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Home My WebLink About0081 SASSAFRAS LANE - Health 81 Sasafras Lane Marstons Mills TOWN OF BARNSTABLE LOCATION S 1 Sa$S0A'rw S LN SEWAGE# 01o)q - ZZO VILLAGE (VJars40nS fYl;11$ ASSESSOR'S MAP&PARCEL '*'0 INSTALLER'S NAME&PHONE NO. B g EXCaU,_4; oA S►`77- O653 SEPTIC TANK CAPACITY on) 1( f LEACHING FACILITY. (type) (size) NO.OF BEDROOMS OWNER PERMIT DATE: l COMPLIANCE DATE: it I 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 M FURNISHED BY A 30r ya* AZ-39 REAR i 32-48' A3.3G, t83-GZ A4- 60' (D _ o Town of Barnstable Barn Regulatory Services Department Public Health Division Q D 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL #7012 1010 0000 2851 July 16, 2014, 2014 Anne Marie Mrozinski 81 Sassafras Lane Marstons Mills, MA 02648 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 81 Sassafras Lane, Marstons Mills, MA was last inspected on 6/17/2014 by Matthew Gilfoy, a certified septic inspector for the State of Massachusetts. The inspection of your septic system showed that the system "Conditionally Passes" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: • Distribution box in poor condition and should be replaced You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Ltr not sent—work in progress. — permit 2014-220 Thomas McKean, R.S. CHO Q:\SEPTIC\Conditionally Passes Ltr\81 Sassafras Lan MM Jul 2014.doc Agent of the Board of Health TM/sc Q:\SEPTIC\Conditionally Passes Ltr\81 Sassafras Lan MM Jul 2014.1oc ao q d4 Commonwealth of Massachusetts Title 5 Official Inspection Form 9bT3 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 Sassafras Lane Property Address Ann Marie Mrozinski Owner Owner's Name information is Marstons Mills Ma 02648 6-17-14 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. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Matthew Gilfoy use the return Name of Inspector key. B & B Excavation,lnc. rs� Company Name 14 Teaberry Lane Company Address Forestdale MA 02644 City/Town State Zip Code 508-477-0653 SI 13640 Telephone Number License Number ra n B. Certification I certify that I have personally inspected the sewage disposal system at this address!and that ttLe information reported below is true, accurate and complete as of the time of',the inspection. Their specn was performed based on my training and experience in the proper function 'and maintenance of Qn sitff� sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.3-4�of �i Title 5(310 CMR 15.000). The system: ❑ Passes ® Conditionally Passes ❑ Fails 'J ❑ Needs Further Evaluation by the Local Approving Authority 6-18-14 Inspect '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. Logged -1-101 ii t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 a� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 Sassafras Lane Property Address Ann Marie Mrozinski Owner Owner's Name information is required for every Marstons Mills Ma 02648 6-17-14 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: ❑ 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: ® One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 i 1' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,..' 81 Sassafras Lane Property Address Ann Marie Mrozinski Owner Owner's Name information is required for every Marstons Mills Ma 02648 6-17-14 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): D-box in poor condition and must be replaced. ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 Sassafras Lane Property Address Ann Marie Mrozinski Owner Owner's Name information is required for every Marstons Mills Ma 02648 6-17-14 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: i I **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow t5ins•1 Ill 0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 GA Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 Sassafras Lane Property Address Ann Marie Mrozinski Owner Owner's Name information is required for every Marstons Mills Ma 02648 6-17-14 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 I® i h Commonwealth of Massachusetts - Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 Sassafras Lane Property Address Ann Marie Mrozinski Owner Owner's Name information is required for every Marstons Mills Ma 02648 6-17-14 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 Sassafras Lane Property Address Ann Marie Mrozinski Owner Owner's Name information is required for every Marstons Mills Ma 02648 6-17-14 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ❑ No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 81 Sassafras Lane Property Address Ann Marie Mrozinski Owner Owner's Name information is required for every Marstons Mills Ma 02648 6-17-14 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: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 Sassafras Lane Property Address Ann Marie Mrozinski Owner Owner's Name information is required for every Marstons Mills Ma 02648 6-17-14 page. Cityrrown State Zip Code Date of Inspection D. System Information Approximate age of all components, date installed (if known) and source of information: 11-1989 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 216„ 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.): At time of inspection building sewer appeared to be in working order no sign of leakage or blockage. Septic Tank(locate on site plan): 2' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ® No Dimensions: 1500 gal Sludge depth: 6„ l5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 Sassafras Lane Property Address Ann Marie Mrozinski Owner Owner's Name information is required for every Marstons Mills Ma 02648 6-17-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 12" Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 7" 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.): At time of inspection septic tank appears to be structurally sound. No sign of back-up. Tank should be pumped for maintenance and again every two years. 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 um in P P 9 Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '( 81 Sassafras Lane Property Address Ann Marie Mrozinski Owner Owner's Name information is required for every Marstons Mills Ma 02648 6-17-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 I f - Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 Sassafras Lane Property Address Ann Marie Mrozinski Owner Owner's Name information is required for every Marstons Mills Ma 02648 6-17-14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box in poor condition and should be replaced. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 81 Sassafras Lane Property Address Ann Marie Mrozinski Owner Owner's Name information is required for every Marstons Mills Ma 02648 6-17-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 I' ❑ 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.): Leaching consists of two 6'X6' pits. One pit has no effictive leaching remaining and the other has 4'6" of leaching remaining. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 Sassafras Lane Property Address Ann Marie Mrozinski Owner Owner's Name information is required for every Marstons Mills Ma 02648 6-17-14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 Sassafras Lane Property Address Ann Marie Mrozinski Owner Owner's Name information is required for every Marstons Mills Ma 02648 6-17-14 page. Citylrown 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 .. A O O At AZ - 3a' 6Z - LAS A4 . so qi t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 Sassafras Lane Property Address Ann Marie Mrozinski Owner Owner's Name information is required for every Marstons Mills Ma 02648 6-17-14 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 high ground water: No GW @14' 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: Aug 8-1988 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 one file at BOH Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 I Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .' 81 Sassafras Lane Property Address Ann Marie Mrozinski Owner Owner's Name information is required for every Marstons Mills Ma 02648 6-17-14 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 No.�v r I�k OGV Fee V" THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS es 2ipfitation for Disposal *pstem Construction permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System �[Individual Components Location Address or Lot No. �� _55 - Ln Owner's Name,Address,and Tel.No. /� Assessor's Map/Parcel 047 r do y A0 P Q I'Z-r- k t Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 2_0 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board a cSigned Date Application Approved by / r Date R Y� Application Disapproved by Date for the following reasons Permit No. oq y _a&b Date Issued 61 Cf -- CC _ %� No.C� �� ` � � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. I-ef PUBLIC HEALTH DIVISION — TOWN OF BARNSTABLE, MASSACHUSETTS Yes fipfication for Misposal *pstttn `construction vermit Application for a Permitt to'Construct(' ) Repair(,.,) Upgrade( ) Abandon( ) ❑Complete System individual Components Location Address or Lot No. 8 �'J ssa&L5 L 1 Owner's Name,Address,and Tel.No. ((`` Assessor's Map/Parcel 3 7 3 �' TOnV —AO P a.G Z-e cvs k� Installer's N e,Address,and Tel.No. Designer's Name,Address,and Tel.No. `_� X L�VG�fransa -�177-b�53 1A Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design•flow provided gpd Plan Date Number of sheets Revision Date Title �,. Size of Septic Tank Type of S.A.S. Description of Soil i Nature of Repairs or Alterations(Answer when applicable) o y( Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5,of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by thisi Board a Sgnn�ed, _ Date Application Approved by / r Date Application Disapproved by Date for the following reasons Permit No. oZ0 Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS -N2,Cj 6 -bpy (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired('�) Upgraded( ) Abandoned( )by at ( 1 S 5-5 G ( S LG n P ([Shas been con c�eyd in a o dance with the-M ions of Title 5 and the for Disposal System Construction Permit N . ( ated Installer �� Designer #bedrooms Approved de flow ,� gpd The issuance of this permit shad t ,e const ed as guarantee that the system on as designe Date '/� f^) Ins ector ��J,%? _._,,..•-' ,f�, 't ''-' - - -------------------------------------------------------------------- = -- _ --------------- --------------------------------------- - No. a G I`4-o(a� Fee, 410t THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS ]Disposal *pstem Construction J)trmit d,.j3Q� Permission is hereby granted to Construct( )j Repair( ) Up ade( ! (Abandon( ) System located at C91 � Q-4 V and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:-Cons ctio must be completed within three years of the date of this permit. Date % Approved by {i't C c 6 / TOWN OF. BARNSTABLE I CATION 4eil SEWAGE #04 VILLAG �1 ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO.i z, SEPTIC TANK CAPACITY r LEACHING FACILITY:(MO � � s' / -(size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PER ISSUED: � 145V '` e f DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No G � No.. ..Ca. Fzcs..... ,,'.......` THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH 7i!4.r1...................OF...... Applirativaa for Diapas al Wurkii Tomitrurtiun rumit Application is hereby made for a Permit to Construct (x) or Repair ( ) an Individual Sewage Disposal System at: .... - -- _s i�--S ---------•--Q � .. •-------•-----------........--•- - n-----....MtrnsM Location-Address or Lot No. P,a . fox.._ �9. .................•-----------••----•----.....-------•-------------------•-----•- - - caner Address W Installer � Address _t, U Type of Building Size Lot.A?�!�P.._"....Sq. feet Dwelling—No. of Bedrooms..:s...............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building _Red_•_______________ No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other fixtures ------------------------•----------•------------•---------•-•••••--•------•-•-----•-•._....-•-.....------•-••---•--•--•••••......-•-•-••••...._.••---- W Design Flow............ 5..........................gallons per person per day. Total daily flow....`�4 .........gallons. WSeptic Tank—Liquid capacity.►SeO..gallons Length`i.°..!P..... Width__.5...._..... Diameter................ DepthAP_'.1011 x Disposal Trench—No..................... Width............ Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-------1__._______-- Diameter.....10.......... Depth below inlet_!'.5........ Total leaching areal q VS...._..sq. ft. Z Other Distribution box ()() Dosing tank ( ) a Percolation Test Results Performed by.... euo-b?...........Mq$................................. Date.7/Z.W _../............... Test Pit No. 1....K3�n---minutes per inch Depth of Test Pit...j ._........__ Depth to ground water__Nd-A._-______._. f4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-_..________•__---..____ a --------------------------------------------- ---- ---------------------......------------........................................ Description of Soil c4 » Tom° °!�...--��Ann--- .5 PMd f " M'KedA`� / U --•-•-•-•-•..................•-------•-------•--•--...-•----•----•-•-------------••-------...----•------...-•--•-•--•••--••••-•-•---•--- W UNature of Repairs or Alterations—Answer-when app�cable.-___________________________•--__-_-_______-_-•-•-•__-_--•-_----__-_-______-___-•---•---------. ........................................................... ----• -----------------------------------•---------...---------------•-•----------..•....--•-•---- Agreement: The undersigned agrees to inPtatheNaf(5-redescribed Individual Sewage Disposal System in accordance with the provisions of T i..i; 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. n� Date Application Approved By--••••....... - .�... -.L.i�.►.s. ---------- ^-- Date Application Disapproved for the following reasons:-------•-------•---------------------------------------•----------...---------------------•-•-•-------•--.•--- r ..--..-•---•-----•---------------------•----------•-----•-.-•..-------_------------------------ 0 0 Date PermitNo.•-•.............•----•-.._......�....:............. Issued....................................................... Dsxz Fim \ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH i. :-- ...................OF......'C�k4 �� 5'l� �1 . A4141firation for Bispiial orkri Tottstrnrtion " unfit Application is hereby made for a Permit to Construct (n) or Repair ( ) an Individual Sewage Disposal System at: .? Z 5 � . � ; . � •. t � ..... -__....-_. ....._ .............. --------•- _ ..•...----- - -•---•---•-•-------------•-•-----.•....------....-•------•-----•----- Location-Address or Lot No. .... ^ _--- - ��.......--.�?..... `.....1-----------------------------------------•-----------------.....------------------...------ I Owner t Address ►W-a �_ I J :.--__ i f_F•C O�/)- x rl' PQ Installer Address UType of Building Size Lot_.1 v.�:.��.....�---..Sq. feet Dwelling—No. of Bedrooms.�S!.�.`.• ...........................Expansion Attic ( ) Garbage Grinder ( ) No. of persons............................ Showers — p-, Other—Type of Building _��-�_________________ p ( ) Cafeteria ( ) QI Other fixtures .----•-•--•-•---••------•--•-- - W Design Flow............................................gallons per person per day. Total daily flow......"4 P... ............................gallons. WSeptic Tank—Liquid capacity_l_5�9..gallons Length l'.+�;..... Width."!-S'.A....._ Diameter................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No-------k------------ Diameter-----!Q...._..__. Depth below inlet.M.-_5......... Total leaching area %.......sq. ft. Z Other Distribution box ()Q Dosing tank ( ) aPercolation Test Results Performed by �KOc_o_lb __._.._... 19Y>.................................. Date_7/2.&/- ............ Test Pit No. 1_.._�.?:....minutes per inch Depth of Test Pit---I`............... Depth to ground water__j�/6------------- fs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....................... Ix ------------------------------------............................................................................................. O Description of Soil .i S o .�� ..�l n C ? --_( rt! C.1 n. !' - 1 N p ?.... 1 ---•-----------•--•--•-•- W UNature of Repairs or Alterations—Answer when applicable................................................................................................ Agreement: e"� o The undersigned agrees to install tfie afo:edescribed Individual Sewage Disposal System in accordance with the provisions of'T: 4: p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signedm �� t��4a�<� 4�► 4 \t Date Application Approved By-•-•• ^r" . ,�..,:�= ..................... Date Application Disapproved for the following reasons------------------•--------------••---------------------•--------------------------------...................... ..............•------------•----------•----------•-•---------.....-------•----•----------...---------•--.-•--------...---•-•------•----------•------•-------•------------•--.....•----------•-•••------- Date PermitNo....... .......................I------------------ Issued..................................................... L;.t.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....�off?. ......................O F....... c�� n S t`f ` .................................. C_Errtif iratr of Tout pliatta THIS IS TO CERTIFY, That the Individual_Sewage Disposal System constructed ( ?Q or Repaired ( ) t tC.1�- � � S �•r, t�� by----- { �..... ---- ((.'.._.. -------------------------------------------------------------------Il---.....--............----..........------------------. at.......-k-C?-'. ........5�-5S_4-Tr A 1'�..._ Instalgr , H t T --------------•-•------- (V� ---------- has been installed in accordance with the provisions of T I T IE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No._.....r�r___:___. ..... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE._...__... 1.- `..- p..._.. Inspec ` .. �.v THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH 0 uJ C� '. '1....................OF......`.>c"1 r) `a"'t�'f)VJ(`p ,,,,s,,................._............ \TO.. ... ..�?. FEE./7 ......-- _. Disposal Works Tonstrudion motif Permission is hereby granted..- =�'•S ---* c-- Ire �•-- ............................................. ------ to Construct (1,) or Repair ( ) an Individual Sewage Disposal System at No...3�- -S S S�i-Fc�F1.S.. .(Tr- ...:._.. street �7 /s as shown on the application for Disposal Works Construction Permit No..__.___>�5 9 Dated.......................................... ............................... ---------------- DATE---...-- ............................................ Board of Health FORM 1255 HOSES & WARREN, INC., PUBLISHERS AsBuilt Page 1 of 1 �0',jx TOWN OF. BARNSTABLE LOCATION �rJl # ✓�.� r�S_ _ SEWAGE # VILLAGIQ t ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO.�), SEPTIC TANK CAPACITY LEACHING FACILITY:(type) y� �� (size) lr y NO.OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER�y �� `.-r ••z y� DATE PERMIT ISSUED: DATE COZiPLIANCE ISSUED; VARIANCE GRANTED: Yes No G � http://issgl2/intranet/propdata/prebuilt.aspx?mappar=043073&seq=1 6/17/2014 CE 25 SPA 28° 53' 40" W 8rS —77 OPY., LOT 32 � o TAW o 30 Bp � : 00 34 N N Y� 4 � 34 .hh cr i Co f A _ /20.00 R 60.00 j 90 �- rFsT SA SSA FRA S L A NE 4 _RES ZONE "RF 0 /0 20 30 FLOOD ZONE "C" �� ,r PLAN_REF: 448188 I I �� A f �•.� ' 4 rop OF Far kG4 TAow . .f CONCRETE COVEW COAC ETr GLOVER av EL 9.0 4"schoatdr. 40 PVC ARST STGhE NVERT NVFIPT ;f •�• PI�JECy/ST INVERT ... EL87.5 S�'T1C rAAK Ez. B7.J4 6 < < Ma�lhp p4► O EL 3/4" toGAL. ovvmr AVER timr 6' < :� WAShW EL. 87.3 - EL iLii • EL. •r ••• STONE EL JraW l0' S' lO' --4-- ...6' --4•' I � S � 4 EL : PROFILE OF �s• e � AV GRO" WA rM TABLE SEPTIC SYSTEM ( : . SOIL L OG DAB .7128188 A�R 599B GENERAL NO TES T tiacE TOWN WA MRrEs . 90. - EL Er. I TAIS DESIGN DA 'TA 3-6' CLA Y I M ac-am wowCIPD •y a TOTAL FLOWT BOTTOM LEA CMW AREA a f'T. sM LEAQWW AREA 0 sox r ar as. fL=76.O GARsA GE.� l� 9,0 , FT TOTAL LE4CN WG AREA SQ,{ s �— AAa1LFr. PENCt"T)k N RA rE NO WA rW EAxOoGIVnmED _ CAL CGCATIOA ~ i17 Tn i L 2 a Opp e� F ` J p SITE PLAN OF LAND L O CA TED IN ;a �� LOT ,_Ja } BA RNS TA IX E � -: E RED FOR ' r Sr LL;S2Of'\• 4 1 `\McA GROUP. Q w F . RF AU6/JS7` 80 W8 NKEF , UL . A N TS YA UR VE Y 143 ROUTE CONS T S MIL LS MA SS 02648 MAR STON