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HomeMy WebLinkAbout1740 RACE LANE - Health 1740 Race Lane Marstons.Mills... P --- --- --- ,` A =. 048 .003001 -- - t i i� f j o I, j i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1740 RACE LANE Property Address COELHO, MARCIO G&CRISTINA Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/28/2013 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information (� �r on the computer, use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection Company Name 74 Beldan Ln. Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmaii.com SI4522 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 5/28/2013 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****Thils 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. II t5ins•3/13 Title 5 Official VInspectionrm. urface Sewage Disposal/Ystam•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M , 1740 RACE LANE Property Address COELHO, MARCIO G &CRISTINA Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/28/2013 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The dwelling located at 1740 Race Lane Marstons Mills is served by a Title V septic system consisting of a 1500 gallon septic tank, distribution box and 5 Infiltrators. The system was found to be in roper working condition at the time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 1740 RACE LANE Property Address COELHO, MARCIO G&CRISTINA Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/28/2013 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection forth:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GM , 1740 RACE LANE Property Address COELHO, MARCIO G &CRISTINA Owner Owners Name information is required for every Marstons Mills Ma 02648 5/28/2013 page. Citylrown State Zip Code Date of Inspection B. Certification Cont. 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1740 RACE LANE Property Address COELHO, MARCIO G&CRISTINA Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/28/2013 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A co of the analysis p gg copy e a a ysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 1 0,000g pd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No the system is within 4❑ ❑ t 00 feet of a surface drinking water supply Y 9 pp Y ❑ ❑ 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M s 1740 RACE LANE Property Address COELHO, MARCIO G& CRISTINA Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/28/2013 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 342 gpd provided t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 1740 RACE LANE Property Address COELHO, MARCIO G &CRISTINA Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/28/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 5/2013 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 1740 RACE LANE Property Address COELHO, MARCIO G &CRISTINA Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/28/2013 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 1740 RACE LANE Property Address COELHO, MARCIO G& CRISTINA Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/28/2013 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: original system installed 1997 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): Depth below grade: 1 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: 1500 gallons Sludge depth: 6" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 f Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 1740 RACE LANE Property Address COELHO, MARCIO G &CRISTINA Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/28/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 3" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? opened covers, took measurements Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1740 RACE LANE Property Address COELHO, MARCIO G&CRISTINA Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/28/2013 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ' Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1740 RACE LANE Property Address COELHO, MARCIO G& CRISTINA Owner Owner's Name information is Marstons Mills Ma 02648 5/28/2013 required for every � page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box was in good condition, no rot, water level was even with outlet invert. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 1740 RACE LANE Property Address COELHO, MARCIO G &CRISTINA Owner Owner's Name information is Marstons Mills Ma 02648 5/28/2013 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 5 Infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): soil and stone surrounding s.a.s. was probed and found to be dry with no sign of past hydraulic overloading. Vegetation was normal Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•1113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1740 RACE LANE Property Address COELHO, MARCIO G&CRISTINA Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/28/2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 1740 RACE LANE Property Address COELHO, MARCIO G& CRISTINA Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/28/2013 page. Cityrrown 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M '< 1740 RACE LANE Property Address COELHO, MARCIO G &CRISTINA Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/28/2013 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 p-P` - pl- wv5e P` 4, O 3 A-� Z7 13-I 3N A-Z 3y 13-? ,S2 A-3 y 1 G-3 9s- t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '< 1740 RACE LANE Property Address COELHO, MARCIO G& CRISTINA Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/28/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells I Estimated depth to high ground water: 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: 2/4/1997 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: Design plan dated 2/4/1997 on file at Town of Barnstable Board of Health indicates that no groundwater was encountered at 138"and system is designed to have 5'+ seperation between bottom of s.a.s. and adjusted groundwater elevation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form k Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 1740 RACE LANE Property Address COELHO, MARCIO G &CRISTINA Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/28/2013 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 ' ' TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date Time: In Out Owner !-A!ow*o Tenant '6 Address IIYA 61 L-L- Address 11 HH Lt 1.AN26 Mw (zs ions ryi�L_�5 : �� Compliance Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities • �� 11 Z�tl 3. Bathroom Facilities o n /_._..L 1�Celt - -9 _ 4. Water Supply --A)Di oL _ 5. Hot Water Facilities -� 6. Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use _ 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17. Temporary Housing AA 18. Driveway Width 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms —:9 Number of Vehicles Allowed (max) 1 Number of Persons Allowed (max) Person(s) Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here 4 TOWN OF BARNSTABLE BOARD OF HEALTH Gt ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date H T/ D Time: In Out Owner C lS"1+J4- Tenant 1JAC Address CD U SkO f J�J/N 6 h)t-lL le� Address 14�O g)qCC- �&6- Compliance Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities ' _ ._ .I'l r __. - 3. Bathroom Facilities 4. Water Supply 1� 5. Hot Water Facilities 6. Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal _ (� 17.Temporary Housing /tj -T 18. Driveway Width 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms J Number of Vehicles Allow Number of Persons Allowed (max) Person(s) Interviewed � N Inspector If Public Building such as Store or Hotel/Motel specify here f 1 TOWN OF BARNSTABLE ASS C V 6. 0c-�- 00 aGe_ Lane_ SEWAGE # 9 o VILLAGE ,AZ5LQrns All-S �ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO.S l0�H r"VE'i OrAl D -31?a3 SEPTIC TANK CAPACITY J5 DD �ta1 ions LEACHING FACILITY: (type) tL'� 1 I raforS �K) (size) NO.OF BEDROOMS [� �( � � � BUILDER OR OWNER �n f Q1(CiC l — #�tn11 lionD(11P.� PERMTTDATE: -3_19" 9,1 COMPLIANCE DATE: 5 —I f- 22 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 1 � I No. / Fee �D a THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUS S 01ppiication for Migo!gal *pgtem Construction Permit Application is hereby made for a Permit to Construct( or Repair( )an On-site Sewage Disposal System at: Location Address or Lot/No. Owner's Name,Address and Tel.No. 6k C e. t-0 el e— Ham;OV7 bowler, T,'2e, /77/ �q/y �,0� o l< v2 ay Instal s Name,Address,and Tel.No. ��� Dejner's Name/ ,dd ss and Tel.No., J�� Lr I �. �'QvOS�U. xca�v�,i;�,v` �39 t'r ai 5;� 1�5�IV% �� A v�, 2 It o Yctr • 05' Type of Building: Famil lr�+�� 5��1 ��Dvl/1i'� ;,✓� !✓rf� '� Dwelling No.of Bedrooms �� GarbkCGrinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow �Y gallons. Plan Date 2. NumbQr of sheets I Revision Date Title 91L= 40 S&Wac,en VtC41Q o p r ✓I�i '� Descri tion o it f$� �(� SU 75 b— 3 O` lo-omllSif 2-5-Y 7 C P1 La 17 Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agree ensure the construction and mai tenance of the afore described on-site sewage disposal system in accordance with the visions o the ironment Code and not to place the system in operation until a Certifi- cate of Compliance ha been iss ed by is f Health. Si ed O Date,-- Application Approved by Application Disapproved for t e following reasons Permit No. / 7—C'a— Date Issued — e2 r7t,n TOWN OF BARNSTABLEAas C y b' cos LOCAnON A�,JI'7 V Q.r PLn n e SEWAGE # 97 10 VILLAGE /�'/Ql�c S /'�ILI S ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. CO SEPTIC TANK CAPACITY 15 o0 G a1 Lo n LEACHING FACU lTY: (type) ►ltr-a �r_S �.5) (size) NO.OF BEDROOMS BUILDER OR OWNER S�Clh f� G l — H(aYYLI UfY1eS PERMTTDATE: �T COMPLIANCE DATE: a1�- 2�'2 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by t 7. - I U s h -.....4....+..-.^\-..».. ; �,.;�w..r..�-. •T",-�w�+^- _'�*^'•+�.. /f. ,//Y�...)'-^�• -.,/://(;-Y....��j\.,,;^,. -�.r-,. -^--r.�.-..—,_,r.. ._ � � _�. ,t.;+.., r-•.'i:,:.+r-�•c--+v�'..',e�Jl No. $,j THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Application for Zigpogar *Pgtem congtruction permit Application is hereby made for a Permit to Construct(J/or Repair(. )an On-site Sewage Disposal System at: j Location Address or Lot No. Owner's Name,Address and Tel.No. C e GQ✓1 a Na M Too 140M p r, p.0, boY 11211-( Installer's Name,Address,and Tel.No. j��Q D ner's Nam dd ess an 1.No. Jay/ ` /� ,i7 n[ OW✓? Lade, ✓kql✓�Pt�/in 14C.� �arrf F. �'avOS�ct FXCG{t/GITYrnC�i, /•-/dG, /i a.fi7 Ph Im ow A✓ci N3R Mai,7 S7iee7' a O Yu✓ ►'� o (�r��C `')'`� 1� lfOw�� ar w� cfC Type of Building: S!o g 1 e ra y►�1 �' r Dwelling No. of Bedrooms GarbGrinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria Other Fixtures i f Design Flow gallons per day. Calculated daily flow �y gallons. Plan Date _ # Number of sheets Revision Date -` Title . Lt O 11 /'J�J �'� Descr' tion of Soil �� � err► �Mw\. 7,r k) Ala c 7 P -9' -rNature of Repairs or Alterations(Answer when applicable) _ J Date last,inspected: Agreement: The undersigned agre ensure the construction and mai tenance of the afore described on-site sewage disposal system 3 in, cordance with the, ovisions of_Titl the vironment 1 Code and not to place the system in operation until a Certifi- ,� kale of Compliance habeen is ed by t is f Health. Si ed e Date Application Approved by 9 Application Disapproved for e fol owing reasons 1 Permit No. Date Issued a THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION BARNSTABLE, MASSACHUSETTS ' Certificate of Compliance THIS IS TO CERTIFY that the On-site'Sewage Disposal System installed( )or repaired/replaced( )on by for as has been constructed in accordance r- i P P Y f 2 with the provisions of Title 5 and the for Disposal System Construction Permit No. dated 4 Use of this system is conditioned on compliance with the provisions set forth below: i No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS migpogal 6Pgtem Construction Permit Permission is hereby granted to Q —' 1JAN C.. V to construct()W-)repair )an On-site Sewage System located at ! 7—t 6 U19)__*e 4,&Z 14 �1 and as described in the above Application for Disposal System Construction Permit.The applicant recognizes hi /her duty to comply with Title 5 and the following local provisions or special conditions. All construction ffiust Ve co pleted within two years of the date below. e, e Date: `7 Approved by _ 0 1 it ` TOWN OF BARNSTABLE V LOCATION 9 X" SEWAGE # VILLAGE A - 12/44- S ASSESSOR'S MAP & LOT /y5PFc7..-s n /� WSTAttE-R'S NAME& PHONE NO. SEPTIC TANK CAPACITY — 7 c- 1w5/O£ cc7/,A- LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNER PERMIT DATE: CAI-SCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by w: � __ ,, �______ ,.,- r �, • ' ��f�'� � y, �7, n y, �� yd� '- �5, -- COMMONWEALTH OF MASSACHUSETTS = EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS r DEPARTMENT OF ENVIRONMENTAL PROTECTION y bV� �' -- 350 MAIN STREET WEST YARMOUTH,MA 508-775-2800 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORMQ� � PART A MAP ■�'"""'o" MAP 48 PAR 1 CERTIFICATION PARCEL • O 03 O A Property Address: 1740 RACE LANE LOT i P Y MARSTONS MILLS,MA 02648 Owner's Name: RICHARD BEDARD Owner's Address: 1740 RACE LANE T MARSTONS MILLS,MA 02648 Date of Inspection MARCH 28,2002 Name of Inspector:(please print) JAMES D"SEARS RECEIVED Company Name: A&B Canco Mailing Address: 350 Main Street APR 17 2002 West Yarmouth,MA 02673 Telephone Number: 508-775-2800 TOWN OF BARNSTABLE HEALTH DEPT. CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: '%"o,9 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 tot he buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1740 RACE LANE MARSTONS MILLS,MA 02648 Owner: BEDARD,RICHARD Date of Inspection: MARCH 28,2002 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X _ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N/A _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined" please explain. _ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: _ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health)" broken pipe(s)are replaced obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 2 Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 1740 RACE LANE MARSTONS MILLS,MA 02648 Owner: BEDARD,RICHARD Date of Inspection: MARCH 28,2002 C. Further Evaluation is Required by the Board of Health: N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety,or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b)that the system is not functioning in a manner which will protect public health safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone l of public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Title 5 Inspection Form 6/15/2000 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 1740 RACE LANE MARSTONS MILLS,MA 02648 Owner: BEDARD,RICHARD Date of Inspection: MARCH 28,2002 D. System Failure Criteria applicable to all systems: N/A You must indicate"yes"or"no"to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in leaching is less than 6"below invert or available volume is less than''/s day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone I of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: N/A To be considered a large system the system must service a facility with a design flow of 10,000.gpd to 15,000 gpd. You must indicate either"yes"or"no to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well. If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system is failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Title 5 Inspection Form 6/15/2000 4 Page 5 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1740 RACE LANE MARSTONS MILLS,MA 02648 Owner: BEDARD,RICHARD Date of Inspection: MARCH 28,2002 Check if the following have been done. You must indicate"yes"or"no"as to each of the following Yes No X Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X Was the facility or dwelling inspected for signs of sewage back up? X Was the site inspected for signs of break out? X Were all system components,excluding the SAS,located on site? X Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum X Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)has been determined based on: Yes No X Existing information. For example,a plan at the Board of Health. X Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Title 5 Inspection Form 6/15/2000 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1740 RACE LANE MARSTONS MILLS,MA 02648 Owner: BEDARD,RICHARD Date of Inspection: MARCH 28,2002 FLOW CONDITIONS RESIDENTIAL Number of Bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 330 Number of current residents: 1 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): YES Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): 2000 53,000/2001 61,000 Sump pump(yes or no) NO Last date of occupancy: PRESENT COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: N/A Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 1997 PERMIT#97-62 Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1740 RACE LANE MARSTONS MILLS,MA 02648 Owner: BEDARD,RICHARD Date of Inspection: MARCH 28,2002 BUILDING SEWER(locate on site plan): N/A Depth below grade: Materials of construction: Cast iron _ 40 PVC _ other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): X Depth below grade: 14" Material of construction: X concrete metal fiberglass polyethylene other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 4,500 GALLON Sludge depth: 1" Distance from top of sludge to the bottom of outlet tee or baffle: 29" Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: 4" Distance from bottom of scum to bottom of outlet tee or baffle: 22" How were dimensions determined: ASBUILT AND TAPE Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): TANK AT WORKING LEVEL.TANK AND COVERS 14"BELOW GRADE.ONE INLET TEE,OUTLET TEE NO SIGN OF OVERLOADING SEEN IN TANK. GREASE TRAP(located on site plan) N/A Depth below grade: Material of construction: concrete metal fiberglass polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: 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 Title 5 Inspection Form 6/15/2000 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1740 RACE LANE MARSTONS MILLS,MA 02648 Owner: BEDARD,RICHARD Date of Inspection: MARCH 28,2002 TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain) I Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no) Alarm level: Alarm in working order(yes or no): Date of last pumping _ Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of -, leakage into or out of box,etc.,): DISTRIBUTION BOX IS 16"XI6",T BELOW GRADE.BOX IS CLEAN,LEVEL AND SOLID.NO SIGN OF OVERLOADING OR SOLID CARRYOVER. PUMP CHAMBER: N/A (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Title 5 Inspection Form 6/15/2000 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property.Address: 1740 RACE LANE MARSTONS MILLS,MA 02648 Owner: BEDARD,RICHARD Date of Inspection: MARCH 28,2002 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: X leaching chambers,number: 5 leaching galleries,number leaching trenches,number,length leaching fields,number,dimensions: _ overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) LEACHING IS FIVE INFILTRATORS 41'X4'.LEACHING IS 30"BELOW GRADE.PROBED AND DID TEST HOLE ABOVE AND BESIDE LEACHING. NO SIGN OF OVERLOADING. CESSPOOLS: N/A (cesspool must be pumped as part of inspection)(locate on site plan). Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): PRIVY: N/A (locate on site plan) Materials of Construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Title 5 Inspection Form 6/15/2000 9 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1740 RACE LANE MARSTONS MILLS,MA 02648 Owner: BEDARD,RICHARD Date of Inspection: MARCH 28,2002 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. a Title 5 Inspection Form 6/15/2000 10 Page 1 1 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 174 A r . RACE LANE 0 MARSTONS MILLS,MA 02648 Owner: BEDARD,RICHARD Date of Inspection: MARCH 28,2002 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater 53.6 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observation site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation X Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS WELL DATA SDW 253 WELL SDW 253 53.6 ZONE B 7.8 ADJUSTED 45.8 30 Title 5 Inspection Form 6/15/2000 11 T own of Barnstable, P tt 69514y Department of Health,Safety,and Environmental Services dpTIN?a Public Health Division Date 367 Main Street,Hyannis MA 02601 KAM II twwareetB, t ii r rF �' Date Scheduled "2� 17 Time 1 h� Fee Pd. t Soil Suitability Assessment for Sewage Disposal Performed By: D 03 A -A Witnessed By: �1�-t W"f �a✓�'��1 C r � LOCATION &.GENERALINFORMATION Location Address L � � ��v Owner's Name Fe4 1.4.A-M�f� ^/IA Address' �I. � If\- 4NML j .,"4"1 Assessor's Map/Parcel: �"��I�j -, Engineer's Name-DOWN 6"it NEW CONSTRUCTION -1 Z REPAIR Telephone N 6-Z 1 S LA Land Use Slopes(%) 4:52 Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well � ft Drainage Way ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) 2 LOT �... 1%-5 LA-7C-1 G Parent material(geologic) y`iti�++v '�/ Deptfti to Badrork _ Depth to Groundwater: Standing Water in Hole:_ Weeping from Pit Face Estimated Seasonal High Groundwater ''V/ G QDw., "j -Y1_ -PPuNib DETERMINA ION F.011 SLASONAL:H1GH WA TER TABLE Method Used: Depth Observed stuudiug in cbs.hole: in. Depth to soil mottles: """ in: - w Depth to weeping from side of obs.hole: V in. Groundwater Adjustment ft. Index Well H Reading Date: Index Well level Adj.factor Adj.Groundwater Level_ PERCOLATION TEST Date :< 'Ttme Observation j} '� 01` 00 Hole# I t I Time at 9" !/ ti 0 ; Depth of Perc re, Time at 6" 8 r � Start Pre-soak Time Qa O t ©� Time(9%6") !!� o C) End Pre-soak Rate Min./Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back— Copy: Applicant DEEP'OBSERVATION'HOLE LOG Dole # � Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulderes. % I r3a—lc C- l G l 38 G 2-- c;a-y,�-,;:51WP '21 4 -(7/y DEEP:OBSERVATION;HOLE LOG! Hole Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulderes. % DEEP 013SE1 YVATION HOLE LOG`.; Dole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulderes. % GravelL DEEP OBSERyATION HOLE.'LOG :' Hole Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) Munsell Mottling Structure Stone(Munsell) s Boulderes. g ( a DEEP.GBSER ATIOIet HOLE L- Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency % PROJECT LE OJ TITLE T ul Af t -- _ ._... - � D c4 1 cP )31Q �Y-77-! All B S I�� tt EPARED 14 t �- rn — �-- �' Central Construction Company, Inc. Steve Devlin •President 261 Blackthorn Drive•Marston Mills,MA 02648.508420-1340 %klck", SCALE _ t I 0 ' DATE DWG NO. t' DESIGN CHECK t DRAWN JOB NO. SHEET OF k ------------------ �,,� ­,�-, ­­"O., ", � ­. ­,", ,-­�,i: . 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