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HomeMy WebLinkAbout0139 TIMBER LANE - Health 139 Timber Lane (Marstons Mills) 1. TOWN OF BARNSTABLE LOCATION tam 6AZ SEWAGE# d —Q "VILLAGE ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) I Cra1J If al 6 (size) /® Z X 10 NO. OF BEDROOMS . -14a t-ro4zrJ OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 6ee,q�jrA feet Y' Private Water Supply Well and Leaching Facility(if any wells exist { on site or within 200 feet of leaching facility) Q feet Edge of Wetland and L'aching Facility(if any wetlands exist �• _ within 300 feet of leaching:facility). ( OX feet FURNISHED BY r 7 A 143 Oil '� 4 3 ^tinn/. No. .o[D V"! a D �:�-- Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes RppliCotion for 3kgpo al i§p.5tem Con0trUction Permit Application for a Permit to Construct( ) Repair(t Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address,and Tel.No. AAron G3ebb Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. '4�. G,rti� C� �e Sfc,� Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder (Po Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 gpd Design flow provided 3L4 Q gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of SA. `mot `>r z kn%r 1(� r" 5C .�y"'I Description of Soil I Nature of Repairs or Alterations(Answer when applicable) 2 9- Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date CO) Application Approved by YNIN Date og Application Disapproved by: Date for the following reasons Permit No. p��� � Date Issued No. V"1 ;` Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for �hgpo.5al *p5tem Con.5truction Permit Application for a Permit to Construct O Repair( Upgrade( ) Abandon O ❑ Complete System ElIndividual Components Location Address or Lot No. /Ll I_ Owner's Name,Address,and Tel.No. AA on Webb Assessor's Map/Parcel `3cA Ina. �,Add d�es�s and Tel.No. Designer's Name,Address and Tel.No. riJ r.�v %;�Ywg, \.2 c+f kj 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) 33 0 gpd Design flow provided 3y O gpd Plan Date ' ( O`1 Number of sheets , Revision Date Title Size of Septic Tank eX.k 5A Type of S.A.6. `"r r,G (P Description of Soil MC Nature of Repairs or Alterations(Answer when applicable) Date last inspected: 1 Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. p Signed M ��/ _ Date �/~j, ) U //,� Application Approved by � Y +�"�p�-u.� Date 4 t 61 Application Disapproved by: Date for the following reasons r Permit No. V 1 CA Date Issued .. .. -.._.. __. —————— + •�,.�.�.+ir�r ear rrll+wt+raag= - _ .__ .. . — - -�c�sca v-�oo _ oar•.• THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( V_� Upgraded ( ) Abandoned( .)by SeO{A V erg, at 'Ct ­.C..el' has been constructed i acc�or,,ance with the provisions of Title 5 and the for Disposal System Construction Permit No. C� 7 C� ' / dated Installer ��'�N`z�— Designer !SR ` #bedrooms ApprovedQ;indesign ow C C �— gpd The issuance of this permishho construed as a guarantee that the systemun 'o/a � igned. (t-)' Date 1 Inspector x+�+s�.s� �i� am �r+�•a.5� �� �►�t.rstwow��+� +5r•►+pan+R!�+.��rt�r�nr+is.� i�tn�!'r.�+sir• .+��+1�+�!rdi+e+w+Nsweir�+e.���++r:.+�s�. ��� - - Na. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS �Bigoal *p! tem ✓5truction Permit Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) System located at \ 3c( L G,%.IZ f A ^� and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title-5 and the following local provisions or special conditions. Provided- Construction must be completed within three years of the date of this permit. Date I VV Approved by Town of Barnstable �F THE Tp� yP� Regulatory Services Thomas F. Geiler,Director • BARNSTABLE, + �Q "s"SS. Public Health Division v i639• �� ArfDMa+A Thomas McKean, Director 200,Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: c( Q kp� Sewage Permit# _ - Assessor's Map\Parcel Designer: �P t-tE4-_-� k V IS Installer: SCUT- q. 1=p- _ Address: 9 Z3 ,;-� &A Address: i 13 ®L-b On d was issued a permit to install a ( ate) (installer) septic system at �� �, , L C_s LPINp based on a design drawn by (address) !�Z P A. 14AAsi�, PC dated- 3 Qc( (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. OF g b > HEN A. (Installer �ature) CIVIL zro; > (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH. THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNS-TAB LE PUBLIC HEALTH DIVISION. T17 NK YOU. Q:\Septic\Designer Certification Form Revised.doc oF�� Town of Barnstable P# Department of Regulatory Services mMAMRNerABm Public Health Division Date 7 �Ar 1639.�`°� 200 Main Street,Hyannis MA 02601 Eo Date Scheduled ( Time Fee Pd. too ' Soil Suitability Assessment fog- Sewage is os l Performed B y: �5-/L-v Witnessed By: ✓ �N• G,q y� Location Address LOCATION& GENERAL INFORMATION £ Owner's Name n � Address 1 797 Assessor's Map/Parcel: (� n'1cJs'saM<<<Sr l � ' Engineer's Name NEW CONSTRUCTION REPAIR `� S Telephone# Land Use 4 e- Slopes(30) 2- Surface Stones ,Cw Distances from: Open Water Body /t-.4' ft Possible Wet Area A _ft Drinking Water Well 'd�Property ft Drainage Way ft Pro p y Line �� ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) SO, .7—/ 1-4 6 L_ A.0 c Parent material(geologic): ?43 H Depth to Bedrock Depth to Groundwater. Standing Water in Hole: A-)I A Weeping from Pit Pace Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: i( O A-C Depth Observed standing in obs.hole: in, Depth tq sgll mottles: Depth to weeping from side of obs.hole: ln, Index Well# In, Groundwater Adjustment ft. Reading Date: lndex Well level Adj,factor _y_,__ Adj,Oroundwater Level PERCOLATION TEST bate v Time F tion Time at 9" f Perc �Z Time at 6" 7 Start Pre-soak Time @ Time(911•611) � End Pre-soak y Rate Min/inch 7- Site Suitability Assessment: Site Passed v Site Failed: Additional Testing.`Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one (1) week prior to beginning. Q:\S EPTIC\PERCFORM.DOC DEEP.OBSERVATION HOLE LOG # Depth from Soil Horizon Soil Texture Sdil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. onsiste c vel DEEP OBSERVATION HOLE LOGa7e Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistent, %Gra el ,t DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Qnsistency.%G DEEP OBSERVATION HOLE LOG Hole# Depth from, Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders, Consistency.%QMvI Flood Insurance Rate Map: Above 500 year flood boundary No— Yes Within 500 year boundary No Yes Within 100 year flood boundary No f'/ Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious,m�a�terial exist in all areas observed throughout the area proposed for the soil absorption system? ---e:75 If not, what is the depth of naturally occurring pervious material? 4, Certification I certify that on f` S (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the required trainin rtise and experience described in 3 10 CMR 15.017. p Signature Date Q:\S EPTIC�PERCFORM.DOC OCA.T 1-O-N SEW Q_C,.E_P-E.RMIT 1�l_O.: - Z' -- - - T lal`►-�T Ql_l_E R-5-1J-�,NI-E S A D-D R E-S-S 5-U-1-L D-E R-S 1.1-�,1�/l E A D-D-R E-SS D-ATE—CO N�-P-L - 7 �a " _ �s J. ali No.._:�`.y.3....... THE COMMONWEALTH OF MASSACHUSETTS BARD OF HEALTH .............le". ......OF......�,J"Gf.�t(c•STf9,b�. ............................................ Appliratiun for Thgpviial Works Tuttitrurtion Vamit Application is hereby made for a Permit to Construct ( or Repair ( } an Individual Sewage Disposal cati n, d re oNo - ......... --- = �,------------ --------- ,.... ��� --. y 6wner Address a C - -- - ------ - ------•---- --.. ..- ---- . . .. �••--------- . ........................ Installer Address Type of Building Size Lot �. �7 ----Sq. feet .-� Dwelling—No. of Bedrooms;---I------------------------------------Expansion Attic (� Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Pa Other fix�iires ------------------------------------------------------ W Design Flow---------------J-.0-__---_-_____--_-__-_gallons per person per day. Total daily flow.-_--_-----.-�--0z�, __--_------_..__gallons. WSeptic Tank—Liquid capacitAM__gallons Length................ Widtli_ ---- Diameter---------------- Depth.__.-.-.--.----- x Disposal Trench—No________________---- Width-_--__-_-______--__- Total Length-------------------- Total leaching area--------------:-----sq. ft. Seepage Pit No.......!1 D..G_-. Diameter____________________ Depth belo i et__________-___-__- Total leachiii�<trert/_..-__-___-------sc. ft. Z Other Distribution box ( ) Dosing tank ���-�/ 1 Percolation Test Results Performed by-------- ---- ----------•-----•-----•--------------------•-•-•---•---- Date................ ------------------ a Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water.--.----__-_.----_.-__-- r-14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water-----._--__-.----______- a+ pt; •-------- ---14---- --- ' = _ f 0 --- ---- .l Description of Soil °� ��t �., yl c . .. ------.... e:- z . __x ------------- ------- = - V Nature of Repairs or Alterations—Answer when applicable._..-------------------------------------------------------------------------------------------- ----------------------------------------------Agreement: , The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance hAued by t o o r of health. urn Sig e -------° ---- DApplication Approved By----• � ------- --- _ ------------------------ _7""-//t ���� • Date Application Disapproved for the following reasons:----------- ---------------------------------- ------------------------------------- -------------------------------------------------------------------------------------•------------------•-------------------------------------- = Date ' ..... :_ ..-_.....Permit No--------------------------------------------------------- Issued....:i:- --------------- Date No. ....... " FEs....A....�G... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Apliliratinn -for Bi5puiitt1 Works Towitrurtion Vlerntit � / �y a5 Qt'i.Application is is hereb made for a Permit to Construct (���///) or Repair ( ) an Individual Sewage"`Disposal st a IL /+ t' d r o _ /L k r.- ..f3 w.va- • -caner` Address' - a ••... •... . -• . ...... -•........... ... ..... ...•.... ----------- .. ................... p Installer Address �l , Type of Building Size LotW _f 7r-__:_Sq. feet Dwelling—No. of Bedrooms---- ....................................Expansion Attic Garbage Grinder ( )_ Other—Type of Building --------:___________________ No. or persons..__________________.__-_.__ Showers ( ) — Cafeteria P-I Other fi_j lures --•--------------------------- d tt --------- W Design Flow...............�i.lQ....................gallons per person per day. Total daily flow............. -_-_____--....gallons W Septic Tank—Liquid capacityIl�©..gallons Length--------------- Width................ Diameter_..-- .-------- Depth---.....-...� i x Disposal Trench—No..................... Width-------------------- Total Length----_-------------- Total leaching area_-_..._.____---_____sq. I Seepage Pit No......ZJ 0C.. Diameter____________________ Depth beloJ� i et.._ ..__._..__ tal leaclii i area -----se. it.�ww Z Other Distribution box ( ) Dosing tank ( ) —C zv" i��"' j�� �!� Y"� aPercolation Test Results Performed by------ --------------------------------------------------------- Date-------------------------------- W Test Pit No. 1----------------nunutes per inch Depth of Test Pit.................... Depth to ground water............... ►1-4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to grou d water__.._.___-__.._ - _.. D Description of Soil `. ! '110 * -.: J � ----- - jr W ' ---------------------- --------------------°-----------------•----•------------------------•----- ---------•-••--•--•--------- ------------•---.- ------- V Nature of Repairs or''Aiterations—Answer when applicable-----------------------__________ __ ________________________ ________ _______ - , ------------------- -- ---- ----------------------------- Agreement: R r The undersigned agrees to install the aforede ribed Individual Sewage Disposal System in accor " e,with ,. the provisions of Article XI of the State Sanitary C —The undersigned further agrees not to place the tem in operation until a Certificate of Compliance has e ued by t1le llo�r ealth. y t Si ed. M1 . A-jat' Application Approved By...... '' ��,.ter/•........................... Application Disapproved for the following reasons = - .....................-------- ------------------ .� „S Date r.^ Permit No.---•--....••----......•...:............. ------ Issued........................................................ Date G .V THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . . tea-. .........OF..........Al 6164--re.-It--....................................... Y err ifir: #ie gf "'Joutphaurr ._ C IFY, That th Individual Sewage Disposal System constructed ) or Repaired ( _ - ' . ' Installer , Aat.. ---- -- -"..-------... ......... :�-----! -- ... . .----------- has been installed in accordance with the provisions of Article XI of The State Sanitary Code de ibed in the ,,application for Disposal Works Construction Permit No..._...2..�:3................. ate ------ t �' /�`�............ . ,.: .' THE, ISStJAN, E. OF THIS, C. RTIFICATE SHALL. NOT BE CON R EI) A RANTEE THAT THE SYSTEM WILL F CTION SAYISFA�T RY. DATE. Inspector - •- ------- .................................... r' J, THE COMMONWEALTH OF MASSACHUSETTS BOARD OF 11 YALTH , ................ ..... ................ f_ No... •• •- ••• FEE ,! .......... giark n ni#rurti rrutit --- Permission;..i t h ..eby,granted ---- ------ -A,--- -------------------------- to Cons or Re air ( an 'Sndi dual Se e Disposal 0.00 • Street gr as shown on the application for Disposal!Works Construction -No. . .._._ " ated..� .__�� ,-/............. -" / Y G�Gs /�- Bo r o Health d f J • F � DATE--- FORM 1255-,HOSBS IN WARREN. INC.. PUBLISHERS - '2-Vj•l • 2y�' *k�' - •■ ■®■ ■.•■■� ■f■■®�i®moot:■ �1 .� ■� �f�� i �■ ■�� ■MENNEN:No 00 M:�:moommmmoms MN :■.■■■■.■.■■■■■■■.■■■■■■.■.0 NNA NO SN ■ ■i■ J ; //. r ■ ■■M ■ ■ ME ■■■■■■■■■■■■■■■■M. 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Nye■■..■■.■■■■■■..■E..■■■.■■■w..e.■.■■■■N.■.■.■■■■■■■■.■E.■■e■■■■■■e■■■■■■■■■■..■■e■■■■. ■ ■■■■■■■■■.■.■■..e■N■e■■N.■■■■■■e■.■■■.■■eNN.e.■■■■.■■.N■e■■■e.■■■See■■■■■■.■■■■■■■e■■. eE■■.■■■■■E■E■■■■■..■.■■..■.■■.■.■.■■■E■■■■■■..■eee■e.■■■.■e■e■■s■ee�■■.ee■■■■e■■■■■■.e■ ■EMS■■■■■■E■■■.■■■...■■■..■..■■■.e.■.■.■■■■■.■.E.e■■■e.■..■s■■e■■Mee ■■■.■.e..■■■■■■e■■■ ■■■■■E■E■■■E■.■■■■■.■■■■...■.e■■■..■.■■■■■.ee■■■■e■■■e.■■.■■e■e.■■■■e■■■■■■■N■■.■■■e■■E■ eee..■■■■■■■■■.■.■e..■.■■...■■e■■■...e■■■e■■■■■■■■■■.■e■■Ee.e■■■.■■■■■■.■■■■■■.■■■e■■■e■ iiiiiiiiiiiiiiiiiii'■iiiiiiiiMENOMONiiiiiiiiiiiiiiiiiiiiii�■iiiiiiiiiiiiiiiiiiiiiiiiiiii r f COMMONWEALTH OF MASSACHUSETTS M EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION A 4 ti I � � SV TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS 'A SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM 1A PART A 0, �9�' G CERTIFICATION Property Address: 139 TIMBER LANE MARSTON MILLS BARNSTABLE MA.02648 Owner's Name:TRIPLE J REALTY TRUST Owner's Adress:28 ALEWIFE RD PLYMOUTH MA 02360 Date of Inspection_4/19/2001 Name of Inspector: (please print)_PAVED WARD_ Company Name:_WARD T-5 Mailing Address: PO BOX 1934 _MANOMET MA.02345 Telephone Number: 508-224-5749 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000� The system: _ _X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature:: Date: _4/19/2001_ 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. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 139 TIMBER LANE MARSTON MILLS BARNSTABLE MA.02648 Owner's Name:TRIPLE J REALTY TRUST Date of inspection: 4/19/2001 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: YES 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. 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: Page 3 of 11 OFFICIAL.INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICA-nON(continued) Property Address: 139 TIMBER LANE MARSTON MILLS BARNSTABLE MA.02648 Owner's Name:TRIPLE J REALTY TRUST Date of Inspection: 4/19/2001 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. 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: i Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 139 TE%IBER LANE MARSTON NMLS BARNSTABLE NU.02648 Owner's Name:TRIPLE J REALTY TRUST Date of Inspection: 4/19/2001 System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No —X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X— Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than'/day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _X_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _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. [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 anal-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.] NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as — -described in 310-CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or`Sao"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 H of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 139 TEVIBER LANE MARSTON MILLS BARNSTABLE MA.02648 Owner's Name:TRIPLE J REALTY TRUST Date of Inspection:4/19/2001 Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes No X _ Pumping information-was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? _— X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? _ NA— Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS,located on site? _X _ Were the septic tank manhole uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing information.For example,a plan at the Board of Health. X_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 139 TIMBER LANE MARSTON MILLS BARNSTABLE MA.02648 Owner's Name:TRIPLE J REALTY TRUST Date of inspection 4/19/2001 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_3_ Number of bedrooms(actual):_3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330_ Number of current residents 0_ Does residence have a garbage grinder(yes or no):NO Is laundry on a separate sewage system(yes or no):YES_ [if yes separate inspection required] Laundry system inspected(yes or no):NO:PIPES CAPED NOT TO BE USED Seasonal use:(yes or no):NO_ Water meter readings,if available(last 2 years usage(gpd))WELL Sump pump(yes or no): NO Last date of occupancy: 4 MONTHS COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): god 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 NONE Source of information NOas system pumped as part of the inspection(yes or no):NO_ If yes,volume pumped: gallons--How was quantity pumped determined?_ Reason for pumping:_ TYPE OF SYSTEM _X_Septic tank, 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: 1966 PER OWNER + Were sewage odors detected when arriving at the site(yes or no): NO Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 139 TIMBER LANE MARSTON MILLS BARNSTABLE MA.02648 Owner's Name:TRIPLE J REALTY TRUST Date of Inspection: 4/19/2001 BUILDING SEWER(locate on site plan) Depth below grade: 22" Materials of construction:_X_cast iron _40 PVC other(explain): Distance from private water supply well or suction line_:OK Comments(on condition of joints,venting,evidence of leakage,etc.):_GOOD CONDITION SEPTIC TANK: X (locate on site plan) Depth below grade:9"UNDER DECK Material of construction: _X_concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate). Dimensions: 1000GAL Sludge depth_ 2" Distance from top of sludge to bottom of outlet tee or baffle: 22" Scam thickness 2" Distance from top of scum to top of outlet tee or baffle:_8" Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined:_TAPE AND MIRRORS Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.):_ TANK GOOD AND TEES—NO—NEED TO BE PUMPED UNDER DECK DOOR IN DECK GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 1 l OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 139 TIMBER LANE MARSTON MILLS BARNSTABLE MA.02648 Owner's Name:TRIPLE J REALTY TRUST Date of Inspection: 4/19/2001 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.): i DISTRIBUTION BOX:--(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:_ Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): 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.): Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 139 TIMBER LANE MARSTON MILLS BARNSTABLE MA.02648 Owner's Name: TRIPLE J REALTY TRUST DATE OF INSPECTION: 4/19/2001 SOIL ABSORPTION SYSTEM(SAS):_X (locate on site plan,excavation not required) If SAS not located explain why: Type X_ leaching pits,number: 6'X 6'PLUS STONE _ 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.) NO SIGNS OF HYDRAULIC FAILURE_ON 4/19/2001 FLOW WAS GOOD SOME WATER IN PIT AND SCUM CLEANED OUT PIT ON 4/19 HAS AN OUTFLOW PIPE IN PIT IT WAS CLEAN 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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): -------------------------------------------------------------------------------------------------------------------------------------- Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 139 TIMBER LANE MARSTON MILLS BARNSTABLE MA.02648 Owner's Name:TRIPLE J REALTY TRUST Date of Inspection: 4/19/2001 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. v Ovv/` r -y. 1 1' y. � D lao Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 139 TIMBER LANE MARSTON MILLS BARNSTABLE MA.02648 Owner's Name:TRIPLE J REALTY TRUST Date of Inspection:4/19/2001 SITE EXAM Slope OK Surface water OK Check cellar OK Shallow wells 100+ Estimated depth to ground water8+_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 _X 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: PIT WAS DRY WHEN PUMPED • `tea COMMONWEALTH OF MASSACHUSETTS z f EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION Y TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS 'A SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A ozz CERTIFICATION Property Address: 139 TIMBER LANE MARSTON MILLS BARNSTABLE MA.02648 Owner's Name:TRIPLE J REALTY TRUST Owner's Adress:28 ALEWIFE RD PLYMOUTH MA 02360 Date of Inspection_4/19/2001 Name of Inspector: (please print)_DAVID WARD_ Company Name:_WARD T-5 Mailing Address: PO BOX 1934 _MANOMET MA.02345 Telephone Number: 508-224-5749 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: _ _X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: _4/19/2001_ 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. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. r Page 2 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 139 TIMBER LANE MARSTON MILLS BARNSTABLE MA.02648 Owner's Name:TRIPLE J REALTY TRUST Date of inspection:4/19/2001 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: YES 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. 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 i 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: f Page 3 of 11 OFFICIAL.INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 139 TINIBER LANE MARSTON MILLS , BARNSTABLE NU.02648 Owner's Name:TRIPLE J REALTY TRUST Date of Inspection: 4/19/2001 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. 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: r Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 139 TUVIBER LANE MARSTON MILLS BARNSTABLE MA.02648 Owner's Name:TRIPLE J REALTY TRUST Date of Inspection: 4/19/2001 System Failure Criteria applicable to all systems: You must indicate`yes"or`no"to each of the following for all inspections: Yes No _X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X Liquid depth in cesspool is less than 6"below invert or available volume is less than`/z day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _X_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _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. [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.] NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as -described-in 310-CMR 15.303,-therefore the system fails.The system-owner should contact the Board of Health to determine what will be necessary to correct the failure. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either`yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone R 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. r Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 139 TIMBER LANE MARSTON MILLS BARNSTABLE MA.02648 Owner's Name:TRIPLE J REALTY TRUST Date of Inspection:4/19/2001 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No X _ Pumping-information-was provided-by the owner,occupant,-or Board of Health X Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? NA_ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X_ _ Was the facility or dwelling inspected for signs of sewage back up? _X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS,located on site? _X _ Were the septic tank manhole uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing information.For example,a plan at the Board of Health. _X_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)-[310 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 139 TIMBER LANE MARSTON MILLS BARNSTABLE MA.02648 Owner's Name:TRIPLE J REALTY TRUST Date of inspection 4/19/2001 FLOW-CONDITIONS RESIDENTIAL Number of bedrooms(design):_3_ Number of bedrooms(actual):_3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):330_ Number of current residents 0 Does residence have a garbage grinder(yes or no):NO Is laundry on a separate sewage system(yes or no):YES_ [if yes separate inspection required] Laundry system inspected(yes or no):NO:PIPES CAPED NOT TO BE USED_ Seasonal use: (yes or no):NO_ Water meter readings,if available(last 2 years usage(gpd))WELL Sump pump(yes or no): NO Last date of occupancy: 4 MONTHS COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,ete.): 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 NONE Source of information NOas system pumped as part of the inspection(yes or no):NO_ If yes,volume pumped: gallons--How was quantity pumped determined?_ Reason for pumping:_ TYPE OF SYSTEM _X_Septic tank, 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: 1966 PER OWNER + Were sewage odors detected when arriving at the site(yes or no): NO Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 139 TIMBER LANE MARSTON MILLS BARNSTABLE MA.02648 Owner's Name:TRIPLE J REALTY TRUST Date of Inspection: 4/19/2001 BUILDING SEWER(locate on site plan) Depth below grade:22" Materials of construction:_X_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line:OK Comments(on condition of joints,venting,evidence of leakage,etc.):_GOOD CONDITION SEPTIC TANK:X_(locate on site plan) Depth below grade:9"UNDER DECK Material of construction: _X_concrete_metal_fiberglass polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 1000GAL Sludge depth_ 2" Distance from top of sludge to bottom of outlet tee or baffle:22"_ Scum thickness_2" Distance from top of scum to top of outlet tee or baffle:_8" Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined:_TAPE AND MIRRORS Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.):_ TANK GOOD AND TEES—NO—NEED TO BE PUMPED UNDER DECK DOOR IN DECK GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 139 TIMBER LANE MARSTON MILLS BARNSTABLE MA.02648 Owner's Name:TRIPLE J REALTY TRUST Date of Inspection: 4/19/2001 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:--(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:_ Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): 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.): I Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 139 TIMBER LANE MARSTON MILLS BARNSTABLE MA.02648 Owner's Name:TRIPLE J REALTY TRUST DATE OF INSPECTION: 4/19/2001 SOIL ABSORPTION SYSTEM(SAS): X_(locate on site plan,excavation not required) If SAS not located explain why: Type X_ leaching pits,number: 6'X 6'PLUS STONE 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.) NO SIGNS OF HYDRAULIC FAILURE_ON 4/19/2001_FLOW WAS GOOD_SOME WATER IN PIT AND SCUM CLEANED OUT PIT ON 4/19 HAS AN OUT FLOW PIPE IN PIT IT WAS CLEAN 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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): --------------------------------------------------------------------------------------------------------------------------------------- Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 139 TIMBER LANE MARSTON MILLS BARNSTABLE MA.02648 Owner's Name:TRIPLE J REALTY TRUST Date of Inspection: 4/19/2001 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. ma's fir® s,eJ D �� pOv/` r �'D /Dp f , Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 139 TIMBER LANE MARSTON MILLS BARNSTABLE MA.02648 Owner's Name:TRIPLE J REALTY TRUST Date of Inspection:4/19/2001 SITE EXAM Slope OK Surface water OK Check cellar OK Shallow wells 100+ Estimated depth to ground water8+_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 X 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:_ PIT WAS DRY WHEN PUMPED . , . x E Wt THIN RS MUST B T CCESS COVE `NOTES ES - -, A INSPECTION 9 MINIMUM. VA T l ONS . DES l GN CR I TER l A GENERAL INVERT FLE RAD 6 OF FINISH G MAXIMUM COVER-` PORT 3 M TANK: 98.0 NVERT OUT SEPTIC C T N DES t GN FLOW: FIRST 2 TO I. THIS PLAN IS,FOR DE SIGN AND CONSTRUCTION 97. l7 BEDROOMS AT l l0 G.P.D. PER , MIN 2. OF PEASTONE: '� INVERT IN D/ST.` 80X. 3 ONL Y. BE LEVEL OF THE SEWAGE D/SPOSAL SYSTEM FABRIC X: 97.0 BEDROOM EQUALS 330 O.P.D. OR FILTERINVERT OUT DIST. BO 4PIPE-- INVERT N LEACH CHAMBER 96.9 3 1 3/4 / I/2- DIA. 2. VERTICAL DATUM /S ASSUMED, FOR BENCH MARKS ° NO GARBAGE GRINDER • BOTTOM OF LEACH CHAMBER. 96. l o DOUBLE WASHED STONE SET. SEE SI TE'PLAN. GAs ADJUSTED GROUND WATER N/A 7 ,� �96.93 SEPTIC TANK REQUIRED: • ` BAFFLE 97. N/A N OBSERVED GROUND WATER. ALL CONSTRUCTION METHODS AND MATERIALS AND 3 OUTLE T 4 HlGH`°CAPACITY INFILTRATOR - 330 G.P.D. X 200x - 660 GAL. J. 88.5 SYSTEM SHALL - ,BOTTOM OF TEST HOLE *l. ` . MAINTENANCE OF SEPTIC EXISTING D 80X CHAMBERS W/3.5 = STONE AROUND SEPTIC TANK PROVIDED. 1000 GAL. EX1STlN 10r z38 / z l0d <, CONFORM TO MASS. D.E.P." TITLE 5 AND LOC AL • JO OO GAL BOARD OF HEALTH REGULATIONS. 6 CRUSHED `STONE OR SOIL ABSORPTION;SYSTEM REQUIRED ' SEP T l C TANK , COMPACTED BASE DESIGN PERC RATE_f 5 M/N/I NCH - SOIL TEXTURAL CLASS - ! 4 ALL SEPTIC SYSTEM COMPONENTS LOCATED UNDER : • F OR GREATER PROF / �• • OT TO SCALE `AREAS SUBJECT TO VEHICULAR TRAFFIC P1� 0!� 1 L C N EFFLUENT LOADING 0.74 GPD/SF x ' ,330 GPD /.0.74 GPD/SF 446 S.F. REQUIRED: THAN 3 IN DEPTH SHALL" RE CAPABLE OF W l TH- S TAND I NG H-20 WHEEL LOADS. • N •. PROVIDED. 4 HIGH CAPACITY INFILTRATOR CHAMBERS W/3.5 •tSTONE AROUND, A460 S.F. 5. ALL SEWER_ PIPE SHALL BE SCHEDULE 40 PVC OR WELL OVER 150 FROM sAs 460 S.F. x 0.74 340 GPD APPROVED EQUAL. , tid 6. SEPTIC ;TANK AND D BOX .SHALL BE REI NFORCED TOWN WATER . PRECAST CONCRETE 'OR 'APPROVED POLYETHYLENE. BOTH SHALL BE WATERTIGHT. D BOX SHALL BE WATER 00.9 4 HIGH CAP ACITY , TESTED FOR LEVEL WHEN THERE IS MORE THAN ONE .. INFILTRATOR CHAMBERS N/3.5 s STONE AROUND OUTLET. . � : ;;..•' ::: ,..:., � �. 7. BEFORE: CONSTRUCTION CALL DIG-SAFE. . P e LEACH PIT 1888 DIG SAFE AND THE LOCAL :WATER DE PT. LE F :. 0 LOCATION OF UNDERGROUND UTIL I TIES. D BOX .. 6. SEPTIC SYSTEM .INSTALLER SHALL .NOTIFY T ENGINEER 7W0 DAYS PRIOR TO CONSTRUCTION : �' •. 100.E 100.7 DES i GN -k ,. , . OF THE SYSTEM TO ALLOW FOR SCHEDULING OF THE: CONSTRUCTION INSPECTIONS. TOW WATER 9. EXISTING LEACH PIT TO BE PUMPED DRY AND / EXISTING s£Prlc TANK g. BACKFILLEO. oba Q T 2 5 L CB/DH FND I WELL OVER iso• Fy G� FROM SAS 20. 975E S.F.�o SOIL TEST PIT DA TAB SL P F p t INDICATES INDICATES _. PERCOLATION = OBSERVED r.sL.2® TEST _ GROUNDWATER St •1 P*12660 SL 02 F, / \ \ - HORIZON TEXTURE COLOR BM CORNS BULKHEAD Q HORIZON TEXTURE COLOR \ EL-100.JB �� / LOAMY IOYR LOAMY IOYR A A . 24•WHITE PINE \ t / SAND 2/2 SAND 2/2 10 i 9 0� , "`` . .......................... _ SANDY IOYR SANDY IOYR \ g /• QF i B LOAM S/8 LOAM OAM 5/6 OI {� \. a 36 MED-COARSE IOYR \ 0! $ Ae l4 STEF{EN GJ, C I MED-COARS E IOYR C I A. r• SAND W/TH 6/4 SAND WITH 6/4 \6 '� GRAVEL No* ��CIVIL IVI R �3 CL .., GRAVEL No.35461 !38 NO WATER NO WATER 88.5 ' 1384 88.5 Q1 \\ _�_. �•"'9 1 G� � DATE: AUGUST 7. 2009 TEST BY: STEPHEN HAAS Oe ape WITNESSED BY: DAVID STANTON Op s• \ sE� PERC RATE: f 2 MIN/INCH TOWN 1�dTfR j SE—PT SYSTE- M DES / 0/V 39 T / MB ER L A ME MA P / 4 9 , PA R CAE L S O SAR /VS TABI E . CMARSTONS MILLS > MA PRiTPARE-0 FOR L EG' ND /RA 4/ l/ l/ � 5 [_J �-LA � A AR O ■ CB I' CONCRETE BOUND U WELL —W WATER L I NE , • 1 SCALE . I — 20 STPTEMBEF? 3 2009 HYDRANT •—G GAS L INE EAG E � UR \/ EY I NG I NC z OHW — OVER HEAD WIRES 923 :Route 6A r I GHT POST --- i t MA 02675 u Yarmou# hpor . E UNDERGROUND ELECTRIC l C LINE 6 2-8 '1'3 2 5O8 � 3 c T UNDERGROUND TELEPHONE LINE; /111� 50 8 43 =5333 � 2 FP CTV_ UNDERGROUND CABLEVISION LINE WELL PER -{-40.4 SPOT ELEVATION P i TOWN RECORDS _40 — EXISTING CONTOUR P P e OUR , PROPOSED `CONY . SAN CK ;`CFW ' DRN L 000S MAP o l0 20 4o JOB NO. O9 os3 FIELD. CFW/EEK ` CAL C• SAH/CFW CHECK.- T E WITHIN , ACCESS COVERS MUST B INSPECTION MINIMUM INVERT EL E VA T l ONS : DES / GN CR i TER / A : GENERAL NOTES : - 9 -: 6 OF FINISH GRADE PORT 3 MAX/MUM COVER INVERT OUT SEPTIC TANK 98.0 FIRST 2 TO DES f GN FLOW; MIN 2' OF PEASTONE INVERT IN DIST. BOX: 97. 17 3 BEDROOMS AT 1/0 G.P.D. PER I. THIS PLAN IS FOR THE DESIGN AND CONSTRUCTION BE LEVEL OR F I L TER FABRIC VVER T OUT D I S T. 'BOX: 97.0 BEDROOM EOUAL S 336 G.P.D. OF THE SEWAGE DISPOSAL SYSTEM ONLY. {• TAM PIP 3/4 ! !/2' DIA. INVERT IN LEACH CHAMBER: 96.93 ' ' BOTTOM OF LEACH CHAMBER: 96. 1 NO GARBAGE GRINDER 2. VERTICAL DATUM IS ASSUMED. FOR BENCH MARKS _ DOUBLE WASHED STONE 98.0 '97.0 � l0 �' SET. 'SEE SITE PLAN. GAS .0 � ADJUSTED GROUND WATER: N/A SEPTIC TANK REQUIREO: BAFFLE 97. 17 96.93 ' ` 3 OUTLET 4 HIGH CAPACITY INFILTRATOR OBSERVED GROUND WATER: N/A 3. ALL CONSTRUCTION METHODS AND MATERIALS AND 330 G.P.D. X 20oz 660 GAL. CHAMBERS W/3.5'f STONE AROUND BOTTOM OF TEST HOLE +�1: 86.5 EXISTING D-BOX SEPTIC TANK PROVIDED: 1000 GAL. EXISTIN MAINTENANCE OF THE SEPTIC SYSTEM SHALL - 1000 GAL JO'r x 38'1 x 10'd CONFORM TO MASS. D.E.P. TITLES AND LOCAL *SEPTIC TANK 6' CRUSHED STONE OR SOIL ABSORPTION SYSTEM REOUI RED: BOARD OF HEALTH REGULATIONS. COMPACTED BASE DES/GN PERC RATE C 5 M I N/l NCH SOIL TEXTURAL CLASS 1 4. ALL SEPTIC SYSTEM COMPONENTS LOCATED UNDER PROFILE : NOT TO SCALE EFFLUENT LOADING RATE - 0. 74 GPD/SF AREAS SUBJECT TO VEHICULAR TRAFFIC OR GREATER 330 GPD / 0. 74 GPD/SF - 446 S.F. REQUIRED THAN 3' IN DEPTH SHALL BE CAPABLE OF WITH- STANDING H-20 WHEEL LOADS. NPROVIDED: 4 HIGH CAPACITY INFILTRATOR WELL OVER I50 CHAMBERS W/3.5't STONE AROUND. A-460 S.F. 5. ALL SEWER PIPE SHALL BE SCHEDULE 40 PVC OR FROM $AS 460 S.F. x 0. 74 - 340 GPD APPROVED EOUAL. 6. SEPTIC TANK AND D-BOX SHALL BE REINFORCED TOWN WATER ��, PRECAST CONCRETE OR APPROVED POLYETHYLENE. oa.q 4 HIGH CAPACITY BOTH SHALL BE WATERTIGHT. D-BOX SHALL BE WATER INFILTRATOR CHAMBERS TESTED FOR LEVEL WHEN THERE IS MORE THAN ONE W/3.5•: STONE AROUND s OUTLET. ;ram. 7. BEFORE CONSTRUCTION CALL 'DIG-SAFE'. f,1' 3a LEACH PIT �' F l-888-DIG-SAFE AND THE LOCAL WATER DEPT. D-BOx FOR LOCATION 0 F-UNDERGROUND UTILITIES. 8. SEPTIC SYSTEM INSTALLER SHALL NOTIFY THE 1 +100.4 > + ro0.6 100.7 DESIGN ENGINEER TWO DAYS PRIOR TO CONSTRUCTION • OF THE SYSTEM TO ALLOW FOR SCHEDULING OF THE CONSTRUCTION INSPECTIONS. r TOW WATER /r EXISTING / SEPTIC raroK 'g� 9. EXISTING LEACH PIT TO BE PUMPED DRY AND $ oo BACKFILLED. L 0 T 25 ..• CB/DH FND WELL OVER I50' �F 20. 975+ S.F. FROM sns a�.� �5 sroy IOO.s c�P�, SOIL TEST PIT DA TA t \ 5 J ND I CA TES N7 I ND I CA TES' SL•?s PERCOLATION- :.. OBSERVED,:. ...__, I, f _ TEST = GROUNDWATER 1 0�, t _•-__-- ice---,��..---" SL •I P•I2B60 SL *2 BM-CORNE BULKHEAD Q�i� /r HORIZON TEXTURE COLOR HORIZON TEXTURE COLOR V/ \ EL-100.38 v �, 0 0' 100.0 0' 100.0 \ \ �� / LOAMY IOYR LOAMY IOYR 0 \ 24 WH/Tf PINE S\ / A SAND 2/2 A SAND 2/2 SANDY IOYR SANDY IOYR B LOAM SMB B LOAM 5/8 36 •,:...:......................... 9T.0 34 :............. ..... 97.2 \ t / 6p1 'Py MED-COARSE IOYR MED-COARSE IOYR -lieI�S'f� �r. 6 '7 C SAND WI TH 6/4 C - SAND WI TH 6/4 \ JS�`s ti GRAVEL GRAVEL y RIa.35463 3 NO WATER NO WATER 88.5 /38 88.5 DATE: AUGUST 7. 2009 lop Y TEST BY: STEPHEN HAAS prA WI TNESSED BY: DAVI D STANTON F`y9y PERC RATE: l 2 MIN/INCH TOWN WATER S E P T / 0 S 1 S T E/ V/ D E S 0_9 T / MB E-R L A NE , MA P / 4 9 . PARCEL 5 0 A R/VS 'TA SL G . rIvARs TO/VS M / L L S PRE-PA REO FOR RAC£4 A AAR01V WE- B B U wEtt CB 'CONCRETE BOUND � _ y -W WATER L I NE HYDRANT SCALE : / - 20 SEP TEMBER 0 . 2009 �� �Q" r -G GAS L l NE OHW- OVER HEAD WIRES E �. GI._ E � UR �/ EYI NO i NC LIGHT POST 923 Route 6A g� _#_ = Yarmo P uth ort MA . 02675 E UNDERGROUND EL ECTR l C LINE _.- a°J -T- UNDERGROUND TELEPHONE LINE FPy CTV- UNDERGROUND 5 0 8 � 3 6 2-8 1 3 2 508 432-5333 CABLEV I S ION LINE �\ 1 C ® WELL PER +40.4 SPOT ELEVATION TOWN RECORDS PQ _ „_'--40-_ EXISTING CONTOUR " e PROPOSED CONTOUR o l 0 20 40 0 N . 09 063 FIELD..CFW/EEK CAL C., SAH/CFW CHECK CFW L OCUS MAP e O 4