Loading...
HomeMy WebLinkAbout0121 TROTTERS LANE - Health 121 Trotters. Large Marstons Mills P 032 016 f Commonwealth of Massachusetts _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 121 Trotters Lane - Property Address Bryan H. Schlegal &Sarah M. Paddock Owner Owner's Name information is required for every- Marstons Mills MA 02648 5/17/13 page. City/Town b State Zip Code,- Date of Inspection - Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Informatlon filling out forms on the computer, 6q (I use only the tab 1. Inspector: - - - key to move your cursor-do not Ricky Wright use the return Name of Inspector key. B & B Excavation,Inc. r� Company Name 14 Teaberry Lane Company Address Forestdale MA 02644 City/Town State Zip Code 508-477-0653 S14595 Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based,on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ®- Passes ❑ Conditionally Passes ❑ Fails " Needs Further Evaluation by the Local Approving Authority �M> Q 5/17/13 Inspector's Signature Date . The system inspector shall submit-a"copy of this inspection report to the Appro, ing Authority(hard of Health or.DEP)within 30 days of completing this inspection. If the system is shared isystem-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. cod Nil- t5ins•11110_ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 121 Trotters Lane Property Address Bryan H. Schlegal &Sarah M. Paddock Owner Owner's Name information is required for every Marstons Mills MA 02648 5/17/13 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 121 Trotters Lane Property Address Bryan H. Schlegal &Sarah M. Paddock Owner Owner's Name information is required for every Marstons Mills MA 02648 5/17/13 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 121 Trotters Lane Property Address Bryan H. Schlegal &Sarah M. Paddock Owner Owner's Name information is required for every Marstons Mills MA 02648 5/17/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM , 121 Trotters Lane Property Address Bryan H. Schlegal &Sarah M. Paddock Owner Owner's Name information is required for every Marstons Mills MA 02648 5/17/13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts _Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 121 Trotters Lane Property Address Bryan H. Schlegal &Sarah M. Paddock Owner Owner's Name information is Marstons Mills MA 02648 5/1.7/13 required for every page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done: You must indicate"yes" or"n0. as to each:of the following: Yes No El ® : Pumping information was provided by the owner, occupant, or Board of Health ❑ M 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? Z El Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants,if different from owner) provided with ❑ ® information on the.proper maintenance.of subsurface sewage disposal.systems?_ The size and location of the Soil Absorption System.(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to.Part C is at issue .approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential.Flow Conditions: Number of bedrooms(design 3 Number of bedrooms(actual); 3 ):. DESIGN flow based on 310 CMR 15.203.(for example: 110 gpd x#of bedrooms): 330 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage.Disposal System .Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 121 Trotters Lane Property Address Bryan H. Schlegal &Sarah M. Paddock Owner Owner's Name information is required for every Marstons Mills MA 02648 5/17/13 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [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 n/a 9 ( Y 9 (gPd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 121 Trotters Lane Property Address Bryan H. Schlegal &Sarah M. Paddock Owner Owner's Name information is required for every Marstons Mills MA 02648 5/17/13 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 121 Trotters Lane Property Address Bryan H. Schlegal &Sarah M. Paddock Owner Owner's Name information is required for every Marstons Mills MA 02648 5/17/13 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: 1996 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >150'feet Comments(on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in working order. No sign of leakage or blockage. Septic Tank(locate on site plan): 1' 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 gal Sludge depth: no sludge t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 121 Trotters Lane Property Address Bryan H. Schlegal & Sarah M. Paddock Owner Owner's Name information is Marstons Mills MA 02648 5/17/13 required for every I 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 no sludge Scum thickness no scum Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle no scum How were dimensions determined? scour stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appears to be structurally sound. No sign of back-up. 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•11/10 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 M 121 Trotters Lane Property Address Bryan H. Schlegal &Sarah M. Paddock Owner Owner's Name information is required for every Marstons Mills MA 02648 5/17/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No l5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 121 Trotters Lane Property Address Bryan H. Schlegal &Sarah M. Paddock Owner Owner's Name information is required for every Marstons Mills MA 02648 5/17/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At time of inspection d-box appears to be in good condition. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 121 Trotters Lane Property Address Bryan H. Schlegal &Sarah M. Paddock Owner Owner's Name information is required for every Marstons Mills MA 02648 5/17/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ 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 ondin dam soil condition of ( � 9 Y P 9, P , vegetation, etc.): At time of inspection leaching appears to be in working condition. Water level 5' below invert. No sign of hydraulic failure Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 121 Trotters Lane Property Address Bryan H. Schlegal &Sarah M. Paddock Owner Owner's Name information is required for every Marstons Mills MA 02648 5/17/13 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of:Massachusetts _ :Title 5 Official: Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 121 Trotters Lane Property:Address:. ... Bryan H. Schlegal & Sarah M. Paddock Owner Owner's Name information is required for every Marstons Mills MA 02648 5/17/13 . . page. City/Town. State Zip Code Date of Inspection D. System Information (cont.). Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system,,including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.:Locate .where public water supply enters the building. Check one of the boxes below: hand-sketch in the area.below drawing attached separately _... Al-c IT 131 = t,33'z _ M 13,2 T32 145 'zk � 3= 51 C3y C ' '13• Q O O .. . REAP o r ; c —t5ins•11110 .... I I Subsurface f 1 Title 5 Official Inspection Form: u surface Sewage Disposal System•Page 0 7 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 121 Trotters Lane Property Address Bryan H. Schlegal &Sarah M. Paddock Owner Owner's Name information is required for every Marstons Mills MA 02648 5/17/13 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: >14' feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 10/2/96 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 r � — Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 121 Trotters Lane Property Address Bryan H. Schlegal &Sarah M. Paddock Owner Owner's Name information is required for every Marstons Mills MA 02648 5/17/13 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 i.� COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FO ►.� PART A CERTIFICATION D� 3. �- 2 . Property Address: >'�� ���!1�Y3) ���], � �' � > Owner's Name: r�r � 5t S�,fd, 5ch/iyr'I Owner's Address: Tl z> 1dv f7 e o p %l�lcc r y6+s FYI,'/s /yll� co r Date of Inspection: ='J J. -r' M Name of Inspector:( .lease;print) J4>An 9, #u to Company Name::. Mailing Address:. /$ W� /n,X f S Ala rrs&_> 10471., /99 Telephone Number: 5'0Z—t/2 f5•`777g 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: t/ Passes Conditionally Passes Needs Further Evaluation by the Local.Approving Authority Fails Inspector's Signature: : �� Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. 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. OFFICIAL INSPECTION FORM N0T1F0R'VOLUNTARY=t1SSESSAS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORAM PART A CERTIFICATION(continued) Property Address: - f;?i Owner: Date of Insp tion: S%—-2/— 7 Inspection Summary: Check A,B,C,D or E 1 ALWAYS complete aH o!$aCtio .h A. System Passes: �RJ` 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 of not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank faiil=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)art rqAaced 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: 2 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL;SYSTEM INSPECTION FORM PART CERTIFI CATION-{continued) Property Address: Owner: y. Date of Insp ction: 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(l)(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: OFFICIAL INSPECTION FORM—NOTJ FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION-FOR.NI;' PART A CERTIFICATION(continued) Property Address: Owner: i Date of Insp ction: y/— 2 I-07 ' D. System Failure Criteria applicable to all systems:- You must indicate"yes"or"no"to each of the following for aD inspections Yes No _ V 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 V Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool s/ Liquid depth in cesspool is less than 6"below invert or available volume is less:than'/:day flow V 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 I of a public well. _ 7/ 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'30 feet from -private water supply well with no acceptable water quality analysis. [This system passes if the l all 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.1 /V a (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 tocotrect the failure. E. Large Systems: , To be considered a large system the system must serve a facility with a design flow of 1.,000 gpd to 15,000 gpd- You must indicate either"yes"or"no"to each of the following: (Ile 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 1I 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 CNIR 15.304.The system owner should contact the appropriate regional office of the Department. 4 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 49/ d °vs i 4m-e Owner: 9js- an S`>r h S4ti 1 �I Date of 1� �r tion: �— Check if the following have been done.You must indicate"yes"or"no"as to each of the following• Ye; No Pumping information was provided by the owner,occupant,or Board of Health tr 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) J_ 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? V' _ 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 fSAS)on the site has been determined based on: Yes no I/'_ 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)[3I0 CMR 15.302(3)(b)] 9 OFFICIAL INSPECTION FORM-NOT FOR YOLtNTARY ASSESSMEN"-M . SUBSURFACE SEWAGE DISPOSAL_SYSTEM INSPECTION FORM PART C SYSTEM-INFORMATION Property Address: el k Owner: gi-IfC;a Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): _: Number of bedrooms(actual): 3 DESIGN flow based on 310 CUR 15203(for example: 110 gpd x#of bedrooms): 3 3 c Number of current residents: �2 Does residence have a garbage grinder(yes or no):��o Is laundry on a separate sewage system(yes or no):Ala [if yes separate inspection required) Laundry system inspected(yes or no):— Seasonal use:(yes or no): It le Water meter readings,if available(last 2 years usage(gpd)): /y w /1 -fil ' le- ' `°' Sump pump(yes or no): /UC Last date of occupancy: 61c LW d i E COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system(yes or no):,_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Ow 4 e r 4- 757.8 Was system pumped as part of the inspection(yes or no): } �, If yes,volume pumped:ZLL2gallons--How was quan pumped determined? >12 e //cwo� Reason for pumping: iA gcti'vn 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.Attarh'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): r ----- Approximate, g13of all ccomponents,dat installed(f known) source o ,format Were sewage odors detected when arriving at the site(yes or no): / 0 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: r2 Owner: 1 r c% crr 5eh/j f I Date of Insp tion: 4j_ :2 1 c7 BUILDING SEWER(locate on site plan) Depth below grade: 2 Materials of construction: cast iron V"40 PVC other(explain): Distance from private water'supplywell or suction ' e' P hie: � Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_(locate on site plan) Depth below grade: Material of construction: i/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: F. x 5o 2 Sludge depth: ti" Distance from top of sludge to bottom of outlet tee or baffle: 2 Scum thickness: " Distance from top of scum to top of outlet tee or baffle: 7 Distance from bottom of scum to bottom of outlet tee or baffle: la"'How were dimensions determined:_Ll'lF�s�rr%�, 1fo a( Comments(on pumping recommendations,inlet afid outlet tee or baffle condition,structural integrity,liquid levels as related to outlet inv evidence of.leakage,etc.): AWa?I 25^`07 44' ap ��.t;rs 4.s GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete metal fiberglass_polyethylene other (expo): 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.): c., OFFICIAL INSPECTION FORM—NOT 'VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM: . PART C. r SYSTEM INFORMATION(continued) Property Address: Owner: /el-e/ Date of Inspection: �—2/ G TIGHT or HOLDING TANK: (tank must be pumped at time of inspectionkiwate 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: y475 (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 " Comments(note if box is level and distribution to outlets equal,any,evidence of solids carryover,any evidence of leakage into or out of ox,etc.): �J..�j�,. 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. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE,DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 121' 7rel Sys L.a v!•e Owner: A /.� Date of Insp ction: 2/—ep 7 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type 6� leaching pits,number' 2 leaching chambers,number. - leaching galleries,number leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number innovativelaltemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): 1 ' CESSPOOLS: (cesspool must be pumped as part of inspection)(loeate 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: Dimension's: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): OFFICIAL INSPECTION FORM=-•NOTFOR VOEUNTARY ASSESSMEras SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART:U . • SYSTEM INFORMATION(continued) ' Property Address: Owner: :yc/s7 Savr�r 5'c_Li A< rY Date of p ction: 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. . t Ll 3-3 10• "Page l l of l i ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: iLfar oh Al,'is IYJ# Owner. &r d,h If- : a#-re Date of Insp tion: 21 0 7 SITE EXAM Slope Lkvcl Surface water n�r Check cellar Shallow wells IV x- Estimated depth to ground water d 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: !;ls 6;5• q- ')'own 6� You must describe how you established the high ground water elevation: 1 r� /via �� ,�_ rG lr� 'q vfdX .7C a �vcarti �bf/s�Tlt'y Ca,1-7 bf 01 a� Br vY� b r ,C, • 11 TOWN OF BARNSTABLE • LOCATION .. —'�- SEWAGE # \rII1,AGt MAR g7"oNs.-'A1/L,S . ASSESSOR'S MAP&LOTa' 0/6 INSTALLER'S NAME&PHONE NO.A M• A o if d,d i/�d'g,✓ �J 776 SEPTIC-TANK CAPACITY /, ---- LEACHING FACRM: (type) 24E,4✓'Yf p!/ (sine) NO.-OF BEDROOMS .- i BUILDER OR OWNER ,�•,�� xno t& _a PER UTDATE: L; COMPLIANCE DATE: f� 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 .100 feet of leachin facility) Feet Furnished by 10��el M of 1 .00 _ j f E CERTIFICATE OF ANALYSIS Page: 1 Barnstable County Health Laboratory Report Dated: 05/30/2002 Report Prepared For: Order Number: G0214571 Derek MacKinnon 21 West Walnut Street Milford, MA 01757 Laboratory 11)#: 0214571-01 Description: Water-Drinking Water Sample#: 14571 Sampling Location: 121 Trotters,Marstons Mills Collected: 05/21/2002 Collected by: Dennis J.Con 032-016 Received: 05/21/2002 Routine ITEM RESULT UNITS MCL Method# Tested LAB: IC Lab Nitrates 4.2 mg/L 10 EPA 300.0 05/21/2002 LAB: Metals Copper 0.2 mg/L 1.3 SM 3111B 05/29/2002 Iron <0.1 mg/L 0.3 SM 311113 05/29/2002 Sodium 15 mg/L 20 SM 3111B 05/29/2002 LAB:Microbiology Total Coliform Absent P/A Absent P/A 05/22/2002 LAB: Physical Chemistry Conductance 185 umohs/cm 500 EPA 120.1 05/22/2002 pH 6.6 pH-units EPA 150.1 05/22/2002 Note: The water sample has higher than average levels of Nitrates.Monitoring is recommended(2-3 times per year)to establish any upward trends. Approved By: (Lab Director) s 13o�=aoz Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 I� COMMONWEALTH OF MASSACHUSETTS F EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION 4 iVIAP o�z J PARCEL, ; �� -A. LOT -- TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 121 Trotters Lane (( C) Marstons Mills MA 02648 1 ,> Owner's Name: Derek& Kristen Mackinnon Owner's Address: Samel Date of Inspection: August 9,2004 Name of Inspector: PATRICK M. O'CONNELL co Company Name: SEPTIC INSPECTION SERVICES CO. ry r- Mailing Address: 189 CAM METT ROAD "' rn MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 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 DE� approved system inspector pursuant to Section 15.340 of Title 5(310 CMR I5.000). The system: %�etj%k� Irtt�S�����i _XX_Passes ••� �'•.,C�% Conditionally Passes PATRI N Needs Further Evaluation by the Local Approving Authority M Fails S Inspectors Signature Date: 8/9/2004 The system r�tI fill inspector shall submit a copy of this inspection report to the Approving Authority(Board of Healt�i 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: - System Passes Title 5 standards. Recommend pumping tank and newer leaching pit to remove solids which have carried over from tank due to not pumping frequently enough. ****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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 121 Trotters Lane, Marstons Mills Owner: Derek& Kristen Mackinnon Date of Inspection: August 9,2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _XX I have not found any information which indicates that an of the failure criteria described in 310 M y C R 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 CERTIFICATION(continued) Property Address: 121 Trotters Lane, Marstons Mills Owner: Derek& Kristen Mackinnon Date of Inspection: August 9,2004 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(l)(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 detennine 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: Page 4 of I 1 OFFICIAL, INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 121 Trotters Lane, Marstons Mills Owner: Derek& Kristen Mackinnon Date of Inspection.: August 9,2004 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_ 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. JThis 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 forma _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. 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. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no — _ the system is within 400 feet of a surface drinking water supply the system is.within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered yes in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. A Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE ]DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 121 Trotters Lane, Marstons Mills Owner: Derek& Kristen Mackinnon Date of Inspection: August 9,2004 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? _X_ 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 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: 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: 121 Trotters Lane, Marstons Mills Owner: Derek& Kristen Mackinnon Date of Inspection: August 9,2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: I 10 gpd x#of bedrooms): 330 Does residence have a garbage grinder(yes or no No Is laundry on a separate sewage system (yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use:(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): N/A Well Water(Over 100' From S.A.S.) Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd 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: Pumped Last Year Source of information: Homeowner Was 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,distribution box,soil absorption system Single cesspool Overflow cesspool _—Privy —Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: Tank, D Box and old leaching pit original to house. Newer leaching pit 12-15+/-years old. Were sewage odors detected when arriving at the site(yes or no): No Page 7 of l I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 121 Trotters Lane, Marstons Mills Owner: Derek& Kristen Mackinnon Date of Inspection: August 9,2004 BUILDING SEWER: XX (locate on site plan) Depth below,grade: 1' Materials of construction:--cast iron XX_40 PVC_other(explain): Distance from private water supply well or suction line: 30' Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade, 1' Material of construction:_X—concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:i Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 8.5' long x 5.2'wide- 1000 Gal. Sludge depth: 12" Distance from top of sludge to bottom of outlet tee or baffle: 18" Scum thickness: 6" Distance from top of scum to top of outlet tee or baffle: 7" Distance from bottom of scum to bottom of outlet tee or baffle: 8" How were dimensions detennined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tees intact and clear,recommend pumping GREASE TRAP: No (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 bottorn 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: 121 Trotters Lane, Marstons Molls Owner: Derek& Kristen Mackinnon Date of Inspection: August 9,2004 TIGHT or HOLDING TANK: No (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: XX (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box,etc.): Box set level,traces of solids carryover. PUMP CHAMBER: No (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 I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 121 Trotters Lane, Marstons Mills Owner: Derek& Kristen Mackinnon Date of Inspection: August 9,2004 SOIL ABSORPTION SYSTEM (SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type _X_leaching pits,number: Two 6x6 pits. 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.): Original leaching pit had previously failed and has 10-12"standing water. Newer leaching pit has 2' effective leaching with traces of solids in effluent Recommend puniving pit to remove solids and chemically treating pit at a later date to remove any residual solids CESSPOOLS: No (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: No (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.): n Page 10 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 121 Trotters Lane, Marstons Mills Owner: Derek& Kristen Mackinnon Date of Inspection: August 9,2004 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. Trotters Lane 3� It ,� 17 q6 l� 33 i 1000 gal tank 2 — 1000 gal pits SAS is 125' +/-from well rn f Page 1 I of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 121 Trotters Lane, Marstons Mills Owner: Derek& Kristen Mackinnon Date of Inspection: August 9,2004 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 30 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) _X__Accessed USGS database-explain: USGS and Town GIS You must describe how you established the high ground water elevation: Topo map shows property above el. 120 and town groundwater contour map shows water below el. 60. Bottom of leaching pits 9-10' below grade. w TOWN OF BARNSTABLE ' " LilCAi`ION r2/ 1`s� SEWAGE # VV_,LAGE �I/ S ��5'"/�J/«S ASSESSOR'S MAP & LOT 32- 0I9 INSTALLER'S NAME&PHONE NO.#/.�/, —, If 1011/4/d"-1 Al 6_776 SEPTIC TANK CAPACITY /, a-i LEACHING FACILITY: (type) o4f/3G/f 1,91/ (size) --- NO.OF BEDROOMS BUILDER OR OWNER �,�°�6g 0-e ''Pt6,0� g 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 �;e on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachin facility) Feet Furnished by r �� p )C 0 3o . No. Fee $4 0 . 0 0 THE COMMONWEALTH OF MASSACHUSE S PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MA SACHUSETTS Zipprtcation for Miopooar 6potem Con6truction Permit or Repair x an On-site Sewage Disposal System at: Application is hereby made for a Permit to Construct( ) p ( ) g p y Location Address or Lot No. Owner's Name,Address and Tel.No. 121 Trotters Lane, Marstons Mills Darla Brown 420-1019 Assessor's Map/Parcel 121 Trotters L n, M.M. Installer's Name,Address,and Tel.No. 7 7 5 8 7 7 6 Designer's Name,Address and Tel.No. WM.E.Robinson Sr. Septic Service P.O.Box 1089 , Centerville Type of Building: Dwelling No.of Bedrooms 3 Garbage Grinder( ng Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow well gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil sand Nature of Repairs or Alterations(Answer when applicable) Specifications to engineers plans: D-box, 1000 gallon stonepacked leach pit 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 thi o egilth. Signe a Date L Application Approved by Date Application Disapproved for the following real s /1009 Permit No. ..r l�V Date Issued ——————————————————————————————————————— T i I0, ' r THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MA SACHUSETTS } Zipplicatiou for Digpoml *pgtem Congtruction Permit Application is hereby made for a Permit to Construct( )or Repair(x )an On-site Sewage Disposal System at: q Ka. Location Address or Lot No. Owner's Name,Address and Tel.No. i 121 Trotters Lane, Marstons Mills .Darla ,Brown 420-1019 j Assessor'sMap/Parcel 121 Trotters Ln, M.M. . Installer's Name,Address,and Tel.No. 7 7 5—8 7 7( Designer's Name,Address and Tel.No. Wm.E.Robinsoyn 'Sr.. � /Septic Service P.O.Box 1089, Centerville F Type of Building: Dwelling No.of Bedrooms 3 Garbage Grinder(nth Other Type of Building No.of Persons Showers.( ) Cafeteria( ) Other Fixtures 1 r , Design Flow we 11 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title. . S x./ Description of Soil Band t Nature of Repairs olterations(Answer when applicable) Specifications to engineers plans: F n hnx 1000 nation stoneoacked leach pit' 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 an knot to place the system in operation until a Certifi- cate of Compliance has been issued by this B of alth. aI` Signe - -, . Date,�U Application Approved by r' Date Application Disapproved for the f lowi g{reas ns n % / r 4 Permit No. .. 2.2p� Date Issued tl + ------------ — -- --- THE COMMONWEALTH OF MASSACHUSETTS i BARNSTABLE, MASSACHUSETTS Brown Certificate of Compliance.,. THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced(X )on by Installer Wm E Robinson. Sr. at 121 Trotters Lane, Marstons Mills has been constructed in accordance with the provisions of Title 5 and the for Disposal System Constructio ermit Nod dated 2.-- / Date 44.... C; Inspector 6^ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAN'THE SYS- TEM WILL FUNCTION SATISFACTORY. -——————————————————————————————— -— ,._— E NO. Fee $4 0.0 0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS 1 r. Brown Mi5pogar &pgtem Congtruction Permit f *; Permission is hereby granted to Wm.E Robinson, Sr Septic Service to construct( )repair( an On-site Sewage System located at No.#. 121 Trotters Lane Marstons Mills Street and as described in the above Application for Disposal System Construction Permi ''' 1 No. uate The applicant recognizes his/her duty to comply with�Title 5 and the following local provisions or special cond'tions. All construction must be c mpl/eted within three years of the date below. ,�3,_� � � ,.�/ Date: /-0... a( Approved by / NfY I. `f i/'t v I J J Boazd of"Heal ' , 4�., • u r�. --- .2 0 0. 0 o /-vT /S a - 2 U, 000 S.F `� l Nil 1�7I,LF_ l C� 1.1 73 - • O Sri O h 1 O' Li L �• of. :� d Q {l C 1 ►� H 0 F �o 11 ROSE Ti cf P• �l BUNIKIS H I -- — — --- -- -0 9 No.22162 \on STEP ,c 0� LEGEND CERTIFIED PLAT PLAN_ EXISTING SPOT ELEVATION 0,,0 ` oT /S T,�•o-f7e1Cs EXISTING CONTOUR - - 0 - - ��� FINISHED SPOT ELEVATION ;Q FINISHED CONTOUR - 0 - IN \ APPROVED $ BOARD OF HEALTH ,A1; ��l S'f � ��j� },1 � '70 DATE , (o Zv l AGENT — -DATE 1 LOREDGE ENGINEERING CO. ING' ' CLIENT ' �� � � 'N I CERTIFY THAT THTHPROPOSE[LAN �; �) ;' / :� BUILDING SHOWN ON EGISTERE[� i REGISTERED ) JOB N0. . CIVIL - CONFORMS TO THE ZONING LAWS LAND DR. BY ' I � ' ' OF BARNSTgBL ENGINEERS�� ,SURVEYOR ,l j > � CH BY , )'' . � -kA n,( MAIN Sr 712 MAIN - T f R AAir) SURVEY r y , � n 4 J h ,� .� �L� �$ � l� ., CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, William E. Robinson, Sr.,hereby certify that the application for disposal works construction permit signed by me dated , concerning the property located at 121 Trotters Lane, Marstons Mills, meets all`of the following criteria: * There are no wetlands within 300 feet of the proposed septic system * There are no private wells within 150 feet of the proposed septic system * The observed groundwater table is 14 feet or greater below the bottom of the leaching facility * There is no increased in flow and/or change in use proposed * There are no variances requested or needed SIGNED: DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER (Attach a sketch plan of the proposed system. Also,if the licensed installer posesses a certified plot plan,this plan should be submitted). a Q &ONO l� 42'-0" 11 6 1 OD �• K-- N 0 13-f0" 11 4 -r =-9=T"-- 3t10• a' 13•_5, N 6 � B �1 42 " _ I I LOCATION SEWAGE PERMIT NO. VILLAGE INSTA LLER'S NAME i // ADDRESS r sGs�► .G4. - ��� � .eL.t..yt.c.ti, 3. U I L D E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED A - E-3 s :i 03 , NfoCW - -e..: ........ -• . ` THE COMMONWEALTH.OF MASSACHUSETTS BOAR® Off HEALTH ...........O F............ . ....�!.�1�. ...--................................................ Appliration for Disposal Morks Tnnstrnr#inn rnntit Application is hereby made for a Permit to Construct ( V/ or Repair ( ) an Individual Sewage Disposal System at �..::::.e:...:. � . mod?,% = - : ................. f............................. - -- ..... _................ ...........•-- ,�L_ -Lo�,cation-Address Lot No. ...._ .. W J `�Owner � `'� :e `—Address .............. ----•-•---------....................................................... Instal r Address Pq UType of Building Size.Lot.................... .....Sq. feet Dwelling—No. of Bedr oms......... ............................Expansion Attic ( ) Garbage Grinder ( ) 'PL,� Other—T e of Buildi i No. of persons............................ Showers YP g P ( ) - Cafeteria ( ) dOther fixtures --------------- •-----...._---------------- ------------------------------------------------------------ ......._.. W Design Flow............ ap city.10"gallons Length................ Width................ Diameter..._......__.__. Depth.......... x Disposal Trench—No. .................. Width.................... Total Length.....................Total leaching area....................sq. ft. Seepage Pit No............. .... Diameter.....�Q__.._..... Depth below inlet......16.......... Total leaching area---fib 6....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ 14 Test Pit No. 1..... .........minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -•---------...........-/.....-----------------•-•--•-•--------------------_------------------------------- Description of Soil.....---�� -----.... �---..$.r�-a—�x_..._ U -•------------------------------- = " 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'J 1'1 U 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. igned.� � s�2 1�Q ... . v ..........................J.................... DaEe Application Approved By...............- ---c--"2 ...................................................... ��:_. .d --_� ...... Date Application Disapproved for the following reasons:-----•--------•---------------------------------------••------•------- ......................................... .................................•••-----...•---....---------........------------•---•--------•---------•-•----------------------......---••--------------•---••-••----------•-•------------•----- Date PermitNo......................................................... Issued....................................................... Date No.......... — FxB�„ ............. THE COMMONWEALTH 07 MASSACHUSETTS BOARD O HEALTH ------ ............ . .... - ,. Appiiration for Disposal Workii Tous#rnr;ion Vamit Application is hereby ma&for a Permit to Construct ( V�or Repair ( ) an Individual Sewage Disposal System at, ... "" . _.._. ....... sr. . JC-- .............................. ....................... . Location Address ,�/ .... ... l� .. `fpr..... ' � �I'It�f�� �t No�.G!! Wi ec, . n'7�t-Sj fr( �'� .. .._. ---.. . . ...... ._ ... .. .-•---..--... r �L�l,�?'+�'"". ...............•----...- -•-- .. .... Addzess �� O • a ( ... ...6f t...... -Owwner Insialler Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.........��-----------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building .............. No. of ersons................___......... Showers — a YP g --------•••--• P ( ) Cafeteria ( ) Otherfixtures --------•--•... ............••----••-••-•••-•------•---••-•---------•••-----•-------- W Design Flow.._..._.._., ......................gallons per person per day. Total daily flow__._.� ...........................gallons. WSeptic Tank Liquid capacity.10-0.0gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area........___........sq. ft. Seepage Pit No........I.......... Diameter...../Q......... Depth below inlet....... .......... Total leaching area...- ?....sq. ft. Z Other Distribution box ( 1) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ af/ ------------ x Description of Soil........ �' 17 ![3 ,/Cfeti,-�r�r r ''�Z, � `r 1z....G4 «' . .,r....�'..... .- ------. :... • --.....•..•...•------------------ W - I6rA. . ----- -- ------ - ---- - 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. ....••. ....._. -- Da e Application Approved BY / •-------•-•.................................•---...... -----7`..s--: -----d:�.... Date Application Disapproved for the following reasons:.............................................................................................................. Date PermitNo........................................................ Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH 11 ....O F.............. .....���........................ ...................... Tntifiratr of Toutplianrr T POW,S I TO CERTIF "That the Individual Sewage Disposal System constructed ( or Repaired ( . ) by t ...........at CA ..... 1 G 11 has been installed in accordance with the provisions of T 5 of The State Sa itary Cade,as described in the alicatio pp n for Disposal Works Construction Permit No - ------- A...... dated_-....Z_-Zlo..-AA4,............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................... ::.:..... THE COMMONWEALTH OF MASSACHUSETTS f BOARD V HEALTH 0.jiQe'' rZ.........OF........ -a..�Z............................................ ✓'� ... No............. . -- . '..._.. FEE. Disposal or T onu#r ion Errant Permissio s h y granted ....... ..... to Const ` c or Repair an vidual Se is osal y at No Ir Street �y as shown on the application for Disposal Works Construction No.__ ... .. _ Dated...._i t.. ..... .d'•-.... - ..... R Board of Health DATE.......`'=-------------•f�- .. - FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS j i� s VICTOR OLIVEIRA, R(tS., C.H.O. r, OFFICE tg" 1498 HIGH STREET 7 '; BRIDGEWATER,MASS.02324 'LABORATORY -� 176 PLYMOUTH STREET BRIDGEWATER,MASS.02324 OLIVEIRA LABORATORIES FOOD- DAIRY PRODUCTS -WATER -WASTEWATER CHEMICAL£t BACTERIOLOGICAL ANALYSES 697-2650 September 1 , 1g80 Morgan Homes c/o SDS Inc. 8 Gristmill Plaza Southwick, Mass. 01077 Source : Well Water - Bored Well with well point - 63 feet deep Located on Lot 15 Trotter' s Lane - Marston Mills, mass. f' Coliform Count /100 ml @ 35 C O Membrane Filter I S.P.C./ml @35C 5 Color (APC units) Sediment none Turbidity (NTU) 1. 0 Odor none Taste satisfactory pH 5.8 Specific Conductance micromhos/cm 1 , 0 -mg /liter Total Alkalinity (CaCO,) 10. Free CO, 30.9 Total Hardness (CACO,) 26. Calcium (Ca) 4.8 Magnesium (Mg) 5. 2 Sodium (Na) 16. Potassium (K) 0. 8 Total Iron (Fe) 0.26 Manganese (Mn) 0. 0 Silica (SiO,) 1.8 Sulfate (SO,) 12. Chloride (CI) 48. Nitrogen - Ammonia 0. 39 Nitrogen - Nitrite 0. 003 Nitrogen - Nitrate 1. 1 Copper (Cu) On site collection made by agent of the Blue Rock Well Drilling Co. - 9/11/80. Sample delivered to laboratory by Mr. Robert Del Pozzo of Morgan Homes - 9/11/80 at 3: 00 P.M ,. Bacteriologically, this well water is of a satisfactory sanitary standard and is suitable for drinking and domestic purposes. Chemically, this well water meets the standards for all the chemicals tested. i Director IVOTE /F E/TN ER THE S..�FPT/C T.41N/C 0 I !EiACti///VG P/T .ARE /YORE 7-,gA.AV /2"BE40AI 3/C'A10E� fa 24 N©/AAl ET.ER CONG:�a, T� CONE'R / �, "PVC P/PF S,,VALL eE BROUGHT To -:7 o?A ��.✓ EXTRA CONCRCTE i EAY H ? C0 /OU.O CODERS AllN• P/TCN I I /`'/ Y C ST / ON IiER S/-.BALL !3E USEU YB PEiP FT. I I F/ V ,OR/V-=IWA Y CU YEJ? CLEAN .SA/VO I- r L/QU/U LEVEL 4" CAST — R.ra. 2 LAYER /RON P/PE I S D d i o -y M/A. P/TCoY GAL. I • u " / • . . • . . 1 / awe o ASNFD 57?�NE S PT/ T NK -" D I S T. �; . 1 ° W t C A � 1 [� ax o B r • r • • • 1 p - D r 3 • �l v c � EFFECT/V� ,; , p 14 - o ° r / • • • 1 / 3 e �:�-,w? OEPTH v ° y✓45HEO STONE 2� I ice:_-;O• 7 y 9 o G °r^ 1. 1 1 • • • • • 1 r ii{p ° ° o ? 1 • • . o . • • • . 1 p D v -- PRECAS T SEEPAG E i /N[ieKT ELE✓AT/oNs o ► o• r' r r t r • • . 1 1'� e • P P17 OR EQU/V /NYERT AT BU/LD/NG 97.0 FT 6 � D/.'�M. /NLET %EPT/C TANK _9 -7- 014M. C(!SEE TfiCULATJ07V, OU}'LET SEPT/C TANK _ 3 FT. �— —� r M' cT!> , /STRIU dT/O/v BOX 95 F 7 T N . GROVv PV.ATER TABLE LETD/STR/BUT/UN BUX 9S�FT. SECT/ON 0.� F77 SEN/AGE ,D/SPOSA L SYSTEM T�4BULATIDN i L EACH//VG P/*T i STALE %4 = / - 0.. UIMENS/JN A __.�.._FT. iDES/GIV CR/TER/A NUMBER OF BEORo4MS __ — D/HENS/ON C_4F_F T M"V v/+RdAGED/SPOSAL C/N/r_ _ — SO/L LOG II TOTAL EST/MATE-p 1--LOVV_99a° G,q��pgy. SOIL. TEST / SOIL TEST#2 SO/L TEST NUMBER OF -E4;N;NG: ,v/T_; �_ �FLEY. 97.0 �ELEY ,DATE OC- SO/L TEST dUTTUM LEf1CN/NG PEK /�/T-7�SQ• FT _ O p RESULTS /•t//TIVESSED BY _ I _r f'4FACOLAT/ON RATE #/ ! ..'S__ M/N /NCH I TOTAL LEACH//YG AREA _S 3 2-S-Q FT. 4 " _ 2 Z l�ERCOLA7-10 V RATE JL 2 / RE ERNE L=ACN/NG AREf� 3 I y^ ~ MJN;/INCH s�4n/•oy c� �'/ i v �- MA s„4'L C- L -- ROSERT,P. \ Z , M�1;�'S'?'D NS Al 1 L._ L .S �cOi BUPJIKIS _ly CGJ}AZSE - .o No.22162�7 (5 2 A I�EL \.p FG� rL I EL DREDGE ENG/)VEER/NG CO/VC... � 7/2 MA//Y ST.�WAL'-' 33 ND, MA/N ST. HYANN/S, MA-"6 . SO. YARMOUTN, MAS-> •} JOB ND. V�-/ SHEET Z OF Z Ail 2. v L�00 F Tic 73 ------ - ---; ' In "J I� 4-Z_ Ise M, . �o ROSERT, �c R BUNIK- o ; No.22162 �GrSTE� �FSS%GNAL�N6\ LEGEND CERTIFIED PLQT PLAN EXISTING SPOT ELEVATION . Ox0 EXISTING CONTOUR - - 0 TiQoT T��. S FINISHED SPOT ELEVATION �0 0� �17,� �� S wA/S FINISHED CONTOUR ---- 0 - IN APPROVED = BOARD OF HEALTH �All ��, -1A1 ., 1+ A ` AGENT --- SCALE / = :Z/� DATE = 6�y/� DATE 1- LOREDGE ENGINEERING CO. ING' ' CLIENT `��J "` I CERTIFY THAT THE PROPOSE[ I'VEGISTERE� IREGISTEREDI SOB NO. �% C.) :' 1 BUILDING SHOWN ON TN13 PLAN CIVIL LAND Y I, .n . _ CONFORMS TO THE ZONING pR. B R LAW ` ENGINEERS (,SURVEYORS OF BANST�BL� , /M� S� 33 NC MAIN Sr 712 MAIN `;T CH =-- - -- �,. _ SO. YARMOG;TH, MASS. HYANNIS, MA`:> SHEET_ .. OF4_'._ D TE REG. LAND SURVEYO