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HomeMy WebLinkAbout0076 SANTUIT-NEWTOWN ROAD - Health %}76 Santuit-NewtownRoad- Marstons Mills A = 031 005004` l 1 a�, C4 e A 6C-A C) v, 5 �CCAAV,L 7 . 61-64, 14,A A/ loo fF �L I� �`o TOWN OF BARNSTABLE LOCATION �Cy eke` ^/w�ew�b Wn f2o SEWAGE VII;i AGE ASSESSOR'S MAP&PARCEL INSTAt4AWS NAME&PHONE NO.' k-�,Qr%wck.OCbnrw4l 4O&I-111 SEPTIC TANK CAPACITY / LEACHING FACILITY:(type) (size) 1060 NO. OF BEDROOMS OWNER— — CC L PERMIT DATE: C ATE:117T�S P. 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 Santuit-Newtown Road Well Line 32 26 36 s0. 50 39 3 TOWN OF BARNSTABLE l� n -� LOt f1TlON a k(J ��SEWAGE # VILLAGE I �, I_� ASSESSOR'S MAP & LOT6,31—cs--U r INSTALLER'S NAME&PHONE NO`.' SEPTIC TANK CAPACITY /60 0 LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNER V., PERMITDATE: COMPLIANCE DATE: 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 ` �tl � -o N � ' �� `r I �. C� ``� � 3� ,a� 39 � ��� ��b` ��� �i Commonwealth of Massachusetts -�s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments L 76 Santuit-Newtown Road, Marstons Mills MA 02648 Property Address Indy Mac Bank C/O Jack Creaven Remax Real Estate Owner Owner's Name information is 167 Lovell's Lane, Marstons Mllls MA 02648 April 22, 2008 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:When filling out A. General Information forms on the. computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name 189 Cammett Road Company Address Marstons Mills MA 02648 gun City(fown State Zip Code 508-428-1779 SI 12855 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 April 22, 2008 khA( A 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. 08-91 Indy-Mac.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 r Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ' 76 Santuit-Newtown Road, Marstons Mills MA 02648 Property Address Indy Mac Bank C/O Jack Creaven Remax Real Estate Owner Owner's Name information is 167 Lovell's Lane, Marstons Mills MA 02648 April 22, 2008 required for State Zip Code Date of Inspection every page. Cityrrown 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: Recommend pumping tank, leaching pit has 10-12"of effective leaching. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 08-91 Indy-Mac.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 76 Santuit-Newtown Road, Marstons Mills MA 02648 Property Address Indy Mac Bank C/O Jack Creaven Remax Real Estate Owner Owner's Name information is 167 Lovell's Lane, Marstons Mills MA 02648 April 22, 2008 required for every page. City/rown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 08-91 Indy-Mac.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .'" 76 Santuit-Newtown Road, Marstons Mills MA 02648 Property Address Indy Mac Bank C/O Jack Creaven Remax Real Estate Owner Owner's Name information is 167 Lovell's Lane, Marstons Mills MA 02648 April 22, 2008 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® 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 El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than_day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 08-91 Indy-Mac.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts : Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 76 Santuit-Newtown Road, Marstons Mills MA 02648 Property Address Indy Mac Bank C/O Jack Creaven Remax Real Estate Owner Owner's Name information is required for 167 Lovell's Lane, Marstons Mills MA 02648 April 22, 2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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 CM 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 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 El ❑ Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 08-91 Indy-Mac.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 76 Santuit-Newtown Road, Marstons Mills MA 02648 Property Address IndY Mac Bank C/O Jack Creaven Remax Real Estate Owner Owner's Name information is required for 167 Lovell's Lane, Marstons Mllls MA 02648 April 22, 2008 every page. Citylrown 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) R ❑ 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)J 08-91 Indy-Mac.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 76 Santuit-Newtown Road, Marstons Mills MA 02648 Property Address Indy Mac Bank C/O Jack Creaven Remax Real Estate Owner Owner's Name information is required for 167 Lovell's Lane, Marstons Mills MA 02648 April 22, 2008 every page. CitylTown State Zip Code Date of Inspection 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 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes 0 No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): N/A Well Water Sump pump? ❑ Yes ® No Last date of occupancy: Unknown 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: Last date of occupancy/use: Date Other(describe): 08-91 Indy-Mac.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 76 Santuit-Newtown Road, Marstons Mills MA 02648 Property Address Indy Mac Bank C/O Jack Creaven Remax Real Estate Owner Owner's Name information is required for 167 Lovell"s Lane, Marstons Mllls MA 02648 April 22, 2008 every page. City(fown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: None 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1984 Were sewage odors detected when arriving at the site? ❑ Yes ® No 08-91 Indy-Mac.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts : Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 76 Santuit-Newtown Road, Marstons Mills MA 02648 Property Address Indy Mac Bank C/O Jack Creaven Remax Real Estate Owner Owner's Name information is 167 Lovell's Lane, Marstons Mills MA 02648 April 22, 2008 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 1' Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 6" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed b a Certificate of Compliance? (attach a copy of certificate) El Yes ❑ No Y --------------------------------------------------------------------------------------------------------------------------. Dimensions: 8.5' long x 5.2'wide 1000 gal. 4" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 26" 2" Scum thickness 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 11" How were dimensions determined? Measured 08-91 fndy-Mac.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Mi Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 76 Santuit-Newtown Road, Marstons Mills MA 02648 Property Address Indy Mac Bank C/O Jack Creaven Remax Real Estate Owner Owner's Name information is required for 167 Lovell's Lane, Marstons Mills MA 02648 April 22, 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level was found at bottom of outlet invert, baffles intact. Recommend pumping tank. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 08-91 Indy-Mac.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments - 4 76 Santuit Newtown Road, Marstons Mills MA 026 8 Property Address Indy Mac Bank C/O Jack Creaven Remax Real Estate Owner Owner's Name information is required for 167 Lovell's Lane, Marstons Mllls MA 02648 April 22, 2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in 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 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.): No solids or high stains. Pump Chamber(locate on site plan): Pumps in working.order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 08-91 Indy-Mac.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 76 Santuit-Newtown Road, Marstons Mills MA 02648 Property Address Indy Mac Bank C/O Jack Creaven Remax Real Estate Owner Owner's Name information is required for 167 Lovell's Lane, Marstons Mills MA 02648 April 22, 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: One 6x6 pit. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Pit was found half full at time of insprction with a high stain line indicating pit had 10-12"of effective leaching, 08-91 tndy-Mac.doc 08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 76 Santuit-Newtown Road, Marstons Mills MA 02648 Property Address Indy Mac Bank C/O Jack Creaven Remax Real Estate Owner Owner's Name information is required for 167 Lovell's Lane, Marstons Mills MA 02648 April 22, 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 08-91 Indy-Mac.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts _ l Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 76 Santuit-Newtown Road, Marstons Mills MA 02648 Property Address Indy Mac Bank C/O Jack Creaven Remax Real Estate Owner Owner's Name information is required for 167 Lovell's Lane, Marstons Mills MA 02648 April 22, 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Santuit-Newtown Road Well Line 32 26 36 50 39 33 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 76 Santuit-Newtown Road, Marstons Mills MA 02648 Property Address Indy Mac Bank C/O Jack Creaven Remax Real Estate Owner Owner's Name information is 167 Lovell's Lane, Marstons Mills MA 02648 A ri122, 2008 .required for P every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to ground water: 30 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water at el. 55 and topo map shows property at el. 100. 08-91 Indy-Mac.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Town of Barnstable OF tNE l� Regulatory Services BAMSPABLE, : Thomas F. Geiler,Director 9 MASS. E16 9. Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER This septic stem inspection report was completed b a private inspector who is certified b p Y p p p Y p p Y the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by receiving p this report the Town of Barnstable Health Division does not _ automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the "Disposal Works Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. Q:\SEPTIC\Disclaimer Private Septic Inspections.DOC L O CATION SEWAGE PERMIT NO. (,4 r-' � 06Ll- I i � VILLAGE I N S T A LLER'S NAME i ADDRESS �•1, 0 6;i c 0 \\ + 5d1i ' VV1 ON%S�-6�, vh A BUILDER OR OWNER DA T E PERMIT ISSUED 7/ zl = DAT E COMPLIANCE ISSUED f� /G t 33 .. 39. ar-® I � ... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH � _._ - kL� ......OF...............�J 1�� j.% :�j. . 11!�-........ Appliratiun for Dispnsttl Works Tnnitrurtinn rantit Application is hereby made for a Permit to Construct k<or Repair ( ) an Individual Sewage Disposal System at: �-�......------••--------------- ---�•---••••.............._...._.1.. Uectl•--••• --. � ���- �1 Locat' n-Addre or Lot No. Owner Address a .................................. .. •-----....P.� Fol---a • .............................................. ........................ Installer Address Type of Building Size Lot._.. -`�S feet U YP g �--r.�.�-..... q. Dwelling—No. of Bedrooms.._.....___......................Expansion Attic ( A,)C) Garbage Grinder (/t6_... Pk Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) OaOther fixtures ..--•-------------------------------------------•- . W Design Flow................... ...!5.............gallons per person per day. Total daily flow............-3__ ...C)................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box (--� Dosing tank ( ) - a Percolation Test Results Performed by............................ . 6/ ..== {`° Date I ..... Z ......... ,a Test Pit No. I._G .minutes per inch Depth of Test Pit........1:.._�- Depth to ground water... Li, Test Pit No. 2.....:. :......minutes per inch Depth of Test Pit..._._. ...._.__ Depth to ground water....._..............___. ............................................................. _ O Description of Soil.................................•--•-•--•----•--------•--.......0.2g ..... ......_`�. ( ��'+.--�---�'-�`'. -� -... -f � -- . w ---•---------- -------------•--•--•---••-------•---•--------•----•-----------...------....-----.,t_...� ......... �=-..�''°�:�':..--- .............. U Nature of Repairs or Alterations—Answer when applicable..h- l ,re v-f- �'4 1/ 7 ------------------------------------------------•-•-----------------------......._.............................--- --------------•---.....------------------------.................----•-•••....... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TL I TL!Lj 5 of the State Sanitary Code.—The undersigned further agrees nol to place the system in operation until a Certificate of Compliance has been issue the board of h t . t cc// igned............... . ... J�.... Application Approved B ... ...... ................ ...� Date Application Disapprove for e f ollowing reasons--------------------------------------------------------------------------------••--------- .................... ---------•-•----------•----------------------------------------•---.....--------•---•..........----•-•-----.................•----------------------•-•-----•------------•---•-••--------------.....-•--- Date PermitNo..................•-----••---•--•......-••••--•......... Issued....................................................... Date l _ .� 41% t- i f y-t -- FEim - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH - �Gv ......OF...............�-� 5-%-1 .--`--........ A;i;i ira ilan for Diipniitti Vorkii Tonfaurtinn Prrutit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: L/ ` ��7 - . ..-••................•-• -----f---- ------ ..� Loc r L o. ......... - .. !�� ....� ( �"�.................. 0/� ..-•--•----------------- .......................... Owner ,1 / Address ic ✓/!�/ r � Installer Address Type of Building Size Lot_.__ -__.`.�Sq. feet Dwelling—No. of Bedrooms--- ......------- ----------------------Expansion Attic ( A�o Garbage Grinder aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) P.I Other fixtures ---------------------------------•-•------•• ` ' - d --- ---------------- W Design Flow.................... ..5�............gallons per person per day. Total daily flow...........�.-......0..............._gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x} Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.-________..,___..-- Diameter.................... Depth below inlet:.:_: .:....__.:... Total leaching area..................sq. ft. Z Other Distribution box Dosing tank Percolation Test Results Performed by..........................:.. __........... . d G /Z a _�� �' ...- -•-- ..... Date.-----:....�.1----------------•-- ,� Test Pit No. 1---e_.y.�.S_.minutes per inch Depth of .e�st�Pit--µ . Depth to ground water....,/. (i Test Pit No. 2.... ' _minutes per inch (Dep , th of�T�st­Pif_'.... ..... .... Depth to ground watery;�-._�t.//............___. { ------------- x Description of Soil . , r .................Q ...........--`. .. .. . ..................................................... ^� 4J�' W �_... .------•-•••••-------- -` C VNature of Repairs or Alterations—Answer when applicable..._._...'....... 1, ------------------------------------------•-------------------------------••..--------------........-•-•....-----.... ------•---•-•••----•-----•-•-••---••--••------•---•--•--••--.....-•-•........... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issue the board of h t igned ----------- Application Approved B .. ... PP PP Y = r Date Application Disapprove f or le following reasons-------------------------------•----•-----------------••---•----------------•-------------=-----.............._ ---------------------••--------------•---•---•--•------------------------....-------•---......-------•----------------•--•-•----...•-----•••---•••--•-•--------------•-• ••---..._..... Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH V ` ...........OF................ �rrtifirtttle ,af f�unt�littnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( ) by--------------------------------------• �......... ••... ............................................ ---.......--•---......•......-- ------ -�• �•- Install f�� jf i has been installed in accordance with the provisions of TI �yyF 5 of The State Sanitary Code s d rib d in the application for Disposal Works Construction Permit No.. %--"'.& �'dated 1 ............... THE ISSUANC OF THIS CERTIFICATE SHALL NOT BE CONSTRUE S A GUARANTEE THAT THE SYSTEM W //FU CTION SATISFACTORY. DATE--... 11.. .............................. Inspector....... ..... ....--------------------------•---------••----•----•-••-•---•------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE�JALTH/ ` ` No.. � ... ` ...............1..j,�I�/ ':....OF.....................� .. 14.s.�....":e................... FEE....���U...... �i���a�tt1 nrk� �un�#rnr#uan rani/# Permission • hereby granted..................... ' fJ..----••----. Cl. .S.. d rl ---------------.. .. to Construct?) or Repair ( ) an Individual Se rage Disposal System atNo.--•-.....--- •-----...•---......._L .._....C/Vt ..... ---� .... ......._ Street as shown on the application for Disposal Works Construction Permit No........ ..........Dated.......................................... �/--• ..--•............................. Board of Health DATE----•• --Z�a-•-�-- •------ FORM 1255 A. M. SULKIN, INC.. BOSTON s. /VOTE /F EI7,HZR 7WZr SEPTIC TAN AC DR 20 FT M!N - LEACs,/IiYG PIT ARE .MORE THA IV /2"SELOlSI 24'D/AMETEK CONCAPETW CdW& SHALL 8.6 BR006.V7 TO GTADE.�i4N .EXTRA 1F% -0 P/Pr t/E f-1�4 DE CONCRETE'. / M/N. .o/TGN j 1 NEAVy C^ST IRON Co R .S LL USED CL_. S /F/N DR/VEyi/A Y 1 U 3 , COVER /}�i PFiQ FT 2 JG MiN. CONCRL'TE �A I dAOB CO liER CLEAN SQL O _ L U/D 9 z LAYER ,- ._ - � . 0 0 GAL. • • . . • . • • • s • WASHED 5rolvE D1ST. � � • • • . • • • ea %'PEJs 1T. SEPTIC TANfC • s • t '• • BOX • t 8 • • • • •` o . • • vim- • o ` * ► •0 314 d • • •EFFECT/✓E r-,Eaou o t • DEPTt/ •'.• t ' • to v WASHED STOXE * :e • D PRECAST SnwmaE /73 • e. • • • • • • • • • t D •oa 443 GA L/v +Y a • . • • . • . . • e o P/7 DR �V/V. INVPR'T �LEVAr14IKS l/� �►PA�r.-ry a c—�. 9 Z•7 6 FT: D/AM. /JiIYERT AT a!//LD/NG �od S."FT f.•2 FT. D/AJ+�• C(.SEE Tr�Bt�A..aTJON�. !NL ET .SEPTIC T.4NK 99.0 FT.,' dtJTLET SEPTIC Ti4NK �FT 6R0vlVD J AYT 7, J/V,CET D/STR/B!/TtDN BOX T 7 FT SECT/ON O F 0&7zLLTD/STR/Bf/T/ON BOX FT. SEWAGE 015A0$A.1. 5 STEM //Y.C6c 7r LEACH 1,VG P/T 6-�FT. EA TAQ�/LI�TION CH//VG PIT DJMENS/ON A 2' DES/G1Y C14/TER/fit $CALF : /4 /`.o' p/J+f,F/vs/ON 8-3- D/HENS/ON C�` _FT. �iN• Nt/MBER.OF BEDRo4MS. . 3 G..ReaGED/sPosAL uv/r tyon�E SOIL. LOG SOIL TEST __ TaTAL.EST/Mt�iTED. FLOi4/_13� G.4L.�0.4Y' SOIL. TEST 0/ SOIL TEST*2 Z �3 ,7 VUMBEr OF:4&rACJV/Nl: P/T,S � f`ELE✓. �"ELEY. OATF OF SOIL TEST tz S/LSE.LEACH/NG PER P/T. Sf FT. RESL/LTS iVJTNESSED BY`� `J� y r� /13 PE/�COLAT/ON RATlf / L-=S.S AVA41JNCH ®OTTOM LEACN/NG Pl°R PJT $Q.. FT. o- L.-v 4 �r • ;'TOTAL LEAGN/NG:AREA . 2`f's SQ FT. 'b 5 e-'/3 P1ENCOLAT/ON RA7,F AZ T' '''r', MJN.f/NCN R6SBR►/E LG'N/NG AREA 2�{ SQ• FT. r. S r !/ r SviL 'resT P - Z3 47 OF r,��Ss'c r- / 3 ' �p ��%tJ miV hi% p ,.rMORSE �' S<tN'D, 3' No.1095.1 O y < AP � 9 �� EL DREDGE ENG1AlAWR/A% CQ,ING. 1 . 90 FGiSTEe` ��`` 712 1gAJN .S'F HYANN/3, AfASS. .. �.� �sRFONAI T � /.ENT' �l gL.crV�/ A GRO UNO yt/ATER AT l�LEt! .lOd /Vd. F3 22 �, SHEET O/a f l 154 .5; • R= a &oe c ` y ' \� 'nJk A. o MORSE sn F q 00,10951�O 3� , ZN >'a ! ,y'b :4 �•`/,ir /S•[ ',f;- A9��G15'(EP �'�� to 0 2• 2�l Y 301 c!1 % lu -i o t►� ? ` N. ROBE �✓ t 9r OR UC E `�i4. g ELD.RE ►0 STS LEGEND � r- CERTIFIED PLOT PLAN .EXISTING '�APOT ELEVATION Ox0 "I$TINA 'CONTOUR ---.0 -� �;4, :p,� 5 PIMISMED : :SPOT ELEVATION '. w' `/ 1A k f!"I 10HEt? CONTOUR. R --�-- � - s APPROVED r bOARD OF HEALTH E AGENT ' + BCALfE+ : /. � .4.0 t)ATE� y t ' :IL NEDSE �ENQ/NEER/NQ CQ fly CLa_ -NTH I .CERTIFY .THAT " THE `PROPOSED . EOIST RE REAISTEAK JOb :NO: 3�. " .O.UILDINO '8HOWN ON .;THIS PLAN CIVIL 'LAD `,. CONFORMS; ,TO THE ZONING' ' 'LAWS": OF IM NSTA®LE, MASS. 112 MAi VSTREEY ' 44 5 A.M N ! q.. M P,di SR. : .IA Gal 4RM wl. ! �.:.t.ar.•': t..- , � �w+r: a n -". �.a.e!c.r.�.. ..,,, _ a COMMONWEALTH OF MASSACH USETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION v JAN 0 6 2004 TITLE 5 TQVt'N OF BARtvSTABLE OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT`S DEPT. SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: `. '.� 77 � MAP Owner's Name: i11?—z1_MN:S M I Lk PARCEL , Owner's Address: � DruLOT S Date of Inspection: Name of Inspector:(please print) Company Name: h Mailing Address: • �36� Telephone Number: — "'as"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 15340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 1 e The system inspector shall submit a copy of this inspection report to the Approving Authority DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 •Y gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This in does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 Page 1 r Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: k4KN— Date of Inspection: L a.-�B 4—o`3 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A.System Passes: , I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: Aj 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 a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box..System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Ihm_)^6 uxJ Q Owner: Date of Inspection: 12—W^e S C. Further Evaluation is Required by the Board of Health: 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 15303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety-and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. F 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 6/1.5/2000,'.; Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 76 5ik►AkAi.-riew "ow)0 Owner: t f-' V M441410,,e Date of Inspection: 16k 0� 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 A Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ -Z Liquid depth in cesspool is less than 6"below invert or available volume is less than'/s day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped— Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓�Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓1Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓�Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.[This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] 0 Q (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: /V A To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either`yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply — _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead.Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Title 5 Inspection Fdit-6/15%2000 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: "76 Swly 'F_Iyeu, e Owner: QA*-y- M Date of Inspection: 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 _ JeLf^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) AZ_ Was the facility or dwelling inspected for signs of sewage back up? Z _ Was the site inspected for signs of break out? ZWere 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 tthhe baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? JL 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: Yes no IZ _ Existing information.For example,a plan at the Board of Health. _ -Z 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 6h5%2000` r Page 6 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: u-�i{-eVN r Owner: ke les 'f1r1&A-0-5®n- Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):—1 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 33ogD Number of current residents:_ Does residence have a garbage grinder(yes or no):�® Is laundry on a separate sewage system(yes or no):&a®[if yes separate inspection required] Laundry system inspected(yes or no):AJ-4 Seasonal use:(yes or no):h® Water meter readings,if available(last 2 years usage(gpd)): t_ Sump pump(yes or no):AO ' Last date of occupancy: COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): epd 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: W-Q Was system pumped as part of the inspection(yes or no):ALO 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) _Tight tank _Attach a copy of the DEP approval —Other(describe): A=oxim�ate age of all components,da a installed ' known)and source of information: Were sewage odors detected when arriving at the site(yes or no):60 _` Title-5Inspection:Form 6/15/2000 ,;' 6 "' Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: IV W10 R� Owner: PeAe-Ir- ffi& 4.&_"0aa Date of Inspection: l,_ ©` BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron ✓40 PVC_other(explain): Distance from private water supply well or suction line: 0®-4- J-&AA Comments(on condition of'oints,venting,evidence o leakage,etc. SEPTIC TANK:1/ (locate on site plan) �t Depth below grade: _ Material of construction:concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions:_;J^1-z X o! Sludge depth: 1 " Distance from top of sludfe to bottom of outlet tee or baffle: e�,� Scum thickness: l^")r Distance from top of scum to top of outlet tee or baffle: AJ A Distance from bottom of scum to botto?An of outlet tee or baffle: _ How were dimensions determined: AS • rvA AC4-,*eY. es= Comments(on pumping recommendationi,inlet and outlet tee or baffle condition,structural integrity,liquid levels at to outlet invert,evidence of leakage a .): pN ©A) r- � ry '���Q < r AtL N r GREASE TRAP:&locate on site plan) Depth below grade:— Material of construction:_concrete_metal_fiberglass polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Title`s Inspection Foi-i`6/TS%2000 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: No&wlu-t k rNftu 4ewu QJ Owner: P�2A-e0-- Date of Inspection: 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/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: Z(if present must be opened)(locate.on site plan) F� Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of 1 e into or out of box,etc.): n b a n4-0 5 �N 3 O ®U4e_r- 5 La-® L- -rIQ'J jA PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Titfe:5:.Irispection;Form'6115/20Q0 - _ 1 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner 00_A v nd Date of Inspection: 11 -'6a--®`3 SOIL ABSORPTION SYSTEM(SAS): ✓ pocate on site plan,excavation not required) If SAS not located explain why: leaching pits,number: Q t- _leaching chambers,number: _,leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: —overflow cesspool,number: —innovativetaltemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): CESSPOOLS:Iv 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: (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.): Ti&5 Inspection Fo—`6/1572000 i .. _ r Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 776 5aa&�A m A�owu iz,� Owner: MA4W Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public.water supply enters the building. -BA e' AA 09 CD A A 6 3 3'--6 " r2 AC- 39 !. 8 .9 1BA 6C 3 ► Gil ,_.. .. . �..•. .. • to ,., Tifle:'S Inspection Fotm•611:5120Q0 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: _]�O 5"i Jr Owner: Date of Inspection: 1 A-.80-0 3 SITE EXAM t'�ope Surface water Check cellar Shallow wells Estimated depth to groundwater.) 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: 67 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 elevatio ,t U s G3 d1� - , tea c:, a , Tit1e'51nsneeti6n Form'6/15%2000 , r VEO Y 2000 , COMMONWEALTH OF MASACHUSETTS H >H&q EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS ,DEPARTMENT OF ENVIRONMENTAL PROTECTION is r"3 ONE WINTER STREET BOSTON MA 02108(617)292-3500 "-t 'u v TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Govemor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 76 SANTUIT NEWTOWN RE MARSTONS MILLS, MA 02648 M031•R 4�� d61 1 Name of Owner MARTIN KENGER Address of Owner: 14 QUAIL RUN ACTON MA.01720 Date of Inspection: 4/10/00 Name of inspector: JOHN GRACI I am a DEP approved system inspector pursuant to Section 15.340 of Tide 5(310 CMR 15.000) Company Name: SEPTIC INSPECTIONS Mailing Address: P.O.BOX 2119 TEATICKET,MA.02636 Telephone Number: 608-664-6813 FAX 608-664-7270 CERTIFICATION STATEMENT 1 certify that I have personalty 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 Evaluay*pniBy the Local Approving Authority Fails Inspector's Signature: Date:4/21/00 The System Inspector shall sub it a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 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. NOTES AND COMMENTS "The inspection is based on criteria defined in Title V code 310 CMR 15.303.My findings are of hour the system is performing at the time of inspection.My inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life." i THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING THE SYSTEM NOW AND MAINTAINED EVERY TWO YEARS. revised 9/2/98 Page 1 of 11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 76 SANTUIT NEWTOWN RE MARSTONS MILLS, MA 02648 M031 P004 Name of Owner MARTIN KENGER Date of Inspection: 4/10/00 INSPECTION SUMMARY: Check A, B, C, Of D: A. SYSTEM PASSES: X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all Instances.If"not determined",explain why not. nLa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance attached)Indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank, ,whether or not metal,is 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 complying septic tank as approved by the Board of Health. n& Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or 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 levelled or replaced n& 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 revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 76 SANTUIT NEWTOWN RE MARSTONS MILLS, MA 02648 M031 P004 Name of Owner MARTIN KENGER Date of Inspection: 4/10/00 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 IN ACCORDANCE WITH 310 CMR 15.303(1)(b)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 surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis 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,Method used to determine distance n&(approximation not valid). 3) OTHER n/a revised 9/2/98 Page 3 of 11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 76 SANTUIT NEWTOWN RE MARSTONS MILLS, MA 02648 M031 P004 Name of Owner MARTIN KENGER Date of Inspection: 4/10/00 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described 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. Yes No X Backup of sewage into facility or system component due to an 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 cesspool is less than 6"below invert or available volume is less than 1/2 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 Q. - X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. - X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. i - X Any portion of a cesspool or privy is within a Zone I of a public well. - X Any portion of a cesspool or privy is within 50 feet of a private water supply well, - X Any portion of a'cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: The follov67ng criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No - X the system is within 400 feet of a surface drinking water supply - X the system is within 200 feet of a tributary to a surface drinking water supply - X 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) i The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further Information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 76 SANTUIT NEWTOWN RE MARSTONS MILLS, MA 02648 M031 P004 Name of Owner: MARTIN KENGER Date of Inspection: 4/10/00 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X - Pumping information was provided Iby the owner,occupant,or Board of Health. X - None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period. Large 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.The size and location of the Soil Absorption System on the site has been determined based on: X - Existing information,For example,Plan at B4O,H, X - Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)1 5.302(3)(b)] X - The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2198 Page 5 of 11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 76 SANTUIT NEWTOWN RE MARSTONS MILLS, MA 02648 M031 P004 Name of Owner MARTIN KENGER Date of Inspection: 4/10/00 FLOW CONDITIONS RESIDENTIAL: Design flow: 110 g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual): Total DESIGN flow: 330 gpd Number of current residents:0 Garbage grinder(yes or no):NO Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no): NO Seasonal use(yes or no): YES Water meter readings,if available(last two year's usage): n/a gpd Sump Pump(yes or no): NO Last date of occupancy: n/a COM MERCIAIJINDUSTRIAL Type of establishment: n/a Design flow: n/a gpd(Based on 15.203) Basis of design flow:n/a 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: n/a Last date of occupancy:n/a OTHER: (Describe) n/a GENERAL INFORMATION PUMPING RECORDS and source of information: n/a System pumped as part of inspection:(yes or no):NO If yes,volume pumped n/a gallons Reason for pumping:n/a 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract _ Tight Tank Copy of DEP Approval Other:n/a APPROXIMATE AGE of all components,date installed(if known)and source of information: 1984 Sewage odors detected when arriving at the site:(yes or no). NO revised 9/2/98 Page 6 of 11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 76 SANTUIT NEWTOWN RE MARSTONS MILLS, MA 02648 M031 P004 Name of Owner MARTIN KENGER Date of Inspection: 4/10/00 BUILDING SEWER:X (Locate on site plan) Depth below grade: 12" Material of construction: _ cast Iron _ 40 Pvc X other(explain) Distance from private water supply well or suction line: n/a Diameter: n/a Comments: (condition of Joints,venting,evidence of leakage,etc.) THE WELL IS 100+FEET TO SYSTEM SEPTIC TANK: X (locate on site plan) Depth below grade: 4" Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other explain: n/a If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO Age: n/a Dimensions: 1000G L 8'6"H 5'7"W 4'10"" Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: 24" Distance from bottom of scum to bottom of outlet tee or baffle: n/a How dimensions were determined: MEASURED 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.) THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING NOW AND EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. r;. GREASE TRAP: _ (locate on site plan) Depth below grade: Na Material of construction: _concrete_ metal_ Fiberglass _ Polyethylene_other Explain: n/a Dimensions:n/a Scum thickness: n/a 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 n/a Date of last pumping: n/a 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.) n/a revlsed 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 76 SANTUIT NEWTOWN RE MARSTONS MILLS, MA 02648 M031 P004 Name of Owner MARTIN KENGER Date of Inspection: 4/10/00 TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: n/a Material of construction: _concrete_ metal_Fiberglass _Polyethylene _other Explain: n/a Dimensions: n/a Capacity: Na gallons Design flow: n/a gallons/day Alarm present: NO Alarm level:N/A Alarm in working order:NO Date of previous pumping: n/a Comments: (condition of inlet tee,condition of alarm and float switches,etc.) n/a DISTRIBUTION BOX:X (locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments: (note if level and distribution Is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) THE DISTRIBUTION BOX IS STRUCTURALLY SOUND.SYSTEM SHOWS NO SIGNS OF FAILURE. PUMP CHAMBER: _ (locate on site plan) Pumps in working order:(Yes or No): NO Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) n/a revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 76 SANTUIT NEWTOWN RE MARSTONS MILLS, MA 02648 M031 P004 Name of Owner MARTIN KENGER Date of Inspection: 4/10/00 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: n/a Type: leaching pits,number:(1)1000 GAL 6'X 6' leaching chambers,number: (n/a)n/a leaching galleries,number: (n/a)n/a leaching trenches,number,length: (n/a)n/a leaching fields,number,dimensions: (nla)n/a overflow cesspool,number: (n/a)n/a Alternative system: n/a Name of Technology: n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT APPEARS TO BE FUNCTIONING PROPERLY,THE SYSTEM SHOWS NO SIGNS OF FAILURE.THE PIT WAS EMPTY AT THE TIME OF THE INSPECTION. CESSPOOLS: _ (locate on site plan) Number and configuration: n/a Depth-top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer. n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater: n/a inflow(cesspool must be pumped as part of Inspection)NO Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n/a revised 9/2198 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 76 SANTUIT NEWTOWN RE MARSTONS MILLS, MA 02648 M031 P004. Name of Owner MARTIN KENGER Date of Inspection: 4110/00 SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) i FC Il. I O�A 1 V 11J .0 C a AA AC 3y p9 50 (� l revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 76 SANTUIT NEWTOWN RE MARSTONS MILLS, MA 02648 M031 P004 Name of Owner MARTIN KENGER Date of Inspection: 4/10/00 NRCS Report name: n/a Soil Type: n/a Typical depth to groundwater: n/a USGS Date website visited: n/a Observation Wells checked: NO Groundwater depth: Shallow_ Moder3te_ Deep_ SITE EXAM _ Slope _ Surface water _ Check Cellar _ Shallow wells Estimated Depth to Groundwater 12 Feet+ Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS-12+FEET revised 9/2198 Page 11 of 111 CERTIFICATE OF ANALYSIS Page: 1 Barnstable County Health Laboratory Report Dated: 7/7/2005 Report Prepared For: Order No.: G0531301 Alene Sibley 76 Santuit-Newtown Rd. Marstons Mills, MA 02648 Laboratory 1D#: 0531301-01 Description: Water-DrinUng Water Sample#: 31301 Sampling Location: 76 Santuit-Newtown Rd.Marston Mills,Ma Collected: 6/30/2005 Collected by: A.S. Received: 6/30/2005 Test Parameters ITEM RESULT UNITS RL MCL Method# Tested LAB. Metals Hardness 1.8 mg/L as CaCO 0.1 SM 2340B 6/30/2005 Sodium 95 mg/L 1.0 20 SM 311113 7/5/2005 LAB: Physical Chemistry pH 8.4 pH-units 0 EPA 150.1 6/30/2005 Sodium level is above the maximum contaminant level. Those on a low sodium diet may wish to consult a ph sician. Approved By: Lab Director) C _ co y U � C:) co crl m RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605