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Home My WebLink About0018 YEARLING LANE - Health 18 ,Yearlirig Lane Marstons Mills,-'., �,�' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH IT.a `...-%/_.....OF.....t3 z.✓ s T'F 1 Z_,=_ ...... Allpfira#ion for Dhipas al Works Cfutw1rurthin Prrutit Application is hereby made for a Permit to Construct ( ✓�*or Repair ( ) an Individual Sewage Disposal S stem at: Location Address or Lot No. L e m/ — S a /I .w�s 2 I_.. �„r_..- -•-- 3/ vL,D-_Tt TE ----------........... ........................................................ Owner Address a ...........tz` _�.. ._.:,y c N z-.......................• ..........................-5 T� � -.... .... Installer Address Type of Building Size feet Dwelling—No. of Bedrooms................. ----------------------------Expansion Attic—�"'J"" Garbage Grinder_(_--)— p`�, Other—Type of Building ........ No. of persons......... .............. Showers ( ) — Cafeteria..( ' G4 Other fixtures ................................. . W Design Flow........................ 'IT _ per person per day. Total daily flow..__........-3�.T ................ WSeptic Tank—Liquid capacity/?QO.gallons Length.-VA.". Width..'F_.!a.� Diameter________________ Depth.S'.`.8_ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area.____.........�,...sq. ft. Seepage Pit No........1----------- Diameter.......V...... Depth below inlet.....`_......... Total leaching area....2..G_Zsq. ft. Z Other Distribution box (K Dosing tavk—(-- / aPercolation Test Result Performed by.. o.w�+_.C.�r.4.....� ....... Date..... .�J✓`8. ...... a Test Pit No. I..............2..minutes per inch Depth of Test Pit---I.. Depth to ground water.... (i, Test Pit No. 2...�..Z.minutes per inch Depth of Test Pit....�.4.4�. Depth to groundwater.. 9 •-•-•---••----- f Description of Soil............& e.�..L.lt!!=.....�'r... = ' e.............. ....9S.................................................. VW -----------------------------------•----------------------------•--•---•--•......------...•--•-•-•-----------•-----------------•-----•---------------••----•-----•------------•---------..........--••-- Nature of Repairs or Alterations—Answer when applicable................................................................................._..._.......__. ------------------------------•- ----•------------•---...------------....-•-------.....----------------------------------------------............................................ Agreement: The tinders d agrees to,install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITLL 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. //LL �/ Signed.?AF -----•--••-------------- `T �`----7- ate Application Approved By............. ''^ .. i — .................................. --------------------- ----------------- Date Application Disapproved for the following reasons--------------------------------------------------------•-----------------------•-----------------------•--•----- ---------------------------------------------------------•--••----------....-----•------....-•------------•-•-------•---•--•--•-------•------•------------••---•-----------------•---------••--•---•--- Date Permit No.--- 1'_.�� J`�........................ Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .........................--•---------------------•......_.._..•.-•••-- Appliration for Uispnottl Works Tmitrurtinn amit Application is hereby made for a Permit to Construct ( w1for Repair ( ) an Individual Sewage Disposal System at: J ..... Location-Address or Lot No. e � � / - S.' /j- ,,,,� s !_ e c., / r 3 / O/1D r�T;4F. r 3 2, r'l Y? <y��✓i ............. .....----...----•--- -------- ---------------•- .....: ._.... - -_.... -- --•-- ..... .... .__.. 5 Owner Address �__ 7'"1,a.7.......................... / 7 ✓ i C, e`_ Pq Installer Address Type of Building Size Lot..9:_0_-5:_!..'a..Sq. feet Dwelling—No. of Bedrooms_________________3..............._.......Expansion Attic" Garbage Grinde�r,,,,,,(._4-- `44 4 Other—T e of Building ......... No. of persons.........�s______________ Showers — Cafeteria a Other fixtures -------------------------------- - W Design Flow.........................-` _ .........gallons per person per day. Total daily flow............ ..................gallons. WSeptic Tank—Liquid capacityLq Q__gallons Length_ _'_ ." Width_'E_el_4__"__ Diameter________________ Depth_ _ �_g_" x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........!------------ Diameter_____.LS;?....___ Depth below inlet......i._.____.____ Total leaching area..... L__7.sq. ft. Z Other Distribution box (pej Dosing ta&4_--)— '-' Percolation Test Results Performed by._�.�_�_---__�_- _ ,._._. -t `'__.__._. Date___._ 1_ _ a____.. Test Pit No. L__.�___�__minutes per inch Depth of Test Pit...1_. t::A...... Depth to ground water....lv,,lza_..... fT Test Pit No. 2__`.___ ___minutes per inch Depth of Test Pit... _ 1__ Depth to ground water_ _�+✓,� _._. x _ .P_c., g O- Description of Soil............&Lg ..!---v..=..-----F� . ' `' £'------- ............................................... U ---•--•---•-----------•--•------•-------------------------------------------------••-•-•---•--.._._...---------------.......-.--------------•--...------------••------------•-----•---------•--•--•-•-- W 1 U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ........................................ = -------------....-•--•--------------••-•-------------•--------------•-•----------------------------•-••••-•-----•--------_--•--• Agreement: >f~ The underj ed'agrees to. install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITL E 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. Signed `-,; -_• '. � --- - -------------------•---•- -��r ate ��... Application Approved By............ _.,�,�., ................................... Date Application Disapproved for the following reasons-----------------------•--------•----•------------------•--------------------•------------------------------•---- .............................................. ---•----------...--------------•---........_..__......-•----•----•-..___..--••-•--•------•-•••-----•--•••--•---------------------•--------•--•-•...._.._ Date Permit No._ 7._..2 Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......�...p.>/✓rv!.........0F...1�zz-is't/...................................................... 01rrtifirate of Tout rliFatta THIS IS TO CERTIFY, That the Individual by -kjSewage Disposal System constructed (� Repaired ( ) --- ._. ............. :.............•. 9 y Installerat _ ...................._................................................._______________________________.______.________________ ____.__........................................................ has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit _____________ dated----------................_............... ______ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......._..__ FEE-�..JS�"..•a,..�.... No.(�7 .1_0 . . Disposal Vorkv 01.111ntrnrtion unfit Permission is hereby granted......�.i•--C-J-`-- -1 �.._..:. to Construct ( --for Repair ( ) an Individual Sewage Disposal System atNo.. =fit `�� ........................................................... ' = Street as shown on the application for Disposal Works Construction Permit Ng7',7r_;t0_S77__ Dated........................................... ------------------------------------------------------------- •-------------- -------------- DATE......./-' --•---------------•-----•-------- ••_ Board of Health FORM 1255 A. M. SULKIN, INC., BOSTON TOWN OF BARNSTABLE _ LOCAnOON Y.G✓c�✓ (n ✓l S� # ;7 VILLAGE I�M_�I�'�l/ ASSESSOR'S MAP & LOT NAME&PHONE NO�'�rtL 06,iru.i 1 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) P 'r (size) NO.OF BEDROOMS __ BUILDER O< LTV ZOO PERMITDATE: COM DATE•T�;rP Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any we ands exist within 300 feet of leaching facility) M - Feet Furnished by ',r J �. 6 • • 4 • ♦ 1 \ 4 4 \ h 4 \ • \ 1 \ \ h • \ \ h • 1 \ 1 • \ \ r ♦ i f f i f r ♦ i r J r J r f f r f ♦ J ♦ r ♦ r f f r ! 4 4 h • • 4 4 4 \ \ \ \ \ h • 4 4 4 4 h 4 4 h • h h \ \ • \ � ' f ! f r f r f ! • F f r f r I f r f f f ! ! F ! ! ! r F r 2 h • \ • • \ 4 \ • 4 \ h 4 4 • h 4 \ ♦ • h \ h • 4 • • • • • �i�/�fkf�fkr 1r • 4r4!\rhfl�h�hfhf\%•f•f•r•f•Ihr•r4 h 4 \ 4 4 \ 4 4 4 4 4 • h 4 \ h • • 4 • 4 • 4 \ 4 \ h h h • 84 39 rfrlfM1fffFfFlrflfrrrtltrrrlrf ! \ k 4 h \ 4 4 \ \ • \ 4 \ \ \ 4 \ \ h \ \ \ \ 4 \ • • \ \ ge % ♦ I I J i f f f f l f f f f f / f f ! f f I f !�yI / f f f f t ! / r ! i f r r F f F I f I f f ! ! ♦ f q Y F ..>t ! f / / ! ♦ f J i f f ♦ i / f ! ♦ f f f f f'f t f 17 later ervice I j Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Yearling Lane Property Address Peter Lauzon Owner Owner's Name information is Marstons Mills MA 02648 September 25, 2010 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co Company Name 189 Cammett Road Company Address Marstons Mills MA 02648 City/Town State Zip Code 508-428-1779 SI 12855 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 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 valuation by the Local Approving Authority V September 25 2010 I spector's Signature Date The system inspector,shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 0 10-238 Lauzon 18 Yearling.doc•08/06 Title 5 Official Inspection Form:Subsurface Sawa a Disposal System•Page 1 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Yearling Lane Property Address Peter Lauzon Owner Owner's Name information is Marstons Mills MA 02648 September 25, 2010 required for every page. Cityrrown 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: Leaching pit was found with 2'of standing water at time of inspection with a stain line indicating pit had never been more than half full Recommend pumping tank in next 12-18 months. 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 10-238 Lauzon 18 Yearling.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts : Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Yearling Lane Property Address Peter Lauzon Owner Owner's Name information is Marstons Mills MA 02648 September 25, 2010 required 6or every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 10-238 Lauzon 18 Yearling.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Yearling Lane Property Address Peter Lauzon Owner Owner's Name information is Marstons Mills MA 02648 September 25, 2010 required for every page. City/town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than_day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 10-238 Lauzon 18 Yearting.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Yearling Lane Property Address Peter Lauzon Owner Owner's Name information is required for Marstons Mills MA 02648 September 25, 2010 every page. City(fown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided'that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.) ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 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. 10-238 Lauzon 18 Yearling.doc•08106 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Yearling Lane Property Address Peter Lauzon Owner Owner's Name information is required for Marstons Mills MA 02648 September 25, 2010 every page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ 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)] 10-238 Lauzon 18 Yearling.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts : Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Yearling Lane Property Address Peter Lauzon Owner Owner's Name information is required for Marstons Mills MA 02648 September 25, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 2 Number of current residents: 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 years usage (gpd)): Sump pump? ❑ Yes ❑ No Last date of occupancy: Currently Occupied Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 10-238 Lauzon 18 Yearling.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Yearling Lane Property Address Peter Lauzon Owner Owner's Name information is required for Marstons Mills MA 02648 September 25, 2010 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Unknown Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Compliance date: 6/22/87 Were sewage odors detected when arriving at the site? ❑ Yes ® No 10-238 Lauzon 18 Yearling.doc-08/06 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Yearling Lane Property Address Peter Lauzon Owner Owner's Name information is required for Marstons Mills MA 02648 September 25, 2010 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 1' Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 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: 8.5' long x 5.2'wide- 1000 gal. 4" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 26" 4" Scum thickness 6" Distance from top of scum to top of outlet tee or baffle 9„ Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Measured 10-238 Lauzon 18 Yearling.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Yearling Lane Property Address Peter Lauzon Owner Owner's Name information is p required for Marstons Mills MA 02648 September 25, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tees are intact, liquid level is at bottom of outlet invert. Recommend pumping tank in 12-18 months. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 10238 Lauzon 18 Yearling.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Yearling Lane Property Address Peter Lauzon Owner Owner's Name information is P required for Marstons Mills MA 02648 September 25, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Liquid level at bottom of outlet pipe, observed trace of solids carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 10-236 Lauzon 16 Yearling.doc•06l06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Yearling Lane Property Address Peter Lauzon Owner Owner's Name information is p required for Marstons Mills MA 02648 September 25, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: One 600 gal pit. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching pit had 2' of standing water at time of inspection with a high stain line indicating pit had never been more than half full. 10-238 Lauzon 18 Yearling.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Yearling Lane Property Address Peter Lauzon Owner Owner's Name information is required for Marstons Mills MA 02648 September 25, 2010 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 10-238 Lauzon 18 Yearling.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 18 Yearling Lane ----- ------- Property Address ------.------_------ - Peter Lauzon -- ---- Owner Owner's Name information is Marstons Mills MA 02648 September 25 2010 required for -- ----- ----- _- every page. City/Town State Zip Code Date of Inspection D. System Information (Cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 6 84 3917 ara Water Service Yearling Lane Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Yearling Lane Property Address Peter Lauzon Owner Owner's Name information is p required for Marstons Mills MA 02648 September 25, 2010 every pace. 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 ground water: 30 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ checked with local Board of Health -explain: ❑ Checked with local excavators, installers - (attach documentation) ® Accessed USGS database-explain: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water below el. 40 and topo map shows property above el. 100. 10-238 Lauzon 18 Yearling.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Q / TOWN OF BARNSTABLE LOCATION /,e A d A a iM SEWAGE# 3 %P VILLAGE ASSESSOR'S MAP&PARCEL INST i�S NAME&PHONE NO A d r�idc � L'I SEPTIC TANK CAPACITY 1060 LEACHING FACILITY.(type) c i'T (size) ' No.OF BEDROOMS OWNER T��( ►- 1 r PERMIT DATE: C®.3 I�DATE:T n`iP boa�'3l I l Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY ry 134 3s ( : ,.. �.L. 17 s ater 'ervice . Yearling Lane Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Yearling Lane Property Address Mary B. Pelkey Owner Owner's Name information is required for Marstons Mills MA 02648 December 31, 2007 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. Impotent: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name 189 Cammett Road Company Address Marstons Mills MA 02648 renen Cityrrown State Zip Code 508-428-1779 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. Th"- spection was performed based on my training and experience in the proper function and maintgnance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 1040 of Title 5(310 CMR 15.000). The system: ' ® Passes ❑ Conditionally Passes ❑ Fails° CD -s ❑ Needs Further Evaluation by the Local Approving Authority ca J C._1___._ ()0 1 December 31, 2007 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 07-287 Pelkey.cloc:•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts r Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Yearling Lane Property Address Mary B. Pelkey Owner Owner's Name information is required for Marstons Mills MA 02648 December 31, 2007 every page. Cityrrown 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Leaching pit was found empty at time of inspection with a stain line indicating pit had never been more than half full. Recommend pumping tank. 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 07-287 Pelkey.doc•:08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Yearling Lane Property Address Mary B. Pelkey Owner Owner's Name information is required for Marstons Mills MA 02648 December 31, 2007 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 07-287 Pelkey.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts P. , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 18 Yearling Lane Property Address Mary B. Pelkey Owner Owner's Name information is required for Marstons Mills MA 02648 December 31, 2007 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than_day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 07-287 Pelkey.doc 08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Yearling Lane Property Address Mary B. Pelkey Owner Owner's Name information i3 required for Marstons Mills MA 02648 December 31, 2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 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. 07-287 Pelkey.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Yearling Lane Property Address Mary B. Pelkey Owner Owner's Name informrequired is Marstons Mills MA 02648 December 31, 2007 required for 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)] 07-287 Pelkey.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Yearling Lane Property Address Mary B. Pelkey Owner Owner's Name information is required for Marstons Mills MA 02648 December 31, 2007 every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): 79,000 gal. _ 109 gpd. Sump pump? ❑ Yes ❑ No Last date of occupancy: UnknownDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 07-287 Pelkey.doc 08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Yearling Lane Property Address Mary B. Pelkey Owner Owner's Name information is required for Marstons Mills MA 02648 December 31, 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: None Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): Approximate age of all components, date installed (if known) and source of information: Compliance date: 6/22/87 Were sewage odors detected when arriving at the site? ❑ Yes ® No 07-287 Pelkey.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 18 Yearling Lane Property Address Mary B. Pelkey Owner Owner's Name information is required for Marstons Mills MA 02648 December 31, 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 1 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): ' Depth below grade: 1 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: 8.5' long x 5.2'wide- 1000 gal. Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle 24 Scum thickness 4 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 9 How were dimensions determined? Measured 07-287 Pelkey.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Yearling Lane Property Address Mary B. Pelkey Owner Owner's Name information is required for Marstons Mills MA 02648 December 31, 2007 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.): Tees are intact, liquid level is at bottom of outlet invert. Recommend pumping tank. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 07-287 Pelkey.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Yearling Lane Property Address Mary B. Pelkey Owner Owner's Name information is required for Marstons Mills MA 02648 December 31, 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 11 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.): Liquid level at bottom of outlet pipe, observed trace of solids carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 07-287 Pelkey.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Yearling Lane Property Address Mary B. Pelkey Owner Owner's Name information is required for Marstons Mills MA 02648 December 31, 2007 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: One 600 gal pit. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number.- innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching pit was empty at time of inspection with a high stain line indicating pit had never been more than half full. 07-287 Pelkey.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Yearling Lane Property Address Mary B. Pelkey Owner Owner's Name information is required for Marstons Mills MA 02648 December 31, 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and co-ifiguration Depth—top of liquid to inlet invert Depth of solids 'ayer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 07-287 Pelkey.doc•08106 Title.5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 I , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Yearling Lane Property Address Mary B. Pelkey Owner Owner's Name information is required for Marstons Mills MA 02648 December 31, 2007 _.—_—_— every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 6 r r r J r • / / / r / / ! r r r r / / r r r , , , ! ! / r / J ! ! / / / ! f / 2 , \ \ \ \ \ , \ \ , \ \ \ \ \ \ \ \ \ \ \ ♦ \ \ ♦ , \ \ \ \ ! ! / ! ! f f / f , ! 84 39 / / /`! ! ! / /"i Water Service Yearling Lane r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 18 Yearling Lane Property Address Mary B. Pelkey Owner Owner's Name information is required for Marstons Mills MA 02648 December 31, 2007 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to ground water: 30 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers -(attach documentation) ® Accessed USGS database-explain: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water below el. 40 and topo map shows property above el. 100. 07-287 Pelkey.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 i Town of Barnstable s OF IME Tpk Regulatory Services HmmsrABM ; Thomas F. Geiler,Director MAM .arE1639. Public Health .Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private,inspector who is certified by the State of.Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. 4 In addition, by receiving this report the Town of Barnstable Health,Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the "Disposal Work Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. ��-- TOWN OF BARNSTABLE LOCATION L O-T #�S9 Ve �IA)S L/y. SEWAGE # 7 - VILLAGE. ASSESSOR'S MAP & LOT' T -�I aO zo INSTALLER'S NAME & PHONE NO. N IC,KF / 771 -Lf/fib IM SEPTIC TANK CAPACITY lb00 Qa) LEACHING FACILITY:(type)t �i (size) Cad � ®NO. OF BEDROOMS PRIVATE WELL O PUBLIC WATER BUILDER OR OWNER LEA L - SOLLow S DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No r/ l' - % L f 3q•a � ,• e �y 3 .......... -. ..._. . .._._.. _-._._ ._. _ _ ........ __... ._. . _... ._ ...... TOWN OF A55E.5.5OR5 MAP _._ _.__.__..LOT I y 20 r1tt.1. "ZONING : tl; OP OF IO MIN. FouND. SEPTIC TANK 01sT. E�Ox. 10 LEACHIN6 FA�11_1 Y I'MINGROUNOCOvE21101 _�-------- i) 00 GAL. Ill ,02 .. iI L10 8� i3ci^ToM or Two SECTION- SEGJACGE SL _ TEST HOLE LOGS `P-# Gc44- DES/GIV FOR >3z- ►kOUs'c TEST eY: _DOWfJ CW15 Ft�C-�I<LIEEZ AM(,j PERC.RATELZ. MIN./IN. TiG ,ynj DATE FLOW RATE 110 GAL./DAY - 5�30 klITNE55: M�l!ELI O 5EPTIC TANK Oi3t� �) 4�-� -`'ram 9//. TAwK T �. r I REQ D. SEPTIC TANK 1000 !2AL l I iiZ.z LEACHING FACILITY I '- IIZ S IIZ,Z . � + 510,E NALL l01C(,= 15v.6� (z, ° 411.7-G/D Gu 30rTOM C' z (I 15,GGID.�� OIL TOTAL 20.o sF =S�9"1 &ID {. — _ MFAIuM (� FIT 101 EFF DI >< USE—�L EACHIIVG IV sally •. �� NOTES 1. DATUM 015L)t TAKEN FROM I'(7/ Q( QUADRANGLE MAP _ _ � '`�z--OPT►� i 2. MUNICIPAL HATER 1lJ AVAILABLE I` I00.414AJ 100 Z` 3.-DE516N. LOAO/N6 FOR ALL PRECAST U1JIT5:AASNO-I-KC9Q Q. PIPE uowr5 SHALL BE MADE WA7EF?TI6147. 5. CO)V5TRUCTIDN DETAILS TO BE 114-ACCORDANCE hUTN CON".OF MASC7. STATE ENVIRONMENTAL C0015 TITLE 7L 6. T1415 PLAN FOR PROP05EO l,IORI(ONLY AND 54OUL-0 NOT BF U5Eo FOR PRoPeRrYi.. LN: sTAK1NZr. i A.kk OF Q f . I ' • yc� ARNE OJALA .C, ;moo ARNE c°� - - 4 CIVIL H o H. d - -- SI-.T��4.�! � AGE _ N6. 30792 OJALA w e� (YOW17 cape ehgine 'ir�q LEGEND: _ Locus : ^� . . t+ti 5 g " 3A8 '0 69STI o CIVIL ENGINEERS CONToUES (EXrST.) — iQEFE ENCE 9� r PREPARED hy S t�?� ,,��/ r a�'/ LAND SURVEYORS PAT E A OJAI A ; CONC. BOUND ® C8 9ZG Main st.YarmoUth,Ma P FOR:. ' \ \ TEST HOLE I • L- `aD(1�.OW� L:Tz�— NO _ board Of health ► SCALE : I" = 4Dt DATE• (� . L108 Cv APPROVED: DATE.. �IGST�C�I MA i