HomeMy WebLinkAbout0234 LAKE SHORE DRIVE - Health MF234 Lake Shore Drive
arstons Mills
A = 030 - 067
t
No. 13 — L Fee "v
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
2ppliLation for Nspo8al *pstem Construction permit
Application for a Permit to Construct( ) Repair(i<Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 2 3'1 L46, a br— Owner's Name,Address,and Tel.No.
Assessor's Map/Parce 1 1
;gstallp�r�s l e, ddcess,and Tel.No. �� —`E,3(cJzS�s}� Designer's Name,Address,and Tel.No.
'(,71R�� i'1�"1
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 7T gpd Design flow provided f gpd
Plan Date Number of sheets. Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil a.
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board=He 9 V e 3
Signed Date i
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. sLo Date Issued
No. 13 e lI Fee 60 wf
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
2pplitation for VspoAal *pstpm Construttion Permit
Application for a Permit to Construct( ) Repair(1r) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components'
Location Address or Lot No. Z 3 L1 � At &p br-- Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel 1 M 141?S IM�L( (J A r\
) alorLs`1XaU,,� ddress,and Tel.No. ��u{—86&-SOc*Lf Designer's Name,Address,and Tel.No.
U$x�t''``I►►�'bbZ.""11"2-_-��
,r
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( ) r.
Other Fixtures
Design Flow(min.required) 1 V gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
i
I
-yam y� •� i
Nature of Repairs or Alterations(Answer when applicable) l✓ [x>X �� �FJ�-
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board ofVe h.
Signed Date
Application Approved by Date 6 a0r'
Application Disapproved by Date
for the following reasons
Permit No. Cku 19 V Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Comptiante
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed Repaired Upgraded
( ) 1
Abandoned( ) y
at has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction.Permit No. Odd 13-4(06 dated
Installer Designer
#bedrooms Approved design flow gpd
The issuance of this permit shally not be construed as a guarantee that the system will funcf n'as,esigded. /1
Date { Inspector �' `
.t -
----------------------------------h--------------------------------------------------------------------------------------------------------
No. OI J �! V Fee l w
I
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposat 6pste Construction Permit
Permission is hereby granted to Construct( ) epair( Upgrade( ) Abandon( )
System located at
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-Construction m t be completed within three years of the date of this permit.J^
Date t U r Approved by '
i
I J
\
?HE T°�y
Town of Barnstable Barnstable
Regulatory Services Department ' ``a'C j
`" LY-
^ter Public Health Division �
1639.
a 200 Main Street, Hyannis MA 02601 200
7
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL #7012 1010 0000 2851 0039
September 9, 2013
Ann Ritter
234 Lake Shore Drive
Marstons Mills, MA 02648
• ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
i
The septic system located at 234 Lake Shore Drive, Marstons Mills, MA was
last inspected on 4/30/2013 by Matthew Gilfoy, a certified septic inspector for
the State of Massachusetts.
The inspection of the septic system showed that the system "Conditionally
Passes" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the
following:
• Distribution-box is deteriorated and must be replaced.
i
You are ordered to repair or replace the septic system 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
• Qs cKean, R.S. CHO
Agent of the Board of Health
Q:\SEPTIC\conditionally,passed\234 Lake Shore Dr MM May 2013.doc
I
Town of Barnstable Barn
Regulatory Services Department
i63 Public Health Division I
9. ��
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL #7012 1010 0000 2850 9255
May 30, 2013
Ann Ritter
234 Lake Shore Drive
Marstons Mills, MA 02648
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 234 Lake Shore Drive, Marstons Mills, MA was
last inspected on 4/30/2013 by Matthew Gilfoy, a certified septic inspector for
the State of Massachusetts.
The inspection of the septic system showed that the system "Conditionally
Passes" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the
following:
C Distribution-box is deteriorated and must be replaced.
You are ordered to repair or replace the septic system 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 cKean, R.S. CHO
Agent of the Board of Health
Q:\SEPTIC\conditionally passed\234 Lake Shore Dr MM May 2013.doc
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C3 ! IaZO F F I I Ln
CO f
rLi Posta n Q�
Certified Fe Y i`".or,
C3 a a posfi
p Return Receipt Fee
p (Endorsement Requi 6- Here
0 Restricted Delivery Fee S�N r
0 (Endorsement Required)
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O Total Postage&Fees „A
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Ann Ritter
r 234 Lake Shore Drive
Marstons Mills, MA 02648
Certified Mail Provides:
a A mailing receipt
o A unique identifier for your mailpiece
o A record of delivery kept by the Postal Service for two years
Important Reminders:
p Certified Mail may ONLY be combined with First-Class Mail®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.
o 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 USPS®postmark on your Certified Mail receipt is
required. ——
o For an additional fee, delivery may be restricted to the addressee or
addressee's authorized agent.Advise the clerk or mark the mailpiece with the
endorsement"Restricted Delivery".
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 an inquiry.
PS Form 3600,August 2006(Reverse)PSN 7530-02-000-9047
i
PLETE THIS SEC
SENDER" COMPLETE THIS SECTION Com TION OWDELIVERY
■ Complete items 1,2,and 3.Also complete A. Signatu
—item 4 if Restricted Delivery is desired. ❑Agent
i P X Print your name and address on the reverse ❑Addressee
so that we can return the card to you. B. Received by(Printed Name) of Delivery
■ Attach this card to the back of the mailpiece, kU _
or on the front if space permits.
D. Is delivery address different from item 1? ❑Yes
1. Article Addressed to: If YES,enter delivery address below: ❑No
I
F
Ritter ake Shore Drive 3. Service Type
Marstons4TAills, MA 02648 i ❑Certified Mail ❑Express Mall
❑Registered ❑Return Receipt for Merchandise
❑Insured Mail ❑C.O.D.
4. Restricted Dellvery?(Extra Fee) ❑Yes f
2. Article Number I, -
fransfer from service label) 'I' 7 012 1010 0 0 0 0 2850 9 2 5 51
PS Form 3811,February 2004 Domestic Return Receipt p10205-02-;W1540 J
UNITED STATIMR0 �'r7: '�;:..
"i Ir
b'& ees Paid
• Sender: Please print your name, address, and ZIP+4 in this box •
Town of Barnstable
Public Health Division
200 Main Street
Hyannis, MA 02601
a �
Town of Barnstable Barnstable
Regulatory Services Department AFAmeftCft
• sn vsrnst.&
16lig. Public Health Division
a�� 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL#7012 1010 0000 2850 9255
May 30, 2013
Ann Ritter
234 Lake Shore Drive
Marstons Mills, MA 02648
•
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 234 Lake Shore Drive, Marstons Mills, MA was
last inspected on 4/30/2013 by Matthew Gilfoy, a certified septic inspector for
the State of Massachusetts.
The inspection of the septic system showed that the system "Conditionally
Passes" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the
following:
Distribution-box is deteriorated and must be replaced.
You are ordered to repair or replace the septic system 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 cKean, R.S. CHO
Agent of the Board of Health
Q:\SEPTIC\conditionally passed\234 Lake Shore Dr MM May 2013.doc
Parcel Detail http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=1910
TILE
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Logged on As: Parcel Detail Wednesday,May 29 2013
Parcel Lookup
Parcel Info
Developer
Parcel ID 1030-067 Lot LOT 109
Location 234 LAKE SHORE DRIVE ' Pri Frontage 35
Sec Road a Sec r
I 1 Frontage] f
Vi'lage[MARSTONS MILLS Fire District
Town sewer exists at this address I No I Road Index 0855
Asbuilt Septic Scan:
p Interactive
030067_1 Map
- Owner Info _
Owner IRITTER,ANN M _ _I Co-Owner
Streets 1234 LAKE SHORE DRIVE ( Street2 i
City FMARSTONS MILLS State'MAT zip j0 648 mm Country
- Land Info
Acres 0.67 use Single Fam MDL 01 I Zoning AF Nghbd 0105
Topography Above Street Road[Paved
Utilities IS p ltlt ,Gas,Public Water 1 Location
Construction Info
Building 1 of 1
Bear Fj-683 — Roof(Gable/Hi Ext 1Nood Shingle
Built� Struct! p Wall
Living 1528 Roof Asph/F GIs/Cmp I T Ac None
Area Cover Type
� -
Int Bed
Style Cape Cod wall Drywall Rooms 13 Bedrooms A
Model Residential Int Carpet Bath Full f o Floor Rooms l
teM
Grade]Average Heat Hot Air Total 15 Rooms ,
Type Rooms e
stories E1 1/ Fuel ation I
2 Stories J Heat +Found poured Conc.
Gross 3570 1
Area
Permit History
http:/iissgl2/intranet/propdata/ParcelDetail.aspx?ID=1910 5/29/2013
i
�� 14
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Commonwealth of Massachusetts ..
_ w : Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
°V 234 Lakeshore Drive -
Property Address ...
Ann Ritter:
Owner: Owner's Name
information i e
required for every ry Marstons Mills MA 02648 - 4/30/13
page. Clty/ToWnr 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 ertd.of the form.
Important:'JVhen A. General Information -
filling out forms
on the computer;
:. use only the ta..::::. - . .
Key to move your
1. Inspector: _
cursor-do not
Y
S1
use the return
Matthew Gilfo .. (/
key. Name of Inspector N
B & B Excavation;I nc. o
Company Name k-
14 Teaberry Lane .
- Company Address �. .. .
Forestdale :.::::. a--
='
MA::. 02644. :..
City/Town State Zip Code
508-477-0653 S113640
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 15000). The system:
❑ Passes_
z Conditionally Passes ❑ _Fails
Needs Further Evaluation by the Local Approving Authority
5/1/13
- 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'systern 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 systemmill perform in the future under
the same or different:conditions:of use.
t5ins•11/10 Title 5 Official Inspection Form u urface Sewage:Disposal System .Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 234 Lakeshore Drive
Property Address
Ann Ritter
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4/30/13
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have noffound any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
® One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
� Y N ®—A40. lain below):
D- box is deteriorated and must be re laced
t5ins-11/10 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
,M 234 Lakeshore Drive
Property Address
Ann Ritter
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4/30/13
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 234 Lakeshore Drive
Property Address
Ann Ritter
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4/30/13
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
El ® 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 '/z day flow
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
234 Lakeshore Drive
Property Address
Ann Ritter
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4/30/13
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a.cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins 11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
L
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
234 Lakeshore Drive
_.-.. :::. Property Address: ... .... ...
Ann Ritter
Owner: Owner's Name
information is .. .
requlred for every::
Marstons Mills MA 02648 4/30/13
page.
-City/Town State Zip Code. Date oflhspection
C. Checklist ..
. .... :.:::Check if he 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
❑ Z 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?
ZWere:as built plans of the ystem.obtained and examined?(If they.were not
available note as N/A)
® ❑
Was the facility or dwelling inspected for signs of sewage back.up?
Z El Was the site inspected for signs of break out?
® ❑. . Were all system components, excluding the SAS, located on site?. .
.... ....
® ❑ Were the septic tank manholes uncovered, :opened, and the interior of the tank
inspected for the condition of the:baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
.... . .... . .... . ....
Was the facility owner(and occupants:if different from Owner) provided with
❑ ® information on the proper maintenance of subsurface sewage disposal systems? .
The size and.location of the Soil_Absorption System.(SAS)'on.the site has.
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.:
Determined in the field (if any of the failure criteria related to Part C is at issue
❑ ® :::approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. S.ystem.lnformation
Residential.Flow Conditions:
- Number:of bedrooms (design)::: 3 Number:of bedrooms(actual):: 3
DESIGN flow based.on 310 CM 15.203.(for example: 110 gpd x#of bedrooms):
330
t5ins-11/10:;: Title 5 Official Inspection Form:Subsurface Sewage_Disposal System.-:Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 234 Lakeshore Drive
Property Address
Ann Ritter
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4/30/13
page. City/Town 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? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage n/a
9 ( Y 9 (gpd))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•.1,Y10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
I
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 234 Lakeshore Drive
Property Address
Ann Ritter
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4/30/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ❑ No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
234 Lakeshore Drive
Property Address
Ann Ritter
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4/30/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
1982
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
2'
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: >20
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
At time of inspection building sewer appeared to be in working order. No sign of leakage or blockage.
Septic Tank(locate on site plan):
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: 1000 gal
Sludge depth:
1
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
u r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
234 Lakeshore Drive
Property Address
Ann Ritter
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4/30/13
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
34"
Scum thickness 1/2
Distance from top of scum to top of outlet tee or baffle
5"
9„
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? scour stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
At time of inspection septic tank appears to be structurally sound. No sign of back-up.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 234 Lakeshore Drive
Property Address
Ann Ritter
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4/30/13
page. Citylfown 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
234 Lakeshore Drive
Property Address
Ann Ritter
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4/30/13
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 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
At time of inspection d-box is deteriorated and in poor condition and must be replaced
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System SAS locate on site Ian excavation not required):
p Y ( )( p
If SAS not located, explain why:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 234 Lakeshore Drive
Property Address
Ann Ritter
Owner Owner's Name
required fo is Marstons Mills MA 02648 4/30/13
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: (1) 1000 gallon
❑ 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.):
At time of inspection leaching appears to be in working condition. Water level 22" below invert. Shows
some sign of carryover in the past
Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
l �
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 234 Lakeshore Drive
Property Address
Ann Ritter
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4/30/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface.Sewage Disposal System Form-Not for Voluntary Assessments
234 Lakeshore Drive
Property Address
Ann Ritter
Owner Owner's Name
information is required for every Mars
tons Mills MA 02648 4/30/13
page. Citylrown 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
f�oN'i c� -Moue �
k
B
A ,
A3-
3i 3` 3
t5ins•11:10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 234 Lakeshore Drive
Property Address
Ann Ritter
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4/30/13
page. Cityrrown 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'
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: 8/5/82
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers -(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M s 234 Lakeshore Drive
Property Address
Ann Ritter
Owner Owner's Name
information is required for every Marstons Mills MA 02648 4/30/13
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
l5ins•1li10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
H-OLL4A3
/ P a .
LOCATION SEWAGE PERMIT 0
ILLAGt 634 - 06
INSTA LLER'S NAME & ADDRESS
IT 1p a R ;tv
BURDEN ON WNER
DATE PERMIT ISSUED F
DATE COMPLIANCE ISSUED ��
r
�t
6
bey
�awt
0�6 0(o-7
� o......� ... 7� ' �' yJ. w FSS..... "... ..... F
THE COMMONWEALTH OF MASSACHUSETTS f
BOAR® OF HEALTH
C ................:.........................OF..............-...................
lutt#iou for Uiupuu�al Works C�uat��ra�r�iva� rruti�
j
A cation is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
S at: t
A fill-
Location-Address or Lot No.
...........
. . .. _,9_d.......
.t.L.T... i � Zr. _kcrcr..r .1�f_i.l,�..... s�R...��t9.T.4.Y_Yt
Owner Address
W
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms.......................................Expansion Attic ( V-� Garbage Grinder (wo)
aOther—Type
of Building ............................. No. of persons.......2...._.........._ Showers ( ) — Cafeteria ( )
POther fixtures --------•---------------•-----------------------•-•---••--------•-••-••--------------------•---•-----------•------------------•--••••------._......_.
W Design Flow.:......5�...........................gallons per person per day.. Total dail flow.........*..1_®................__...gallons.
WSeptic Tank—Liquid capacity �� _.gallons Length----- Width__....__ Diameter________________ Depth................
x Disposal Trench—No.......'...:......... Width;-'.__48...___.... Total Length....40._._......_ Total leaching area----2.Q.®'.....sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (v Dosing tank ( )
a Percolation Test Results Performed by._. i_C. L�_�s�._..BO-K.I.Ir
J.1.a........_............ Date..G:/z,6/0-1..........
a Test Pit No. 1...V.�---minutes per inch Depth of Test Pit________ _ ______ Depth to ground water.._�?IC_
fZ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
.......................:...................................._..........._._..___.__.......p..____...._._______._.._.............._.....__-_____.._..._......
xDescription of Soil..... ? -_ .�..Lacun----*-.S.V_b-._S.�.e--1--•------ --- 1-- ---- tJr.6 ---.54.k.ncty--- -Y_etYG/
V ......•-----•------••---•••------•-•--•-----------------••-----••-•-•-------------...-------------•---------•-------••-------•-••-----•------••-•-----••-----------•-------------...--•---•......._..._..
W
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
... . •• ••-••• ---------------------------------------------------•---------------•
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bccn iss e by board of health.
Sign •---•--•-------------•--------------•••-•--- --------------- --------------
\. L Date j
Application Approved By.. .... .... ...
-� �°
......--...,Date------......_
A lication Disapproved or the following reasons________________________________________________________________________________
PP PP f f 9
-•---------------•------------•--------------__-----••----___----_-_-___---••-----------------------------•----------------•----------------•-------•-------
------------------------------------_.._.. Date
Permit No............... Issued_---` -__.._::...
-----------•-•-•------------...
Date
i �:
n
No.....�................ - FEs..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................OF.........................---•--........ ........-.........................--•---•
ApplirFa#inn for Elhipoliaal Workii Tnnstrurtinn rrmi#
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
r
System at:
-a�k.�...4h�r..e...P.r.►.�1 ¢.r�G.x.�!ns..Ms js ................................................10.9.........................................
Locatton-Address or t No�
:J;r-------------------- ------------------------ rZG�v�xa.�rb�r� .. ..Rcl..�t n rx r..r,:
Owner Address
w
Installer Address
d Type of Building Size Lot............................Sq. feet
U
Dwelling—No. of Bedrooms._._.___3................................Expansion Attic (� *Garbage Grinder (No)
1..a
W
p.l Other—Type of Building ............................ No, of persons...................... Showers ( ) — Cafeteria ( )
Q' Other fixtures --------------------------------•-•--•-••-......--
------- ---------------
WCW4�
DeP>ic Flow.......... _........................gallons per son per day. Total daily
_flow........... gallons.
Set Tank—Liquid capacity] o..gallons Length._.. ........ Width......6y.... Diameter................ Depth................
x Disposal Trench—No. -------`............ Width....... ..._...... Total Length-------f/__........ Total leaching area....W.o.....sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (V� Dosing tank ( )
Percolation Test Results Performed by...... rd...... ................ Date...!/ZS AV......__.
aTest Pit No. 1.1"......L.minutes per inch Depth of Test Pit-------12,. ....._ Depth to ground water.OYr!^.....IZ
Test Pit No. 2________________minutes per inch Depth of Test Pit.................... Depth to ground water-___.:_..______._._____.
o •••-•--••----•-••••--•-•-•-•••••••-•••••--••••-••-`.......................................... -- •---_-------......-••�.....--••_... .
x Description of Soil..... ,r, .m... 6t�?..5�11-_..--••-Z....L?�---- -c';wn-e=--64-s�� ---- ..ra.r:e1
V .....•-••••••-••--•••--....•----•------.....••---.....--•-•-----•--------------------------------••----•---------------......--•----•----••-•---•-•---•---••--......---•----•-------..._..._•---------••.
W
-------------------------------------------------- ---------------------------------------------------------------------------------•-•-------------•-•••-•-•-••-•-••---•-•••..................-----•...
VNature of Repairs or Alterations—Answer when applicable................................................................................................
-------------------•-•-----•-•---------------------•--------------.............--•-----...-•••------------------••.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1.i� 5 of the State Sanit CokYe�" Theme/undersigned further agrees not to place the system in
operation until a Certificate of Compliance -iy s�xe��e-board of health.
Signed........
at e>fr
Application Approved B
PP PP y-•••--••-••......--•- ......--•-••• ---....................................................... -----•-----••-••-••----•--- ••......---
Date
Application Disapproved for the following reasons-.....................................................
........................................=................................................................................................................................................................
Date
PermitNo.......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF...........................................I.........................................
Trrtifirtttr of TnntpliFanrr
THIS S TO CERTIFY, ap the Individual Swage Disposal System co2structed ( ) or Repaired ( )
Installer
at....................••-•--------------.......-•••-•--•••--•---------••----•......---•-•......-• 2 .-
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 No----------------------------------------- dated_.............................................
THE FSSA CE OF THIS CERTIFICATE SHALL NOT BE CONSTR E AS A GUARANTEE THAT THE
SYSTEM UNCTION SATISFACTORY.
DATE... . .......................................................... Inspector .................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH J f
...........................................O F..---•----------.._............._._........._.._............._.......................
No......................... FEE........................
i rr a1 nrk %pal Ilan rrnt #
Permi!!i tf h eb granted-=- >r r :�%t: °v
® }' �c---
to Construct or I:epair ( an ndividual Sewage Disposal System
atNo.................................----•---...-------------•----......-----------•----.......---.---••••--••--------••--•••......----•-••-•••..................•-----..........................
treet
as shown o/thhe pplication for Disposal Works Construc 1I o`n O r`mit 2gb...:� Dated..........................................
Board of Health
DATE_'. --------------------------------
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
Ioo O
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I N S T A LLER'S NAME J& ADDRESS
�l( 0 Rim
t SL& 41
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