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HomeMy WebLinkAbout0275 LAKE SHORE DRIVE - Health 275 Lake Shore Drive Marstons Mils A.= 030 - 096 p, I I, II'�fi S M E A D No.53LY UPC 12943 i smead.com • Made in USA '�� r--�- .� ._._,.,_-L- �. _ __ __ 3 � �P �� � � � lg � t 3 �.�?��� � � 7 1 I � �I ! II i �i 4 i � i 3 I { i TOWN OF BARNSTABLE LOCATION 9,757 1c,/6_ S k6 fe- SEWAGE# ��� ��'y`0 f f VILLAGE Md f-9-66� )'Yl,)lS ASSESSOR'S MAP&PARCE10 INSTALLER'S NAME&PHONE NO. Qy."gin s J�tc�o h' -- SEPTIC TANK CAPACITY Ift LEACHING FACILITY: (type) e) o`Zrx 12+ NO.OF BEDROOMS OWNER #- PERMIT DATE: COMPL '- CE 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 leaching facility) Feet FURNISHED BY A4=33.4 C I� a��. c 2=31 g .2-7 rn AO e�e oar-;ve- 5 .. 4 {{ V " � A TO7 OF BARNSTABLE OCATION �� lI-�1�C. J►, IL SEWAGE,# C3Of- VILLAGE M• M i( ASSESSOR'S M & LOT y INSTALLER'S NAME&PHONE NO. 0�4^ a SEPTIC TANK CAPACITY ' o n LEACHING FACILITY: (type) �' Q4�c rtoA%r (size) NO.OF BEDROOMS BUILDER OR O R PERMTTDATE: � �3 COMPLIANCE DATE: 13 ali0� Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Y 1 � 1 g a a ON L u3 3 � v �� b OW F.BARNSTABLE OCATION +^� S Qft fir• SEWAGE # VILLAGE 6. ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY M LEACHING FACILITY: (type) ,++ 1 G X6 (size) I WD NO.OF BEDROOMS 3 BUILDER OR OWNER �V cis .PERMTTDATE: '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 leachiqg facility) Feet Furnished by s Uj U, i � $ a 3 a 8 y6 a 310 a8 y Commonwealth of Massachusetts 090- a f& Title 5 Official Inspection Form f Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w ' 4 275 lake Shore Drive !' Property Address , Faber Owner Owner's Name ! information is Marstons mills/ - Barnstable Ma 5/29/19 required fo�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. Inspector Information c filling out forms on the computer, use only the tab Chad hathaway key to move your Name of Inspector cursor-do not HPS use the return Company Name key. VQ P.O.Box 151 ,� Company Address Forestdale Ma 02644 City/Town State Zip Code 774 274 2581 12866 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. N Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 5/29/19 Inspector gnature Date The system inspector sTria copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form l" Subsurface Sewage Disposal System Form - Not for Voluntary Assessments »` 275 lake Shore Drive Property Address Faber Owner Owner's Name informatior is Marstons mills - Barnstable Ma 5/29/19 required for every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: This inspection is not a guaranteeand applies no warrantyof the described septic components in this report including but not limited to piping structual intergrity of components and life exspectancy of leaching and described components. This inspection is to describe conditions witnessed at time of inspection only. Regular tank maintenance and water conservation can prolong life of septic systems Information on care and do's and don't's can be found at town health dept or mass.gov 2) 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 275 lake Shore Drive Property Address Faber Owner Owner's Name information is required for every Marstons mills - Barnstable Ma 5/29/19 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. 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: l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 275 lake Shore Drive Property Address Faber Owner Owner's Name information is required for every Marstons mills - Barnstable Ma 5/29/19 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 275 lake Shore Drive Property Address Faber Owner Owner's Name information is required for every Marstons mills - Barnstable Ma 5/29/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 ❑ ® 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 water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 275 lake Shore Drive Property Address Faber Owner Owner's Name information is required for every Marstons mills - Barnstable Ma 5/29/19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: 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 ® El 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)) t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 275 lake Shore Drive Property Address Faber Owner Owner's Name information is required for every Marstons mills - Barnstable Ma 5/29/19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: 2) 500 gal L C Chambers 25'x12.8'x2' Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: 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)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date t5insp.doc•rev.7/2 61201 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 i c� Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 275 lake Shore Drive Property Address Faber Owner Owner's Name information is required for every Marstons mills - Barnstable Ma 5/29/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commerciallindustrial 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: unknown Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.,7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v 275 lake Shore Drive Property Address Faber Owner Owner's Name information its Marstons mills - Barnstable Ma 5/29/19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known)and source of information: tank 1978- leaching and Dbox 2016 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 1.5' 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.): no evidence of leaks or poor venting t5insp.do---rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 275 lake Shore Drive Property Address Faber Owner Owner's Name information is Marstons mills - Barnstable Ma 5/29/19 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) 1000 gal H10 precast tank If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 1000 gal 8'6"x5' Dimensions: 3" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 27" less then 1" Scum thickness Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? tape and sludge judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): baffle inlet tee outlet in place. No heavy decay or visable leaks. recommend pumping tank for maintenance in 1 year under normal use t5insp.doc•rev 7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts r� Title 5 Official Inspection Form nts Subsurface Sewage Disposal System Form Not for Voluntary Assessments 275 lake Shore Drive Property Address Faber Owner Owner's Name information is required for every Marstons mills - Barnstable Ma 5/29/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.dcc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 118 I Commonwealth of Massachusetts Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 275 lake Shore Drive Property Address Faber Owner Owners Name information is required for every Marstons mills - Barnstable Ma 5/29/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. 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.): Dbox is in new condition aand has no visable leaks or decay water level is at bottom of outlet pipe. t5insp.doc-rev.'7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .J 275 lake Shore Drive Property Address Faber Owner Owner's Name information i3 required for every Marstons mills - Barnstable Ma 5/29/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 2) 500 gal L.0 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 275 lake Shore Drive Property Address Faber Owner Owner's Name information is required for every Marstons mills - Barnstable Ma 5/29/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): leaching chamber cover dug up(riser present) sstem dry with clean sand at bottom. System in good working condition 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 275 lake Shore Drive •V Property Address Faber Owner Owner's Name information is Marstons mills - Barnstable Ma 5/29/19 required for-every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 r - Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 275 lake Shore Drive Property Address Faber Owner Owner's Name information is Marstons mills Barnstable Ma 5/29/19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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 w I Bad c,a_ �t i NJ( 01 rA3"a9 bi t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 275 lake Shore Drive Property Address Faber Owner Owner's Name information is Marstons mills - Barnstable Ma 5/29/19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated de 36'pth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: lot el. over septic 90' to 86' low area pond behind property 50' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 r cam, Commonwealth of Massachusetts Title 5 Official Inspection Form 11. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -t s 275 lake Shore Drive Property Address Faber Owner Owner's Name information Is required for every Marstons mills - Barnstable Ma 5/29/19 page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 109 it7 i I Town df Barnstable P# Departiment of Regulatory Services n a wwer,►at�a, Public Health Division_ Date MAU - �. .•. 9. . • � t439. �� 200 Main Street.Hyannis MA 02601 � 'O prEO MKi(' � � I—i : G7 Date Scheduled �y Time Fee Pd._ s> Soil Suitability Assessment for Sewage Disposal . Performed•By: 1fldM A 5 PI C LEIL ki Witnessed By: t LOCATION&.GENERAL INFORMATION Location Address Owner's Name 006 '0 0 ppliq 2-75 V0 SHvRC DE. A MA 1 .Adf dohY'LlrS Address Assessor's Map/Parcel: - 3 0/0[ B Enginoer's Namc TW M�f QA(AZ,,Ufl ij NEW CONSTRUCTION REPAIR Telephone# ®g t `f Land Use• �G� ' Slopes(96) �` /4 Surface Stones Jai Distances from: Open Water Body •.> ff a ft Possible Wet Area '� ft Drinking Water Well ±L� $ Dral'nage Way , Z5 ft Property Line ' i 11 ft Other ft SIMTCH:(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands•fn proximity to holes) TH•Z7M'1 0.�t Parent material(geologic) OU ✓D,�� Depth to Bedrock r " A ' Depth to Oroundwater. Standing Water in Hole:_N11 Weeping from Pit Pnce /V a Estimated Seasonal High Oroundwater ? ��t DETERMINATION FOR SEA ASONAL•HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: In. Depth to soil mottles: Depth to weeping from side of obs.hole: /V/7n-4z, In, Groundwater Adjustment &oat it. Index Well-# Reading Dato: Index WcIl level -_ Adj,factor„-,_ Adj.Groundwater Level PERCOLATION TEST bats, T1Wd _,_,._, Observation Hole# Time at 9" .��Yj_I/J _ Depth of Pere 5 ' Time at 6" Start Pre-soak Time® Time(9"-6") End Pre-soak , Rate Min./Inch Site Suitability Assessment: Site Passed Sit;Failed: Additional Testing Needed(Y/N) 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 Conseirvation Division at least one(i)week prior to beginning. Q:\SEPTIC\PERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# I Depth from Soli Horizon Soil Texture Shcl Color Soil. Other Surface(in.) (USDA) (Munsell) Mottling (Stnucture,Stones;Boulders. Consistency.%'Gravel) r:, LA fo NR- 4 ti p k 50iN4 (M 2'.j� 13Z" G M DEEP OBSERVATION HOLE LOG Hole# 2 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling .(Structure,Stones,Boulders. onsistency, s " qZA . 5A(vv (' Un 4 3 30" 6 5ANV14 UA4 2.5h 6 C (vt S Z,SY 7 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) ' Mottling (Structure,Stones,Boulders.. Consistency, DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders, 0 Flood Insurance Rate Mane Above 500 year flood boundary No— Yes Within 500 year boundary No^ Yes Within 100 year flood boundary No., , Yes Depth of Naturally Occurring Pervious Material t Does at least four feet of naturally occurring pervious 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 material? Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis_was performed by me consistent with . the required training,expertise and experience described in 10 CMR 15.017. Signature Date Q;ISEPnWBRCPORM.DOC No.�I`w& �U Fee 1e THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 4pliLAtion for Misposal *pstrm Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. �� S�,o�e p Owner's Name,Address,and j�Teel.No. rn I / Assessor's Map/Parcel /►�trsf°ns /)� (, IOC/o 30—fi ,7' /s`�� / '(.t✓ FA sob b ''2.2/6 Installer's Name,Address,and Tel.No.Q4,,,,,s Caves ,G,_ Designer's Name,Address,and Tel.No. 3 s Qo R r Q ,. x�143��' � s08 3�q y� yg Type of Building: Dwelling No.of Bedrooms pp Lot Size 30/S Y3 sq.ft. Garbage Grinder( ) Other Type of Building A(',$1 O eJn VG No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided 3 YJ gpd Plan Date If3�(� Number of sheets Revision Date Title / Size of Septic Tank /1 00 Q Type of S.A.S. Description of Soil SQ411, JAM , fts Nature of Repairs or Alterations(Answer when applicable) 112 Cr C 4' M PcS 11 ev L) 'DQPr Date last inspected: f b 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 t n ' onmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Bo alth. Signe Date Application Approved by Date l Application Disapproved by Date for the following reasons Permit No. (� G Date Issued M 4 1 —q t No. Fee _ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TQWNIPF BARNSTABLE, MASSACHUSETTS Yes 2pptication for 30isposal 6pstrut Construction 3perlIlit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 7 La le s�D✓e pr Owner's Name,Address,land Tel.No. rn II / Assessor'sMap/Parcel �'r5bns mills yb �O�/(n( 36-%( � 'T � /��er ! (�✓ �n SOS 6 ���� Installer's Name,Address,and Tel.No.Q„; 5 fiCa v� v Designer's Name,Address,and Tel.No. p (j k X 1163 nvy"- _08 3- q Type of Building: Pnu'I S v?(, i Dwelling No.of Bedrooms Lot Size 36/S y3 sq.ft. Garbage Grinder( ) Other Type of Building 1S eS idetl No.of Persons Showers( ) Cafeteria( ) i� Other Fixtures i Design Flow(min.required) a a 0 gpd Design flow provided 3411 gpd Plan Date /1 /6h(, Number of sheets Revision Date Title j Size of Septic Tank]j /000 !9 c ( Type of S.A.S. Description of Soil ed �/�M , rY1C-S SG, y Nature of Repairs or Alterations(Answer when applicable) ��. 4 C ?q rhb(-CS /7 Pv Q 6o�r Date last inspected: _i Agreement: i 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 oft n. ' onmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Boa �:ealth. = Signe Date � i w Application Approved by Date 1 b Application Disapproved by Date for the following reasons i PermitNo. --- Ci Date Issued-------------------------------------------------------------------------------------------------------------------------------------- V i THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded((/� Abandoned( )by j af-I 75 la Ve �(`C Or Mary%, Mi S has been constructed inCC' accordance with the provisions of Titl 5 and the for Disposal System Construction Permit Np( /4 - 7 "Fdated Ins Designer pci�S ;1re� i#bedrooms d� Approved design flow A y D� gpd The issuance of thisM permit shall not be construed as a guarantee that the system will nction (as,ldesigned Date 1 f a Inspector % t1 ---- ---------)-------------�---(-----------------------------------------------------------------------------------------/--------------- o Fee / G� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal 6pstem ConstrUition i3ermit Permission is hereby granted to Construct( c) Repair( ) Upgrade( ) bandon( ) System located at 9 1 J k IFS S�i e DC l � rv�-, 't5 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 must be comp,ete within three years of the date of this pe it. Date ' \ 1� ZS Approved by Town of Barnstable Regulatory Services Richard V. Scali,Interim Director `: anietvscna�, : . M Public Health Division '0'Enn�ar" Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form p Date: Sewage Permit# Assessor's Map\Parcel 6 1 Designer: BA51 Installer: 3f 8OQ Address: soy, Address: E . �ENN11 An I,, Gull 1 On was issued a permit to install a (date) (installer) septic system at Z75 LAKE 6HOPC MwL based on a design drawn by T-Hofy" bS mcLeaprJ (address) jH SS R-�VEIL NCI NEFRa t�Y2 dated !D 6 (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 major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component 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 rt' that the y em referenced above was constructed in compliance with the terms t IAA appr al etters (if applicable) f � NcW.IAN N ller's ature) Z� CIVtd 0 9 No.36471 a 61 M esigner's Sig e) (Affix ISesgners�`Stamp Here) �F PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:\septic,Designer Certification Form Rev 8-14-11Am TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map d Parcel Application# CX66-5 i cp 3 Health Division Conservation Divisicn Permit# Tax Collector Date Issued Treasurer Application Feed Planning Dept. Permit Fee 1 15- I 1 Date Definitive Plan Approved by Planning Board Historic-OKH Preservaticn/Hyannis Project Street Address c. — ('� Drl✓ti Village N ► CA 14-S 4--o15 &(,LS ' Owner �� �L'^� 4 MvrPk Address ' a 7S- L.eck e.. SWD r{- Telephone 0 �S Permit Request -V >__ ox�s-'e_AVI-4,1Y_7' Gy/ s 7 Square feet: lst floor:existingZ4—V— proposed 2nd floor:existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family W' Two Family ❑ Multi-Family(#units) Age of Existing Structure r Historic House: ❑Yes ❑No On Old King's Highway: ❑Yes ❑No Basement Type: ulI ❑Crawl :alkout ❑Other - Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full:existing new Half:existing new Number of Bedrooms: existing new Total Room Count(not including baths):existing new First Floor Room Count ado— _ _ n COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION Ll TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 275 Lake Shore Drive Marston Mills. MA 02648 Owner's Name: William Evers 3�� Owner's Address: �J Date of Inspection: July 13, 2005 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford I Mailin;;Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508)862-9400 ' Y cr> CERTIFICATION STATEMENT ( a I certify that I have personally inspected the sewage disposal system at this address and that theIs. formatioipreported below s true, accurate and complete as of the time of the inspection. The inspection was perfoed based;--on my= �training and experience in the proper function and maintenance of on site sewage disposal systa I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Needs hi-ther Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: July 18, 2005 The system inspector shall sub 't copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 c Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 275 Lake Shore Drive Marston Mills. MA Owner: William Evers Date of Inspection: July 13, 2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. i The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: I The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 275 Lake Shore Drive Marstons Mills. MA Owner: William Evers Date of Inspection: Juh,1.3. 2005 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. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 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 y passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 J Page 4 of I 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 275 Lake Shore Drive Marston Mills,MA Owner: William Evers Date of Inspection: July 13, 2005 D. System Failure Criteria applicable to all systems: You must indicate either"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 ''/z day flow ✓ Required pumping more than 4 times in the last year'NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 275 Lake Shore Drive Marston Mills M4 Owner: William Evers Date of Inspection: July 13, 2005 Check if the following have been done: You must indicate" es"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: Yes No Existing information. For example,a plan at the Board of Health. V _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. s 5 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 275 Lake Shore Drive Marstons Mills MA Owner: William Evers Date of Inspection: July 13, 2005 RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents: I Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Desigr_flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:_ Pumved annually-per owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed in approximately 1978-ver owner Were sewage odors detected when arriving at the site(yes or no): No 6 I6 _ Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 275 Lake Shore Drive Marstons Mills MA Owner: William Evers Date of Inspection: July 13, 2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comrents(on condition of joints,venting,evidence of leakage,etc.): i SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 12" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): ( (attach a copy of certificate) Dimensions: __ 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: I" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring 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.): Cement tees were resent. The li uid level was even with the outlet invert. There did not aDy ear to be any ijzns of leaka e. i GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): i i 7 J Page'S of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 275 Lake Shore Drive Marston Mills. MA Owner: William Evers Date of Inspection: July 13, 2005 TIGHT or HOLDING TANK: None (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: eallons Design Flow: eallons/day Alarn-.present(yes or no): Alarin level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 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.): The D-box was broken down structurally. A new D-box was installed(Permit#2005 329) PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 275 Lake Shore Drive Marston Mills MA Owner: William Evers Date of Inspection: July 13, 2005 SOIL.ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1-6'x 6'(1000 gal.) 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.): The leach pit had Y ofliauid on the bottom The scum line was anDroximately 4'ud from the bottom There did not appear to be ama signs of failure The bottom to grade was 8' The cover was 20"below grade CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth -top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 275 Lake Shore Drive Ma.rstons Mills MA Owner: William Evers Date of Inspection: July 13. 2005 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. I R AUk 4 0 a b 3 a $ ay 3 10 a8 10 iJ Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 275 Lake Shore Drive Marstons Mills. MA Owner: William Evers Date of Inspection: July 13, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25+/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours inyps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps the maps were showing ypproximately 25'+/-to groundwater at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied,relating to the system, the inspection and/or this report. 11 No. � �' Fee W THE O Entered in computer: COMMONWEALTH OF MASSACHUSETTS Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIppYication for ]Dizpozal *pgt m Cougtruttion Permit Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address of Lot No. a, I IA o jQ ►7(- Owner's Name,Address and Tel.No. Assessor's Map/Parcel o ,, E v t r S b �" Installer's Name,Address,and Tel.No. t 1.-. yl Designer's Name,Address and Tel.No. Go r-)—on 00 os P.0 (�o-( 0-�Ieeo 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 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil 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 un '1 a Certifi- cate of Compliance has been issued by this Board of Health. l Signed t1,22, 4 All Date Application Approved by Date Application Disapproved for Ne following reasons Permit No. __ .20 D�--�2 e Date Issued tI s 'No. ��2 r - Fee /W t. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: !/ r Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZIppYication for aigooal *p5tem Con!5truction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System 0 Individual Components Location Address or Lot No. ,S I A Sh o fc_ ►1.r• Owner's Name,Address and Tel.No. Assessor's Map/Parcel 5 ,(�}A/VM E V e:r S o- M Installer's Name,Address,and Tel.No. to - Y11 Z u t Designer's Name,Address and Tel.No. (jor--Jon aoopds P.0 (fox W'i 0S—let•u.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 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Rep> or Alterations(Answer when applicable) CePAir Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed Date Application Appro Date ved by r C ��i �� �' Application Disapproved for the following reasons - Permit No. 200 �2 Gi Date Issued t u r THE COMMONWEALTH OF MASSACHUSETTS ox ftp&r BARNSTABLE, MASSACHUSETTS 1 Certificate of Compliance r THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( Upgraded( ) Abandoned( by at c r 1')AK� S1�ore t�f. �• /►��I�l has been constructpd ii}g accordance with the provisions of Title 5 d the for Disposal System Construction Permit No. '� D - dated -7 /3/0 '- Installer ;'^^ Ford Gyr�p� R umpuj Designer r The issuance of this permit shall not be construed as a guarantee that the syst me willfuncti�o n as designed. Date ll7 ' / /-q I ii Inspector -- �-- No. Q Uo Sr- 3.2 FeeTHE COMMONWEALTH OF MASSACHUSETTS - ��x rTA,r PUBLIC HEALTH DIVISION - BARNSTABLEJ MASSACHUSETTS Mi5pogat 6pgter-t-))rupgr n5truction Permit Permission is herebyanted to Construct Re airade Abandon � ( ) P ( ( ) J ( ) System located at a_ /A4 SAo►c and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of tls-permit. Date:- I o r Approved k �. A AXI SIN -12 2 �` ,�, •{ 1 4- ) fir.. � � .�. �"}� ; � ��`.�-'`�.- y'�?'rd � �`��- m. ry �- .:fir'" Y"�M`g�,, `�' _� s�' � c•�»:.t,> a r� 3- ,`_ Y � _'1`'^ '�'"��"t��j�' "tr � ::��+-*� 3-_ �- }E-i h �t Y�k•3,fcv z'^4 �__ R"'t-� X". `s 'S .�f � - -'S_ L -._ �.R � tt�.m �" c3. t�� ,ter� �",�.»y��"`� �-��r Y�,�"��•�� � ��� .� x.- ��� a Por vli r Lio ,°J ��aQQS PN 5w� �11( co o5e>� 1 1 w i E-- i 6.. �02 5 Caf 6D% n 5 /N! -10/ �`�'�, exsTwccoNTouR: ---- SEPTIC SYSTEM DESIG J ' 'SEPTIC SYSTEM SECTION /I ��,QSP �O� PROPOSED CONTOUR: ••••••••••••• 2"PEASTONE OR FILTER FABRIC `"--��� gQ 02 EXISTING SPOT ELEVATION: 25.5 FLOW ESTIMATE: FIRST FLOOR PROPOSED SPOT ELEVATION: 25.5 2 BEDROOMS AT 110 GAL/DAY= 220 GAL/DAY 102.35 ELEV.=94.0 COVERS WITHIN 6" 3/4"-1 1/2" TEST HOLE: a TOP OF OF FINISHED GRADE •WASHED STONE m , m' '` DE INSPECTION PORT � . m�% Teo � NFL UTILITY POLE: -O- • SEPTIC TANK: FOUNDATION -���,�m �m� ,FINISHED GRAD FENCE LINE: - �-P HYDRANT: 220 GAL/DAY x 2 DAYS= 440 GAL 3,MAX LOCUS RETAINING WALL: ® USE 1000 GALLON SEPTIC TANK (EXISTING) 96.35 COVER " n ELEV. a 95.65 � (1'MIN) LEACHING AREA: ° (EXISTING) ELEV. , USE 2-500 GALLON CHAMBERS 8.5'x 4.8'x 2'EFF.DEPTH WITH g •g ELEV 4.76 a , ae , veeve . ( ) ELEV. ELEV. _ 91.0 LOCATION MAP ELEV. (( D-BOX LOT 16 (30,543 SF) 4'OF STONE ALL AROUND (25'x 12.8'x 2'DEEP) 1000 GAL MECHANICALLY STONE UNDER OR COMPACTED) 4 H ELEV. ASSESSORS MAP:30 PARCEL:96 SEPTIC TANK •E 25'x 12.8' PLAN BOOK:249, PAGE:79 SIDE AREA: (25'+12.8')x 2 x 2=151 SF (0J4)=112 GAUDAY (TO 93.0 2-500 GALLON CHAMBERS WITH � BOTTOM AREA: 25'x 12.8'=320 SF (0.74)=237 GAUDAY INELET�6EUF� 13 DOWNFIRMED) ELEV. 4'OF STONE ALL AROUND VON, CAPACITY=349 GAL/DAY OUTLET:6"UP, 14"DOWN GAS BAFFLE (25'x 12(.H'201'DEEP) N 0�E �- (TO BE VENTED) SN / ® AT OUTLET TEE P Ed eot 98 GARAGE porch LIVING BED TEST HOLE LOGS O/AHORIZON ELEV. O/AHORIZON E96.0 LEV. 96 ROOM ROOM SANDY LOAM SANDY LOAM 134 39 �� / ENGINEER: THOMAS McLELLAN,P.E. 10YR 4/3 10YR 4/3 P' �' 3° 95.7 5' 95.6 1 WITNESS: DAVE STANTORR.S. B HORIZON B HORIZON 100- _"-_ g4 KIT. DINING bath BED G - _/ /; ROOM ROOM DATE: 10-4-16 SANDY LOAM SANDY LOAM bath 30 2.5Y 6/6 93.5 30" 2.5Y 6/6 93.5 PERCOLATION RATE: <2 MIN/IN _ 100 / 1st FLOOR C HORIZON C HORIZON 1; 92 DECK MEDIUM SAND 2 MEDIUM BENCHMARK ATM SAND 102 \ PERC AT 54" 104-i W yI LEFT CORNER OF ERNE \ It 90 ELEVACONCTION S 101.60 bath 132" 85.0 126" 85.5 106 / i 1 102 N GROUND WATER ENCOUNTERED N stk 1 ouch 2X�EOR NG ' ' ° L R EDGE • E 2 cn GP W -10 LAWN Dtopfnd� FAMILY ROOM 3 NOTES: � g6• BASEMENT 1 VERTICAL DATUM: ASSUME D 104 ex%so 9s�on 1 e �. ECK 98 1 e0t�cts6V, �� 2.MUNICAPAL WATER IS AVAILABLE. 102�s ko ► E C��/ D EXISTING FLOOR PLAN 3.SCHEDULE 40-4"PVC PIPE TO BE USED THROUGHOUT SEPTIC SYSTEM. 96 / / 4.ALL PRECAST UNITS SUBJECT TO TRAFFIC LOADS TO CONFORM WITH AASHTO H-20 SPECIFICATIONS. �, / 88 / 5.PIPE PITCH= 1/4" PER FOOT(UNLESS NOTED OTHERWISE). 94, 100 / / ) 24" LP) / /J / / 86 6.FIRST 2'OF PIPE OUT OF D-BOX TO BE SET LEVEL. oak // 92 / ( 7.THE SEPTIC SYSTEM HAS NOT BEEN DESIGNED TO ACCOMODATE THE USE OF A GARBAGE DISPOSAL. 98 8.ALL CONSTRUCTION DETAILS ARE TO BE IN CONFORMANCE WITH THE STATE OF MASS.ENVIRONMENTAL 4 CODE(TITLE FIVE)AND LOCAL HEALTH REGULATIONS. 9 0 / § 9.CONTRACTOR TO VERIFY LOCATIONS OF ALL UTILITIES PRIOR TO CONSTRUCTION. 96--- /12 hoUy ccoo- 10.GROUND COVER OVERALL SEPTIC SYSTEM COMPONENTS NOT TO EXCEED 3'. 88/ / / m 11.FIELD SURVEY PROVIDED BY TERRY A.WARNER,P.L.S.,HARWICH,MA. stk / / // / // /' 12.THIS PLAN REQUIRES THE REVIEW AND APPROVAL OF ONE OR MORE TOWN DEPARTMENTS AND 92 I IS SUBJECT TO CHANGE UNTIL SUCH TIME. 90-_ - / / 13.EXISTING LEACH PIT IS TO BE PUMPED AND FILLED WITH SAND OR REMOVED. 40 MIL POLY LINER --- // _ 82 14.D-BOX TO BE WATER TESTED TO ENSURE LEVELNESS AND EQUAL FLOW. 46'x 2'DEEP 88_ TOP OF LINER=94.0 86_ 15.THIS DESIGN REQUIRES THE APPROVAL OF A VARIANCE FROM TITLE 5,SECTION 15.221 (7): BOTTOM ELEVATION=92.0 84- --- -80-/ i PORTION OF PROPOSED LEACH AREA TO BE GREATER THAN T BELOW GRADE,(VARIANCE OF 1.6). / i 82- --- � _78-J � 80- i 78- SITE PLAN J LOCATION: 275 LAKE SHORE DR.,MARSTONS MILLS,MA rMM.asJ.4.�w O McLELLAN rtt PREPARED FOR: CIVh � ROBERT & HEATHER MURPHY P�o•36471�iq Q DATE: 10-4-16 SCALE: 1"=30' REVISED: 11-18-16 LABEL AS 2 BEDROOM PER BOH i BASS RIVER ENGINEERING 101.14' TH 'MAS J. McLE AN, P.E. P.O.BOX 1163, EAST DENNIS,MA 02641 M16-56 S 85°33'27"W 508-364-9048