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HomeMy WebLinkAbout0099 RASPBERRY LANE - Health L aspberry Lane ns Mills F/R 20. 086 1aa -oL6(19 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,Z,, rr; ,M 99 Raspberry Lane 10 Property Address Francisco Lima 4R,r Owner Owner's Name information is r, required for every Marstons Mills Ma 02648 11-21-17 r 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 5 on the computer, use only the tab 1. Inspector: key to move your cursor-do not Brett Hickey use the return Name of Inspector key. B&B Excavation reb Company Name 374 Route 130 Companyr Address ess B � Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 11-21-17 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 f Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 99 Raspberry Lane Property Address Francisco Lima Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-21-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System was in working order at time of inspection. Tank was pumped after inspection for maintenance. I 13) 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 i - Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M a' 99 Raspberry Lane Property Address Francisco Lima Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-21-17 page. City/Town 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 Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 99 Raspberry Lane Property Address Francisco Lima Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-21-17 page. City/Town 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 '/z day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Ii Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 99 Raspberry Lane Property Address Francisco Lima Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-21-17 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone 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 99 Raspberry Lane Property Address Francisco Lima Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-21-17 page. CityFrown 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): 330/GPD 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 99 Raspberry Lane Property Address Francisco Lima Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-21-17 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d See below 9 ( Y 9 (gP ))� Detail: 2016-52,000gallons 2015-43,000gallons Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): Gallons per day(gpd) i Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 99 Raspberry Lane Property Address Francisco Lima. Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-21-17 page. Cityrrown 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: Pumper driver Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Tank size Reason for pumping: Maintenance after inspections 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•3113 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 99 Raspberry Lane Property Address Francisco Lima Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-21-17 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2002 per COC Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1'3" feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 3 feet Material of ccnstruction: ® 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: 1500gallons Sludge depth: 6 l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 99 Raspberry Lane Property Address Francisco Lima Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-21-17 page. CitylTown 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 30" Scum thickness 4 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 12 How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was in working order at time of inspection with liquid level equal to outlet invert. Tank was pumped after inspection for maintenance. Grease Trap(locate on site plan): Depth below grade: NA feet Material.of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 99 Raspberry La,-ie Property Address Francisco Lima Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-21-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm presen-: ❑ 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 l5ins•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 °M 99 Raspberry Lane Property Address Francisco Lima Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-21-17 page. City/Town 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 11 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 in working order at time of inspection with liquid level equal to outlet invert. D-box did not show signs of back up. 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.): NA * 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: l5ins 3/13 Title 5 Official al Inspectio n Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 99 Raspberry Lane Property Address Francisco Lima Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-21-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.)Y ( Type: ❑ leaching pits number: ® leaching chambers number: (2) 500 gallon ❑ 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 was in working order at time of inspection with no sign of hydraulic failure. Leaching was'/< full when viewed with no higher staining. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 99 Raspberry Lane Property Address Francisco Lima Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-21-17 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: NA Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts W Title 5. Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 99 Raspberry Lane Property Address Francisco Lima Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-21-17 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 Front ! Rear 2 C A1.23' C 1-22' E3.29' B1-18' D1-34' E2-30' A2.28' C3.29' B2.35' D3.26' t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 99 Raspberry Lane Property Address Francisco Lima Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-21-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: No GW 6' below SAS 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: 5-22-02 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: Plan on file with BOH. 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 99 Raspberry Lane Property Address Francisco Lima Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-21-17 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:Subsurface Sewage Disposal System•Page 17 of 17 ` TOWN OF BARNSTABLE LOCATION S—�fN SEWAGE # '2Uo 2-a2S' VILLAGE >nn► � i 1 y�.��� ASSESSOR'S MAP & LOT 02-00 INSTALLER'S NAME&PHONE NO. �S� a - -�I� a SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER1 ��� PERMITDATE: a q1S 2 COMPLIANCE DATE: S3 U 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 It � QD . . f1 ' No. 2U Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: !T Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01pprfcation for Di5pont *pztem Construction Permit. Application for a Permit to Construct( )Repair( )Upgrade(X Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot Ndq' RaS�G,w�rr� / „( Owner's Name,Address and Tel.No.nr[ 044ke_ &/e�,��, IOY Assessor's Map/Parcel J` ( Wv d L QQ t�N��S{� ✓� Z M.fKd 02— la8-io5� �s -nn.us Me, Installer's Name,Address,and Tel.No.1�6 e �gx,,,, ,,6rlj Designer's Name,Address and Tel.No. $-�3crJ Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank O an Type of S.A.S. ,c rT_ 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 Certifi- cate of Compliance has been issued b o d of He 5--49 y^0 a Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. 62a 5:�! Date Issued -� (/ No. 2 J ...� + Fee THE,COMAONWEALTH OF FASSACHUSETTS Enteredincomputer: ✓✓ Yes ,�►r t PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2pplication for Migool *pgtem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade(,*Abandon( ) El Complete System 0 Individual Components `Location Address or Lot Nol�j" 245pb�e✓% / ,.t Owner's Name,Address and Tel.No. ,( t Assessor's MA /Parcel, J` Y(� WV Q4 �21V�`S Installer's Name,Address,and Tel.No. fQL � Designer's Name,Address and Tel.No. 11v�L( �SGw w� Type of Building: a. Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank T1,ok/n Type of S.A.S. o(?) rl4 c- 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 Certifi- cate of Compliance has been issued by tlm d of Hea h! Signed �� --' � Date A lication Approved b - m t m PP PP Y -r: Date -�y�Q,2 Application Disapproved for the o lowing reasons Permit No. an 0 ' 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 _ - L e te- at�Q a s 0 rrEA 1� has been constructed in accordance with the provisions of�. e 5 an�the for Disposal System Construction Permit-No.�Qd�-��S dated /e Installer Designer The issuance df thislio ermit shall not be construed as a guarantee that the systm will nction 22:&5 Date 0 ;t Inspector f''. --------------------------------------- s�v No. 2n f1 225- Fee ' THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mfig pogal *pgtem Construction Permit Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( ) System located at 90I , PrA., /Ure ri %_'�/S —� . —T and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of thisr�J t. Date: - Approved by 4 �- a TOWN OF BARNSTABLE LOCATION SEWAGE # '2Do 2-222 ' VILLAGE ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. �J �rO -�—XL-A 4:kl0 �( SEPTIC TANK CAPACITY 115oO o oc n LEACHING FACILITY: (type) CS2G,MIfW!� (size) r�u�'' �i�i ✓✓ NO. OF BEDROOMS i BUILDER OR OWNER lc �� 4 Tom► ' PERMIT DATE: S a `/ COMPLIANCE DATE: S 0 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 x ® ® �/ a > O L 3 got ©3 �i� e � - � _ AM CommonwecWof Mo=chusetts -John Grad- -I ft Office Of ENronmentOl Affairs D.E.P. Title V Septic Inspector _ Department -of P.O. Box 2119 Environmental Protection �_ Teaticket, MA02536 • (508) 5644 6813 SUBSURFACE SEWAGE DISPOSAL SFORM- PART A SYSTEM INSPECTION AfCE -CERTIFICATION ' 4&C p��n/�,, ,/ �� C I( Property Address: 99 Rasberry Lane Marston Mills Address of Owner: 6' Ca Date of Inspection:7124196 (If-different) wuf/ Name of Inspector:.John Grad Ray Brown orfan:7 OCeanVlew Dr.Apt 0 o n,Ma.021 Company Name,Address and Telephone Number: g �- CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance.of on-site sewage disposal systems. The system: x Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: 7130196 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater, the.inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer; if applicable and the approving authority. INSPECTION SUMMARY: Check A, B,C, or D: A] SYSTEM PASSES: X I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. 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. I (revised 11115195) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 1 i - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 99 Rasberry Lane Marston Mills Owner: Ray Broom Orfan:7 oceanvlew-Dr.Apt.507 Boston,Ma.02125 - Date of Inspection:7124196 _ _ 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. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public 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 D] 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 stem component due to an overloaded or clogged SAS or ._ P 9 tY Y P 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 i 001, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ PART A CERTIFICATION (continued) PropertyAddress: g9Rasberry Lane Marston Mills - -- i Owner: Ray Brovm Orfan:7 oceanvlew or.Apt.507 Boston,Ma 02125 W Date of inspection:7124196 -- Df 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 s ool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. n _ 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. ss than 100 feet but greater than 50 feet from a private water supply well with no Any portion of a cesspool or privy is le attach copy of well water analysis for acceptable water quality analysis. If the well has been analyzed to be acceptable, 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 because o0ne d or more of greater(Lhe arge System))ding nd the exist:system is a significant threat to public health and safety and the environment _ 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) iance with the water The owner or operator of any 0such ands6 00. Peall bring the system and se consult the local regional officelity into olf the Dlepartment for further information. nforrmation. program requirements of 314 CMR 5.00 a (revised 11115195) 3 E DISPOSAL SYSTEM INSPECTION FORM SUBSURFACE SEWAG PART 8 CHECLIST Property Address: 99 Rasberry Lane Marston Mills Owner: Ray Brown o_rran:7 oceanView Dr.Apt.507 Boston,Ma.02125 - - Date of Inspection:7/24196 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. _ X. As built plans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. x The system does not receive non-sanitary or industrial waste flow. .X The site was inspected for signs of breakout. X All system components, excluding the Soil Absorption System, have been located on the site. X The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. X The size and location of the Soil Abs orptionSystem on the site has been determined based on existing information or approximated by non-intrusive methods. X The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11115195) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION - Property Address:_99 Rasberry Lane Marston Mills Owner:- Ray Brown Orran:7 oceanview Dr.Apt.507 Boston,Ma.02125 Date of Inspection:7124196 _ w�- - FLOW CONDITIONS RESIDENTIAL: _ Design flow: 0 gallons -Number of bedrooms: 9 Number of current residents: 2 - - _Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes - - - Seasonal use(yes or no): No - Water meter readings, if available: nia Last date of occupancy: n1a - COMMERCIAL/INDUSTRIAL: Type of establishment: Iva 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: rda OTHER: (Describe) n1a Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System has not been pumped in the last two years. System pumped as part of inspection: (yes or no)Yes If yes,volume pumped: 1000 gallons Reason for pumping: cesspool byABCO 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: 1976 Sewage odors detected when arriving at the site:(yes or no) (revised 11115195) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C s SYSTEM INFORMATION.(continued) Property Address: 99 Rasberry Lane Marston Mills - Owner: Ray Brown Orfan:7 Oceanview Or.Apt.507 Boston;Ma.02125 Date of Inspection:7124196 SEPTIC TANK:— (locate on site plan) Depth below grade: nia - 1 Material of construction:x concreate_netai_FRp_other(explain) _ Dimensions: n1a - Sludge depth:Na Distance from top of sludge to bottom of outlet tee or baffle: n1a Scum thickness:nla - - Distance from top of scum to top of outlet tee or baffle:n1a Distance form bottom of scum to bottom of outlet tee or baffle: n1a i 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.) n1a GREASE TRAP:_ (locate on site plan) Depth below grade: n1a. Material of construction: _concrete_metai_FRP_other(explain) Dimensions: n1a Scum thickness:nla Distance from top of scum to top of outlet tee or baffle:n/a Distance from bottom of scum to bottom of outlet tee or baffle: n1a 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.) n1a (revised 11115195) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART C _ SYSTEM INFORMATION (continued) Property Address: 99 Rasberry Lane Marston Mills Owner; Ray Brovin orran:7 oceanVlew Dr.ApL507 Boston,Ma:02125 -- -Date of Inspection:7124196 (I TIGHT OR HOLDING TANK:- (locate on site plan). Depth below grade: n1a - - Material of construction:_concrete_metal_FRP_other(explain) Dimensions: n/a Capacity: n1a gallons Design flow: n1a gallons/day Alarm level: nla Comments: (condition of inlet tee, condition of alarm and float switches, etc.) n1a DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: rua Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.) n1a 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.) n1a (revised 11115195) 7 y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ PART C - - _ SYSTEM INFORMATION (continued) _ Property Address: 99 Rasberry Lane Marston Mills Owner:- _ Ray Brown Orfan:7 oceanvlew Dr.Apt.507 Boston,Ma.02125 Date of Inspection:7124196 SOIL ABSORPTION SYSTEM (SAS):x - (locate on site plan,ifpossible; excavation not required, but may be-approximated by non-intrusive methods) If not determined to be present,explain: n1a Type: - - leaching pits, number: 1,000 gallon leach pit leaching chambers, number:nla - leaching galleries, number: nfa leaching trenches,number, length: n1a - leaching fields, number, dimensions:n/a _ overflow cesspool, number:n1a Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) The leach pit has never been more than V2 full.it is structurally sound. CESSPOOLS: x (locate on site plan) Number and configuration: one Depth-top of liquid to inlet invert: 3' Depth of solids layer: 0' Depth of scum layer: 5' Dimensions of cesspool: 1,000 gallon Materials of construction: precast Indication of groundwater. none inflow(cesspool must be pumped as part of inspection) nla Comments:(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) The cesspool is structurally sound and fucntioning properly.Recommend pumping system every one to two years for maintenance. PRIVY:_ (locate on site plan) Materials of construction: n1a Dimensions: n1a Depth of solids: nta Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PrivyComments (revised 11115195) ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART C SYSTEM INFORMATION (continued) Property Addiess: 99 Rasbery Lane Marston Mills Owner: Ray Brown Orfan:7 oceanvlew Dr.Apt.507 Boston,Ma.02125 Date of Inspection:7124198 SKETCH OF SEWAGE DISPOSAL SYSTEM: _ include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' AA V q DEPTH'TO GROUNDWATER Depth to groundwater:12 feet method of determination or approximation: 4 USGS Maps and Charts. (revised 11115195) 9 lit ii: �N, I:., lllt ill, i�'_ql" it.VI .41 IT lT IT i.:l I J Til ES$ORS MAP I,lit, J'T TEST HOLE LOGS I.......... :PARCEL ' Al -20NI i ,,, �).rn+ FLOOD E SOIL EVALUATOR : L^_� WITNESS : ii`,�C)T ­i�t 0''. j CE: DATE: � REFEREN PERCOLATIO� RAT'E - _ ILIA T .......... �b, Az/ iw IN TH- I TH-2 4 -nb,,4 -T or-- L) OA 1pyUb oo .4 J;i;:- -l577- Till, 9N �"',Im U 0 CAT lip 'JI 60,; 'J":,;";ji'X'; j, 'To I, ljj; c lit 7l'i e, "T V Lk) Z�l .. ..... SEPT I C SYSTEM DES I GN 777777777 j ilY, _51 "IN -IT P ti�j�: it , 'T-0,11N, AL/DAY BEDROOMS AT ".77' i T! "Tl�i�% ;Otii, IN, Ti. ?�DGAL/DAY - _9,-QDGAL U C, �ej Vt 9&_ (571 U- Q:� Ny, 0.1 low 17 10, i, r " .I i . -il"; I . , . !iii�, �!, �. I I - ___j . Io Lo L) F 14­1 Wt; IT 'T- IT 0 I L' + __7S 1 tt7777777 I. x -2 z oz, T j!i j TI, EA: 7,4 x 7/1 0 1 j, �`I Ili�!;:,�i! -Y I it; l��i, i T'j, 1�y ITT IN I I Y P T I C - SYSTE IT T FI......... :LY Ill. 4i. v. 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