was at working level and the baffle was in place. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Race Lane Property Address Michael Buckholz Owner Owner's Name information is required for every Marstons Mills MA 02648 12/22/2020 page. Cityrrown 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.): I 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 t5insp.doc•rev.'712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Race Lane Property Address Michael Buckholz Owner Owner's Name information is required for every Marstons Mills MA 02648 12/22/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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 ligWd level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At the time of the inspection the liquid level was at working level and there were no visible signs of leakage or solids carryover. t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1645 Race Lane Property Address Michael Buckholz Owner Owner's Name information is required for every Marstons Mills MA 02648 12/22/2020 page. City/Town 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: One ❑ 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments >r 1645 Race Lane Property Address Michael Buckholz Owner Owner's Name information is required for every Marstons Mills MA 02648 12/22/2020 page. Cityrrown 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.): At the time of the inspection no visible failure criteria was found. 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 layer Depth of scu n la P Y 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1645 Race Lane Property Address Michael Buckholz Owner Owner's Name information is required for every Marstons Mills MA 02648 12/22/2020 page. Citylrown 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts 1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1645 Race Lane Property Address Michael Buckholz Owner Owner's Name information is required for every Marstons Mills MA 02648 12/22/2020 page. Cityrrown 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 A B 1 15'6" 297' (D A s n) 2 19'3" 27'6" 3 35' 29'8" 0 3 4 47' 31'2 4 " t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 1645 Race Lane Property Address Michael Buckholz Owner Owner's Name information is required for every Marstons Mills MA 02648 12/22/2020 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® h C eck Shope ® Surface water ® Check cellar ® Shallow wells j Estimated depth to high ground water: 14 plus feetfeet Please indicate all methods used to determine the high ground water elevation: i ❑ 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: I augered a hole at a lower elevation and shot it with a transit to show 4 plus feet of separation Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 t Commonwealth of Massachusetts Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1645 Race Lane Property Address Michael Buckholz Owner Owner's Name information is required for every Marstons Mills MA 02648 12/22/2020 page. City/Town 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 f � TOWN OF B.ARNSTABLE LOCATION L 6 � SEWAG # (� �(s VILLAGE / ' ASSESSOR'S MAP & I INSTALLER'S NAME & PHONE NO. A r ( - qZ8 7 2 7- ,- ),SEPTIC TANK CAPACITY JMQQc . LEACHING FACILITY:(type) (sue) add Z� -j , NO. OF BEDROOMS _PRIVAT WELL OR PUBLIC WATER jAg L t BUILDER OR OWNER A—A4, k� DATE PERMIT ISSUED: DATE .COMPLIANCE ISSUED: `a 7 7 VARIANCE GRANTED: Yes No ,' ,� �' a �-- � Z '� �, f a. y�f 4 + � _^��, v ,( t N � ��i l �( y- ;7 �' C 1 THE COMMON`VEALTH OF MASSACHUSETTS r BOARb OF HEALTH OF............................ ........ 0 ApplirFation for M-sp sal o nnitrnrtiun anti# Application is hereby made for a Permit to Const ct ( ) or Repair ( ) an Individual Sewage Disposal System at: ----•--••----•------�----------- ---------------•--........... .-..:.---•------------...---••---•-----------•--------......-------------•---..-.-----------•--- (P"tLf:Wow G v G® ti n-Address C a�s O -� or Lot No. ................._.., ........ d... ....---...------......✓..�.. 1C. ............................................................................................... Owne. Address ----....._.....:'.�d_.& .,r ..... ---•- •-----------•---- ........ .......................................•......................................................•... Installer Address UType of Building 3 Size Lot...- AjA---7.0...Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (/14 pa-, Other—Type of Building ............................ No. of persons.......M................ Showers ( ) — Cafeteria ( ) Q' Other fixtures .­ ........... W Design Flow............... . .J..1.........gallons per person pier day. Total daily flow...........�a_�___0_..................gallons. R; Septic Tank—Liquid capacity...J.Pgggallons Length___••........ Width.... ..._...-- Diameter................_Depth_._`'_t........ Disposal Trench—No. .................... Width.................... Total Length__..........._...._i Total leaching area___ _-___•_-•--:--sq. ft. Seepage Pit No.-__-.---0......_... Diameter.........6_.__..... Depth below inlet.........b--- Total leaching area_2 J......sq. ft. z Other Distribution box ( ) Dosing tank ( ) P '~ Percolation Test Results Performed by............. n __....i�rsfk.!....._....._... Date___-- �u )_ �i_ a ----- ,� Test Pit No. 1..L_k.....minutes per inch Depth of Test Pit.................... Depth to ground water........................ f= Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ x Description of Soil:----:------r'z--. ................. ^+� .w.w►5_... ') .............. U �( W x ---------------------------------------------------------------•----------------•------- U Nature of Repairs or Alterations—Answer when applicable_.._j,P ___ :� j %!'►' --------------•---_-.._------------•_-_----•-•-___. ------------•----------------------------------------------•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of 1 p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has�iissueldl the boardof health. igned _ r-..... ................. to Date ApplicationApproved By.....................-----•• --•---.......--•-•----....--•••-------•. .........................................Date Application Disapproved for the following reasons---------------••----------------•----------------------------•-----------------------------------------•-•••••- ••------....•••.--••----....---•••---------•........................•••••---- Date PermitNo......................................................... Issued........................................................ Date - Massachusetts Water-Resource;Commission/Division of Water Resources WATER WELL COMPLETION REPORT r - WELL LOCATI Address /— f�'T7-,c— �^ City/Town 1"G&Y"4-yy1 S G.S.Quadrangle Map Grid Location Owner ,5E Address`. 6 �6,5 O 3 n r WELL USE CONSOLIDATED WELL ic Public ❑ Industrial❑ Type of Water-bearing Rock n t �It ice..► Water-bearing Zones METHOD DRILLED 1) From To Rotary(type) �'77J_��e—Cable ❑ 2) From To Other 3) From To 41 From To CASING Depth to Bedrock Length �� Diameter Type JO✓C UNCONSOLIDATED WELL STATIC WATER LEVEL Water-bearing Materials Feet below land surface �A I r Sand: fine❑ medium❑ coarse a Date measured / —9 Gravel: fine❑ medium❑ coarse❑ Screen: GRAVEL PACK WELL Slot#J[Q length 3 from ��® to_q 3—" Yes ❑ No Split Screen (or 2nd screen) WATER QUALITY TESTS MADE Slot# length from to Chemical IR Biological Depth To Bedrock PUMP TEST Drawdown feet after pumping. days hours at GPM. How measured Recovery feet after hours. LOG of FORMATIONS COMMENTS: (On well or water) Materials From To /u ii DRILLER 3 Firm Address \ City_ Registration perato s ignature Please print nll y 5M-2-76-129780 - No...... 6_!-7,i , . FEs.... j ...`.......... { i' TH -� O E C N1'ONW EALTH OF MASSACHUSETTS� ♦ i � � ,� � ETTS e! PbARD OF HEALTH ------------------ .------------..OF............ Appliration for U44pnsal Works Tonstrnrtion amit ' Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ................. ------------------------ ---•-------.---.....-•------•- --••-----------....-----................---...-... ---------------------- -•-----------......__. Locat n•Address _�• �...t3 i y i ! h varyv" C orLt No. • -... ...... •-•---- --•...............•........_.... : .•-•------------•-•......................_... .............•----•....-•-..........._..... Owner Address ►� -----------------•-----......................... ................................... -•--•-•---•----......•----......_..........•..................._..._ .......................... Installer Address d Type of Building Size Lot..�.�'�.._._...Z�Q----Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (IVo) Othez—T e of Building No. of persons ................. Showers a yP g ---------------------------- P - ( )--- Cafeteria.(...__). Otherfixtures ••---•-•-----------------=-----•-••-------------....--.----•••...-••--------••--•••••--...••-••-••--•-•--•-.....-•--- W Design Flow.............. ..........gallons per person per day. Total daily flow...........3t-u.......................gallons. WSeptic Tank—Liquid capacity.9!�g.gallons Length:............. Width---lb ......... Diameter............... Depth.._......._. x Disposal Trench—No..................... Width..................... Total Length...................e Total leaching area....................sq. ft. ` Seepage Pit No......... Diameter........6...._..... Depth below inlet..... F _._. Total leaching area. _6:l._....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) !! '-' Percolation Test Results Performed by------------ _�%`�' L.t?�<1......._Cn ' yt Date.... . .....u..l_ .. - Test Pit No. 1..4,A......minutes per inch Depth of Test Pit...................: Depth to ground water..................... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water................._....... --•-•••-••- ............................................. O Description of Soil........... '"�^°!?.. + ...................................... -- -- - x -----•-•-----•---••-•••-•---•-•••...... t � V '� y W ✓'� m txj Nature of Repairs or Alterations—Answer when applicable ---------------------------------------•------------ -•--------•------------------------------------•----•------•••----------•-••--•••-••••••-••-••---• ...... Agreement: The undersigned,agrees to install the_afored_escribe_d Individual Sewage Disposal System in accordance with the provisions of tTR 1 i 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance/hasb',�n issued by the , a of health. Slgn .-•---------•---------------•--------•--------................................. �( ............ t � Da. ApplicationApproved By.............-.............Z...........-•----•---•-.........•-----•••.......................•-----. .....................=-------•---....._.. Date Application Disapproved for the following reasons:--- •---------•--•••----•-•----------------------------•---•----------------------------. •-••-••-----_..._ ...•-•--------------------------------------•-----....•------•-•---•••----------......------....------....---•-----------------------------••----•••------------•--------------------------------••.-••-- Date PermitNo................................................. Issued....................................................... Date N _ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF........... � .. ................................. �rrtifirtttr of Trrntpli atta TH'S IS.TO CERTIFY, That.the,Inciivid al Sewage Disposal System constructed Y) or Repaired ( } by---------------------------------------------------------•sue?.. Installer at........................C'-0 -•-•-•..-----•-------=,4,-[-. ---------.-v•-°---......----•--•sa.V-.Y_5 "---- 11��$� 5 'f ll A has been installed in accordance with the provisions of fiiTIE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector - .. �----•---------------•------ THE COMMONWEALTH OF MASSACHUSETTS r--- 3OAR ®F HEALTH ` N o....................: FEE...�.S............ i� �aaa Brkn Tnnotr yrfvt Permission is hereby granted.....__... .. .... to Construct (>I) or Repair ( ) an I111dividual Sewage Disposal System w�t . j V" atNo-_-----------_-- ----------........... --..__ ....---.......... ------•-------- ---.. -•-•--•...........=----•-••------------------------- Street t= _ as shown on the application for Disposal Works Construction Permit No...............` ..__ ated.. �_.�......................... �' I Board of Health DAT . --------•--•---•---------------•--••-..._..... FORM 125 HOBBS & WARREN. INC.. PUBLISHERSv 4 - __ 1 .*THET TOWN OF BARNSTABLE _. OFFICE OF BAH N"IL L = BOARD OF HEALTH .� Ml 00 039. e� 367 MAIN STREET HYANNIS, MASS. 02601 Sewage Permit # f,�� Applicant C�� AL- Proposed Installer: The plan for the on-site sewage disposal system at Z C!E e__n has been approved with the condition that the design engineer must be on-site and supervise installation as well as certify in writing that the system was installed in strict accordance to the approved plan. Approved By to -.-, ALA ul��g� R=714.?1 .. A=174.5 ,aC, �.1ELL ly _ I TS��Ti L f�N ` 5O1 N �oT 2 G8,�720 5 F� ro \ r V /� 6•Zc JOB # 85- 196A2 CERTIFIED PLOT PLAN LOCATION: RACE LANE MARSTONS MILLS PREPARED FOR: SCALE. 1=50 DATE.- 4111187 REFERENCE. LOT 2 PB 402 PG 41 JIM ENOS I HEREBY CERTIFY THAT THE BUILDINGS SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS SHOWN HEREON. BUILDINGS CONFORM TO SETBACK REQUIREMENTS �`n 0f yv OF THE TOWN WHEN CONSTRUCTED. ARNE �rs� OJALA � down cape engineering CIVIL ENGINEERS LAND SURVEYORS /1v ROUTE 6.A YARMOUTH MA DAT f REG. LAND S 'RVEYDR "TOWN OF B RNSTABLE r iON l Cg L SEWAGE# rILLAGEC M/GLS ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. fQabQCV p j� (�� � SEPTIC TANK CAPACITY loon LEACHING FACILITY: (type) - fJ'-- (size) l NO.OF BEDROOMS OWNER 1(A PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: AJ0 Cu p—/-X n Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Zo 7"7- Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Aiak,,,� Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) kjpt,,q Feet FURNISHED BY ' .< coc �� f F r Commonwealth of Massachusetts l - Title 5 Official Inspedtion Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 164.. Race Lane Property Address Garvey ,Mary& Hicks,.Janis Trust _....... _...... ....... __ ____. Owner Owner's Name information is Marstons Mills MA 02648 3 18 16 required for ever .w.. ........ .._..--- ....... page, Cttyfrown � ._. _..__ State. Zip Code Date,of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in an Way.Please:see completeness checklist at the end of the form.. Important:When filling out forms A. General Information : �1# t��93 t��tttturkitrrrrt� on the computer, SIN OF use only the tab 1, inspector; key to move your cursor-do not James D.Sears JAMES m use the return _.. __---_,__�.._._ ____.., ......, _., - key. Name of Inspector �, :c) Caewide Enterprises;'LLC__. Company Name _ �__. ✓, T h'7 tt�, � __ 153 Commercial Street ��, tttN s�'tic�o�O�, .. .. . . _.w.... _... ..... ...,_. ......11 _ Company Address rA Mashpee_ MA 02649__ ._ _.._.. .._._._.. ... .... ........ _.... _ ...:_._.._...._ Cityfrown State Zip Code 508-477 8877 S1623 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 .............: Zf............. .. . _...:w:_ .._. . _._ _ _....._ _ ............................... spector'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. t5ms-3143 Title 5 Official inspection form:Subsurface Sewage Disposal System•Page.1 of 17 Commonwealth of Massachusetts I � Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 164.5 Race Lane ........_w_— ...... . ................ Property Address. Garvey ,Mary & Hicks,Janis Trust Owner _. Owner's_Name information is Marstons Mills MA 02648 3-18-16 required for every _ - ............. _..... _. ...__ page. CitylTown State Zip Code Date of Inspection B. Certification (cont,) Inspection Summary: Check A,B,C,Q or E 1 always complete all of Section D A) System Passes: Z 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 B) System Conditionally Passes: ❑ One.or more system componentsas 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, riot 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-3113 Title 5 Official Inspection Form:Subsurface Sewaga Disposal.Systeirl•Page.2 of 17 Commonwealth .of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments _1645.Race Lane Property Address Garvey ,Mary & Hicks-Janis Owner ._..,.,_... _ ....a Owner's Name information is Marstons Mills MA 02648 3-18 16 required for evert _ _...__ _....... _ _ ....... _ page. City/Town State Zip Code bate of Inspection B. Certification (Cont.) ❑ Pump Chamber pumps/alarms not operational.;System will pass with Board of Health approval if pumps/alarms are repaired: B) System Conditionally Passes(cont) ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain:below): ❑ obstruction'is removed ❑ Y ❑ N ❑ ND (Explain below): ❑. distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): .......................... I . ..........._.............. _ .... __— ..._ ............ I __ ..... ............: _. __ ....._.. ❑ 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),- El broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (.Explain below): ❑ obstr.mtion;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, o"ordering vegetated wetland or;a-gait marsh t5ins•3113 Title 5 Official hspectaan Form'Subsurface Sewage Disposal System•Page of 17 Commonwealth of Massachusetts �� fz Title 5 Official Inspection Form ` Subsurface Sewage.Disposal System Form Not for Vol untary.Assessme,nts. 1645 Race Lane ___.. _.. __.._.... .....................................__. __,. ..._ _ _...... _.... _. ............. Property Address Garvey;Mary & Hicks,Janis Trust W Owner �__...— Owner's Name information is Marstons Mills MA 02648 3 18 16 required for every _. ...,, _..:__. .... _._._ ......._ page. City/Town State Zip Code Date of Inspection B. Certification (cant.) Z System will fail unless the Board of Health (anti 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 welly*. Method used to determine distance; **This'system passes if the well water analysis; performed at a DEP certified laboratory, for fecal conform 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 town overloaded or clogged SAS orcesspool 0 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Fj ® Liquid depth in is less than 6 below.irlvie or available volume is ess than "1a day.flow A 7`" t5ens-3/13 Title 5 Official.Inspection formr Subsurface;Sewage.Dispasal'System o Page4ot.17 Commonwealth of Massachusetts . Title 5 Official Inspection Form '� 1=+ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1645 Race Lane Property Address Garvey ;Mary&.Hicks Janis Trust Owner Owner's Name --- _......_. information is Marstons Mills MA_ 02648 3-18-16 required for 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. ❑ X Any portion of a cesspool or privy Is within a Zone 1 of a public well. ❑ Z Any portion of a cesspool or privy is within 50 feet of a private water supply well. E 0 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 DEF 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 faits.I have determined that one or more of the above failure criteria exist as described in 310 CMR 16,303, therefore the system faits. 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'15,006 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 El n 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 0 o the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—.IWPA) or a mapped Zone`ll 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 cir operator.of any large system considered a significant threat.under Section E or failed under Section D shall upgrade tte system in accordance with 310 CMR"15,304..The system owner should contact'.the appropriate regional office of the Department, t5 ns-3f1 3 Title 5 pfGcial Inspeciion Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments lw 1645 Race Lane .................... ..................... Property Address Garvey ,Mary &,Hicks, Janis Trust Owner ——------------------ 6w-r4FS--N—ame information is required for every Marstons Mills MA 02648 :3-18,-16 .. . .......... page. Cityrrown State* 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 Z El Pumping information Was provided by the owner, occupant; Or Board of Health Fj Z Were any ofthe system components pumped out in the previous two weeks? F1 0 Has the systeamireceived normal flows in the previous two week period? El Z 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) El 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? Z ❑ Were the sOp tic 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? El Was the facility Owner(and occupants if different from owner) provided with 0 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, 6 plan at the Board of Health. D Z Determined.in.the field (if any of the failure criteria (elated to Part C. is at issue ap-prokirnation of distance is unacceptable) [310 CMR 15.302(5)) D. System Information Residential Flow Conditions: Number of bedrooms(design)- 3 Number of bedrooms (,actual)- ........... DESIGN flow based on 310 CMR 15.203 (for example: 11 0.gpd k#of bedrooms): 330 ..........- 15ins-3113 Title 5 Official Inspection Farm'.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 1645 Race Lane ................ ................................................... ........................................ ......... .................................. Property Address _qarvey__,Ma.ry Hicks, Janis Trust ................................................................................ ............. Owner Owner's Name information is required for every Marstons Mills. MA 02648 3-18-16 ............... .......... page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal Tank D Box and pit.. ............... ................. ...................... ........................... ............... ................ .......... ............ Number of current residents: .......... Does residence have a garbage grinder? El Yes E No is laundry on a separate sewage system? (I I nclude laundry system inspection, ❑ Yes No information in this report.) Laundry system inspected? Yes No Seasonal use? F1 Yes 0 No 20144,000G.als Water meter readings, if available(last 2years usage (gpd)): 2_915-?,OOQGal's Detail: ........... ................ ....................... ................... ................... ...................... ................. .......... ............... ................... ................. ............ Sump pump? ❑ Yes No NA Last date of occupancy: ............................. Date Commercial/Industrial Flow Conditions:, Type of Establishment: ................... ................ Design flow(based on 310 MR 16,203)-: ............. Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): ................ Grease trap present? 0. Yes El No Iridustrial.waste holding:tank present? 0 Yes ❑ :No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, ifavailablo- . ........ .................. t5ins-3113 Title 5 Official Inspection Form:Subsuiface Sewage Disposal Sygern;Page 7 of 17 Commonwealth of Massachusetts �1 T ii @ Title 5 official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments : .1 -,� 1645 Race Lane Property Address Garvey;Mary & Hicks.Janis Trust _ _.._. . . ..._ .... ..___ _�_...._ _ _._._ Owner ..� Owner's Name information is Marstons Mills MA 02648 3-1.8-16. required for every .. ..._.._ _ _.._.__— page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last.date of occupaneyluse; .............. ... Date Other(describe below): General information Pumping Records: Source.of information: 2009!2011/2014 Was system pumped as part of the inspection? ❑. Yes..N No If yes, volume pumped: gallons How.was quantity pumped determined? ......____..._..-.. . ....... . _._ .. . _.._.......v . ... .... 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 an ❑ 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 l/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval ❑ Other(describe): t5ins•3113 Title 5:0f€dal InspeaMn Form;Subsurfne.Sewage Disposal System Page 8 of 17 Commonwealth of Massachusetts ^I Title 5 Official Inspection Form Aj Subsurface Sewage Disposal System Form-Not for Voluntary Assessments h . _. 1645 Race Lane Property Address - .Gar _& Hicks; Janis Trust Owner Owner'svey ,Mary_Name information is Marstons Mills MA 02648 3 18-16 required for every ..... ._..__ _ _.._......... _.._. .., —_,r_, .... ...-_ , _ ....... ........,_ ...................... — page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of-all components, date installed (if known) and source of information; 1986 Permit 86 - 1316'1201.6 New D Box. Were sewage odors detected when arriving at the:site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: F e30et " _ .....: ............................. ____ Material of.construction: ❑ cast iron . ®40 PVC ❑ -. _ _,_ .....__._........... other,(expiain): �-- 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. � _ _ .: .......... .__. _.... i Septic Tank(locate on site plat); - 18,. Depth below grade: __.__ _ ....m.. feet: Material of construction: M concrete F1 metal ❑fiberglass n polyethylene E other(explain ......_................._ .. .....w_ ......._. ,_.. ... _.._._ _._...._ .......... . .:__._ _................ I If tank is metal, list age: 4�__ ... ..........�......................� years Is`age confirmed by a Certificate.of Compliance? (attach a copy,of certificate) ❑ Yes [❑ No Dimensions: 1000 Gal Precast li 10 T Sludge depth: .............._ ........ t5hs•3t13 Title 5.01ficial lnspedion Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts r - Title 5 Official Inspection Form "m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .......... � 1645 Race Lane Property Address Garvey;Mary& Hicks; Janis Trust _....._— Owner Owner's Name information is Marstons Mills MA OX48 3 18 16' requiredfor every ......,___ .......:�. ,._.—... . .._ .._.,,�, .._.:_.._....�.. . ......_.__..__..: _�...._ ....._. _._. ....�.......___ page. City/Town State Zip code Date of Inspection D. System Information (cont): Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 28 oil Scum thickness 12" Distance:from top of scum to top of outlet tee or baffle -- 18' Distance:from bottom of scum to bottom of outlet teeor baffle ---- =—.................—------- ......._._...... _ Now were.dimensions determined? Asbuilt-Tape Sludge.4 dqe._. 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 and covers 18" below grade" Inlet tee, Out let baffle: No sign of leak ale or over loading; 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 15ins•3113 Tiitle 5 Official inspectian Form:Subsurface Sewage Dis0sal system Page 10 of 17 Commonwealth of Massachusetts Title 5 {official Inspection Form t i Subsurface Sewage Disposal System Form-Not for Vol untary.Assessments 1645 Race Lane �_ ._... —..........._ _..._.� ......_. —_ �: _.__ Property Address Garvey Mary&Nicks, Janis Trust Owner .._ _ Owners Name information is Marstons Mills MA; d2648 3 18-16 required for every _. ......_ �..__... —......... ........ page. Cityrrown State Zip Code Date of Inspection Q. 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: ..:. ....w....,...... _.._.. Capacity ;..�.,....... � ..._.__.._ . ..:M__..._.... gallons Design Flow: ._...._.. _._. ....... gallons per day Alarm present; ❑ Yes ❑ No Alarm level: ............. . Alarm in working order' , ❑ Yes ❑ No Date of last pumping: Date _ .... _ __W___-_. Comments (condition of alarm and float.switches,etc,): Attach copy of`current pumping.contract(required). Is copy attached? ❑ Yes ❑ No t5iris•3113 Title 5 Official Inweel on Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 1645 Race Lane Property Address Garvey Mary & Hicks, Janis Trust Owner Marstons Mills _.. MAN__. . _ 02 _ Owners Name information is required for every Marston _.__.;� _ 648,_ 3, 18 16 __..._ _._ . ... page. City/Town State Zip Code Date of Inspection: D. System Information (cont.) Distribution Box (if present must be opened)(locate on site plan), 0 Depth of liquid level above outlet invert . __........_.,,.. .__ _..............._.___ Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc:): D Box is 16"x'IT-2'.below grade w/one line out Box is new 2016 w/cover at 8'.' 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 oralarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required). If SAS not located, explain why: .. __. _........_.......... tSins 3113 Title 5 Official Inspection Form`SubswifaceSewap Disposal Systern Pape 12,6117 Commonwealth of Massachusetts x Title 5 Official inspection Form 1L; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s1 1645 Race Lane Property Address Garvey,Mary& Hicks; Janis Trust Owner _ ..: ...... Owner's Name information ie Marstons.Mills MA 02648 required-for every _.._.�.,:... .._..__...__.. __.._ __.._. ___... _.._...._. _. page. CityrTown State. Zip Code Date of Inspection D. System Information (cont) Type: ' 1 leaching pits number: ❑ leaching chambers number: __.__... ...... . ❑ leaching,galleries number: . .... ....._........ ._......... ❑ ieaching.trenches number, length: ❑ leaching fields number,.dimensions: - ---- - -- ❑ overflow cesspool number: ....................__.........._.........._.......... .._ ❑ innovativelalternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure; level of ponding, damp soil; condition of vegetation,etc.): Leaching is a 10WGal.Pecast pit w/2' stone.Pit at 34"below grade w/cover at 20", Pit dry w/stain line at 2'. no saga.of over loading or solid,carry over. No high stain line: 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`ofcesspool __...__... ......... Materials of construction ......__........ -- T_ Indication of groundwater'inflow ❑ Yes ❑ No t5ins-3113, Title 5 Ofc al Inspection Form:Subsurface Sew®ge.oisposa3 System+Page 13 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form -i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1645 Race lan...... _._. _........ :.. : — ,...... _.............. -- Property Address Garve_y_,Mary& Hicks, Janis.Trust Owner _._.. _ ........_,____ Owner's Name information is Marstons Mills MA, . 02648 3 18 16 required for every ....-;---- ..._ ..... .._....... .. .....-......... ...........— _.._._ _..__ .�. page. Cltyrrown State Zip Code Date of Inspection D. System Information (cant:) 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 soi),.signs of hydraulic failure,.level of ponding, condition of vegetation, t5ins•3/13 Title 5 official Inspeclion Form;Subsurface Sewage Disposal System•Page 14 of 17 I � ' Commonwealth of Massachusetts - Title 5 official Inspection Form ti Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments �a 1645 Race Lane Property Address Garvey ,Mary & Nicks, J is Trust _.. ......... __.., Owner _ Owner's Name information is required for every Marslons Mills MA 0264$ 3-1816 page. City/Town 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 7— i It A .r 17 K, t5ins 3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 15 of 17 Commonwealth of Massachusetts l Title 5 Official Inspection Form l Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . V 1645 Race Lade w ...................... ... ...-_-.......................__ —....._-_ _ — Property Address Garvey ,Mary &„Hicks,, Janis Trust Owner _ _ .. ...... _ ,.....� .<.......... ........._ �� _.v . Owner's Name information is required for every TMarstons Mills MA 02648 3-;18 16 .__ .. page. 6i own State Zip Code Date of Inspection D. System Information (cunt:) Site Exam: Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 0 Estimated depth t high ground water_ 14 _ .._.r _. 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 USES database=explain; You must describe how you established the high ground water elevation: Ck area:14'+ to no G W,, Bottom of„pit at'9' below rg ade, _-...................................... ....... ......_ Before filing this lnspection Report;please see Report Completeness Chedklist on next page. tans 3113 Tula 6 Official ins raction Form:Subsaface Swkage Disposal Systern•Page 16 or 17 I Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1645 Race Lane.... __ _...........__ . . Property Address Ga y ,Mary& Hicks, Janis Trust. _ .._..._ _..___._...�_._..... Owner ._ Owners Name ...__.__ information is Marstons Mills MA 02648 3 118-16 W required for every .�._ _._.— _..,_,__ _. ....... ....._.�...,._.. � .......�.__ ........ page. City/Town 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•3113 Title 5 Official inspection Form:Subsurfawe Sewage Disposal Systern•Page 1 T.of 17 r ` � s� No. !`"' O&S �� Fee �y�-.�/b THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pphtation for Misposal 6pstpm Construction Permit Application for a Permit to Construct( ) Repair(X Upgrade( ) Abandon( ) ❑Complete l�System 1XIndividual Components Location Address or Lot No. j(,4f5 Pis CA&_Jg MN, Owner's Name,Address,and Tel No. Assessor's Map/Parcel Q 47 Q/© ®Q C 1(04 r` MARS-COS Installer's Name,Address,and Tel. o. 5'Fg-4'27-997_I Designer's Name,Address,and Tel.No. f c L 17>✓ 0JZMP��S �PE.� N/A Type of Building: Dwelling No.of Bedrooms QD►�/-r Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) A)17 gpd Design flow provided /U�/4 gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank #A Type of S.A.S. AI A 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 Healt Si d Date 3-10 "mZ0(4 Application Approved by Date-&h,0170/ Application Disapproved Date for the following reasons Permit No. ��(� OC 3 Date Issued (� 6 No. 201 ^063 Fee . THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: L PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE,MASSACHUSETTS Yes 01pphtatioll for Vsposal 6pstem Construttion Permit Application for a Permit to Construct( ) Repair()o Upgrade( ) Abandon( ) ❑Complete System [Individual Components Location Address or Lot No. MI A Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Q 477 ,O 16 D6 a 1645 R&-=- y/ Installer's Name,Address,and Tel. o. 5'�-4-77_$$7-7 a Designer's Name,Address,and Tel.No. <Wcs L)t Ue Ems? N/� Type of Building: Y Dwelling No.of Bedrooms JAIA " Lot Size sq.ft. Garbage Grinder( ) Other Type of Building. No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) ° A)A= gpd Design flow provided_ 4 A gpd Plan Date Number of sheets Revision Date J Title Size of Septic Tank CIA Type of S.A.S. I Q j Description of Soil ,z �L Nature of Repairs or Alterations(Answer when applicable) 14 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. SigLi.ed Date 3-(Q -aZ0(4 Application Approved by Date p { Application Disapproved b Date for the following reasons 1 Permit No. ���[ ��'� 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 C�y�/b� �JU7PaL � `` at `b� [ A 25� MARSX:*6 ,11 IUI, has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit Noo& " dated p Installer GAPE-ty[bA UC Designer #bedrooms of- Approved design flow, /U gpd The issuance of this pe it shall not be construed as a guarantee that the system wil nctition as designed. Date 1 Li 7 Inspector / --------------------------------------------------------------------------------------------------------------------------------------- No. 7016 - C%3 Fee ::g 7 5 od THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Disposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair( �O Upgrade( ) Abandon( ) System located at I( �A �� ``M A7)Cj-0X1C jl,.( &-cs 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:Co truo((tion must be completed within three years of the date of this permit. Date 1 J/.�� fi Approved by AsBuilt Page 1 of 1 TOWN OF Z&STABLE LOCATION G SEWAGE# VILLAGESU C MILLS ASSESSOR'S MAP&PARCEL INSTALLERS NAME&�PHHOONE NO._-Q0 b Q V p .�„}�L�/OMJ � SEPTIC TANK CAPACITY LEACHING FACILITY:(type) Q t/E' (size) NO.OF BEDROOMS _ OWNER 1M PERMIT DATE: t COMPLIANCE DATE: Separation Distance Between the: �o01,177t7 Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility /,1—r Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) k)OU'E' Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Qoi,V Feet FURNISHED BY r {a 2- 33 ' o ` Y-�I) http://issgl2/intranet/propdata/prebuilt.aspx?mappar=047010004&seq=1 3/14/2016 F THE T°� Town of Barnstable 9�HARNSrABLE, t ; ,e� Board of Health ArFD N►e�A 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Susan G.Rask,R.S. FAX: 508-790-6304 Sumner Kaufman,MSPH Wayne Miller,M.D. October 18, 2004 Ms. Mary Garvey F 1645 Race Lane Marstons Mills, MA Dear Ms. Garvey, We received correspondence from Ms. Lee McConnell dated August 25, 2004 and laboratory test results which indicated that your private well contained"trace amounts " 0.61 ug/l of perchlorate. This level fell below the recommended limit of 1.0 ug/l and is not considered to be failed or contaminated at this time. During the public meeting of the Board of Health held on September 7, 2004,the Board voted to recommend that you test your well bi-annually in the future. At this time, the County laboratory is not EPA certified for the analysis of perchlorate; however they are planning to obtain the certifications in the near future. You may call Ms. Lee McConnell at the Barnstable County Department of Health and the Environment at(508) 375-6620 to discuss plans for conducting the recommended testing of your private well in the future. Sin rely, Wayn Miller, M.D. GarveyWell A atj/iS'�",i`o\ COMMONWEALTH OF MASSACHUSE TTS 1 v EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIR DEPARTMENT OF ENVIRONMENTAL PROTECTION y. r TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: ,�� �M _ Owner's N 1` i ��S Tocr S m rz Z Owner's Address: Q Vaj d la Date of Inspection: • � � S J Name of Inspector: 0 � Company Name: Mailing Address: Telephone Number: �So91 C qq �aSo CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal pystem 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 pursu�an�t to Section 15.340 of Title 5(310 CfvfR 15.000). The system: V Passes _Conditionally Passes. _Needs Further Evaluation by the Local Approving Authority. I ,.j _Fails 'Inspector's Signaturg; ' Date: (5 C; The system inspector shall submit a c6py 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 ~� f gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office)f the DEP.The original should be sent to the system owner and copies sent to the buyer;if applicable, and the approving i authority. Notes and Comments **'k*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. There is no guarantee or waranty of future such. performance and should not be interpreted as Title 5 Inspection Form 6/15/2000 Page l of 11 . riI f OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: i 4A ! Owner: ��wR� (� of Date of Inspection: y Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D �ASystem Passes: LL7--,I have not found any information which indicates that any of the failure criteria d or in CMR 15.304 exist.Any failure criteria not evaluated are indicated below. described in 310 CMR 15.303 Comments: B. System Conditionally Passes: One or mote 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 ND explain: distribution box is leveled or replaced 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 ND explain: obstruction is removed Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: �''� � 1 - f �A&j r- Owner: M A R Y Q R U'F y Date of Inspection: � ) I C. Further Evaluation is Required by the Boar 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. I. 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 I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 3 of 11 , - A OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: /�[I� A:�,C—f kw , , Owner: ��\�� G WOE- 1� Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No ZBackup 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. 41!!�I- tatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than %2 day flow equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Vy 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. y 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.] ti" (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 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered"yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: �o�� Rr)F- F- A ' Owner: Date of Inspection: Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes N zPumping information was provided by the owner, occupant,or Board of Health 4Were 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? —PA,—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 if the es 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: Lp� No_Existing information.For example,a plan at the Board of Health. _Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: IC V ,f�wCr Owner: ��Date of Inspection: R� G A Ku F `� RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):Number of current residents: / Does residence have a garbage grinder(yes or no):&P Is laundry on a separate sewage system(yes or no) [if yes separate inspection required] Laundry system inspected(yes or no):. FS' Seasonal use: (yes or no):_ 1u Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):_ Aj j Last date of occupancy:_ COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancyiuse: OTHER(describe): , GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): 00 If yes,volume pumped:----gallons--How was quantity pumped determined? Reason for pumping; ��— F SYSTEM Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank_Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arrivingat the site �© (yes or no): Page 6 of 11 OFFICIAL INSPE CTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 16cls� PRW "r, Ny Owner: 'Aft ���� Date of Inspection: BUILDING SEWER_(locate on site plan) Depth below grade: /6 Materials of construction•_cast iron_40 PVC—other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: (locate on site plan) Depth below grade:�� Y Material of construction:—concrete_metal_fiberglass—polyethylene=other(explain): If tank is metal list age:_Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) X k 6 Dunensions: � �r 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: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determine.: ;eQ,1 Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet inv^evidence of leakage,etc.): GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass polyethylene_other(explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Page 7 of 11 } t 1111i OFFICIAL INSPECTION FORM NOT FpR#VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C :j i i SYSTEM INFORMATIO,N(continued) operty Address: kl�u fi i P � Owner Nit,," Date of Inspection: ! i iI taCp � .4 � t�TIGHT or,HOLDING TANK: (tank must be pumped_ at ti a of i nspe tion)(locate on site plan ept}ibelow'grade / 4 M t ' r+ Material of construction: concrete_metal_fiberglass #polyethylene_other(explain): iIIY i• �. ��P��{`,Dtmens�oris: � 'Capacity:C allons Design Flow: 3Q allons/day Alarm present(yes or no):_____j2Q ' Alarm level: P Alarm in working order(yes or no): t t `Date of last pumping: i `}4 t, Comments(condition of alarm and float switches,etc.): 1 1 ! r DISTRIBUTION BOX:_(if present must be opened)(locate on site plan) }�4'Dep�th of liquid level above outlet invert: Comment,,(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of i G t: I i 4,leakage into or out of box,etc.): 0�2 l C.��„,��' � 6 i �� PUMP CHAMBER:—(locate on site plan) i } i Pumps in working order(yes or no): zl yF� Alafryms in working order(yes or no):_ t Comments- note condition of pump chamber,condition of pumps and appurtenances,etc.): i 1 1t j t '.,4 ¢ , ilk Page 8 of 11 t � M i OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: W1 �'&v I;Owner: G Lj 9P4�—'w Date of Inspection: '--1 .` I � ' O SOIL ABSORPTION SYSTEM(SAS):_(locate on site plan,excavation not required) If SAS located explain why: 7T ; leaching pits,number: Cs `� �1'0►� leaching chambers,number:_ leaching galleries,number:_ —leaching trenches,number, length:_ leaching fields,number, dimensions: _overflow cesspool,number: _innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): CESSPOOLS: (cesspool must be ptrnped 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: y 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: (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.): Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: C Owner: Date of Inspection: 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. 411 Cub 6y' Page 10 of 11 Y OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water_feet ti o w 4T 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: too �r f 1 Page 11 of 11 r S CERTIFICATE OF ANALYSIS Page: 1 �srirsN_Sti�i Barnstable County Health Laboratory Report Dated: 6/22/2004 Report Prepared For: Order No.: G0425433 Mary Garvey 1645 Race Lane Marstons Mills, MA 02648 Laboratory ID#: 0425433-01 Description: Water-Drinldng Water Sample#: 25433 Sampling Location 1645 Race Lane Marstons Mills MA Collected: 6/7/2004 Collected by: M Garvey 047-010-004 Received: 6/7/2004 I Test Parameters ITEM RESULT UNITS RL MCL Method# Tested LAB: IC Lab Perchlorate 0.61 J ug/L 1.0 0 EPA 314.0 6/14/2004 Routine +Ammonia ITEM RESULT UNITS RL MCL Method# Tested LAB: IC Lab Ammonia BRL mg/L 0.1 EPA 350.1 6/9/2004 Nitrates 4.6 r mg/L 0.1 10 EPA 300.0 6n12004 LAB: Metals Copper 0.1 mg/L 0.1 1.3 SM 3111B 6/14/2004 Iron BRL mg/L 0.1 0.3 SM 3111B 6/14/2004 Sodium 19 mg/L 1.0 20 SM 3111B 6/14/2004 LAB: Microbiology Total Coliform Absent P/A 0 Absent 307 6n12004 LAB: Physical Chemistry Conductance 170 umohs/cm 1 EPA 120.1 6n12004 pH 6.2 pH-units 0 EPA 150.1 6n12004 J means lower than the RL higher than the MDL(minimum detection limit). Sample has higher than average levels of Nitrates. Monitoring is recommended(2-3 times per year)to establish any upward trends. Approved By: ( Director) RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 n Commorwecilth of MOSSOChuSett8 John Grad Executive Office of ErMronmerdal Affairs D.E.P. Title V Septic Inspector 2119 Department of Te P.O. Box A0 aticket,MA 0253G • Environmental Protection (508) 564-6813 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 01 PART A AaCfu n 0 CERTIFICATION FLf = Q `�' 2 �, ►� Property Address: 1645 Race Lane Marstons Mills Address of Owner: 1991, (If ent) Enos; B Boo Date of Inspection:5119197 (Tj7�^6?gg x 650 Marstons Mills Ma.026 fPj �f Name of Inspector:John Graci N Company Name,Address and Telephone Number: e ` CERTIFICATION STATEMENTthat the I certify thatI have as of the time personally oi n pectionh The inspection was performed sposal system at this based on my t aining and fexperience n he belowproper function andaccurate and complete maintenance of on-site sewage disposal systems. The system: This Inspection Is based on criteha defined In Title V X Passes code 310 CMR 15.303.My findings are of how the system is _ Conditionally Passes performing at the time of the Inspection.My inspection does Needs F rh Evaluation By the Local Approving Authority septic system and arty of itsu omponenis useful Irfy of the Fails Date: 5119197 Inspector's Signature: in thirty(30)days of leting his The System Inspector f he systemllis ubmit a copy of this a shared system or inspection has a design flowto the Approving of 10 000 gpd orAgreat Authority the inspector and the systempownertshall submit thea report the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and he approving authority. INSPECTION SUMMARY: Check A,B,C,or D: A] SYSTEM PASSES: X I have not found any information which indicates that he system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If "not determined",explain why not.) _ The septic tank is metal, cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11115195) � One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 i 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1645 Race Lane Marstons MOTs Owner: Enos;Box 550 Marstons Mills Ma.02648 Date of Inspection:5119197 Sewage backup or breakout or high static water level observed in the distribution box is due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced _The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. ER LIER, IF APPROPRIATE) 2) SYSTEM WILL IM IS FUNCT ONING IIN A MANNER THAT PROTECL NLESS THE BOARD OF HEALTH(AND PUBLICTN HTE PUBL CPHEALTH AND SAF TY AN THE INES THAT HE SYSTEM ENVIRONMENT: _ The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and is within a Zone 1 of a public water supply well. _ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm. 3) OTHER Dj SYSTEM FAILS: _ I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged cesspool. SAS is in hydraulic failure. (revised 11115195) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) PropertyAddress' " Mills marstons Enos;sox 650 Ma stops Mills s Ma.02648 Own Date of Inspection:5119197 D] SYSTEM FAILS(continued) _ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. _ Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped _ Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. _ Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. _ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria: _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) shallThe owner or operator of any such system th the grounwatr re uirements of 314 CMR 5 00 a d 6.00. Please r consult the local regionalf office of l compliance i f the Department for further Information. program q (revised 11115195) 3 SUBSU RFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: En s;B ls Owner: Box 650 Marstons MillsMlll Ma.02648 Date of Inspection:5119197 Check if the following have been done: X Pumping information was requested of the owner,occupant,and Board of Health. X None of the system components have been pumped for at least two weeks and the and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. n1aAs built plans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the Interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. X The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. )were provided with information on the proper maintenance of Sub- X The facility owner(and occupants,if different from owner Surface Disposal System. (revised 11115195) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1645 Race Lane Marstons Mills Owner: Enos;sox 650 Marstons Mills Ma.02648 Date of Inspection:5119197 FLOW CONDITIONS RESIDENTIAL: Design flow:330 gallons Number of bedrooms: 3 Number of current residents: 2 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): Yes Water meter readings,if available: nia Last date of occupancy: n1a COMMERCIAL/INDUSTRIAL: Type of establishment: ola Design flow:0 gallons/day Grease trap present:(yes or no) No Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system: (yes or no) No Water meter readings,if available: n1a Last date of occupancy. n1a OTHER:(Describe) n1a Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System has not been pumped In the last year. System pumped as part of inspection: (yes or no)Yes If yes,volume pumped: 1000 gallons Reason for pumping: Maintenance. TYPE OF SYSTEM X Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records,if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source information: 1987 Sewage odors detected when arriving at the site: (yes or no) No (revised 11115195) 5 SUBSURFACE SEWAGE DISPORT CSYSTEM INSPECTION FORM SYSTEM INFORMATION(continued) Property Address: En" ons Mills sRBox 650 Ma s Lane u s Mills Me.02648 Owner: Date of Inspection: 5l19197 SEPTIC TANK: X (locate on site plan) Depth below grade: 15" Material of construction:X conereate_metal_FRP_other(explain) Dimensions: I-g'6"HT 7"W 4'10- Sludge depth:31— Distance from top of sludge to bottom of outlet tee or baffle: 24' scum thickness:5' Distance from top of scum to top of outlet tee or baffle:6' Distance form bottom of scum to bottom of outlet tee or baffle: 13" Comments: (recommendation for pumping,condition of inlet andf liquid level�n relation to outlet invert,structural integrity. outlet tees or baffles,depth o evidence of leakage,etc.) s stem every two years for maintenance Septic tank and an components are structurally sound.Recommend pumping y GREASE TRAP: (locate on site plan) Depth below grade:nla Material of construction: _concrete_metal_FRP_other(explain) Dimensions: Na Scum thickness:Na Distance from top of scum to top of outlet tee or baffle:Na Dislance from bottom of scum to bottom of outlet tee or baffle:nla Comments: recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) Na (revised 11115195) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1645 Race Lane Marstons Mills Owner: Enos;Box 650 Marstons Mills Me.02648 Date of Inspection:5119197 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: n1a Material of construction:_concrete_metal_FRP_other(explain) Dimensions: Na Capacity: n1a gallons Design flow: Na gallons/day Alarm level: n1a Comments: (condition of inlet tee,condition of alarm and float switches,etc.) Na DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert: Liquid level with bottom of pipe. Comments: (note if level and distribution is equal,evidence of solids carryover, evidence of leakage into or out of box etc.) D-box is structurally sound. PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) Na (revised 11115195) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1645 Race Lane Marstons Mills Owner: Enos;sox 650 Marstons Mills Ma.02648 Date of Inspection:5119197 SOIL ABSORPTION SYSTEM(SAS):x (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present, explain: nla Type: leaching pits,number: 1,000 Gallon leach pit leaching chambers,number:n1a leaching galleries,number: n1a leaching trenches,number,length: nla leaching fields,number, dimensions:n1a overflow cesspool,number:n1a Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) The overflow is structurally sound and functioning ro ert . CESSPOOLS: (locate on site plan) Number and configuration: n1a Depth-top of liquid to inlet invert: nla Depth of solids layer: n1a Depth of scum layer: n1a Dimensions of cesspool: n1a Materials of construction: n1a Indication of groundwater: n►a inflow(cesspool must be pumped as part of inspection) n1a Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) n1a PRIVY: (locate on site plan) Materials of construction: n1a Dimensions: nia Depth of solids: Na Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) n1a (revised 11115195) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1645 Race Lane Marstons Mills Owner: Enos;Box 65o Marstons Mills Ma.02648 Date of Inspection:5119197 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' Gw� t C o AAr DEPTH TO GROUNDWATER Depth to groundwater:12 feet method of determination or approximation: USGS Maps and Charts (revised 11/15195) 9 TOWN OF BARNSTABLE � ��yS LCCAT:ON � "Z (Z LA SEWAGEr7\ i VIL LACE i' t' `� �A, NlIkSASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. Wv cn,0 — SEPTIC TANK CAPACITY O LEACP.ING FACILITY:(t9Pe)`Q0-0 (Size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATE BUILDER OR OWNER i Lq­W'l( DATE PERMIT ISSUED: A' , DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No - r eo x .I 1 SECTION SEWAGE - - ___ _ �� �., �_ „�- - _ x_ . :.. , � ry Do ��I :SEPTIC TANK — 5 I —"D..BOX — I —LEACH TOP/OF F/D (MSL)• "2..OF t�8TO rh" r �J 'S pa'rti I WASHED STONE Olf H 5 IN• OUT• 1"u� ' L� II' IN+ OUT• IN• f,: - (o4,�Z 5, j 1SEPTIC QQQ51 c 31 —/ �. Co I ELEV. TANK ELEV. ELEV. �Tr O ELEV. 1 y .. �� S of^/� �vl ELEV. ELEV. Q I`' IV S J ( WASHED STONE 7' TEST HOLE LOG P-5�75 TEST BY I`•t t• �JC�C(J�1 l lJ•Or!'f: ) V w i { E,. ` WITNESS i ! � TEST DATE DESIGN ' —BEDROOM HOUSE T.H. 1 ^ T.H. # 2 __w ELEV. Co7�I ELEV. N, p NO r� U IL PERC RATE �MINAN. DISPOSER DISPOSER 24 &5701 FLOW RATE I IO (GAL./DAY)/ �' �-✓ 1 SEPTIC TANK �J3O 1�.$f Pau��.>• Yibc�iAc(�� M REQ'D SEPTIC TANK SIZE I Kt1�EtA.tJsKAS LEACH FACILITY g-I'�II�RIK SIDE WALL p I (��) >_ ]I, Z G/D. �•'i' CD BOTTOM 2 z v ( 10 )°R G/D. PRDCED El..>✓\I: C0�•(D�1 TOTAL 2& -O _, Z_Ct/D _ 1� ELL.11X.�T1O1J' • USE: OL LEACHING Pi n �Q ��I1 G' .R� WATER ENCOUNTERED �0, G�1�' D1��'�R X �01 6. P .;G... � &13Ig2GO�.W CIt rc,L� - NOTES: (UNLESS OTHERWISE NOTED) 1.DATUM(MSL):TAKEN-F M . ?ib:_a •1pUAORANGLE MAP 2.MUNICIPAL WATER -_AVAILABLE 3.PIPE PITCH:W"PER FOOT - 4.DESIGN LOADING FOR ALL PRECAST UNITS:AASHO• 4- 10 -44Lli 5.MIN.GROUND COVER OVER ALLSEWAGE FACILITIES:(1)FT. ` 6.PIPE JOINTS SHALL BE MADE WATERTIGHT 7.CONSTRUCTION DETAILSTO BE ACCORDANCE WITH COMM.OF MASS. STATE ENVIRONMENTAL CODE TITLES : •„ .1"i SITE PLAN $fl�lSPLm MKPR011061D t ow,pL1l.Ypt.1D.4>�bt�t��pp- ;n _ / LOCUS, K10 r' f� USED FOR PROPeAllzr Likis 4sAYMcr- ` - RE ENGINEER .. ARNE REF�_1' dovk wa ca a 'ea' LA PREPARED F Rr p 34 . - - -- 445 - - ,.,.BOARD- F ,...�.'_ _- ' O HEA H c'r g LAND S UR EYORS ..>,. EXISTING T...: i z. .CONTOURS w r - SCAL. -ROVED GATE .--•-_ MA�. ��. 1�M�I r, �:: ,:.. A�ly " Q