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HomeMy WebLinkAbout0027 TROTTERS LANE - Health 7 Trottercs Lane, Marstons Mills P y 047 133 - -- - --- R - y� i l Cl No. r. ! Fee O — THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: �/ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplitation for Migogal *pgtem Congtruction Permit Application for a Permit to Construct( )Repair( 11<pgrade( )Abandon( ) ❑Complete System [J Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. d� %ro t(•eIs /Ane d8 -- 190� h-,..vr _0.srt 7-c e k Assessor's Map/Parcel ®4l.�M 133 5Arvt— Name,Addres�a� .IyQ�NAo Designer's Name,Address and Tel.No. ��` 350 Main Street A114 G►�o� Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /O ><.�n Type of S.A.S. Description of Soil PL4 � 11 Nature of Repairs or Alterations(Answer when a plicable) 2nls A. t o K Ty Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Hea Signed Date '4,alo-99 Application Approved by Date .-41 09 Application Disapproved for the following reasons Permit No. "'G Date Issued Z0, 0 L sue„ f� rr ? .l5 • _ Fee J THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ye � PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS- 2pprtcation for Migogal *p5tem Construction Permit Application for a Permit to Construct( )Repair( 45pgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.C) He f�s lA^,a Owner's Name,Address and Tel.No. 41d 9 D J Y n-i ,IV" ,5-u1.4.1 Te_x,�c Assessor's Map/Parcel ©�7„ 13S S Aro-e_ JystaWr=s Name,Address,and Tel.No. Designer's Name,Address and Tel.No. lii nor" / r..P Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria Other Fixtures Design Flow gallons per day. Calculated-daily flow gallons. Plan Date Number of sheets \ )VOW Revision Date Title . Size of Septic Tank /UD0 ype of S.A.S. o u o Description of Soil Nature of.Repairs or Alterations(Answer when applicable) ��/is _20 U !i A /. /P cr e-`� CGi I,7Z !s 6,)/ 4 r Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Hea t . Signed 4 Date -d a - 9 9 Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued O' THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS QCertificate of (Compliance,\. THIS IS TO CERTIFY, that the On-site Sewa is2osal System'Constructed(a .,)Repaired.( ✓f Upgraded( ) Abandoned( )by -orv4V� G^ 1 c-'¢ . at -)i %r a tfr r S 1 A vt D has been construct din ccordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 97 (r/e dated Z./ Installer Designer The issuance of this permit shall nut be construed as a guarantee that the sy t will f ct' s designe.. Date —2 Z' Inspector r No. � -----Fee SCE o- _99 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Mi!4001 *pgtem Construction Permit Permission is hereby granted to nstruct( )Repair( Upgrade( )Abandon( ) System located at ') `i /f o/`/ /s �A�. /W /3 � 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:Constrif tion must be completed within three years of the date of this permit. Date: 2 v Approved by II 1/6/99 r t NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated 9 -.7 y- 5'Q concerning the property located at 027 Tr-6 fF_fs 1,y,_e `v(, (i(,( meets all of the following criteria: • The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. ✓• The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. ✓• There are no wetlands within 100 feet of the proposed septic system ✓• There are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed ✓• There are no variances requested or needed. ✓ The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] % If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W. Elevation • +the MAX. High G.W. Adjustment. rTi = —�e � � DIFFERENCE BETWEEN A and B 1 63 P SIGNED : J Ul DATE: C 'C)t) [Sketch proposed plan of system on back]. q:health folder.cert J k r } 130 k ♦ � w ry 41CLr e ✓ ,I°Cam,+ ° ' TOWN OF BARNSTABLE c LOCATION J271, 7r�b�fe�eS I�, ,SEWAGE # VILLAGE I)lAk5V 0115 f')/111 ASSESSOR'S MAP & LOTC V 7 r133 INSTALLER'S NAME&PHONE NO. A4,9 CAnGy SEPTIC TANK CAPACITY /Uzi (1,4/Ion S LEACHING FACILITY: (type) 0�/. C-4Ande-C S (size) 9$ NO. OF BEDROOMS �` BUILDER OR OWNER 5 Z4A) /?, /ye;9 PERMIT DATE: 7— Zd COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility. Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 1"T �i LAI 0 ,r$ 0 r T TOWN OF BARNSTABLE � LOCATION R 7 7 3 -6ek.S /!?, SEWAGE # VILLAGE ~V00—,5 fl"111 ASSESSOR'S MAP & LOT --q-7�t INSTALLER'S NAME&PHONE NO. r 4 (An co 725- o29b0 SEPTIC TANK CAPACITY 16M ('�®R 00 n S /e•�c ')TEACHING FACILITY: (type) a .boo 41AI C4,g 3eg S' ,NO. OF BEDROOMS �' BUILDER OR OWNER L'4.J / 7• 7ee-49 PERMITDATE: "'�� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands.-exist within 300 feet of leaching facility) F..eet .r Furnished by .; i u� 9 �e `yea aF LOCATION SEWAGE PERMIT NO. VILLAGE Lo f.,0 A g IN.STA LLER'S NAME & ADDRESS BUILDER OR OWNER VAiv,5.' 4l.�s DATE PERMIT ISSUED 71",f 77 MPLIANCE ISSUED D A T E CO ��4 ' it ��-�--�^ �� � 9� °� � --�.. ,t `� �ACl:Pf�o` LOCATION �f'c�►[e�5 �a - DATE VILLAGE Y�1 ��r�� Y�9��1� ASSESSOR'S MkP & LOT •INSBFCTOR T K CAPACITY 1000 SEPTIC AN iLEACHING FACILITY: (type)( 1-Yli� Y11 t� (size) ,NO.OF BEDROOMS BUILDER OR OWNER OWNER MAILING ADDRESS L �QCk O¢ go�3e. . 00 0 0P PARCEL, �OT _ 20 DATE_-�1-23.E-ors-- PROPERTY ADDRESS:-_-22-srntte --.—Lane Marstons Mills, MA 02648 ,. ------------------- RECEIVED On the above date, the septic system at the above addre s was Inspected. AUG 2 7 2004 This system consists of the following: BARNSTABLE 1- 1.000 ga eion beet is tank,, TDWH�HEALTH DEPT. 1-Dizt2.igut.i.on 9ox.• 2- 500 ga-eeon geach-ing cham9e2z., Based on inspection, I certify the following conditions: 7h.i s. .i3 a 7.it.ee five Sept-ic S4y st em.• The zel2.t.ic. ,3y,3tem .iz iti 121copea wo>ck.ing oAdea at the /22e,6ent t bMe.' SIGNATURE:ZLZ'-A- ce Name:-- Rri7C'e Maca1 ister-------- Company:_Jgsgph _ pmh r. JL.-Son, Inc. Add ress:--2-a--BoX--6z----------- Centerville, MA 02632-0066 I Phone:----L5Sa1-.2z5- _-------- THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY KW .IOSEPH P. MACOMBER SON, INC. Tanks-Cesspools-Leachfields Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 } 775.3338 775-6412 COMMONWEALTH OF MASSACHUSE'I"rS _. EXECUTIVE OFFICE•OF EIVIR(�NM" N'rAL AFFAIRS DEPARTMENT OFRNVITODNMENTaLpR(�T CTION 'TITLE 5 OFFICIAL INSPECTION FORM—NOT E VOLUNT SPOSAL SYS EM FORMNTS SUgSiTRFACE SEWAGE D PART•A CERTIFICATION Property Address:' 27 mrnt t ers Lance_ 02648 Owner's Name; Owner's Address:. Date of inspection: Name of inspector:(please print)_ Rr�,, P ^tea ' per Company Name, a om�e�t .Sri Iric. Mailing.Address: -333 •ubb.•0263Z Telephone Number: 5 0 8-7 7 CERTIFICATION STATEMENT personally inspected the sewage disposal system.at this address and Sh e��d basaed on my reported I certify that I have p Y me of the inspection below is true;accurate ands'complete fu°.ct on f the a d maintenance of on tt�e sewage l disposal systems.I am a DEP training and experience m p P approved system inspector pursuant to-8ection.Y5c340.of•'Fitle 5(316 CMR 45:000). The system: Passes Conditionally Passes Needs Further Evaluation.by the Local Approving_Authority Fails Inspector's Signatmre: , action rep (Board of Health or ort-to the.Approving Authority The system inspector shall submit a copy of this inspection.If the system is.a.shared system or has a design flow of 10,000 DEP)within 30 days of completing this insp roving. d or eater,the inspector and the system owner.shaltsubmities sent the buyerp f applicable,and the appf the gP. DEP.The original should be sent to•:the system owner an copies authority. Notes and Comments ****This•report only describes conditions at the time of inspec tidtr and under the conditions of use at that ins ection does not address how the system will perform in the future under the same or different time.This p conditions of use. Date 1 . Page 2 of 11 OFFICIAL INSPECTION FORM—.NOT:FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Ad dress: 27 Trotters Lane Marstons Mills y Mn Owner: Daniel Osgood Date of Inspection: a g 3,10 4 Inspection Summary: Check A;B;C..D or.E/ALWAYSyeomplete=all of Section rD A. System Passes: NO. I have not found any information which indilates'that-any of the failure criteria described in 310 CMR 15.303.or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The bel2.tic zurtem 1z i.n Raoaea woakina "deg at .the aezen.t .time., B. System Conditionally Passes: NO 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. NO 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: NO Observation of sewage backup or breakout 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: NO 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: 2 Page 3 of 11 OFFfiCIA.L INSPECTION FORM-NOT YOR VOLUNTARY ASSESSMENTS SUBStjRFACE SEWAGE DISPOSAL SYSTEM INSPECTIONTORM PART:A CERTIFICATION*(eontinued) : Property Address: Owner:. Date of Inspection: 9A231 C. Further Evaluation-is Required by the Board of Health: NO Conditions.exist which require further.evaluationby.the Board.ofHealth:in order to*terrnine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines ti accordance with 310.CMR 15.303(1)(b)that the system is not functioning in.a manner which:will.protect public health,safety ano the..environment: no Cesspool or privy is within 50 feet of asurface water n o 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 mariner that protects the p►lblic health,safety and environment: n o 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. n o The system has a.septic tank and SAS and the SAS is within a Zone I of apublic 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;rriore fron]a private water supply well".Method used to determine distance, V i A a ri P "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: NONE Page 4 of 11 OFFICIAL INSPECTION FORM-NOT'FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 27 .Trotters Lane Marct-nnc Mills, MA Owner: nan; Al nc_T^a Date of Inspection: u—�-r0 4 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to.each of the.following:for.all inspections: Yes. No _ x Back-up-of sewage.:into facility.:or..system component due to overloaded.or clogged SAS or.cesspool _ x Discharge:orponding 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 V below invert or available volume is less than'h•.day flow _ 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 l 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 niust be attaehed.to this forM..] NU (Yes/No)The system fails.I have determined that:one or.more-of the:above failure:criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner.should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the.system must.serve.a;facility with a design flow of 1,0;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 abov ( g e) yes no x the system is within 400 feet of a surface drinking water supply x the system is within 200 feet of a tributary.to a surface drinking water supply x the system is located in a nitrogen sensitive area(1Tnterim Wellhead Protection Area—IWPA)or a mapped Zone lI 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS gitSURFACE SEWAGE DISPOSAL'' YSTEM INSPECTION FORM PART B CHECKLIST Property Address: 27 Trc)tt-PrG Tone Ma_ -stops Owner: . Mani Pj Osgood., Date of Inspection: g 49-11 n A Check if the following have been done.You must indicate` f or"no"as to each.of the(ollowing: 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' th 7— e previous two week period? x Have large volumes of water been introduced to the system recently or as part of this,inspection? x _ Were as built plans of-:the system'obtained and examined?(If they were not available tote 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.? _ Were the septic tank manholes uncovered,.opened,and the interior..of the tank inspected for the condition x ion,dimensions,depth of liquid,depth of sludge and depth of scum of the baffles or tees,material of construct ? 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 CN1R 15.302(3)(b)J 5 Page 6 of 11 V OFFICIAL 11.Nspm'T FOR IGN M'-NOT FOP,VOLUNTARY AS�SESSM- NT—S S TBSITRF� S '.AGE DISPOSA �;3SYSTUM,IINSPECTION FORM � PART.0 SYSTEM INFORMATIOAI Property Address: 27 Trotters Lane -Mars tons Mills, MA Owner: Daniel OGgnnd Date of Inspection:„8/2 3 DA FLOW CONDITIONS RESIDENTIAL Number of bedrooms(desip): 3 . .. Number of.bedrooms{actual):2 DESIGN`.flow based on'310 CI iR 15.203'(for exatnplec'I IO gpd z#of bedrooiiis): Number of current residents: .:3 Does.residence have a garbage grinder(yes br no): n o Is laundry on a separate sewage.system.(yes or.no):n o [if yes separate inspection required] Laundry system inspected(yes or no):&Q Seasonal use?(yes or no):no e Q Q / a /t, .Z 1 W X e.e wa t e a h a.6 n o.t Water meter readings, if available(last 2 years usage(gpd)): P P A - �v_.s�n r/_.c a e �a� yea 2 Sump pum (yes or no): no itmazt ge done at .th.iz .t.ime. See Last date o'occupancy: /22 c e n t i2 a ge,3 6 A&6 B. COMMERCI. USTRIAL Type of estab :, nt: NA.M Design flow ,d on 310 CR 15.203) >�d. Basis.of ow(seats/.persons/sgft,etc.):, NA Grease trap�present(yes or no):NA Industrial waste holding tank present(yes or no):NA Non-sanitary waste discharged to the Title 5 system•(yes or no):NA Water-meter readings,if available: N.A Last date of occupancy/use: .NA OTHER(describe):. NA 'GENERAL INFQATION Pumping Records Not ava.i.eag ee Source of information: Was system pumped as part of the inspection(yes or no): az If yes,volume pumped? gallons--How was quantity pumped determined? m e a ua e d Reason for.Pumping: Pang fled 4o R m2 i n J n rza r o,y,,p 64n_7.,nn c.o..t TYPE OF SYSTEM Ile Septic tank,distribution box,soil absorption system a a Single cesspool n o Overflow cesspool a o Privy n o Shared system(yes or no)(if yes,attach previous inspection records,if airy) �Innovative/Alternative.technology,Attach a copy of the current operation and maintenance contract(to be obtained from system owner) �- xza .copy.of the DEP.approval Tight tank.n o Attach a no Other(describe): no Approximate age of a]) components,date installed(if known)and.source of information: 20 to 25 ueaaz. Were sewage odors detected when arriving at.the site(yes or no)n o 6 - I Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 27 Trot-tPrs r Ane Marsfons Mill -, , MA Owner: Dan i P 1 sgood Date of Inspection: 3;' f 0 4 A Y BUILDING SEWER(locate on site plan) Depth below grade: 12 Materials of construction:_cast iron x 40 PVC_other(explain): Distance from private water supply well or suction line: n a Comments(on condition of joints,venting,evidence of leakage,etc.): oin ' a 12 RZa2 .t4,.ahf_. No n�nee ol eeakage Sub.tem iz vented thorough house vent SEPTIC TANK:y,"(locate on site plan)l 0 0 0 ga a o n.3 Depth below graded 6" 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: 8' 6".e o a g 4 ' 10"wide 5 ' 8"h.i gh Sludge depth: ,t 2 a c e Distance from top of sludge to bottom of outlet tee or baffle: t a a c e Scum thickness: t 2 a c e Distance from top of scum to top of outlet tee or baffle: .t a a c e Distance from bottom of scum to bottom of outlet tee or-baffle: it a a c e How were dimensions determined. l u mpe d at time o .t n,6/2 e c t i o n Comments(on pumping recommendations,inlet and outlet tee or baffle condition'structural irate as related to outlet invert,evidence of leakage,etc.):AP gnh'�liquid levels t outQet . tee� ate �eaka e. GREASE TRAP:NA(locate on site plan) Depth below grade:�&A Material of constructionAA_concrete AAmetal&Lfiberglass lig-PolyethylenOl .other (explain): NA Dimensions: NA Scum thickness: NA Distance from top of scum to top of outlet tee or baffle: NA Distance from bottom of scum to bottom of outlet tee or-baffle: NA Date of last pumping:.NA Continents(on pumping recommendations,inlet and outlet tee or baffle condition'structural integrity, as related to outlet invert,evidence of leakage,etc.): liquid levels gaeaze not paezent \ I Tifla 5 Tnanartinn T7nrm Oil eionnn 7 Page 8 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS S.-Vt8U,WACE SEE.WAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 27 —;`4a_s;o new 441. MA Owner: Date of Inspection: TIGHT or HOOLDING TANK: NA (tank must be pumped at time of inspe`etion)(locate on site plan) Depth below.grade; NA Material of construction: N,4 concrete NR metal NR fiberglass L_polyethylene_S&other(explain): NA Dimensions: N,q _ Capacity: NA- gallons Design Flow: .NA gallons/day Alarm present (yes or no): N,4 Alarm level: N,R Alarm in working order(yes or no): NA Date of last pumping:N,4 Comments(condition of alarm and float switches, etc,): 7.ight o2 Hoid.ing tanks not jn.Svnt DISTRI$UTION BOX:ye,3 (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:no Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box, etc.): No 2. o eve enee o,� t?eakage .in oz out ou" Lhex_ PUMP CHAMBER N4 (locate on sife.plan) Pumps in working order(yes or no): NA Alarms in working order(yes or no):NT Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): l umI2 chamge2 .ie not /2ae.3ent . 8 Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM I.NSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 27 Trotters T,ane Marstons ; 1G� MA Owner:. T);;nJel Osgood Date of Inspection: R.191.10 d SOIL ABSORPTION SYSTEM(SAS):y e {locate on site plan,excavation not required) If SAS not located explain why: Type no leaching pits,number: 0 yeas leaching chambers,number: 2 no leaching galleries,number: n .no leaching trenches,number, length: 0 no leaching fields,number,dimensions: 0 no overflow cesspool,number: 0 no inn-ovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): So.iez ate d1ty.• .Loamy .3to dine zand.� Wo '6'i n.6 o hydaauilr e a on .cis nonma CESSPOOLS: NA (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: N•A Depth—top of liquid to inlet invert: NA Depth of solids layer: NA Depth of scum layer: N,4 Dimensions of cesspool: NA Materials of construction: NA Indication of groundwater inflow(yes or no): NA Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Ce�s� oo �� ate no PRIVY:NA (locate on site plan) Materials of construction: 414 Dimensions: IV A Depth of solids: Nfl failure,level of ponding,condition of vegetation,etc.): Comments(note condition of soil,signs of hydraulic l2.iv .ins not 9 i Page 10 of 11 OFFICIAL INSPECTION FORK—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C` SYSTEM INFORMATION(continued) Property Address: 27 m,-pi-toQ aa..e d a.-Sten-s--P41119, 'Ma Owner: naniol Qsgeod Date of Inspection: o i i 0.4 .x. AKETCH OF SEWAGE DISPOSAL SYSTEM Pr6vide 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. tQCk Of -17 66� o. 10 i Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS �—. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 27 Trc) rS Lane M•3rStnnG Mills., Ma Owner: Danl01- Osgood Date of Inspection: 2,423,404 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water JL} 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: 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: 11.6ed:Gaheaty and m.iieea modei 12116194 Gaound watea agove .6ea levee Uzed:7echnicai gaieetirz - -1 p-Ea e anua2y f 9 , aangez o," gaound watea eievat.ion'3 Hiotf gaoundwatea adjustment 1.,8�t. /2ea �a.in/2tea method a� Veat.icai hepaaat.ion Between. Bottom o� ieach.ing aaea and adjurted gaoundwatea .ins Titles S Tnenortinn Tlnrm 4/ vonnn 11 ,T^^"'><''.--.'•`-`�'_"r'..'-'�-:'rz--:-r,:,.�•..Q.r.. BOARD OF 11EALTII .1.OWN OF SUBSUIVACE SEWAGE; DISPOSAL SYSTEM INSPECTION FORM - PART D '- CERTIFICATION - .T.:•t:T��.t1 ••,�T.T.T.:it'R:TTI'.-.{ir SC1f:T'T1TT-'•t T{4Ttt"0 T.ZTTT-Tr'�TC�f its iTilfR'TR[TR►S1Tt7TfTRRr'f�fl'"t•T'T•'�tt —TYPE OR PRINT CI.EARLY— PROPERTY INSPECTED STREET ADDRESS 27 . 71Lot;tea6 Lane ASSESSORS MAP , BLO,PK AND PARCEL # 47-133 OWNER' s NAME Daniei 0,s-good PART D - CERTIFICATION NAME OF INSPECTOR Z32uce Naeaiiis.tea COMPANY NAME a• 1•'Nacomee2 and hon 'frzc., COMPANY ADDRESS Box 66 C n 02632 Street Town or City State LIP COMPANY TELEPHONE ( 508 f 775 - 3338 FAX ( ? R CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate, and omplete as of the time of �inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on site sewage disposal systems - check one: Systeui PASSE.;D The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public healti, or the environment as defined in 310 CMR. 16 . 303 , Any failure criteria .not evaluated are as stated in the FAILURE CRITERIA section of this. form . System FAILED* The inspection which I have con meted has found that the system fails to Protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART CC - JFAILURE CRITERIA of this inspection form . Inspector Signature ( � Date ne copy of this certification must be provided to the OWNER, the. BUYER ( where applicable ) and the 130ARD OF HEALTH. * If the inspection FAILED, the owner or operator shall up.grade ' the system. within o'ne year of the date of the inspection, unless allowed or requ.i..red otherwise as provided in 310 CM.R 16 . 305 , partd..doe Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 27 Trotters Lane Property Address Federal Home Loan mortgage Corp. Owner Owner's Name information is required for Marstons mills Ma. 02648 8/17/2010 , 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: A. General Information When filling out forms on the • I computer,use 1. Inspector: I` only the tab key to move your robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name r� P.O.Box 763 Company Address P Y Centerville Ma. 02632 City/Town State Zip Code (508)428-4028 S14454 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes D Fails I ❑ Needs Further valuation by the Local Approving Authority AU 3 nct, 1 B / ° y 8/17/2010 Inspect is 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. H l t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Di sal System I Pag 1 of 1 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M ay 27 Trotters Lane Property Address Federal Home Loan mortgage Corp. Owner Owner's Name information is required for Marstons mills Ma. 02648 8/17/2010 every 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: The septic system is in proper working order at the present time. 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 27 Trotters Lane Property Address Federal Home Loan mortgage Corp.Cor Owner Owner's Name information is required for Marstons mills Ma. 02648 8/17/2010 every page. City/Town 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): ❑ 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 27 Trotters Lane M Property Address Federal Home Loan mortgage Corp. Owner Owner's Name information is required for Marstons mills Ma. 02648 8/17/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for 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 Y2 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 27 Trotters Lane Property Address Federal Home Loan mortgage Corp. Owner Owner's Name information is required for Marstons mills Ma. 02648 8/17/2010 every page. City/Town 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M40 27 Trotters Lane Property Address Federal Home Loan mortgage Corp. Owner Owner's Name information is required for Marstons mills Ma. 02648 8/17/2010 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous.two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 I t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pa ge 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 27 Trotters Lane M Property Address Federal Home Loan mortgage Corp. Owner Owner's Name information is required for Marstons mills Ma. 02648 8/17/2010 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 I' 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 Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d Well Water 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 27 Trotters Lane M Property Address Federal Home Loan mortgage Corp. Owner Owner's Name information is required for Marstons mills Ma. 02648 8/17/2010 every page. City/Town 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-09/08 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 27 Trotters Lane Property Address Federal Home Loan mortgage Corp. Owner Owner's Name information is required for Marstons mills Ma. 02648 8/17/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site?. ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 32"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line. 1001+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidenc eof Ieakage.System vented through the house vents. Septic Tank (locate on site plan): 3' 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: 1000 gl. Sludge depth: 4" t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 27 Trotters Lane Property Address Federal Home Loan mortgage Corp. Owner Owner's Name information is required for Marstons mills Ma. 02648 8/17/2010 every 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 28 Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 27 Trotters Lane Property Address Federal Home Loan mortgage Corp. Owner Owner's Name information is required for Marstons mills Ma. 02648 8/17/2010 every 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.): I *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 27 Trotters Lane Property Address Federal Home Loan mortgage Corp. Owner Owner's Name information is required for Marstons mills Ma. 02648 8/17/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No 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.): Box is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage. 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 27 Trotters Lane Property Address Federal Home Loan mortgage Corp. Owner Owner's Name information is required for i Marstons mills Ma. 02648 8/17/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ 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.): Sandy soil.No signs of hydraulic failure.Chambers were dry at time of inspection.Stain line observed 13" below invert. 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 27 Trotters Lane M Property Address Federal Home Loan mortgage Corp. Owner Owner's Name information is required for Marstons mills Ma. 02648 8/17/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 27 Trotters Lane Property Address Federal Home Loan mortgage Corp. Owner Owner's Name information is required for Marstons mills Ma. 02648 8/17/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) J � 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 14�1 •'Ni��'/,� ` ' �/ ; 1. k { i I t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 27 Trotters Lane Property Address Federal Home Loan mortgage Corp. Owner Owner's Name information is required for Marstons mills Ma. 02648' 8/17/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of LC 50' feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: As-Built ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 27 Trotters Lane Property Address Federal Home Loan mortgage Corp. Owner Owner's Name information is required for Marstons mills Ma. 02648 8/17/2010 every 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 12/06/2010 MON 14: 35 FAX 5083627103 Barnstable CTY HealthLab --- Barnstable Health Z001/001 CERTIFICATE OF ANALYSIS Page: 1 J� 9•, Barnstable County Health Laboratory Report Prepared For: Report Dated: 12/6/2010 Leo N.Beauvais Jack Conway Realtors Order No.: G1060522 38 Route 134 South Dennis, MA 02660 9 Laboratory IDJ: 1060522-01 Description: Water-Drinking Water Sample#: Sampling Location: 27 Trotters Lane,Marstons Mills,61A Collected: 12/3/2010 Collected by: Customer Received: 12/3/2010 Routine ITEM RESULT UNITS RL MCL Method k Tested Nitrate as Nitrogen 6.5 mg/L 0.10 10 EPA 300.0 125/2010 Copper 0.15 mg/L -0.10 1.3 SM 3111 B 12!3/2010 Iron 0.20 mg/L 0.10 0.3 SM 31 I I B 12,13/2010 s PH 6.3 Pli AT 25C NA 6.5-8.5 SM 4500-H-13 12!3/2010 Sodium 46 mg/L 1.0 20 SM 311 I B 12/3/9-010 Total Coliform Absent P/A 0 0 SM9223 1213/2010 0 Conductance 320 umohslcm 2.0 EPA 120.1 12,1312010 t 8 Sodium level is above the maxiam contaminant level. Those on a tow sodium diet may wish to consult a physician. - ........ --- -- --- --- -- � 1 E t Attached please rmd the laboratory certified parameter list. Approved $y (L irector) 5 r 6 1 4t E pgf E 3 f 1 ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, P0.Box 427, Barnstable, MA 02630 Ph:508-375-6605 r- No. ....y5......... F.Es....���a ....... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH mod ..'`......... ....OF............ 4..P ..P..S' ...:.......... Appliratilan for Dispatial Works Tomitrnr#inn ramit Application is hereby made for a Permit to Construct (4�<or Repair ( ) an Individual Sewage Disposal System at: .K. •--------•---. --•---L�� p---•------------------------------------- ........ ... ..............•-- I.o a'on-Address or Lot No. .. .av C4.V. .._ vl. _.. ' �. - «5 5. !Kr...W.Ci` .�:F'lgtJ......................... caner Address .'----------------------- ---- Int�1��C._w.e T..►s ........................ Installer Address (X7 Type of Build'> Size Lot..2 d...... t..0................Sq. feet Dwelling—No. of Bedrooms..... ..................................Expansion Attic (W\ Garbage Grinder (W4 Other—Type T e of Building yp g __.___._._.. No. of persons_______ _________________ Showers Cafeteria (VV g- Pa Other fixtures ------------------------•---•--•-• W Design Flow..........................5 . .........gallons per person peer day. Total daily flow................. .®.............gallons. WSeptic Tank—Liquid capacity/lIbAgallons Length..!..:... Width.1.!�.._._ Diameter____- ----- Depth..7.......... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. -Seepage Pit No./................ Diameter.._.__. ..... Depth below inlet................ Total leaching area. .! ...sq. ft. z Other Distribution box Dosing tank ( ) `��,�� 0-4 Percolation Test Results Performed b /> /> Y ;_�r•.s '?.G_.. Date (................. Pew lot-Pit No. 1...4_>!.7_minutes per inch Depth of Test Pit...... Depth to ground water........................ 0-4 (14 Test Pit No. 2..:.............minutes per inch Depth of Test Pit.................... Depth to ground water........................ ,. ......... •-------------------------•------------------------------------- Cg` � 5�0 Description of Soil------......` '`-i .. _ a �_. ............... x �-a ve V ------. ----- W U 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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. S• ned. --0► -•..• --- � �� 7. Date Application Approved BY----- 4 4p,j.--- Date Application Disapproved for the following reasons:................................................................................................................ •------•---•--------•-•---------------•---------------------....--••---•-•----------•••-••-•--------•••-----------------------•---------------•------•---------•---•--••----••------•--•--•-•--•-•--••-- �y Date Permit No. ._. Issued ................................................../ Date t No..................... Fes$...L::...U........... THE COMMONOEALTH•OF MASSACHUSETTS BOARD OF HEALTH G S � pplir�at" u f ur 11ispos al Works Tanstrnrtiun rrutit Application is hereby made for a Permit toy Ccanuct (4-<or Repair ( ) an Individual Sewage Disposal System at: _ •: v_..:_'::`:j��'c . G-`-------------•-----------•---•---------• -••-•-LG-T-••Z-�•---.......------ ---.....-•-------•----•--..........------. ` .$,q Lgcation-Address or Lot No. �.. v�. . !:�.. �Sut Ic1C-s _lll G sT{^!!�!I caner Address a ... ;' Installer Address Type of Build x' ` Size Lot.......:...................Sq. feet Dwelling "No. of Bedrooms._......................................Expansion Attic Garbage Grinder (Iv L) pa-, Other—Type of $uildit,ig _..___................... No. of persons............................ Showers Cafeteria (1' Otherfixtures , •-------------------•------•----•-----------"-•---.•-_----•---•------------------------------- d W Design Flow............................. _________._gallons per person per day. Total daily flow.............................................gallons. WSeptic Tank'—Liquid capacity?0-gallons Length ..... Width- %__._I..... Diameter...... ....... Depth._.___.......... x Disposal Trench—No.............::.:_:__ Width._._..._......_.... Total Length.................... Total leaching area..............-____sq. ft. L01Seepage Pit No%_________________ Diameter............... Depth below inlet...6_•__....____. Total leaching area ............... sq, ft. Z Other Distribution box (klo' Dosing tank ( )I �C //, - �,�/� '� Percolation Test Results Performed by..... __--... �" �'• --------- ____ Date________________________________________ ,aa P,-v 6 '_Tes'I• Pit No. L.0'__-'�-_-•minutes per inch Depth of Test Pit....a...`.r.._.. Depth to ground water........................ rTq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �i r' .............................._• ...r =-- ------•---------------•- D Description of Soil............. �."' .... A�y /a - e , "-" - x r [-•-j v U -•-•-•••-•••-•-••-••••-••••••••••••••.....•••••••••••-•••••-•-•-•-•-•-•-••-•-•••-•-•--•--•-•---••••••••--•-•••••••••••••-••-•••••---•••--•--•--•••••••••-•••••--•••••-••---•---••--•..............•••••- W -------- ---------------- ••-----••----•••••-•••••----•---•-•••••••-••••••••--.....•-••••••••••-••------•••••••--------•••-----••••••••-------•--•••-•-••••-••-••••••-•••••••......••••.......::.:_:._. UNature 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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. la — 77 e ..........................f...............••••..................•-- •-•••-•--•--._........ Da e Application Approved BY . .. �- ..........". ..�7-••__-•---- Date Application Disapproved for the following reasons: ----•--------•------------ .......................................................................................................•---••-........---•-•......--...--••••••••--.................................................... Date a PermitNo......................................................-.. Issued_.....................................- --------------_ Date t THE_-COMMONWEALTH OF MASSACHUSETTS ax•. BOARD OF HEAL H ..........................................OF...... .....:........ .. ::. .............................. (Irrtifirate of f VautpliFanrr THIS IS TO CERT . T at e Individual Sewage Disposal System constructed (/) or Repaired ( ) by __.,'' +` .-,' "'"i""au► .... .rs+..... .:: iif%�'f�--.-"----"---- -•---------------------------"-------"--._....----------------------------..........---------------.._. Installer ......... .........................T at..... _•r' ---------------------------------------------------':-°--•_..1_....____••-•---•-•••---••••--•--••••-••-••••••••----•-•._......._....__............_..__..._ has been installedin, accordance with the provisions of T FF 5 of The State Sanitary Cod a,� described in the application for Disposal Works Construction Permit Nod.. ." "_•t�" ------------- ---•---- dated"."'------- -------. 77.----•--------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector ='=------------ --------------------- J... THE COMMONWEALTH .OF MASSACHUSETTS BOARD F HEALTH :..... ........OF...... ........ � .'................. `fir............... rk rrmit Peir sion i ereby granted �` . --•-• :..................."-•--•-------..........-••----•------- to Con'tstor.R r an 1r3ua1 Se ,*ge•Dl sal . t "�`l rex ----- a Street -y ,- as shown on the application for'Oisposal Works.Construction, Per o..___ :- ated.._.7-A JI-•-_!7__1......._. C ' w Board of Health !. DATE••• "" ' FORM 1255 HO�BBS & WARREN, INC., PUBLISHERS �. r ! trAcH PVY' 1 N s 70 / 36' b Z+ LA IVe5 w _ TA Oe ROBERT 5G �t al' P. i ry o BUNIKf9 o, No.8420 1 i E � i 1 l9�fOe3TtP��a .I , LEGEN CERTIFIED PLOT PLAN "IUYII`�e SPOT IrL.EVATIQ>� 'Qx4 , - . CIVOTING CONTOUR - 0 -� �t�118�tLt3 SPOT ELEVATION "7' c7 7" : r�s4nr F141SHgo CONTOUR AOPROVED & BOA'kD. OF MEA LTH I to ` SAAAS" ' d : SOO � DATE AQE'"T SCALE, � '� 4 d � DA'TE,� CO. IAA CLIENT lod I CERTIFY THAT tlfi PR4P>aSEtt Et3t3TER REf31; 41r�?Et? JQB t40, 77 _ BUILDING SHOWN ON THIS.'PL AN � C>ViL LAfi o CONFORMS T4 THE ZONING . LAWS DR.BY: A.�'i:� C I SU Y0 OF OARNSTABLE !� ss. i 5 NO MA►fRi �7' �� IAA#Pd Sfi � CN. BY v�R OUTH R ��ASS. t1�Y t S .'A14 SS 7 # SMI ET I,fill: DATE RES. LAND SURVEYOR lie 20 FT. M//V. /O I•T MIM CONcAr7'E g"PI�C P/P.C' CL CAN S AIP L=G. /!To_ CODERS �N. PITCH . CONCRETE Coven 4: L/04/40 LEVEL %�:• �� a� 4'"CAST 2 LAYER IRON~'•¢ MIN. �TGN DI Sr •o� d� 4 1 • • . • • • • I v •'°' W 5 ED S717NE :..•� %4"pro P-r StPT/C TANK o o . • • . . . . • ,oe d O B p', _ o c 1 • •EJrFECT/VE • ` • 3�4ap o ° f • • DEPTH • • ' ' o WA5J•/EAy D STaNE rill 'e. o •v o • • • • • • • • • • p D a v. a • • • • • • • • • p o��, Pi?EC,.AST$EEP.4GE R/T OR EQu/v. fNVeR'T ELEVATIONS ° ► • • • . . , a o INyrERT AT BUILDING 97.0 FI. v E TABI//_ss�TION l INLET SEPT/C TANK 9 t'� FT. --L_ FT. O/AM. C CSE -OUTLET SEPTIC TANK /N�.ET pJSTR/f3UT/ON BOX GROUND W,,47'EK TABLE OUTLETDI5'TR1B(ITm&BOX 96,d FT. /N[.ETSEFPACsE PST S.r FT SL'N/.4GE O/Sf�QS.4 L. SY3TE/Y1 TABIJLATIDIV LEACHI/VG f?/T plMENS/ON A 3 FT. DESIGN/ CRITERIA\ sc.a�E : %t"' _ / - 0- O/MEN5/aN $_.�FT NUMBER OF BEDROOMS D/MENS/ON G 4 FT• GARQA6EF/SPO.S:4L 40'N/7- TAL E3T/M�4'T-EC� •FLOkv 3 a0 AL.�DAY' SD/L TEST TO NUMBER Of SEEFa4GE JO/rS_ . ,DATE OF SO.,4, TEST 6 Z -7 7 SI1�B,tt.�CH/ivG PEi7•P/ fs� ,yam -T• ., fll�. L4�s •"RES'uj_-rs /N/TNESS,ED BY /; 7C' 3r3+VlKIS BOTTOM 4A;4c lA,c- F'�ER PIT 7� So. �=T. TE�� p�� TEST PST#� PERCOL.4T/ON lRA Z 0-7- � M/N,//NCN TOT,►C LEACH//VG AREA 26 6 S* FT. EGE{vAT/ON R,ESERI/ELEi4Cf/JN6r41?EA b $Q. FT. 4444 P/ 0AJ OF M o buN1KIS J COA R.Se _..._ . t7i?E!yr_Z rENrs//VFMR/A CO'INC. `w. C- I-eth v'EL. 712 MA//Y ST- 33 NO, MA/.N S'r, HY,4NN/3, PJA55. So. YARMOVTK,MATS, Q vt/.47E� For a Vi> JOB ND. 70 SHE.ET - OF t�