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Home My WebLink About0329 LAKE SHORE DRIVE - Health 29;�. k-: Shire Drive . - - _ - WF31 al StOliS;fVlllls p Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 329 Lake Shore Dr. Property Address Joseph & Lindsay Corona Owner Owner's Name information is required for Marstons Mills Ma. 02648 4/20/2010 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. 'mP°'a"t When filling out A. General Information forms the `=t computeto r,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name r� P.O.Box 763 Company Address Centerville Ma. 02632 City/Town State Zip Code (508)428-4028 S14454 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection' was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails, C ❑ Needs Further Evaluation by the Local Approving Authority , w 4/20/2010 + , Insp tors Signature Date rQ The system inspector shall submit a copy of this inspection report to the Approving Authorit.t(Boef� of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner.shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. `D t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Dispo al System•Page 1 of 17 , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 329 Lake Shore Dr. Property Address Joseph & Lindsay Corona Owner Owner's Name information is required for Marstons Mills Ma. 02648 4/20/2010 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/08 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 ,.•y'' 329 Lake Shore Dr. Property Address Joseph & Lindsay Corona Owner Owner's Name information.is required for Marstons Mills Ma. 02648 4/20/2010 every page. Cityrrown 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): t ❑ 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•09/08 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 329 Lake Shore Dr. Property Address Joseph & Lindsay Corona Owner Owner's Name information is required for Marstons Mills Ma. 02648 4/20/2010 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments . �M 329 Lake Shore Dr. Property Address Joseph & Lindsay Corona Owner Owner's Name information is required for Marstons Mills Ma. 02648 4/20/2010 every 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 El ® 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 li I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 329 Lake Shore Dr. Property Address Joseph & Lindsay Corona Owner Owner's Name information is required for Marstons Mills Ma. 02648 4/20/2010 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any_of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® El Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material'of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 329 Lake Shore Dr. Property Address Joseph & Lindsay Corona Owner Owner's Name information is required for Marstons Mills Ma. 02648 4/20/2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 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 5,000 :4 Water meter readings, if available (last 2 years usage (gpd)): 2002008: 5,000 Detail: 2008:123gpd 2009:151gpd Sump pump? ❑ Yes ® No Last date of occupancy: 4/20/2010 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 329 Lake Shore Dr. Property Address Joseph & Lindsay Corona Owner Owner's Name information is required for Marstons Mills Ma. 02648 4/20/2010 every 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? q tY Reason for pumping: f 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M ,•' 329 Lake Shore Dr. Property Address Joseph & Lindsay Corona Owner Owner's Name information is required for Marstons Mills Ma. 02648 4/20/2010 every page. Cityrrown State Zip Code Date of Inspection D. System,Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2'feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of leakage.system vented through the house vents. Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon Sludge depth: 3" t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 329 Lake Shore Dr. Property Address Joseph & Lindsay Corona Owner Owner's Name information is arstons Mills Ma. 02648 4/20/2010 required for M ' every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 3" 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 10" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump tank every two years.lnlet and outlet tees are in place.No evidence of leakage.tank appears structurally sound. 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•09108 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 •''w 329 Lake Shore Dr. Property Address Joseph & Lindsay Corona Owner Owner's Name information is required for Marstons Mills Ma. 02648 4/20/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No l5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 329 Lake Shore Dr. Property Address Joseph & Lindsay Corona Owner Owner's Name information is required for Marstons Mills Ma. 02648 4/20/2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box is level.Box has two outlet laterals.No evidence of solids carryover.No evidence of leakage. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments note condition of um chamber, condition of pumps and appurtenances, etc.): ( pump P P PP ) Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 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 329 Lake Shore Dr. Property Address Joseph & Lindsay Corona Owner Owner's Name information is required for Marstons Mills Ma. 02648 4/20/2010 every page. City/Town State Zip Code Date of Inspection D..System Information (cont.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy soil.No signs of hydraulic failure.Pit#1 water level 3' below invert.Stain line to invert.Pit#2 water level 4.5' below invert.Stain line 4' below invert. 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 I . Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 329 Lake Shore Dr. Property Address Joseph & Lindsay Corona Owner Owner's Name information is required for Marstons Mills Ma. 02648 4/20/2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 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 329 Lake Shore Dr. Property Address Joseph & Lindsay Corona Owner Owner's Name information is required for Marstons Mills Ma. 02648 4/20/2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate ` where public water supply enters the building. Check one of the boxes below: I 4 ❑ hand-sketch in the area below ❑ drawing attached separately f t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 329 Lake Shore Dr. Property Address Joseph & Lindsay Corona Owner Owner's Name information is Marstons Mills Ma. 02648 4/20/2010 required for every 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: Bottom of LP 60'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: As-Built ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 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 329 Lake Shore Dr. Property Address Joseph & Lindsay Corona Owner Owner's Name information is required for Marstons Mills Ma. 02648 4/20/2010 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 CERTIFICATE OF ANALYSIS Page: 1 Barnstable County Health Laboratory Report. Dated: 6/15/2005 ' tv Report Prepared For: 0 cn Order No.: G05307 9 c_ Joe Corona. CD C N 100 Five Corners Road < ODcn o0 Centerville, MA 02632 0 -� X Cr: 1 am Laboratory ID#: 0530739-01 Description: Water-Driuldng Water N r' M Sample th 30739 Sampling Location: �329 Lake Shore Dr.Marston Mills,MA Collected: 6/13/2005 Collected by: R.Melville t Received: 6/13/2005 Routine r1rE.1a1 RESULT UNIf S RL MCL Method# Tested LAB: Inorganics Nitrate as Nitrogen 6.5 mg/L 0.10 10 EPA300.0 6/14/2005 LAB: Metals Copper 0.12 mg/L 0.10 1.3 SM 3111B 6/14/2005 iron 0.12 mg/L 0.10 0.3 SM 3111B 6/14/2005 Sodium 13 mg/L 1.0 20 SM 3111B 6/14/2005 LAB: Microbiology Total Coliform Absent P/A o 0 309 6/13/2005 LAB: Physical Chemistry Conductance 280 a nohs/cm 1.0 EPA 120.1 6/13/2005 pH 7.1 pH-units 0 EPA 150.1 6/13/2005 Water sample meets the recommended limits for drinking water of all the above tested parameters. Approved By: ( Director) t RL = Reperting Limit MCL=Maximum Contaminant Level Superior Court House,'PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 r i Z RECEIVED OCT 2 5 2004 TOWN OF BARNSTABLE DATE 10110104 HEALTH DEPT. PROPERTY ADDRESS 329 Lake Sho2eAP �72. ,, (7a2�ston�s 17.i.Q.Q�s, 17a. DARCEL, ' On the above date, the4eptic system at the address above was Inspected. This system consists of'the following: 1. 1-1000 gaiion zept.ic tank.-, 2.- 1-d.iztaj ut.ion gox.. 3. 2- 1000 ga.QQon eeach.ing 12.it,3.- Based on inspection, I certify the following conditions: 7hiz iz a i-ii-ie live .se�.tis Zy�stem(78 code). 5. The �se�t is system i�5 .in PloPea wo2k.ing o2dea at the time. SIGNATURE IT) Name: Robert A. Paolinl Company: Joseuh P Macomber & Son Inc Address: P. O. Box 66 Centerville Mass 02632 Phone: 508-775-3338 or 508-775-6412 JOSEPH P. MACOMBER & SON,. INC. Tan ks-Cesspools-Leachfields Pumped & Installed Tower Sewer Connections P.O. Box 66 Centerville, MA 026.32-0066 775-3338 775-6412 i • COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF +NVII3QNNiI3TA3�pROTCTION Y r TITLE 5 OFFICIAL INSPECTION FORM—NAT.:FOR VOLVNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYS'I'M FORM PART•A CERTIFICATION Property Address: .329 Lake Shoae Dlt., Owner's Name: 9n h n C,7 n n o n Owner's Address: aim Date of Inspection: i n l°n nI Name of Inspector: (please print) 13 0 9 e 2 t h.a.o i n i Company Name: , m a c o m$.e2_ L c. Mailing.Address: en ezv c e, czbb..02632 Telephone Number: 5 0 8—7 7 :3 3 3 8 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the-Information reported below is true;accurate and complete as of the time of the inspection.The inspection-was performed based on my training and experience in-the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to=Section.15:340.of-Title 5(31-0 CMR•15:a00). The system: xzx Passes -Conditionally Passes Needs Further Evaluation,by the Local Approving.Authority A�- ils InsP ector's Signature: % %►' Date:, The system inspector shall submit a copy of this inspection report-to the.Approving Authority.(Board of Health or action.If the S stem is a,shared sy4tern or has a design flow of 10,000 DEP)within 30 days of completutg this inspection. y . 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 tothe system owner ewer copies sent co the buyer,if lkpp(icab(e,and the approving authority. Notes and Comments ****'phis report only describes conditions at the time of ins pectibn-a, nd under the conditio ns 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. 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FQR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR PART-A CERTIFICATION(continued) Property Address: 329 Lake, S h o z e D . 1la2ztonz Ni"_ •s, 17a.- Owner• Sohn Caaven Data of Inspection: 9 Q 10 n 4 Inspection S.uinmary: Cheek A,B C,D or.E/ALWAY'S�comploWalI of Section;D A. System Passes: no I have not found any information which indicates`btf and of the failure criteria described in 310 CMR 15.303.or in 310 CMR 1.5.304 exist.Any failure criteria not evaluated are indicated below. Comments: The- 3e/?tic zuh.tem "ih in Rn'o/zea woak"ing o2dea at .the . P2e.6en.t time., B. System Conditionally Passes: no 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. a.o- The septic tank is metal and.over20 years old*or the septic-tank(whether metal or not).is structurally unsound,exhibits substantialeinfiltratiQn or exfiltration or tank failure is-eimmineni. System.will pass inspection_if the existing tank is replaced with'a complying septic-tank.as-pproved by.the:$oard of Health. 'A metal septic tank will pas§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: no 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: no 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 OFP:ICLA L INWIECTION FORM-NOT VO V0LUNTARY -SS �1SP1�CT�N�`O�ES-SMENTS SUBIgt"A CE SEV�AOR i SROS�IL Sy STEM A . . 'CERT-MCATION•(6ontinued) : Property Address: 3 2 9 f _ Owner:. Date of spection: I C. Furtber Evaluation•is Required by the Board of Health: no Conditions.exist which require finther..eualuation by.the Board:of=Heaith;in•order,•toAdtennine ifthe system is failing to protect public.health,.safety or the environment. t )t ) I. System will;pass unless Board-of determines�in a cordance with 310.CMR t4e.. .•i b that the system is-not functioning in a•mattner-which:w111•protect public health,safety.antl•tbe:.tnYironment: no Cesspool or privy is within,50 feet of asurface water no 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'Af any),determines:that the system is functioning in a manner.that proteets the public health,safety and environment: no The system has a septic tahk and soil absorption system.(SA•S)..and the$AS is within 100 fe.etvofa surface water supply or.-tributary to a surface water-supply. no The system-has-a-septic tank and SAS and the;SAS ivwitbin a Zone 1 of a-public water�supply. n o The system has a septic tank and.W*and•the SAS is within,50 feet of a private water.supply well. n o The system has a septic tank and SAS and the SAS is less than 100 feet..biit 50 feet ox:iriore fiom 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 colifonn 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.criteiia are triggered.'A copy of the analysis must be attached to tl}ls form. 3. Other: Page 4 of 11 OFFICL4 L-INSP.ECTIOrN FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION:FORM PART A CERTIFICATION(continued) Property Address:3 2 9 Lake S h o 2 e Da Owner: 2ohn Cahiven ' Date of Inspection: D. System Failure Criteria applicable to all systems:. You must indicate."yes"or"no"to.each.of the:following:for all inspections: Yes No _ x. Backup.of sewago into•fathity.or system component due.-to.overloaded,or clogged SAS...or.cesspool _ x Discharge:or-ponding of effluent to the.surface bfthe:;ground or,..surface:waters due to an overloaded or clogged SAS or cesspool ' _ x Static liquid level in the distribution box above•outlet invert due.to an overloaded or clogged SAS or —' cesspool _ x Liquid depth in-cesspool is less than.6"below invert or available volume is less than'A-day flow _ x Required pumping more,tham4 times in the last year NOT due to clogged of obstructed pipe(s).Number of times pumped ' x Any portion of.the SAS;cesspool or privy is below high ground water elevation. _ x Aiiy.portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface '— water supply. x Any portion,ofa cesspool-or.privy is withinoZone:1.•of apublic.well. x Any portion of a cesspool-or privy is within 50 feet of a private water supply well. x. Any portion of a-cesspool or-privy is less-than 100 feet but greater-.than 5,0 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 pollutloq:from: hat,facth 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 niust be attaehed.to this forte.] no (Yes/ND)The system fails.I have determined that one ormore-of.the:4bove.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:syst`0m must.serve.a.faeility,with a design flow of 10;00.0 gpd to 15�000. gpd• You must indicate either"yes"or"no"tq 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 x the system.is within 206 feet of a tributary to a surface drinking water supper r x. the:system is located In a nitrogen sensitive area Qnterim Wellhead Protection Area=IWPA)or a mapped 77 — 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 tender 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 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS 81�RSURFACE-SEWAGE DISPOSAL"SYS'TEM INSIPEC'PIoN FORM PART$ CHECKLIST Property Address:329 Lake ShoaOe DIt, Owner: Date of Insp—ectlo x Check'if the following have been done You must indicate"yes°'or"no"alto each.of the following: Yes No x _ Pumping information was provided by the Owner,occupant,or Board-of Health x Were any of the system components pumped out in the previous two weeks? x Has the system received normal flows in the previous two week period? — .— , _ X Have large volumes of water been introduced to the system recently or as-part of thigs,.inspection? x _ Were as built plans of the system•obtained and examined?(If they were not availabletote is N/A) x Was the facility.or•dwelling inspected for signs of sewage back up? z Was the site inspected for signs of break out? z • _ Were all system components,excluding the SAS;located on site.?- x Were• _ the septic tank manholes uncovered;:opened,and the interior of the tank inspected for the condition _ of the baffles or tees.,material of construction,dimensions,depth of liquid, depth of sludge and depth of scum? x _ Was.the facility'owner(and occupants if diffbrent 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 Xo — _ Existing information.For example,a plan at the Board of.Health. " _ x Determined in the field(if any of the failure criteria related to Part C is at issue approxifttion-of distan, is unacceptable)[310 CMR 15.302(3)(b)J �. 5 Page 6 of 11 OFFMIA,L NSPEC'TION 1F'A}RM'!'_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE-SEWAGE OISFOSA:L aSYSTMINSPEETI01.�1:PORM PART•C SYSTEM:INFORMATION Property Address: 329 Lake S h o 2 e Da Owner: 7nhn Cnnuon Date of Inspection: 1.a,�Z j11,LLl FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):�,j.I Number of bedrooms.•(actual): 3 DESIGN`flow•based on-3la CMA 15.203':(for example:'110 gpd z#•6tbedrodl&l.- '3 x.110 3 30 gRd Number of current residents: .: 2 Doestesidence have a garbage grinder(yes or no):r�e� Is laundry on a separate sewage.sysiem,(yes or-no):._0_12 [if yes separate iuspection required] Laundry system inspected(yes or no):Y-" Seasonal use:(yes or no): . Water meter readings,if available(last 2 years usage(gpd)): ,.,v P P wn t e 2 .i?P- we i i h a b n o t Sump pump(yes or no):.AO keen t'e r e d in /a a t yea 2 it Last date of occupancy: 7Q%g,6Qat' .6hou.ed ge done at th.iz time ,. zge 12ages 6a-69, COMMERCIA..I USTRIAL Type of estA' ,. nt: _n a Desk flgw( on 310 PR 15.203):. n a apd- Basis.of d4ign flow(seats/persons/sgft,etc.): nn � . . : Grease trap present(yes or no):`n n Industrial waste holding tank present.(yes or no):n M Non-sanitary'waste discharged to the Title 5 system-(yes or no)4.a Water-meter readings,if available: • na Last-date of occupancy/use: . na . OTHER(descrilze)•. . CANERAL INFQATION ". Pumping Records Source of information: . Was system pumped as part of the inspection(yes or no):_ If yes,volume pumped:_gallons--How was quantity,pumped determined? Reason for.p..umping: TYPE OF SYSTEM y e 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: 1974 Were sewage odors detected when arriving at the site(yes or no):n o 6 - BARNSTABLE COUNTY DEPARTMENT OF HEALTH & THE ENVIRONMENT P.O: BOX 427 Of 61^4H SUPERIOR COURT HOUSE o BARNSTABLE, MASSACHUSETTS 02630 PHONE: 362-251 ' X(A EXT. 3 31 SAMPLING INSTRUCTIONS FOR PRIVATE WELLS An improperly taken sampl,. wastes your money and has neither scientific accuracy nor legal acceptance. 1. Obtain sterile sampling bottle from the County Lab or Town Health Department. Bottles sterilized at home are not acceptable. 2. It is recommended to use a-sttlight faucet, preferably NOT swingtype. 3. Turn on the cold water and let it run for five (5) minutes. 4. Fill the bottle leaving one inch air space. Do not fill bottle to the top. Be careful not to touch the inside of the bottle or cap with the faucet, your hands, or anything else. S. Fill out the reverse side of this form. The laboratory requires accurate and complete information. The person filling the bottle must sign the form 6. The charge for a routine well analysis (coliform bacteria, pH, conductivity, iron, nitrate, sodium and copper) is 525.00. Checks should be made payable to BnrnstAble Counrv. Exact change is required if paying in cash. Additional tests require additional fees. Consult Lab or a price list for exact information.. ?. Samples are accepted Monday - Thursday from 8:00 AM to 4:00 PM and Friday BMW to 1:00 PM. They must be delivered to the lab within 6 hours of collection or 24 hours if refrigerated. S. Completion of tests and results takes 7-10 business days. Results will be sent in the mail. 9. Special requests such as results in 2 -3 days and sample acceptance on Friday from 1:00 PM to 4:00 PM are available for an additional charge. Contact the laboratory for availability. �QTTCE: WATER FRO' ` T�'~ PROQUCE CONT RFSt LTS T nr ut~rrr TIMF4 AND/OR D I TF E IF lco � G� A �.�� A E CQ TY OF BARNSTABLE SHALL NOT BE LIA.BL &ES& j;:'G FROM THE RF1 ( CE ON 1:SLJLT9 OF WATER M� ACCLM�6TE> Y PERF PLEASE COMPLETE REVERSE UDE ( F FORM b.-RIVATE WELL WATER SAMPLE DnTT COLLECTION SHEET \l I A L _t^l t 448 E R S FIELD D LA 1J K �c I°D 1}Uf:1DER DATE REC ' D 1 COLLECTION DATE ?.Af T NG ADDRESS COLLECTION TIME WELL DEPTH ' R4 T ADDRESS YEAR WELL INSTALLED MAP/PARCEL -;-f'LCPH0NE COLLECTED BY : E APPOINTMENT N-EODED' ? F N FOR TESTING : ( ) SUSPECT A PROBLEM (EXPLAIN) ( ) REQUIRED ( ) FOR It4FORMATI011 OULY ( ) 1IE14 WELL ( ) REAL ESTATE TRANSACTI011 ( ) OTHER (EXPLAIN) CJ'57RNCE OF WELL FROM POSSIBLE COt1TAMINATION SOURCES ( IN FEET) SEPTIC TANK\CESSPOOL FARM SALTED ROAD UST LANDFILL INDUSTRY :,AS STATION OTHER TXF-PrT4ENT USED: ( ) NOV E ( } WATER SOFTENER ( ) FILTER; SAMPLE TAKEN BEFORE/AFTER TREATMENT (CIRCLE) RESULTS VOC ROUTINE Cl}-LpROFORM TOTAL ROUTINE ML 1 . TRICHLOROETHANE ( PPB) pH _ CONDUCTIVITY IRON (PPM) 11ITRATE-111TROGEN ( PPM) SODIUM (PPM) COPPER (PP14) At 1S DATE : ANALYSIS DATE: I Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION(continued) Property Address: 329 Lake Shoae Da.• lYlnnAfnn.t Owner: Date of pection: 1040.104 BUILDING SEWER(locate on site plan) Depth below grade: 2 0" Materials of construction:_cast iron x 40 PVC_other(explain): Distance from private water su}rply_we;or suction line:10 0,, Comments(on condition of joints,venting,evidence of leakage,etc.): so.intz' a/z/2eaa t.ight.4o evidence. o eeakage.-Syztem vented thnough the houze vents., --' SEPTIC TANK:_(locate on site plan) Depth below grade: 2' Material of construction: x 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:5' 8"h.igh/4' 10"w.ide/8' 6".eond Sludge depth: 1-2 a c e " Distance from top of sludge to bottom of outlet tee or baffle: 24 Scum thickness: t 2 a c e " Distance from top of scum to top of outlet tee or baffle: 6 Distance from bottom of scum to bottom of outlet tee or b�8" How were dimensions determined. m e a s u a e d Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 2-3 eaa.6.,7aak .iz ztauctuaaeey zound..No nv.i_rin_nce o4 eaakaae.-Inigt and ouRe ees ane 7a GREASE TRAP:n o (locate on site plan) Depth below grade: n a ' Material of construction:_concrete_metal_fiberglass_polyethylene—other (explain): n a Dimensions: n a Scum thickness: n a Distance from top of scum to top of outlet tee or baffle*: n a Distance from bottom of scum to bottom of outlet tee or-baffle: n a Date of last pumping: n a Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet inver�evidence of leakage,etc CG2eaze Zap not /22e.6en . I Title S Tnar%^M^n Tinrrn(./i S/,)nnn 7 Page 8 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS S�iIfI? 'ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C• SYSTEM INFORMATION(continued) Property Address329 Lake Shoae Dlt.- Owner:• ag-ab,�ra ection: 9 n 7(j n Date of Insp N TIGHT or HO-IrDING TANK: no (tank must be pumped at time of inspettion)(locate on site plan) Depth below grade: na Material of construction: na concrete metal fiberglass_,_polyethylene other(explain): Dimensions: rba' Capacity: na gallons Design Flow: na gallons/day Alarm present(yes or no): na Alarm level: aa Alarm In working.order(yes or no): Date of last pumping: na Comments(condition of MUM and float•switches,etc.): nt. 7.igh2t o/t hoid.ing tanks not. 12ILe,6e. DISTRIBUTION BOX: ye-3 (if present must be opetud)(locate on site plan) Depth of liquid level above outlet invert: no Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box, etc.): Box haz two iateaaiz.4o evidence o� zoiids ca/t2y ovea. o ev.c ence o ea age into oa ou o ox-' PUMP CHAMBER: no (locate on sife.plan) Pumps in working order(yes or.no):rza Alarms in working order(yes or no): na Comments(note condition of pump.chamber,condition of pumps and appurtenances,etb.): Pump cham9e2 not /2ae-6en.t.' 8. Page 9 of 11 OFFICIAL INSPECTION FORM—NOT-FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PARTT C SYSTEM INFORMATION(continued). Property Address:329 Lake Sho2e DIt., blame.-nn 6 Mi.PL60 Na., Owner: zn,An Date or Inspection: SOIL ABSORPTION StSTEM(SAS):_-(locate on site plan,excavation-nrgt-required) If SAS not located explain why: Located ze4 % age 10 Type ye,3 leaching pits,number: 2 leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: _inn ovative/alternative'system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): r-•. zo.i-ez a1212ea2 dau.-No evidence of hUdAga e is �a i tune no evidence oZ /2ond.inc,, Veg _t_n n_ i.y no2maL, CESSPOOLS: n o (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: -na Depth—top of liquid to inlet invert: na Depth of solids layer: Ra Depth of scum layer: n a, Dimensions of cesspool: n a Materials of construction: na Indication of groundwater inflow(yes or no):dry Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Cezzpooiz no.t R2es.en.t., PRIVY:n o (locate on site plan) Materials of construction: na. Dimensions: na Depth of solids: na psi► u .:. Comments(note condition of soil,signs of hydraulic failure,level of*ponding,condition of vegetation,etc.): P 2.ivy not /22ezent.. 9 Page 10 of 11 0C ;.INSPEION'1�'4R�VI> NO'1�'�POI ?VOI� FA3tYIAI. :AS3ES5NTS / SU89URFAE'<SEWAGEMISgOSAL SYSTEMINSBEG`330�i:FQR1V'f C` PART-C SYSTEM 04FORMATION(icontinnued)' Address: 2 9 /n k o S h o n v 72 Propertx a., Owner: Date of Inspection: SKETCH OF SEWAG�•DISPOSAL SYSTEM referenre,landmarks ,,,,Prov ide a sketch of the sewage disposal system including ties to at least er su p l entgrstthe b lding. or benchmarks.Locate all wells within I00 feet.Locate where public pp AIR f I 1 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARYFORM ASSESSMENTS �,- gUgSUgFACE SEWAGE DISPOSAL SYSTEM INSPECTION SYSTEM INFORMATION(continued) Property Address: '?; r t-o S h o n n_ 22•' . a. Owner: Date of Inspection: > n SITE EXAM Slope Surface water Check cellar. Shallow wells Estimated depth to ground water feet Please in (check)all methods used to determine the high ground water elevation: date of design plan rFviewed: Obtained from system design p lens on record-If checked, 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 ta l sh llermodel h ground2 n water elevation: • used;Gahert & Mi used.•USGS observation w 1 used- Technical bul — wa er a eva ions. Leaching Pith :eet Groundwater: Feet Below Bottom-of Pit Hi&h Groundwater Adjustment 1.8 ft der FiLir te�Method 3 Therefore,the.vertical.separation distance between the bottom f of the leactaing pit and the adjusted groundwater table is feet: I • tt ) >•�r,r,.-R„�.rr.,,r-n,....,R.a-,.r.�.,�„r,rr,re.re.....�.,.r�-...,a-.rr,��, BARD OF IiE;ALTfI 'TOWN OF SUBSURFACE SEWAGE DJSPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION ••T!•t•T•:-::r.�„r..�rrn:nr+n•rtr..,r+sr.7retrr+r:Tirt:ra'irnrtn:�m'n74T�T �� —TYPE 08 PRINT CLEARLY— F'ROPERTY INSPECTED STREET ADDRESS 329 Lake Shoae D zive ASSESSORS MAP, DWC, 'K AND PARCEL # 0 30-10R OWNER' s NAME John ` PART D - CERTIFICATION NAME OF INSPECTOR COMPANY NAME Joseph P ' Macomber & ''ion Inc_ COMPANY ADDRESS Box 66 Centervi a MA Q261? street To►In or city state ZIP COMPANY TELEPHONE ( 508 ) 775 3338 FAX ( 508 ) 790 - 1578 MINE 9W CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at ', this address and that the information reported is true , accurate, and omplete as of the time of Inspection , The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my 't'raining and experience in the, proper function and maintenance of on- site sewage disposal systems , Check one: XXXX Systeui PASSED The inspection which I have conducted has not found any information which indicates that. .the system fails to adequately protect public health or the environment as defined in 310 CMR. 16 , 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this. form . System FAILED* The inspection which I have cots t ted has found that the system fails tc protect the jiublic health and the environment in accordance with Title 5 , 310 CMR 15 , 303 , and as specifically noted on PART -JAILURE CRITERIA of this inspection form . r Inspector' Signature' f Date ` O.•--.r•-., .___• ._—.r —•-fie• e copy of this certification must -be provided 'to the OWNER, the IIUYER here applicable ) and thim• B9ARD of HEALTH. * If the inspection FAILED, thv owner or operator shall upgrade ' the eyatem. within o'ne year of the date of the inspection., unless allowed or requiyed otherwise as provided in 340 CKR 16 . 3.06 , partd .doc DATE:_3/10/00_-__ : 329. Lakeshore Drive PROPERTY ADDRESS ____ 02648 On the above date, I Inspected the septic system at the above address. This .system consists of the following: 1 . 1 -1500 gallon septic tank. 2. 1 -Distribution box. 3 . 2-1000 gallon precast leaching pits. Based on my Inspection, I certify the.following condltlons: 4. This is a title five septic system. ( 78 Code ) 5. The septic system is in proper working Q c3 O order at the present time. 6. Waste water is 52 inches below invert pipe on #1 pit, waste water is 31 " below invert pipe on #2 pit. SIGNATURE:,fVIA 1Al N a m e:_�,,��.ltss.2akt --ism______ Company: Joae,Qh_P_ Macomber& Son, Inc . Address Box_66______ Centerville ` Na__02632-0066 Phone:___508 775_3338_______ TWS CERTIFICATION ODES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MAC & SON, INC. Tanks•Cesspoois•leachf lelds Pumped L Installed Town Sewer ConnM^102692_0066 P.O. Box 66 Centerville, 775.3338 775.6412 RECEIVED MAR 2 12000 TOWN OF BARNSTABLE HEALTH DEPT. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617)292 6600 TRUDY c Sau ARCEO PAUL CELLUCCI DAVM B. STF Governor C0=--"" SUBSURFACE SEWAGE DISPOSAL SYSTEM.WSPECTION FORM PART A CFRTUWAT10N Prop.ay Ada,.,,: 329 Lake Shore Drive N.of O,wn ,Patricia Strong Marstons M � �7g$ss. 02648 Addr.ssofOwner: ta Da of Inspecdon: N,nw of 4�apecta: (Pt+as•Print) Joseph P.Macomber Jr. I ant a DEP oval&yourn v4pocta pursuarst to section 16.W of TW* 6(310 CIAR 15.0001 c4e,pae y k.ne: J. .Macomber & Son Inc_ M.&&ng Address: 02632 T4*pfwrw Numbs -')Ub— / /.5-3338 MnACAMN STATEMENT I certify that I have personally Inspected the *.wage disposal system at thls address and that the Information reported below is true. accu,sts and complete as of the time of Inspection. The In*pecdon was performed based on my traJning and experience In the proper function ano maintenance of on-she sewage disposal systems. The system: r^ asses Conditionally Posses _ Needs Further Evaluation By the Local Approving Authority _ Fell* ,y,J'/, vapectoes s4-ture: l �/frK Date: The System Inspect shoal submit a copy of this Inspection report to the Approving Authority(Board of Health or DEP)wWn thirty (30) osys completing this Inspection. If the system Is a shared system or has a dsslgn flow of 10,000 gpd or greater,the inspettor and the system o» Mail submit the report to the appropriate regional otflce of the Department ohfnvironmemal Protection. The original should U.sent to rw system owner and copies sent to the buyer, If applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 Pa`elof11 �'Fmied on RscycW►apw SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(corttf wow PropwtyAddrass:329 Lake Shore Drive Marstons Mi11s,Mass. Owner. Patricia Strong Date 3/1 0/0 0 INSPECTION SUMIAARY: Check A, B, C, of D. A. SYSTEM PASSES: I have not found any Information which Indicates that any of the failure condldons described In 310 CMR 1S.303 exist. Any f4we criteria not evaluated are Indicated below. COMMENTS: B. SYSTEM CONDMONALLY PASSES: A) One or more system components as described In the 'Condltlonal Psss'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. Indicate yes, no,or not determined(Y, N, or NO). Describe basis of determlrtation In all Instances. If'not determined',explain why not. The septic tank Is metal,unless the owner or operator has provided the system Inspector with a copy of a Certificate of CompUanc•(attached)Indicating that the tank was Installed within twenty(20)years prior to the data of the Inspection: or the septic tank, whether or not metal, Is cracked,structurally unsound, shows substantial Infiltration or exfIlvation, or tsnk failure is Imminent. The system will pass Inspection If the existing septic tank Is replaced with a complying septic tank as approved by the Board of Health. �Q Sewage backup or breakout or high static water level observed in the distribution box Is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass Inspection If(with approval of the Board of Health). broken pipe(&)are replaced obstruction Is removed distribution box Is levelled or replaced The.system required pumpMg"am dtart•fourtfinesti•yeardue to broken orobmcted plpe(s). Thevystsm vrW-pv= inspection If(with approval of the Board of Health): broken pipe(&) are replacid obstruction Is removed revised 9/ /9 2 a Page 2 of It SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) PropertyAddre": 329 Lake Shore Drive Marstons Mi11s,Mass. Owner: Patricia Strong Date of kupection:3 10/0 0 D. SYSTEM FAILS: You must Indicate either "Yes" or "No" to each of the following: _&) _ I have determined that one or more of the following failure conditions exist as described In 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes Noi. 1/ Backup of-sewage irrtofeciiity"er•s/atem component dne�to an overloaded orcbggedS:AS;orceespool. 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�t�ithe dis,�riibuutiog box above outlet Invert due to an overloaded or clogged SAS or cesspool. >c+�Mf ., �JJ (� Liquid depth in,Feaspo�is less than 6" below invert or available volume Is less than 1/2 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 Soil Absorption System, cesspool or privy Is below the high groundwater elevation. Any portion of a cesspool or privy Is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy Is-within a Zone I of a public well. 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for »coliform bacteria,volatile organic-compounds, ammonia nitrogen-and nitrate nitrogen. - E. LARGE SYSTEM FAILS: 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: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system Ia a significant threat to publi health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system-is-witWn 200 teetof•♦•t#ibutaryteaourfaoe.drinkiag•water•wpply•••• - -- • -- •• _ _ P' 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further inforpation. revised 9/2/98 Page 4orn SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST P►opertyAddress: 329 Lakeshore Drive Marstons Mills,Mass. Owner: Patricia Strong Date of Inspecdm: 3/1 0/0 0 Check if the following have been done:You must Indicate either'Yes' or'No' as to each of the following: Yes No Pumping Information was provided by the owner, occupant, or Board of Health, None of the system eompowenis iwru:bean pasnped4owatJ$ast two aweWW aAdtbe'aysto hasJbaeoveceiw�gwra:al flow rates during that period. Large volumes of water have not been Introduced Into the system recently or as pan of this Inspection. As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or Industrial waste flow. _ The site was Inspected for signs of breakout. _ All system components owluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was Inspected for condition of baffles or tees,imaterial of construction, dimensions,depth of liquid,depth of sludge, depth of scum. / The size and location of the Soil Absorption System orrthe site has been determined based on:- Y Existing Information. For example, Plan at B.O.H. _ Determined in the field(if any of the failure criteria related to Part C is at Issue,approximation of distance is unacceptable) 115.3020)Ib)) The facility owner(and.^ ;*=,Jf dittar&Qt troat.owoer),war&;w4jridad with 1,Mr—atlomon*hA p~p_•m,IAt&^• ^f SubSurface Disposal Systems. revised 9/2/98 Page 5ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC-41ON FORM PART C SYSTEM INFORMATION PropartyAddress:329 Lake Shore Drive Marstons Mills,Mass. Owner: Patricia Strong Date of lns b : 3/1 0/0 0 FLOW CONDITIONS RESIDENTIAL: Design flow: 116 g.p.d./bedro m. Number of bedrooms(desi )• Number of bedrooms(actual): Total DESIGN flow Number of current residents: Garbage grinder(yes or no): Laundry(separate system) (vas or q ._; If yes, sepuateJnspection.required Laundry system inspected rye%Ar no) Seasonal use(yes or no): 'Water meter readings,if a.v,�ilable(last two year's usage(gpd): 1�r�` Iva j, � L047ap Sump Pump(yes or no):� / If the well has not been tested y 'Last date of occupanc _ in the last year. It sholld be COMMERCAIJINDUSTRIAL: done at this time. See Pages ALA Type of establishment: 6A & 6B Design flow: N 9ad ( Based on 15.203) Basis of design flow _ AM Grease trap present: (yes or no)jVy Industrial Waste Holding Tank present:(yes or no)lld Von-sanitary waste discharged to the Title 5 system: ly or no)m 'Water meter readings,if availpble: i-ast date of occupancy: AYI OTHER:(Describe) 60 Last date of occupancy: i GENERAL INFORMATION PUMPING R CORDS and our e f information: NAT System pumped as part of inspection: (yes or no)10 If yes, volume pumped: a gallons Reason for pumping: — TYPE OF YSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy AfA Shared system(yes or no) (if yes, attach previous inspection records,if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank .tJll Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed{if known)-and source 04Wormation: Sewage odors detected when•arriving at the site: (yes or no) 11V i revised 9/2/98 Page 6of11 BARNSTABLE COUNTY DEPARTMENT OF HEALTH & THE ENVIRONMENT Of B„qy P.O. BOX 427 s� SUPERIOR COURT HOUSE BARNSTABLE, MASSACHUSETTS 02630 J ''+.ass • PHONE: 362-2511 EXT. 337 SAMPLING INSTRUCTIONS FOR PRIVATE WELLS An improperly taken sample wastes your money and has neither scientific accuracy nor legal acceptance. 1. Obtain sterile sampling bottle from the County Lab or Town Health Department. Bottles sterilized at home are not acceptable. 2. It is recommended to use a straight.faucet, preferably NOT swingtype. 3. Turn on the cold water and let it run for five (5) minutes. 4. Fill the bottle leaving one inch air space. Do not fill bottle to the top. Be careful not to touch the inside of the bottle or cap with the faucet, your hands, or anything else. 5. Fill out the reverse side of this form. The laboratory requires accurate and complete information. The person filling the bottle must sign the form 6. The charge for a routine well analysis (coliform bacteria, pH, conductivity, iron, nitrate, sodium and copper) is S25.00. Checks should be made payable to Barnstable County. Exact change is required if paying in cash. Additional tests require additional fees. Consult lab or a price list for exact information. 7. Samples are accepted Monday - Thursday from 8:00 AM to 4:00 PM and Friday 8:00 AM to 1:00 PM. They must be delivered to the lab within 6 hours of collection or 24 hours if refrigerated. 8. Completion of tests and results takes 7-10 business days. Results will be sent in the mail. 91. Special requests such as results in 2 -3 days and sample acceptance on Friday from 1:00 PM to 4:00 PM are available for an additional charge. Contact the laboratory for availability. NOTICE: WATER FROM THE SAME SOURCE CAN PRODUCE CONTRARY RESULTS IF TESTED AT DIFFERENT TIMES AND/OR DIFFERENT LOCATIONS THE COUNTY OF BARNSTABLE SHALL NOT BE LIABLE FOR DAMAGES RESULTING FROM THE RELIANCE ON RESULTS OF WATER TESTS ACCURATELY PERFORMED, PLEASE COMPLETE REVERSE SIDE OF FORM f PRIVATE WELL WATER SAMPLE DATA COLLECTION SHEET VOC VIAL NUMBERS FIELD BLANK BOTTLE ID NUMBER DATE REC ' D NAME COLLECTION] DATE MAILING ADDRESS COLLECTION TIME WELL DEPTH 'STREET ADDRESS YEAR WELL INSTALLED MAP/PARCEL TELEPHONE COLLECTED BY : SAMPLE APPOINTMENT NEEDED ? REASON FOR TESTING: ( ) SUSPECT A PROBLEM (EXPLAIN) ( ) REQUIRED ( ) FOR INFORMATION ONLY ( ) NEW WELL ( ) REAL ESTATE TRANSACTION OTHER EXPLAIN DISTANCE OF WELL FROM POSSIBLE CONTAMINATION SOURCES (IN FEET) : SEPTIC TANK\CESSPOOL FARM SALTED ROAD UST LANDFILL INDUSTRY GAS STATION OTHER TREATMENT USED: ( ) NONE ( ) WATER SOFTENER ( ) FILTER; SAMPLE TAKEN BEFORE/AFTER TREATMENT (CIRCLE) ***************************************************************** RESULTS VOC ROUTINE CHLOROFORM ( TOTAL COLIFORM\100 ML 1 , 1 , 1 TRICHLOROETHANE (PPB) PH CONDUCTIVITY IRON (PPM) NITRATE-11ITROGEN (PPM) SODIUM (PPM) COPPER (PPM) v ANALYSIS, DATE:_ ANALYSIS DATE: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC71QN FORM PART C SYSTEM INFORMATION(continued) Property Address: 329 Lake Shore Drive Marstons Mills,Mass. o—w: Patricia Strong Dace of kapectim: 3/1 0/0 0 BUILDING SEWER: (Locate on site plan) j Depth below grade:�d Material of construction:cast iron 240 PVC 4,thr(explain) Cistance trosyJivate water supply well or suction line Ciameter Comments: (condition of joints,venting, evidence of Ieak"e,-etc.) - - Joints appear tight No PvidAnnA of lAakAge The sstam is SEPTIC TANK: (locate on site plan) Depth below grade: j �/� Material of construction: YconcretoV metal Al�FiberglassN�Polyethylene�other(explain) If tank is Instal, list age VQ Js.aga.confirmed by Certificate of Compliance_(Yes/No) Dimensions: rd 1 J l�d ll7rd/. .�rLiVid ') SE 214 4 Sludge depth Distance from top o sludge to bottom of outlet tee orbaf e-.2a,1 Scum thickness: Distance from top of scum to top of outlet tee or baffle:./ Distance from bottom of scum to bottom of outlet t e or baffle:z1&� How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or-baffles, depth of liquid level In relation to outlet invert, structural•integrity, evidence of leakage,etc.)- PUM the se is resent Inl ' -Liquid eve at the outiet invert is fifty one inch g The- tank Jg gtrnr•t•nrally snnnd and GREASE TRAP: 8_ (locate on site plan) Depth below grader Material of con struction:)Y-*oncretdl?metaV�lFibergl asa#V &Polyethylene other(explain) AA Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle:-AY Distance from bottom of scum to bottom of outlet tee or baffler Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) grease trap JR not =rPgPnt revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM PART C ` SYSTEM WFORMATION(continued) P►opertyAddress: 329 Lakeshore Drive Marstons Mi11s,Mass. OwnK: Patricia Strong Deft at Mspeetion:3/1 0/0 0 TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, Inspection) (locate on sits plan) Depth below grade: Material of construction:,aconc rots ametalNLFibergl ass AMPolyethylsne l�Qi other(explain) AM AM Dimensions: 0 Capacity: NO gallons Design flow: ZIA gallons/day Alarm present AIA Alarm level: �V4 Alarm In working order:Yea NotV4 Date of previous pumping: , A1,4 Comments: (condition of inlet tee, condition of alarm and float switches, etc.) Tight or hnlding tanks arc nr%+—gesent DISTRIBUTION BOX:/ (locate on site plan) Depth of liquid level above outlet Invert: o Comments: (note if level and distribution Is equal, evidenoe of solids carryover, evidence of leakage Into or out of box, etc.) — — Distribution box has two laterals N- -Aridence of solfals carry over, No evi denep of 1 Aaka a into-nr—alit of the hpii PUMP CHAMBER:&i✓ (locate on site plan) Pumps in working order:(Yes or No) /1 Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) PumA chamber is not p raar=nt revised 9/2/98 Page 8ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(cwklmsed) PropwwAddress: 329 Lakeshore Drive Marstons Mills,Mass. owner: Patricia Strong Date of inspection: 3/1 0/0 0 SOIL ABSORPTION SYSTEM(SAS)�--V/ (locals on sits plan,If possible;excavation not required,location may be approximated by non4ntruslve methods) If not located, explain: Type: > . leaching pits, number: +� leaching chambers,number: leaching galleries,number:= leaching trenches,number,length: leaching flelds, number, dimensions: overflow cesspool,number:_ Alternative system: w 1 e ive ( 78 Code ) Name of Technologyy:: Comments: (not@ condition of soil, signs of hydraulic failure,level of ponding, damp soil,condition of vegetation, etc.) Loamy sand to medium fine sand_ No si_gnc of h3AAran1in fa i l iira or =nndi ncg cn; 1 cz a-re—dxT.—V099t•aat J Q•R J 6—Her-FRal CESSPOOLS:Zve (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: LZ _ Indication of groundwater: Inflow(cesspool must be pumped as part of Inspectlon) � I ArPm n�i" p rcaone— Comments: (not@ condition of soil, signs of hydraulic failure.-level of ponding,condition of-vegetation, etc.) Cesspools are not crecant PRIVY: (locate on site plan) Materyals of conav�c on: �iq Dimensions: Depth of soAds: • Comments: (not@ condition of soil, signs of hydraulic fallurs,level of ponding, condition of vegetation;etc.) Privy i s nnf p racani- - - revised 9/2/98 Pallf9of11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C ` • SYSTEM INFORMATION(contirr»d) Prop-mAd&—: 329 Lakeshore Drive Marstons Mi11s,Mass. O`"""' Patricia Strong Dou of kispecdon: 3/1 0/0 0 SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two permanent reference landmarks or benchmarks locate all walls within 100' (locate where public water supply comes Into house) i I revised 9/2/98 Page 10of)) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 4 s PART C ' SYSTEM INFORMATION(cortdnued) PropwtyAddre":329 Lakeshore Drive Marstons Mills,Mass. Owner: Patricia Strong Date of Inspection: 3/1 0/0 0 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep _ SITE EXAM Slope Surface water Check Collar Shallow wells Estimated Depth to Groundwater 1!V/Feet Please indicate all the methods used to determine High Groundwater Elevation: _Obtained from Design Plans on record bserved Site(Abutting prop• y, observation hole,basement sump etc.) Determined from local conditlons Checked with local Board of health Checked FEMA Maps Checked pumping records _ZChecked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Used water contours map. Gahrety & Miller Model 12/16/94 '7 revised 9/2/98 Page 11of11 y.•r.rn rw -nlr�>—•n� rnrmr•nsenrs'TnrnRrrrn::�•rn11►f1/R+t*mn gerw fl/s�'7n�rtOT T71'97T 4�n�...t•.r-••t. A 'I'UNN OF Barnstable GUARD OF IIEALT11 II 0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CEfi'fIF1CATI0N I•••1••1•T".':' �T.11T.�.�1T{1S T111'1I.1S1TTifl.TiT7R1:r.5'1+,VfR't 71RfT-1��Af�l�Trt 7�.1. .:TrT•T•�• •�...1 -TYPE OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRESS 329 Lakeshore Drive Marstons Mills,Mass. ' ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME Patricia Strong PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & Svtt 'Inc. COMPANY ADDRESS Box 66 Centerville,Mass. 02632 Street Town or City state LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790-1578 R - 7TIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate, and omplete as of the time of .inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one ; System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection which I have con tcted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 3.10 CMR 15 . 303, and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature Date copy of this certification must be provided to the OWNER, the BUYER One where applicable ) and the 130ARD OF HEALVI. ..w * If the inspection FAILED, the owner or apoperator shall upgrade ' the system within one year of the date of the inspection, unless allowed or required otherwise as provided in 3.10 CMR 16 . 305 . partd .doc TOWN OF BARNSTABLE LOCATION S�IIl/� ��,�� SEWAGE # ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type)` /wo / (size) -YA NO.OF BEDROOMS BUILDER OR OWNER r PERMITDATE: 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 achi g Eac Feet Furnished by r� r LOC&.TION SEW&C,E PERMIT UO. VILLAGE IW5T LLER5 WE ADDRESS BUl DER 5 &MF— ADDRESS - - - - ��Let � — = - - - - - — MITE PERNAVT ISSUED DATE COMPLI &&ACE ISSUED : e �� _,_ _ � , �- �� '� E j ��, i -�� y �� '� ,.� I L.00QTION,: 5EWQGE PERMIT UO. L—L Lo v,- 0 vLu/2.�- ` VILLAGE • � � . " '?-.�:. � cs� — i IW -T LLE:R 'S WE ADDRESS 15UI DER 5 &"F— ADDRE 55 , ! 026 DATE PERIv.A T 155UED DATE COMPLM aCE ISSUED : m - _ THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTHY fig` OF......... .. ... ' .... .................. / a Allplira#ion -for Dig uittl Workii Ti mitrurlijan Vrrufil Application is.hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal ,« Sy tem at _ . ------- ----- ----- ------- Location•Address Lott,No. ------------------------------ g 1 .........Q� .--�---.-Aj...--- O er Address ------------- - - --------------------------------- .. . Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedroo 4.. ---_Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ._. ....._.. No. of persons.__________________________ hoovers (�. ) Cafeteria ( ) Q' Other fixtures ----------------------------- W Des'gn Flow___________________f� .............gallons per person per day. Total daily flow........................................ ... gallons. WSeptic Tank—Liquid capacity?r' _gallons Length---------------- Width................ Diameter__---- ......... Depth---__.-__._.... x Disposal Trench—No..................... Width-_-..._ Total I en h.................... Total leaching area--------------------sq. ft. Seepage Pit No........Z.......... Diameter_&d!@____.___. et__ .____ Total leaching a7_11/. ._.___________..sq. ft. z Other Distribution box (�-� Dosing tank ( 0 �� 7/ut' aPercolation Test Results Performed by--------------------------------------------------------------------------- Date--------------------------------t ... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water..._.-�_---. - �14 Test Pit No. 2________________minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------------ --------... -- �-r�.� _t - - ----- --- Description of Soil----- 1 4... 7------------- ------------*-----------------� --/.... @„�....--- !y?g+ ----- W ; ----------- ----••-------- ........ ------ ...... - ............. U Nat-ure of Repairs or Altei=ations—Answer when applicable-------------------------------------------------------------------._.-_-- __._..____.___-__--- Agreement: W The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article \1 of the State Sanitary Code— The undersigned further agrees not to lace the system in operation until a Certificate of Compliance haAbe issued by t boar lth. Sig ----- — . ,I IV ate _ ... Application Approved BY Z '� -- � -- ,r^'� � �%�e Date - Application Disapproved for the following reasons:---•...:..............•--... •-----------....._.....------•-------.....-------------------------------__.. ..................•--....-•----•---•-••--••-•----.... ................................................-----•--•----------------•------------------------------------------------------------------- / L/Date _J Permit No......................................................... Issued...--- 1--�'�--- ... J Date No._ .... 1 FEs... ................. .,l': THE COMMONWEALTH OF MASSACHUSETTS BOARD QF HEALTH _.. - ._-----OF......... .: Appliration -for Disposal Works Tomitrurtion Vrrniit Application is hereby made for a Permit to Construct ( ) or Repair (� Individual Sewage Disposal Location.-Address a?l j Iot No. ,/� Ovner /� Address p Installer Address Q Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedroo _r '. ...................Expansion Attic ( ) Garbage Grinder ( ) PP., . Other—Type of Building "«. Jw�......... No. of persons............................ Showers (Z — Cafeteria ( ) Q' Other fixtu es -------------------------------- Design Flow.......................................gallons per person per. day. Total daily flow---------------------------------------------gallons. k ,; 1:4 Septic Tank—Liquid capacity----.---_--.gallons Length............... Width................ Diameter................ Depth---------------- x Disposal Trench—No..................... Width............ _.• Total Ren h.................... Total leaching area.--._-_-.._-...__-_.sq. ft. Seepage Pit No........�1 ......... Diameter_! !�------- ept"-eVow nlet � p ,_- _..... Total leach1'ng are.------------------sq. ft. Z Other Distribution box (4�f" Dosing tank ( ) � • Percolation Test Results Performed bY.......................................................................... Date..................................,-.-.. Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water----A�_ ..------ G14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water__._-.-__._--_--_-_----. 04 Description of Soil_---_- / --- T�. "` ----- . -- -- ---------- ------------ • `r:; y� W ------------------------- ---- ---------------------------�' .... � ' ::.-. ----- =, l � -------------- 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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be n issued by tl.�e,�,boat-&-of-health. Signe, ��t _y�__•: � Q.=- ------------ �1_1� •--j-�-•-- ate Alication Approved B • -- --- ----• ••-- . ' • "- ---- - PP PP Y--- Date _ Application Disapproved for the following reasons: :_ _ -------------------- ----------"----------------------------"------------------------•----------•---------------••------------••-•--••--•-------•--•----•••---------...-------•-------•••--------------- Date PermitNo.......................................................... Issued............----•-----."-------------------------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH OF. .............................:......... ............ Trrtifiratr of Tlintpiiatta T I IS TO CE LFY 1 hat t�Ie Individual Sewage Disposal System constructed ( or Repaired ( ) ... by---.. s4kl .--••-•-•---•......•. 71 1I�staller A PP P !Z, -'t----------------- dated-�. ___c7n the has been Installed in accordance with the provisions of Article I of The State Sanitary Code as described I application for.Dis osal Works Construction Permit No______________ ��..•- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A SUACRANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........................... ............................................. Inspector•• ---•--"-•------"-----•-•---""-•-----------•-----------••........................ THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH r .7 . ...�YZsrM........OF..... .. .... .. ................. 1� No A ._. ..•.... FEE... ............. r1T r- �. Permis ion is by granted ----------- ------- to C str t ) or epatr ) Ind d 1 Sewage D> os System :--. / , l atNo. -- ----�....'. - ---- ------- r`" ---.. .. --- ----- •------- Street as shown on the application for Disposal Works Construction er t N:o. __✓'_ _____,- ed.. � f .................. oard of ealth DATE / // / FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS d/ o� r S J