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HomeMy WebLinkAbout0190 LAKE SHORE DRIVE - Health 190 Lake Shore Drive --- - Marstons Mills - - A= 030-031 t 'i x j 'r f I F I 1 TOWN OF BARNSTABLE LOCATION R Lqq, ,Rp� ��_SEWAGE# VILLAGE � .�LS ASSESSOOR'S MAP&PARCEii INSTALLER'S NAME&PHONE NO. S Vim_ L4 C SEPTIC TANK CAPACITY � a G a LEACHING FACILITY: (type)ikw 5, (size) NO.OF BEDROOMS OWNER y PERMIT DATE: f -�, °' 2.01 COMPLIANCE DATE: 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 leacknacility) Feet FURNISHED BY 4 Z°i � Li �� Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 190 Lake Shore Dr Property Address h+ RYSHAVY, MILDRED H _ Owner Owner's Name information is X: required for every Marstons Mills Ma 02648 5/7/18 page. City/Town State Zip Code Date of Inspection = U1 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 Information C - filling out forms U 1 Z9 on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain r� Company Name 35 Content Ln Company Address Cotuit MA 02635 City/Town State Zip Code 508-364-9587 SI 13522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 5/7118 ,srrspector'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. al V,L t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth f o Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 190 Lake Shore Dr Property Address RYSHAVY MILDRED H Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/7/18 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: System contains a 1,000 gallon septic tank. As well as a concrete distribution box and two 500 Gallon leaching chambers in stone 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 190 Lake Shore Dr Property Address RYSHAVY, MILDRED H Owner Owner's Name information is required fcr every Marstons Mills Ma 02648 5/7/18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 190 Lake Shore Dr Property Address RYSHAVY, MILDRED H Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/7/18 page, Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) Y 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 '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 f Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 190 Lake Shore Dr Property Address RYSHAVY, MILDRED H Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/7/18 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 190 Lake Shore Dr Property Address RYSHAVY, MILDRED H Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/7/18 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 u ? ® ❑ Y 9 P 9 9 P ® ❑ 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 190 Lake Shore Dr Property Address RYSHAVY, MILDRED H Owner Owner's Name information is Marstons Mills Ma 02648 5/7/18 required far every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 168 Gpd 9 ( Y 9 (9P ))� Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: 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: l5ins•3M 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 190 Lake Shore Dr Property Address RYSHAVY, MILDRED H Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/7/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Not provided 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•3113 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 190 Lake Shore Dr Property Address RYSHAVY, MILDRED H Owner Owner's Name informatics is required for every Marstons Mills Ma 02648 5/7/18 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: Oct 27th 2014 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: feet Comments Iron condition of joints, venting, evidence of leakage, etc.): System is vented at the roof line Septic Tank(locate on site plan): Depth below grade: 1.5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1,000 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 t- Commonwealth of Massachusetts W Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 190 Lake Shore Dr Property Address RYSHAVY, MILDRED H Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/7/18 page. Cityrrown 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 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle " Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 190 Lake Shore Dr Property Address RYSHAVY, MILDRED H Owner Owner's Name information is Marstons Mills Ma 02648 5/7/18 required for 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.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 190 Lake Shore Dr Property Address RYSHAVY, MILDRED H Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/7/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Level and at normal level Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): I * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)"(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 190 Lake Shore Dr Property Address RYSHAVY, MILDRED H Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/7/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No break out or ponding 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 190 Lake Shore Dr Property Address RYSHAVY, MILDRED H Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/7/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 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 °M 190 Lake Shore Dr Property Address RYSHAVY, MILDRED H Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/7/18 page. Cityrrown 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M ,•''y 190 Lake Shore Dr Property Address RYSHAVY, MILDRED H Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/7/18 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: 10+ ft 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: Oct 27 2014 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: Test hole data on plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 r 5/7/2018 Assessing As-Built Cards LQCCATION NQ*') SEWA6E PERMIT NO. lea LAKE SAgaz vIILACE f.:SSESSUS MAP NO: INSTALLER'S -- NAME i ADD:RE5S IA Z-wic6 I U I L 0 E R OR OWNER DATE PERMIT ISSUED DATE C 0 M P I I A N C E ISSUED t_ YS'_.. [ID23 �C 2a/y http://www.townofbarnstable.us/Assessing/HMdisplay.asp?mappar=030031&seq=1 1/2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 190 Lake Shore Dr Property Address RYSHAVY, MILDRED H Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/7/18 page. Cityrrown 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 - DAD No. Fee I THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH 0 DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2p pfitation for _ sposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 0 Dr M Owner's Name,Address,and Tel.No,AL S k0--_ Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. 03 SUm" &4 & Ste,LcL P-G ►��,� 5 M� ���G 3 Type of Building: Dwelling No.of Bedrooms pp Lot Size sq.ft. Garbage Grinder( ) Other Type of Building Rt fil-J4 trA No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.re uired) 336 gpd Design flow provided gpd Plan Date 0 211 Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. IZ Description of Soil Mj&k^ A Nature of Repairs or Alterations(Answer when applicable) A&Aw SAS Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described,on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by th' Board of Health. S ed M ate Application Approved by ate Application Disapproved b Date 01 for the following reasons Permit No. Date Issued f r r _ No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in cornputer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS application for Misposaf *Vstrm Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.140 la S Dr 'm/11 Owner's Name,Address,and Tel.No 3 �yS�avy 1 AV �GICt Assessor'sMap/Pazcel ,- A4US.� �S (1 �,� Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. I"1+L� } aL,L Eat & S .Lcc- ' 6'� 4�Z5 �. ✓,. G25G3 Type of Building: Dwelling• No:of Bedrooms Lot Size Vj s .ft. Garbage Grinder L 9 g ( ) Other Type of Building ReS� � ,�` No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.re uired) 330 gpd Design flow provided gpd Plan Date I O Z1)1 Number of sheets, Revision Date Title'e4"' _ ` w r.,,ir ' "sw Size,of Septic Tank_ /GGG Type of S.A.S. 1Z S� (a 4CtGti I p4,t, C�l s _ Description of Soil Nature of Repairs or Alterations(Answer when applicable) C1A/ SA S Date last inspected: Agreement: >, Thelundeisigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by th' Board of Health. ed 4' ate , Application Approved by ate Application Disapproved by Date for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS f Certificate of Compliance THIS IS TO C bFY,that the On-Ate Sew Die"osal syste onstructed( ) Repaired( Upgraded( ) Abandoned( )b IL at Arl� A 0 f/I�� has been constructed i ac r with the provisions of Title 5 and the for Disposal System Construction Permit N . ���-dat d Installer Co,8 -, 4 11(h- L L [ Designer .. 5 6 u 1"t l #bedrooms Approved design-fil 3 3 gpd The issuance of s ermit s all at be construed as a guarantee that the system wil ctid designed, Date Inspector t No. Fee �--- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS- Disposal *pstem Construction 3permit Permission is hereby granted to CConstruct( ) Repair( ) Upgrade( ) Abandon( ) System located at NO {ate. A� ®r, _M r6icAS / ,((C and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construct' n mNsta omp t d thin three years of the date of this permit. / Date Approved by v Town of Barnstable VIE Inspectional Services _ $ Public Health Division • a�uvsrne�.s, Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6504 Installer& Designer Gertirication Form l� I Date: Sewage Permit# 2C)A1"% S_ZAssessor's MapWarcel Designer: Installer: ! „-� ``t / Address: ( __ Address: 1_91 �1�'� MMs on f/ 2 � was issued a permit to install a (da ) (ins alte j C c septic system at d �£.. ,;�'b Lo P based on a design drawn by (address) 0_o-y1 i?.% dated la ?e ll (designer) I certify that the septic system referenced above was installed substantially according to the design., which may include minor approved changes such as lateral relocation of-the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with mianycomponent or changes (Le. greater than 10' lateral relocation of the SAS or any vertical relocation o of the septic system)but in accordance with State & Local Regulations._Plan revision or certified as-built by designer to follow. Strip out(if required)was inspected and the soils were found satisfactory, I certify that the system referenced above was constructed in 6hlil_atice with the to rms of the 11A approval letters(if applicable) j er s Signature) f Re-esi p er's Si Rgner'sStamp re-3-LE E TURN STA13LE T'VB1iJ C.HE T 1V AT IlA 1. l' ISSUED F A E BRNSkE,FjjPL1CA THL DI S p THAri1 U tltetWt siFIEALTIis EWEM Torn ttw 14-13.DM Town of Barnstable P#. / '. Department of Regulatory Services �+arter.Uar� Public Health]Division Date MAB3 A i619 ti 200 Main Street,H annis MA 02601 tEtt r�u't� Date Scheduled — Tfine Fee Pd. x1cl S A Sorb Suitability Assessment for Se a 1)is. s Performed By: Witnessed By: LOCATION& GENERAT,INFpR ON Location AddresslG�� C Owner's Name �l�!! '" `�✓ �� �7 Address Assessor's Map/Parcel: t�0 r F1 Engineer's Name: *,7 NEW CONS TR UCTION y� 'REPAIR Telephone ik Land Use Slopes Surface Stones Distances from: Open Water Dody a °� ,- possible Wet Area Drinking Wafer Well Drainage WAY � �---, =-' Property Line Other ft �/' SIB+TCII:(Street name,dimensions of lot,exact locations of teat holes&Pere tests,locate wetlands in proximity to boles) 5v43p m L�rtl2 1 t / o ivzt,.e / Parent material(geologicA Ci �U flTDepth to 9edroclt AI/A.y . Depth to Groundwater. Standing Water in Hole: ti/�- Weeping thin Pit F'ce Estimated Seasonal High Oroundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: /.Ui✓ In, Depth to Soil mottles:NMA�� In Dop'r;;o weeping Hunt side of obs.hole: An, nrnuudwater Adjustment ft. r - Index-Well# Reading Date:._ ]ndex Well level_ Adj.factor_�/ Adj.Groundwater Lave) PERCOLATION TESL' bate"d- a 1d � Observation Hole# 2, Time at 9" Depth of Pero �/y /-` r✓ (�" Time at 6" j S -Start Pre-soak Time @ l/9 ' l Tima(9"-6") End Pre-soak RateMih./Inch GJJ"� �✓°�7d Site Suitability Assessment: Sito Passe$-. Sitp Failed: Additional Testing Needed(YM) Original: Public Health Division Observation Hole Data To Be Completed on Back------------ ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one (1) week prior to beginning. Q:1S EPTICIPERCPO RM.DOC I DE EP.OBSIERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Sdil Color Soil Other Surface(in.) (USDA) (Mansell) Mottling (Stnucture,.Stones;Boalders. onsistency %urivel) �i try -------------------- DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders. Z� onsi ten % a ✓lam DEEPP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Sail Color Soil Other Surface(in.) (USDA) (Mansell) Mottling (Stiucture,Stones,Boulders. Con i to c Gravel) (DEEP OBSERVATION HOLE LOG Hole# . Depth from Soil horizon Soil Texture Soil Color soil Other Surface(In.) (USDA) (Mansell) Mottling (Structure,Stones;Boulders, Consistency. I+lood Insurance Rate Map: Above 500 year flood boundary No— Yes ` Witidn 500 year boundary No Yes Within 100 year flood boundary No.,_ _ Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervi u material exist in all areas observed throughout the area proposed for the soil absorption system? �� If not, what is the depth of naturally occurring pervious matal'ial? Certification I certify that on �j � (date)I have passed the soil evaluator examination approved by the Department of Bnvironmental Protection and that the above analysis was performed by me consistent with . the required tr ' ' ,expertise and eri ce described in�10 CNR 15.017. Signatu Datr; Q:15BP1r1CPBRCP0RM.D0 C i Town of Barnstable Bartlstable * . Regulatory Services Department j 7"11 . M" Pudic Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-8624644 Richard V.5cali,Director FAX: 5(1a-7PM304 Thomas A,McKean,CHO CERTIFIED MAIL#7014 1200 0001 0358 0208 September 23, 2014 Mildred H kyshavy 190 Lake Shore Drive Marstons Mills,MA 02648 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 The septic system located at 190 Lake Shore Drive,Marstons Mills,MA was last inspected on 8/20/2014,by Michael DiBuono,a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Fails"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS, You are ordered to repair/replace the above listed septic system components within silty (60) days£torn the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF TIE BOARD OF HEALTH e� �M2�L -I-- 4�9/1/ . Thomas McKean,RS.,C n e.d'k � la.S � 41 5' Agent of the Board of Health h U d ze Q:1SElyl'IC%Let1crs Septic Irtspcotion Failures or Future DR190 Lake Shure Dr MM Scpt 2014.dne zoo in YU VT:CT VTOZ/TO/OT E' aN TOO12 YV3 VT:CT tTOZ/TO/OT etiCb � • , p `N �. • 10 -o Ln Q Postage $ —- (0,_�ostark A rV r=1 Certified Fee RetumReceipt FeeO (Endorsement Required)O U Restricted Delivery FeeO (Endorsement Required)TU Total Postage&Fees ra loft Mildred H Ryshavy 190 Lake Shore Drive Marstons Mills, MA 02648 Certified Mail Provides: o A mailing receipt o A unique identifier for your mailpiece n A record of delivery kept by the Postal Service for two years Important Reminders: • Certified Mail may ONLY be combined with First-Class Maile or Priority Mail®: o Certified Mail is not available for any class of international mail. n NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. e For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return- Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPSe postmark on your Certified Mail receipt is required. n For an additional fee, delivery may be restricted to the addressee or' addressee's authorized aent.Advise the clerk or mark the mailpiece with the endorsement"Restricted-Delivery. r o If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,.detach and affix label with postage and mail. IMPORTANT.Save this.receipt and.present it when making aninquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 Y '7 SENDER: COMPLETE THIS'SECTION- 1 I 1 I ® Complete items 1,2,and 3.Also complete ture item 4 if Restricted Delivery is desired. ❑Agent ® Print your name and address on the reverse Addressee so that we can return the card to you. B. Received by(Printede) W- to f D 'v rym Attach this card to the back of the mailpiece, / N or on the front if space permits. �' D. Is delivery addre$�s different from'ftem 1?,U-Y fes 1. Article Addressed to: If YES,enter de inery address°below: ,13 No I N c;.- to i Mildred H"Ryshavy I 190 Lake Shore Drive 3. Service Type I Marstons Mills MA 02648 I❑Certified Mail® ❑Frior`ty Mail Facpress" ' ❑Registered ❑Return Receipt for Merchandise ❑Insured Mail ❑Collect"on Delivery 4. Restricted Delivery?(Extra Fee) ❑Yes 12. Article Number I (transfer from service fadeO fi '7 014 i t 12 ob�i9 0 0 l t 0 3 5 8 0208 � PS Form 3811,July 2013 Domestic Return Receipt � I I UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid USPS Permit No.G-10 • Sender: Please print your name, address, and ZIP+4®in this box• M Town of Barnstable I Public Health Division 200 Main Street i Hyannis, MA 02601 ii)�d.fiss�ilt.�t'iif�i���hi�it tHE Town of Barnstable Barnstable Regulatory Services Department MAnnWam + BARN35ABLE, s ,T9. Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7014 1200 0001 0358 0208 September 23, 2014 Mildred H Ryshavy 190 Lake Shore Drive Marstons Mills, MA 02648 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 The septic system located at 190 Lake Shore Drive, Marstons Mills, MA was last . inspected on 8/20/2014,by Michael DiBuono, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS. You are ordered to repair/replace the above listed septic system components within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S., CHO MAgent of the Board of Health • Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\190 Lake Shore Dr MM Sept 2014.doc I R © htkp,Jjissgl2JintranetjpropdatajParcelDekail,aspx?ID=1876 Application Center(2) ®http--www.town.barnstable... E Application Center ®Suggested Sites• Web Slice Gallery J Favorites ®Parcel Detail DOE THE67 — w� i BAWSTAOL 4 i 109, dtlp. No d In As: P Log a I2014 Parcel R • Parcel Info Parcel --- Developer 030-031 lot LOT 112 Location 190 LAKE SHORE DRIVE I FrontaP9e 334 . ; Sec Sec Road Frontage V01age MARSTONS MILLS ( Fire 0 0 MM District , Town sewer exists at this address Road Index 0855 No s 1 ' Asbuilt'Septic Scan: Interactive 4` 030031_1 Map . Owner Info Owner I RYSHAVY,MILDRED H Co-Owner Streetl 1190 LAKE SHORE DRIVE Street2 City MARSTONS MILLS I State Zip Country ! Land Info Acres=.70Use Isingle Fam MDL-0Fl Zoning RF Nghbd=0105 ;Done ��;�! '� ` Local Intranet j 100°!0 Start f Parcel Detal Windows i lip Advertisement-Window,,, _ Wum � 1 10;17 AM oc�r6 /0, �0/� r a I ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 190 Lake shore dr Property Address Mildred Ryshavy Owner Owner's Name information is Marstons Mill Ma 02649 8/20/14 required for every page. City/Town State Zip-Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms I f.� on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiiBuono use the return Name of Inspector f key. -� DiBuono Sewer and Drain - � Company Name 8 Johns Path Company Address Yarmouth ma 02664 City/Town State Zip Code 508-364-9587 Si13522 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 maintenar�cq of ota.$ite sewage disposal systems. I am a DEP approved system inspector pursuantl- d Section=45.34Af Title 5 (310 CMR 15.000).The system: ❑ Passes (Fat ,.--a ❑ Conditionally Passes ;® _Earls rz ❑ Needs Further Evaluation by the Local Approving Authority ./�... 8/21/2014 t spector's Sig iature 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. t5ins•3/13 Title 5 Official Inspe o orm:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 190 Lake shore dr Property Address Mildred Ryshavy Owner Owner's Name ` information is required for every Marstons Mills Ma 02649 8/20/14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: r ❑ 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: This system contains a 1000 gallon concrete septic tank. A Distribution box and a 6x6 Leach pit. All three units show signs of failure as the levels have been up and over normal operating levels. " SYSTEM HAS NEVER BEEN PUMPED" 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 190 Lake shore dr Property Address Mildred Ryshavy Owner Owners Name information is Marstons Mills Ma 02649 8/20/14 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or breakout or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ 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•3/13 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 G1A, 190 Lake shore dr Property Address Mildred Ryshavy Owner Owner's Name information is required for every Marstons Mills Ma 02649 8/20/14 page. City/Town State lip 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, pifovided that'no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: r 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 El ® 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 '/2 day flow .t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 r - Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 190 Lake shore dr Property Address Mildred Ryshavy Owner Owner's Name information is required for every Marstons Mills Ma 02649 8/20/14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Any portion of the SAS, cesspool or privy is.below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E). Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large I 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection. Form Subsurface,Sewage Disposal System Form -Not for Voluntary Assessments ° 190 Lake shore dr Property Address Mildred Ryshavy Owner Owner's Name information is required for every MarstQns Mills Ma 02649 8/20/14 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR,15.302(5)] D. System .Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN,flow based on 310 CMR 15.203 (for example:-110 gpd x#of bedrooms): 330 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 190 Lake shore dr ` Property Address Mildred Ryshavy Owner Owner's Name information is required for every Marstons Mills Ma 02649 8/20/14 page. City/Town State Zip Code Date of Inspection D. System Information Description: This system contains a 1000 gallon concrete septic tank. A Distribution box and a 6x6 Leach pit. All three units show signs of failure as the levels have been up and over normal operating levels. " SYSTEM HAS NEVER BEEN PUMPED " Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 2012 27,000 2013 42,000 Detail: Average is 95.83 GPD over two years. Sump pump? ❑ Yes ❑ No Last date of occupancy: 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 190 Lake shore dr Property Address ' Mildred Ryshavy Owner Owner's Name information is required for every Marstons Mills Ma 02649 8/20/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Currently Occupied Date Other(describe below): General Information Pumping Records: - Source of information: Never pumped 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 • ❑l 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 Ti ht tank. Attach a copy of the DEP approval. ❑, Other(describe): One concrete leach pit 6x6 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 190 Lake shore dr Property Address Mildred Ryshavy Owner Owner's Name information is required for every Marstons Mills Ma 02649 8/20/14 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: 28 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 4ft feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: NA feet Comments (on condition of joints, venting, evidence of leakage, etc.): Vented through the roof Septic Tank(locate on site plan): I Depth below grade: 1ft feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000 Gallon If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 190 Lake shore dr Property-Address Mildred Ryshavy Owner Owner's Name information is Marstons Mills Ma 02649 8/20/14 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 18 Scum thickness 2 Distance from top of scum to top of outlet tee or baffle 3" Distance from bottom of scum to bottom of outlet tee or baffle 28" How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level in tank has reached max capacity in the past. Sludge attached to both covers"Tank has never been pumped". 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 3 Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 190 Lake shore dr Property Address Mildred Ryshavy Owner Owner's Name information is required for every Marstons Mills Ma 02649 8/20/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was Never pumped in 29 years. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 190 Lake shore dr Property Address Mildred Ryshavy Owner Owner's Name information is required for every Marstons Mills Ma 02649 8/20/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert NA 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.): _ Levels have been at max capacity. D Box is also decaying. 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.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If-SAS not located,._explain why: - - t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 190 Lake shore dr Property Address Mildred Ryshavy Owner Owner's Name information is required for every Marstons Mills Ma 02649 8/20/14 page. CityFrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology. Concrete pit 6x6 Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Pit shows levels up over inlet 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 I_ Commonwealth of Massachusetts- fo Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 190 Lake shore dr G'IA. Property Address Mildred Ryshavy Owner Owner's Name information is required for every Marstons Mills Ma 02649 8/20/14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Needs New Leaching facility 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.): CT-1 •t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 190 Lake shore dr Property Address Mildred Ryshavy Owner Owner's Name information is required for every Marstons Mills Ma 02649 8/20/14 page. CityFrown 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 A= Mlllt Cards 1'ai4t.c I i�l I L-�-�-CATION SE_VdACE _PERMIT. .H0. bra L6Kc- -5H z n2 SLit V I L L A C E INSTALLER'S NAME A ADDAESS R UILDER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED r a� hiin: kw.tc,"n.hLI n tahlcIII Li.u,s/Assessi112 1MdisHay. 0031&seo 1 8/11/2)014 Commonwealth of Massachusetts - Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 190 Lake shore dr Property Address Mildred Ryshavy Owner Owner's Name information.is required for every Marstons Mills Ma 02649 8/20/14 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 high ground water: 12+ ft 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: 8/1/ 1986 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: plan on file dated Aug 1 st 1986 Shows over 6 ft seperation between Adj GW and bottom of leaching ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Plan on fie shows no ground water encountered at 12 +ft Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 190 Lake shore dr Property Address Mildred Ryshavy Owner Owner's Name information is required for every Marstons Mills Ma 02649 8/20/14 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist i ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed Z System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 � V CAT ION ®� SEWAGE PERMIT NO. Ili LAK5 54 p2 7-6 -- 5YL V I L l A C E ASSESSORS MAP NO:o, ® M�1 'i o N S PAR"EL NO.- 1 N S 7 A LLER'S NAME i ADDRESS rlAXw c�I B U I L D E R OR OWN ER /-Ic/(�--®�J ja �+ps DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED .fin V o• y s ti IYIr k DESIGNING ENGINEER MUST SUPERVISE -'' INSTALLATION AND CERTIFY IN WRITING •� THE SYSTEM WAS INSTALLED IN STRICT ' ACCORDANCE TO PLAN. ..... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ............. WN....................OF..................BARNSTABLE............................................ A41v tra#ilan for Uwpaotal Works Tonstrurttun "truth Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal System at: Lot #112 LAKE SHORE DRIVE Marstons Mills ................_.._._.._........................._.......... ._...._....... ...._..... ..--•-----••-- --------- JohnLocation-Address r Lot No. John C. Mc Keon P. 0. Box 54� Centerville ......................___...................................................................... --.....----------------•------•--•----•--.....---.._..----•--•---•••-•----••-•----....••.......•-- Owner Address aRobert Our Co., Inc. Great Western Road N. Harwich Installer Address d Type of Building Size Lot.... 0-t 927.....--_..Sq. feet U Dwelling—No. of Bedrooms......_..Three.......................Expansion Attic (N/� Garbage Grinder (N/� 'k Other—T e of Building N/A_........ No. of persons......NZA.............. Showers / — Cafeteria Otherfixtures ----------------N/A-----------._..........------.•---------•----------------------............................................................. W Design Flow.._...._..55..............................gallons per person per day. Total daily flow.........330 gallons. 1:4 Septic Tank—Liquid capaX}ty_._100�allons ength___.816��__ Width____4'10"Diameter...N/A..._. D_epth.....`...�.."... W Disposal Trench—No....N/-A... Width......N A...... Total Length....N�`°......... Total leaching area....................N..........__sq. ft. Seepage Pit No.---___1_________-- Diameter...._..12.-__-__- Depth below inlet.....6........... Total leaching area....264-------sq. ft. Z Other Distribution box ( X) Dosing tank (j/A Percolation Test Results Performed by._Conlon/Baxter_&__Nye__________________________ Date_..._.9-10-85 �a Test Pit No. 1 less_.2.minutes per inch Depth of Test Pit... 11......... Depth to ground water_._ .None....... (TA Test Pit No. 2.less__2-minutes per inch Depth of Test Pit....... �....... Depth to ground water.._.._.None_..---_ 1:4 ---•------•------------•----•-----•----•.............•-•-------------•-........••....__...----...---......................................................... O Description of Soil.._Test Pit-••#1•:......(Q'...-_3-'_) loam_&--subsoill....3!,._-•-11'-)-__san(q__with_.gravel..... Vlenses. Test Pit_-#2 ...... 2 1�2"�-.loam•&. subsoil,____�2.-1/2' _----_11'_)_ sand with W gravel lenses----- - U Nature of Repairs or Alterations—Answer when applicable ____-.N/A......... ......... ......... ......... .............................. 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 ag>iees not to place the system in operation until a Certificate of Compliance has been issued by the board of h t . Sign ...- ------------- ................... .... .......APPlication Approved B .....:: . = / to Application Disapproved for the following reasons--------------------------------------------------------------•--------------------........................... -----•------•--------------------•----..............---------•-•-•--••--•--...--------.........-----•-•--.....----•-----•-•----•-•----------------------------------------------------------------.....-- Date Permit No�. .......... Issued Issued...................................................... `--- ..... .......................•- Date _ o � No. : P...._.... �v FEs..��+'��.� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN BARNSTABLE O F............................. Appliration for Disposal Works Tonstrnrtinn Prrutit Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal System at: Lot #112 LAKE SHORE DRIVE Marston Mills ...... - ..........-•- .............................................. .......------•--...--••----••-----.......-•---....----------------•--•---....----........._....-- Location-Address or Lot No. John C. Mc Keon P. 0. Box 545 Centerville ..... _ ............................... ...... ------.... -........... Owner Address a Robert Our Co., Inc. __........Great_Western Road _N._•Harwich........ ....--•----------------•---------•-•----•----------......_.....---.._..................._ -- Installer Address Q Type of Building Size Lot..30 927__.__.__..- Sq. feet U Dwelling No. of Bedrooms........T(?ree-------•-.�-, g— ______________Expansion Attic Garbage Grinder (4/� Other—Type T e of Building p•, yp g ...........NJA......... No, of persons.....N/A............... Showers V/P) — Cafeteria (4/4 Otherfixtures .................N/A •••••••---•--•-------•••••-••••---•--••-•-••••-----•••••-•••-•--•-••---•-•...................•••• W Design Flow..........5...............................................................gallons per person per day. Total daily flow-_._._._330.............................gallons. 9 Septic Tank—Liquid ca as ity..l000gallons ength.__8 6"._. Width. ..4'10" Diameter._N./A_..__. Depth...5'.$'�_.. Disposal Trench— o. __ /- ___....... Width A...... Total Length_._NjP'._._._... Total.leaching area....A./-A........sq. ft. Seepage Pit No_______ ____________ Diameter........._.._._..._. Depth below inlet....6`............ Total leaching area...264.......sq. ft. Z Other Distribution box ( X) Dosing tank ]�/p) `-' Percolation Test Results Performed by_Conlon/Baxter------NIfe--_-•-------- ------------ Date...... -10-85.................. a less 2 p p P ground,...a Test Pit No. ?................minutes per inch Depth of Test Pit.__ 11_.....__. Depth to water------Nor-le........ 44 Test Pit No. 21ess 2-minutes per inch Depth of Test Pit------111...._.. Depth to ground water...___None--_ ----•-----•--------------------------•-----•-----•-----•---••--•-•---------------------------....... -----------.-.------------------•-----•---•-------....... D Description of Soil__ est Pit #r1.; (0' - 3') -loam & subsoil_{....(3'_ -_.11') sand•_with__grayel..._.- x lenses. Test Pit_#2a (0! 2 1�2"? loam & subsoil, (2 1/2' 11!_)__-sand_with..- U W gravel lenses. -------------------------------•--------------------------------------------------•-----••------------------------------------------------------------------•-----------------------------------........ U Nature of Repairs or Alterations—Answer when applicable.--____-A44................................................................................ . ..............•-----.._._...._................................_._..............._..................................._.------....y--•••••-••-•--•---•••-•••••.___.•_.-------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT11 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. Signe �"" C. M n Date Application Approved By........... Application Disapproved for the following reasons:--••••••••---•••••••-•-••••--•••••••-•--••--•-•----•-•••••••--•••••••-••••••---•••••--••-•...................._ --------------------------------------------•---....-----------------•------------------........------....---------------------------------•------------------------------------------------------•- tt'' Date Permit No..— ....:.:. 7. ............. Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN BARNSTABLE ...............................I..........O F.................. .............................................................. (9rrtifirFate of TnntpliFanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (X ) or Repaired ( ) Robert Our Co., Inc,. by----------------------------------------------•--------•----------------•--------•----------------- ----------...----..-----------------.--.-.--------------•-----..-----•-----------•--------•---- Lot 112 Lake Shore Drive Marsbnns giftls at-••••-••-••••••••••-•••••-•••-•-------•-••••--•--•-•-----••-•------••---•--•••......-••-••......--•--------•-----•••----••••---•••-----•-----...--••-•••••••-•-•-•---••-••-•••----••................. has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code lis d scribed in the application for Disposal Works Construction Permit No .----5­'-1..6_... dated-....�a ' ZE-E 2f-1............... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARAN THAT THE SYSTEM WILL FUNCT1O S�TiSFACTORY. . DATE.:..... --•--•.................. Inspector .....-......-•----••--•-...-•••-••.............•-•._.....----....-•.---•-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH t, TOPlb1 BARNSTABLE ; N �( ...................... .............. ................................_.............................---- .........--- •• - FEE........................ Disposal Works Tnntrttrtinn Vvrrmit Rof0brt Our Co:., Inc. Permissionis hereby granted............................................................................................................................................. to Construc X In vid e Is osa 1(2 �ffAR&e( DY i% a Jujj j vgjjlsl System p at No...­. Z Street as shown on the application for Disposal Works Construction_Derm� .._j/�y�2. Dated.__�2 fU............... L,, �- -'6?'•'- -- ---------• Board of Health DATE.. ...... j : FORM 12LKIN, INC., BOSTON • QN. . ' ,.; . , ;, QESI.CIall�l �1 _.I1d4iS.L.SI.�PR)fIS ., STALLATION.AND CERTIFY IN .WRITING;I.,..­�'Itj0r -/-..-;�—r I.r I. I.r"....*. ./I. ..I,/.—'. 0. NOTE;;.The. location of navy existing der 7r ound 'sewer, ' - wells; or other uti Mies .sho on: t>r is.p�an .is .appro � YSTENI;WAS-INSTALLED IN STRICT. . ►►�.,{r� ACC AN, , TO PLAN.. � . ,. tmate. only►; as determine - records or-: , ,y I /// ? information; ;The _contraetor .is: respons ble the' ; verificatian ,of the exi ' O C'. .. N :', 4 It :;,� ,, ems. rl,. ' 1. 0 9 p .99•% x i F , , ""`•, u . 9 L,� a 1 ' � �(rl � , t t;x v .yl ` 7t ,, ' 1.k' _ y. \1 L�r �. s; �i . \�I '� -`/ _ems o A�( �� ,V L D?", '. ti Y ?y y�. . ,_. /. a '� I.y _ s i ) a y..-"; .} r ` i4/(,;'" I n. 1 �-1 �' t 'S:{� _�-^�i �� t z Ix Tia � ! r } A ��0 1/, 11 " ` ! * s a s }. /� r , r�Qrr z d & Y r3a \ G, T. 9 3 60 f 81 7 `I t , r y✓e t i .; .r - 6 ,.,a/ ,rI ''' 't' /n ?,, ip �`pcs p j` c 0'. (C.-"/�P.c a..(.tom - ,0'' U a t /; i,l, / -e ., Q y w. �1 i �. '' r w1a , + `Z"C .,! , ( y^ /j .. JFIr �� tr , Ir ,S7 r s \ 7 I a r. x ,' *• fir b - /R -_ y.r i ,► (/per�. � L. 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'SG�l47ES � r: TES,1. �. � � T TRL`;:e5noo s 4e F.1o*v. .4G'.,:0.4Y:> cSQJ� Tt�$T;I - ld 2 `: SD/L s,. r , . � /IIuMBER'QF CgG�IlniG P/Ts .,r ELE1r, ( EL�Y �0 2.3 ACHJNG PEft P/TS !0�4TE XTLs'Q- t' J'f c _ B0T,'7 o/w 4z4cN/NG PER P/T Jl "'$Q T .:.Sf/ oil r`=`� - 'YgSa � �E/�CO�LAT/ON AATE#/ TQTi4C' LEACHING ARE�4 : I°ERCOLA770N/PATE 2 hfJN f INGX K RESERVE LEfiC'NlNG AREA _SQ FT, k, ".7� , lx 7' t .�", ! SO/Lf .'•; r �' ys S'fINb ¢A' `k/ TES% Of .� �.$. E`yG :� L E`iS/�E� .e � �,}tv"F su FtOiSM u �'ALBERT s� t �. A, s s { z ,` ELOREDGEENGrIN.E�JP/NG CII/YG. r ELDREiG o MORS as L QQ 6 EC 9.!•3 T/2 MAIN,._57' NYANNl9 .'MASS 10451 Q'' . a' e�+` �? C!.✓/4+�.�:.1 T . CL/.ENT°: P.tTE '¢•'. ; F„3 cG;cTcF.Cl, 4�� fi 75 u ,NOGROUNb Yt�iaTt`R ArAICOUN ARE, . IS'lcltG-0I1/;• sa,; ?: ; i f�� 1 wT" r G.RO C!/1�/O: ^✓.ATER A T ,EL.EN 2 ,li -j l.f:P,L .-.4• - - Jog wo: Pr AsBuilt Page 1 of 1 Ll10 CAT ION `t SEWAGE PERMIT NQ. eta LAKE SA�l4� VILLAGE �.SMS'S;'PS MAP N0: C� INSTA LLER'S - NAME A ADDRESS n R Ca 9 U I L D E R OR OWNER f4C�Cra�J H0 4 e DATE PERMIT ISSUED _ DATE COMPLIANCE ISSUED _ I_c Dn I v 'e Yse http://issgl2/intranet/propdata/prebuilt.aspx?mappar=030031&seq=1 9/17/2014 LOCUS DATA CURRENT OWNER: BARBARA A. RYSHAVY & THOMAS F. RYSHAVY, TR. h EXISTING LEACHING PIT PLAN REFERENCE: PI.Bk. 222 Pg.157 AND D—BOX TO `BE PUMPED AND REMOVED :'FROM SITE IN �d DEED REFERENCE: Bk. 25306 Pg.201 ACCORDANCE WITH TITLE 5 . G ZONING DISTRICT: RF LOT 1 1 190 g . . FLOOD ZO NE: X 1 _ BENCHMARK IS COR. OF I 90.7 2 CONC. FOOTING BLOCK ASSESSORS MAP 30 ELEVATION 92.12 �o 02 LOCATION MAP PARCEL 31 5 �g�9 87.9 o o O 88 I `so.ao Assessors Map 30 OVERLAY DISTRICT: ZONE II 89.6� 4 LOT 49 Parcel 31 - �' �� — LOT AREA: 30,921 S.F.+/- 86 - �� Area 30,927 s.f. 84.7 ' '—�90.9 � TF' 2 F 90.9 9 0 SITE 8c SEWAGE \ FND �' H#1 � EXISTING SEPTIC COMPONENT REPAIR L, DE BOX TANK TO REMAIN ji'90 CAT BASIN CHo_ � I \ ^M pECk 91.8 � LAKE SHORE DRI VE �; /� ► TT�\�`�` \ 3 &/STNc 2� 92 \ IN ` �o \\ / �\ \� owfl�?O MARSTO N S MILLS, MA OVERHEAD FND DATE: OCTOBER 28, 2014 �� ��� ELEc. / LOT 112 APPLICANT: \ 30,927 S.F. \ rr MILDRED RYSHAVY 190 LAKE SHORE DRIVE \ QP MARSTONS MILLS, MA 8 5 SHEET 1 OF 2 \jH OF mA5�9 / + 88 PREPARED BY:, EDWARD �CtiGcn i A,2 4 93 A. EAS SURVEY, INC . -aoT 8980 � - � ��F �� � 88 P.O. BOX 1729 sso A SHORE SANDWICH , MA 02563 PH. (508) 888-3619 CELL (508) 527-3600 EAS.SURVEY@YAHOO.COM SCALE 1 ." = 30 ' JOB S M 14-2- 1 TOF RAISE COVERS TO WITHIN SYSTEM D ES I G N ELEV. 95.16 ELEV. 89.64 6" OF FINISH GRADE - 1 F.G. 91.7 F.G. 9 F.G. 90.5 F.G. 90.3 i F.G. 90.0 EXISTING DESIGN FLOW 3 BEDROOMS @) 1 .10 GPB/D = 330 GPD ELEV. 89.47 Set level first 2' j Filter Fabric 3i4 to 11/ REQUIRED SEPTIC TANK 36' ELEV. 86.30 Sto�ee unshed ' 330 x .2 = 660 GAL 11 1 EL. 87.3 _ EXISTING 1000 GAL. TANK)TO REMAIN a-10" - S=0.077 14� S=0.02 ooevev0000� v0000 SIZE OF LEACHING FACILITY REQUIRED GAS „ eee°00000ee v000e000000 ........ 36 BAFFLE 2� ELEV. 84.30 330 0.74 S.F./GPD = 446 S.F. MIN. ELEV. 86.53 INVERT = • - EXISTING ELEV. 86.70 FB- 4' oIN 17' DIM 4' -9-1 SIZE OF LEACHING FACILITY PROVIDED USE 2 - 5'0"x 8'6 X 3'0" CHAMBERS 5,0 PROVIDED USE 2 CHAMBERS WITH 4' STONE ALL RETAIN EXISTING D-BOX 5 MIN. REQUIRED AROUND LEACHING FAC I LITY m ELEV. 79.30 1000 GALLON 3 OUTLET W/TEE Btm. T.H.#2 SIDEWALL = 2(13 + 25) x 2 = 152 S.F. (H-2O) (H-2O) NO GROUNDWATER BOTTOM = 13 x 25 = 325 S.F. SEPTIC TANK TOTAL LEACHING AREA = 477 S.F. JOB SM 14-2-2 SYSTEM PROFILE SAS CONSTRUCTION DETAIL 477 S.F. x 0.74 GPD/S.F. = 353 GPD NOT TO SCALE tNOF I (H-20) 353 GPD PROVIDED > 330 GPD REQUIRED = SITE & SEWAGE s� 500 GAL. 23 GPD RESERVE DA ID I LEACHING CHAMBER STONE DESIGN PERC RATE 2 MIN./INCH COMPONENT REPAIR F ""' ""'" " ""'"'"" ' "' LONG TERM APPL. RATE 0.74 GPD/S.F. p90 21 NO GARBAGE DISPOSAL ALLOWED ��G/STE��O I' LAKE SHORE DRIVE sq"'jA �aN `�' 0 0 L' P # 1 451 3 CONSTRUCTION NOTES � /L� 1. CONTRACTORS/INSTALLERS TO VERIFY GADES AND / D.T.H. #1 D.T.H. #2 IN ELEVATIONS AND SITE CONDITIONS PRIOR TO COMMENCING DATE: 10/10/14 DATE: 10/10/14 GROUND ELEV. 90.5 GROUND ELEV. 90.3 WORK ON THE SITE. .............................._..................: MARSTO N S MILLS, MA 2. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE t' NO GROUNDWATER NO GROUNDWATER WITH DEEDED OR ZONING REGULATIONS. OWNER IS TO 4' 8.5' 8.5' 4' OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. 3. VEHICULAR TRAFFIC, PARKING OF VEHICLES AND PLACING LOAMY SAND . LOAMY SAND DATE: OCTOBER 27, 2014 MATRERIALS OVER THE SEPTIC TANK IS PROHIBITED. + 1j (� 25' 1OYR 4/3 10YR 4/3 GENERAL NOTES I I B 12" B 8" 1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. I CERTIFY THAT I AM CURRENTLY APPROVED LOAMY SAND LOAMY SAND TITLE V AND TOWN OF YARMOUTH RULES AND REGULSTIONS BY THE DEPARTMENT OF ENVIRONMENTAL FOR SUBSURFACE SEWAGE DISPOSAL. PROTECTION TO CONDUCT SOIL EVALUATIONS 7.5YR 5/6 7.5YR 5/6 APPLICANT- 2. AT LEAST ONE ACCESS POINT OVER TANK TEES SHALL BE AND THAT THE RESULTS OF MY SOIL EVALUATION ACCESSIBLE WITHIN 6" OF FINISHED GRADE. �'• ARE ACCURATE AND IN ACCO ANCE WITH 310 24„ 18 MILDRED RYSHAVY 3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CMR T ROUG Cd1 Cd1 190 LAKE SHORE DRIVE CAPABLE OF WITHSTANDING H-10 LOADING UNLESS THEY ARE SANDY LOAM SANDY LOAM UNDER OR WITHIN 10' OF A DRIVEWAY OR PARKING AREAS THEY . �� 10YR 6/4 10YR 6/4 MUST WITHSTAND H-20 LOADING. 10% DENSE 10% DENSE MARSTONS MILLS, MA 02648 4. THE EXCAVATION CONTRACTOR SHALL VERIFY THE LOCATION 1 ED D A. STONE, CERTIFIED SOIL EVALUATOR PACKED GRAVEL PACKED GRAVEL ALL 5. AONY MASONRY(ES UNITSIOUSEDOTONBRIINGACOVEERS TO GRADE OR SHEET 2 OF 2 WITHIN 6" OF GRADE SHALL BE MORTARED IN PLACE. ELEV. = 86.5 48 ELEV. = 86.8 42' 6. FINISH GRADE SHALL HAVE A MINIMUM SLOPE OF 0.02 FEET y INDICATES DEEP PER FOOT OVER THE S.A.S. AND DISTRIBUTION BOX. DTH #1 TEST HOLE . C2 C2 MEDIUM SAND PREPARED BY: 7 SCHEDULE 40 PVC AND PTIC TANK SANITARY ESHALL ES AEXTEND LL BE CONSTRUCTED MINIMUM EOF06" ABOVE 2.5Y 7/6 MEDIUM 7/6AND .60" THE FLOW LINE AND SHALL BE ON THE CENTERLINE AND EAS SURVEY INC.. LOCATED DIRECTLY UNDER THE CLEANOUT MANHOLES. NO WATER 132" NO WATER 132" 8. THE INLET PIPE INVERT ELEVATION SHALL BE NO LESS THAN INDICATE P .O. B 0 X 1729 2 INCHES NOR MORE THAN 3 INCHES ABOVE THE INVERT P-1 60" PERC TEST EL. = 79.5 EL. = 79.3 ELEVATION OF THE OUTLET PIPE. i SANDWICH M A U L 5 3 THE SEPTIC TANK SHALL HAVE A MINIMUM COVER. OF 9 INCHES. B.O.H. 10. THE OUTLET SANITARY TEE SHALL HAVE A GAS BAFFLE, 4 INCHES. � �> 132" INDICATES ADJ. DONNA MIORANDI IN DIAMETER AND CONSTRUCTED OF 4" PVC I GROUNDWATER SOIL EVALUATOR 11. ALL PIPES SHALL BE SCHEDULE. 40 PVC SEWER PIPE AND SHALL NO OBS. GROUNWATER ED STONE PH. (508) 888-3619 BE SLPOED 1/4 INCH PER FOOT MINIMUM. BACKHOE OPERATOR 12. CHANGES OR REVISIONS TO THIS SEPTIC DESIGN REQUIRE NOTIFICATION NO OBSERVED GROUNDWATER CLOUGH EXCAVATING CELL (508) 527-3600 TO EAS SURVEY INC. FOR B.O.H. AND DESIGN ENGINEERS REVIEW AND APPROVAL. DEPTH TO BOTTOM OF HOLE 132" SOIL -TYPE- 1 13. MAGNETIC TAPE OVER ALL COMPONENTS. LPERC OADING EAS.SURVEY@YAHOO.COM RATE: 4 GAL/SF/MIN I