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HomeMy WebLinkAbout0342 LAKE SHORE DRIVE - Health 342 Lake Shore Driver _ i Mars tons Mills 1 1 S� TOE Q�EARNST LE Lt?C14TI�I�I` � r °� G GIY SEWAGE,. LA - Gtl d"L A5SESSOR`StMAF;�&f.QT V3L IlVST 'S s'lAl►tE&PHOAIE i�'C3 ` `` A3.I.ER . SBPTZC TANK CAFACTfY �'' mmm LEACHING. ACIt;1Tlt ( ) Gt cM /S (sine) 5—Do s NO.-OFBEI3I�OOMS EUSI DER OR bWt R PEITDATE COl►�'I3ANCE DA1 Separation Dcstsnce Betwesl the Maxurtum Adjusted Groandwater Table to the Battomof Leaching Facility 1~eet Pn�rate Vflater Supply Well ands fiacility (zany webs eats€ od seta nc wtehtn Zt3t)feet "f leaching fac ity) t Edge;of Wet#and and Leaching#"�aatity(if ariy wetlands exist ' within 3Q0 fee 4eW a facility) t f G S Furzushed by: back 1� 3 0 A-1- o ' 6 -1- 3� '6`� A-a - 36 r T TOWN OF BARNSTABLE EG LOCATION �/� 1�' SEWAGE # -260,'7- JaA VILLAGE��S ASSESSOR'S MAP & LOT DD INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /3eo C.4 LEACHING FACILITY: (type) 9 dd Ci t CAo�,j 6y (size)'-// Y 3 9 ><e7 NO. OF BED;;;Ef BUILDER O lzraui/Z PERMITDATE: 7- COMPLIANCE DATE: Separation Distance Between the: 5 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 C�oti✓ C�9� G� w•--1.4 ��i2 �rar✓ '/, S 7(� �Q � �9, ��� y5� `Il ��'G S� c---- I. Commonwealth of Massachusetts /�-003 f �I Title 5 Official Inspection Form ' -II Subsurface Sewage Disposal System Form -Not for Voluntary Assessments A . s,✓ 342 Lake Shore Dr " Property Address Peter Duffy Owner Owner's Name information is / O? required for every Marstons Mills MA 02648 9-30-16 page. City/Town State Zip Code Date of Inspection r• S,tl Inspection results must be submitted on this form. Inspection forms may not be altered in arfg3 way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Ev tion by the Local Approving Authority 9-30-16 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3/13 < Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form, Subsurface Sewage Disposal System Form -Not.for Voluntary Assessments 342 Lake Shore Dr " Property Address Peter Duffy Ownerlo Owner's Name information is required for every Marstons Mills MA 02648 9-30-16 page. . City/Town State Zip Code Date of Inspection cy J; T- B. Certification (cont.) Inspection Summari Check A,B,C,D or E/always complete all of Section D A) System Passes: - ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. 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): r c... t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 342 Lake Shore Dr Property Address Peter Duffy Owner Owner's Name information is required for every Marstons Mills MA 02648 9-30-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber.pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out'or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced' ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): • f ❑ The system required pumpin g more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning.in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 _ Commonwealth of Massachusetts =1 Title 5 Official Inspection Form -A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. av 342 Lake Shore Dr Property Address Peter Duffy Owner Owner's Name information is required for every Marstons Mills MA 02648 9-30-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ` 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: , . . - ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within ` 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No".to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool `' ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I Commonwealth of Massachusetts as Title 5 Official Inspection' Form �q Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 342 Lake Shore Dr Property Address Peter Duffy Owner Owner's Name information is required for every Marstons Mills MA 02648 9-30-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ' Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- ' 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection ❑ ❑ Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 , Commonwealth of Massachusetts a=1 Title 5 Official Inspection Form 311A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 342 Lake Shore Dr Property Address Peter Duffy Owner Owner's Name information is required for every Marstons Mills MA 02648 9-30-16 page. CitylTown 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 y ® • ❑ 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? .0 ❑ Has the system received normal flows in the previous two week period? El ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ®: ❑ Was the site inspected for signs of break out? ®, ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 MR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 f Commonwealth of Massachusetts a=, Title 5 Official Inspection Form ' �,-1 Subsurface Sewage Disposal System Form Not for Voluntary Assessments t 'r" 342 Lake Shore Dr Property Address Peter Duffy Owner Owner's Name information is required for every Marstons Mills MA 02648 9-30-16 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (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: 9-2016 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts f0 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments p_Jt�Y 342 Lake Shore Dr Property Address Peter Duffy Owner Owner's Name information is required for every Marstons Mills MA 02648 9-30-16 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: Owner--pumped 6-2016 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: . gallons How was quantity pumped determined? Reason for pumping: Maintenance Type of System: Y ® 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form - I Subsurface Sewage Disposal System Form Not for Voluntary Assessments 342 Lake Shore Dr , t JY Property Address Peter Duffy Owner Owner's Name information is required for every Marstons Mills MA 02648 9-30-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2002 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 24"feet Material of construction: ❑ cast iron ® 40 PVC '❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank locate on site plan): p ( P ) Depth below grade: 16"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: 1500 gal Sludge depth: 4" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts �a=1 Title 5 Official Inspection Form i+ i41 Subsurface Sewage Disposal System Form Not for Voluntary Assessments e' 342 Lake Shore Dr Property Address Peter Duffy Owner Owner's Name information is required for every Marstons Mills MA 02648 9-30-16 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 28" Scum thickness . f. : 0 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 16" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet' Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum,to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Pill Title 5 Official Inspection , Form �i�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �.J! 342 Lake Shore Dr Property Address Peter Duffy Owner Owner's Name informations is required for every Marstons Mills MA 02648 9-30-16 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts al Title 5 Official Inspection Form x� f Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 342 Lake Shore Dr Property Address Peter Duffy Owner Owner's Name information is required for every Marstons Mills MA 02648 9-30-16 page_ City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present,must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from field. 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.): ' F * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form q Subsurface Sewage Disposal System Form -Not for Voluntary Assessments J� �_J3 342 Lake Shore Dr Property Address Peter Duffy Owner Owner's Name information is required for every Marstons Mills MA 02648 9-30-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4-500's ❑ 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.): Leach chambers in good working order and empty at inspection with stain line at 6" off bottom of chamber. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts .a Title 5 Official Inspection Form 11� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1!' 342 Lake Shore Dr Property Address Peter Duffy Owner Owner's Name information is required for every Marstons Mills MA 02648 9-30-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) - 1 - Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts k=1 Title 5 Official Inspection Fora A Subsurface Sewage Disposal System Form Not for Voluntary Assessments ` t.r4.✓ 342 Lake Shore Dr Property Address Peter Duffy Owner Owner's Name information is required for every Marstons Mills MA 02648 9-30-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) • I 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 C.- r C� f 36 6 ,01 r / r o , jail/^ •I)� (`TI t5ins•3113 . Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts as Title 5 Official Inspection Form f Subsurface Sewage Disposal System Form -Not for Voluntary Assessments J!% 342 Lake Shore Dr Property Address Peter Duffy Owner Owner's Name information is required for every Marstons Mills MA 02648 9-30-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) r Site Exam: . ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ 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: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 • � Commonwealth of Massachusetts 1 � Title 5 Official Inspection Form l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 342 Lake Shore Dr Property Address Peter Duffy Owner Owner's Name information is lVarstons Mills MA 02648 9-30-16 required for every - page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 No. 'ZN r Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZippYication for aigogar *potem Con6truction Permit Application for a Permit to Construct( )Repair( )Upgrade(v)Abandon( ) ❑Complete System 14ividual Components Location Address or Lot No. A Owner's Name,Address and Tel.No. Assessor's Ma /Pazcel AfOK57—M-9 Installer's Name,Address,and Tel.No. ® L Designer's Name,Address and Tel.No. aw4 7 7/-y'3 Type of Building: Dwelling No.of Bedrooms Y Lot Size Z® sq.ft. Garbage Grinder(/ � Other Type of Building 1°d)!lo.of Persons Showers( ).Cafeteria( ) Other Fixtures f��/ Design Flow. gallons per day. Calculated daily flow /! `Z� gallons. Plan Date D Number of sheets Revision Date Title S A-- d1a.11 O 3 41Z 1 Size of Septic Tank ®�9ZZ _Aej9 —.)j Type of S.A.S. D MI Description of Soil Nature of Repairs rAlterations(Answer when applicable) �/�L� �.d���� 1wD 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 t ' Board o ealytt _ Signed Date 711oll z Application Approved by Date Application Disapproved for the following reasons Permit No. - Date Issued i No. Xi� t '�f if+ -tag. _,,.y` r'f3 Fee COMMONWEALTH OF.MASSACHUSETTS Entered in computer: o Yes PUBLIC HEALTH DIVISION°-TOWN OF,BARNSTABLE, MASSACHUSETTS, . rfcatfon for t�pozdl *pgtem Congtruction Permit Application for a Permit to Construct( )R'e air U rade(/)Abandon ❑Complete System lo6ividual Components PP I ;1 P r ) pg ( ) P Y Po Location Address or Lot No. � / Owner's Name,Address and Tel.No. Assessor's.Map/Parcel r • Y S Installer's Name,Address,and.Tel.No. C`Designer's Name,Address and Tel.No. ,r -7'vi-073 Type of Building: Dwelling No.of Bedrooms_ Lot Size Z03?D sq.ft. Garbage Grinder(/�0 Other Type of Building i!5) e' omo.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow /419 gallons per day. Calculated daily flow `� `�� gallons. Plan Date // 0 Z Number of sheets / Revision/Date Title T%7� f' •S S/7�' 3 yZ 4'��5rt4/' •��1, Size of Septic Tank '10610,0�� ,�iY/5/Type of S.A.S. ` 5?7v 01el X e Ae,!9 Description of Soil G D'!l9 S Nature of e-Repairs r Alterations(Answer when applicable) x`/x`/lo cLG- 4 w 4P/0-, l ,c �`d P t ' 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 o ealtta. Signed 7 Sn{ �' Date Application Approved by e e �. Y_ Date /to # �--; Application Disapproved for the following reasons JJ Permit No. cDL_0_1�5 _7An Date Issued /I THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliatire THIS IS TO CE4TIFY,that the O -site S wage Disposal System Constructed( )Repaired( )Upgraded(4--l") Abandoned )by D!at 3 q Z [.,�� e S 0/ l• f f`SrO!/$ i as been constructed,in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. Y -"Z_4�2 dated _�/11n A(1 Installer Designer The issuance o s pe it shall not be construed as a guarantee that the sys ill fu ct* as jigjd:, Date V. !(7 Inspector �'W C ! V � --------------------------------------- No. FeeV THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mtgaal bpgtem Congtrurtton Permit Permission is hereby granted to Cons ctSS )Repair )Upgrade(✓)Abandon( ) System located at y Z / _Z 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 fbe completed within three years of the date of this p- t. Date: ! l� /�� Approved by G � \� , S TOWN OF BARNSTABLE cc, • LOCATION 44&:�4w D& SEWAGE # eg6Q, 30� VILLAGE S ASSESSOR'S MAP & LOT 011'' DD INSTALLER'S NAME&PHONE NO. osT��o�i SEPTIC TANK CAPACITY /rao C�4 LEACHING FACILITY: (type) 32d 6.t CAM �� (size) X 3, X� NO:OF BEDROO S r BUILDER O OWNER Irrya,lZ PERMITDA COMPLIANCE DATE: Separation Distance Between the: i 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 Tacility (If any wetlands exist Feet within 300 feet of leaching facility) Furnished by (7oti� C�� .u •-rr�� I , k — r rTLE 0. 00 L -'I IJ_ H1i L. Jc� . . .,II . JS 5r5ro; INOTICE: This Form Is To Be Used For the Repair Of Failed i Septic Systems Onlv. PERCOLATION TEST AND SOIL EVALUATION EXEMPTION F'ORNI �j�, hereby certify that the engineered plan signed by me dated G t oz , concerning the property located at meets all elf the Following criteria: * This frilled system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. i The soil is classified as CLASS I and the percolation rate is less than or equal to S minutes per inch. The applicant may use historical data to conclude this fact or may conduct preliminary tests at the site without a health agent present. There is no increase in ifow and/or change in use proposed ® There are no variances requested or needed. I 0 The bottom of the proposed leaching facility will not be located less than fourteen (14).feet above the maximum adjusted groundwater table elevation. LAdjust the groundwater table using the Frimptor method when applicable] Please complete the following;: A) Top of Glt)und Surface Elevation (using GIS information) B). G,W. Elevation + adjustment for high G.W. _ DIFFERENCE BETWEEN A Lind 13 -40 SIGN ED : DATE: 61— 0 2 -- NOTICE Based upon the above information, a repair permit will he issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered peptic system plans y:lw.dtn Folder.IMCCimp V Commonwealth of Massachusetts ` Title 5 Official Inspection For Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 342 LAKESHORE DR. Property Address Owner C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, CENTERVILLE, MA, 02632 information is Owner's Name required for MARSTONS MILLS every page. City/Town MA 02648 _ 10/10/07 State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the d 6 � computer,use 1. Inspector: t only the tab key to move your Michael DeDecko 1 =� cursor-do not use the return Name of Inspector ` key. Compass Realty Development Corparation Company Name '-7,E r� P.O. Box 2384 Company Address I -' Mashpee i u Ma i 02649 r---- t fe"0A Cltylrown e= 508-221-5003 State Zip Cod Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 1V. 10/10/07 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This.report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 342 LAKESHORE DR•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15 commonwealth of Massachusetts Title 5 Official Inspection Subsurface Sewagep tion Form Disposal System Form -Not for Voluntary Assessments �M 342 LAKESHORE DR. Property Address Owner C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, CENTERVILLE, MA, 02632 information is Owner's Name required for MARSTONS MILLS MA every page. Utyrrown 02648 10/10/07 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: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,:upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltratipo or exfiltration or tank failure is imminent. System will pass inspection if the existing tank 14 replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspecUop if it Is structurally sound, not leaking and if a Certificate of Compliance indicating that the jSnis Iq less than 20 years old is available. ND Explain: ❑ Observation of sewage bpCkup or f ttrpak but or high static water level in the distribution box due to broken or obstructed pip. ip pf broken, settled or uneven distribution box. System will pass inspection if(with app�ptp)Af ► of Health): ❑ broken pipe(s) are rq ❑ obstruction is removed 342 LAKESHORE DR•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts M Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 342 LAKESHORE DR. Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, CENTERVILLE, MA, 02632 Owner Owner's Name information is MARSTONS MILLS required for MA 02648 10/10/07 every page. Clty/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 342 LAKESHORE DR•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 342 LAKESHORE DR. Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, CENTERVILLE, MA, 02632 Owner Owner's Name information is required for MARSTONS MILLS MA 02648 10/10/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/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. 342 LAKESHORE DR•108/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 342 LAKESHORE DR. Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, CENTERVILLE, MA, 02632 Owner Owner's Name information is required for MARSTONS MILLS MA 02648 10/10/07 every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection x Area—IWPA) or a mapped Zone 11 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. 342 LAKESHORE DR•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 342 LAKESHORE DR. Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, CENTERVILLE, MA, 02632 Owner Owner's Name information is required for MARSTONS MILLS MA 02648 10/10/07 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? ® ❑ 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 f® ❑ y g p or 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)] 342 LAKESHORE DR•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 342 LAKESHORE DR. Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, CENTERVILLE, MA, 02632 Owner Owner's Name information is required for MARSTONS MILLS MA 02648 10/10/07 every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d N/A 9 ( Y 9 (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: N/A 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: Last date of occupancy/use: Date Other(describe): 342 LAKESHORE DR 08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth & Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 342 LAKESHORE DR. Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, CENTERVILLE, MA, 02632 Owner Owner's Name information is required for MARSTONS MILLS MA 02648 10/10/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: repaired 2002 Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 342 LAKESHORE DR•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 342 LAKESHORE DR. Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, CENTERVILLE, MA, 02632 Owner Owner's Name information is required for MARSTONS MILLS MA 02648 10/10/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2'feet Material of construction: _ ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): JOINTS TIGHT,YES VENTED,NO LEAKAGE. 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 gal Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle 31" 1 Scum thickness Distance from top of scum to top of outlet tee or baffle 11 Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? MEASURED 342 LAKESHORE DR-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 342 LAKESHORE DR. Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, CENTERVILLE, MA, 02632 Owner Owner's Name information is required for MARSTONS MILLS MA 02648 10/10/07 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): NO NEED TO PUMP, TEE'S INTACT,STRUCTALLY SOUND, LIQUID LEVEL EQUAL WITH OUTLET INVERT, NO LEAKAGE, Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): 342 LAKESHORE DR•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 i -Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 342 LAKESHORE DR. Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, CENTERVILLE, MA, 02632 Owner Owner's Name information s required for MARSTONS MILLS MA 02648 10/10/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert EQUAL WITH 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.): D-BOX IS LEVEL AND DISTRIBUTION EQUAL, YES SOLID CARRYOVER, NO LEAKAGE. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 342 LAKESHORE DR•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 342 LAKESHORE DR. Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, CENTERVILLE, MA, 02632 Owner Owner's Name information is required for MARSTONS MILLS MA 02648 10/10/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 4/500 GAL ❑ 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.): SOIL-GRAVEL/SAND, NO SIGNS OF HYDRAULIC FAILURE, PONDING DRY,NO DAMP SOIL, VEGETATION - NORMAL. 342 LAKESHORE OR 08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 -Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 342 LAKESHORE DR. Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, CENTERVILLE, MA, 02632 Owner Owner's Name information is required for MARSTONS MILLS MA 02648 10/10/07 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 3 Z- �( 2 :56 Ifs 342 LAKESHORE DR-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 -Commonwealth of Massachusetts Title 5 Official Inspection Form JSubsurface Sewage Disposal System Form - Not for Voluntary Assessments ' M 342 LAKESHORE DR. Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, CENTERVILLE, MA, 02632 Owner Owner's Name information is required for MARSTONS MILLS MA 02648 10/10/07 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privylocate on site plan): ( p ) Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 342 LAKESHORE DR 08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 -Commonwealth of Massachusetts _ Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 342 LAKESHORE DR. Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, CENTERVILLE, MA, 02632 Owner Owner's Name information is required for MARSTONS MILLS MA 02648 10/10/07 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 ground water: 107' 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: BARNSTABLE GIS You must describe how you established the high ground water elevation: BARNSTABLE GIS 342 LAKESHORE DR•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Town of Barnstable y�4pF 1HE Regulatory Services EAMSTABLE, Thomas F. Geiler, Director 9� 1639. ••� Public Health .Division AtfDMP•(A Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-8624644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor(foes this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the "Disposal `'York Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. Fimic ........... THE COMMONWEALTH OF MASSACHUSETTS BOARD ZO - HEA 1,11-3 y * .�pp1uatiun for Uiiposal Works Cnomitrurtion runfil Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Sy temIt at - Location-Address - �- .. ................................................... ----- ---•----------------- ! ..... Ow r /��• � Add ss ---------------------------------- -`fix Etj,Lc --- ......... t'?S-.�i__ ............... Installer !/ `/ ddress UType of Building Size Lot.40 f.-y'Z .....Sq. feet U Dwelling—No. of Bedrooms............... ........................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures --------------- •----•-----•--•------•----•-- W Design F?ow_______-_•-.$7�•________________________gallons per person per day. Total daily flow.........:!k�pQ-----------------------gallons. W Septic Tank Liquid Liquid capacity/Zo e.gallons Length................ Width---------------- Diameter---------------- Depth---------------- x Disposal Trench—No..................... Width-------------------- Total Length...................... Total leaching area....................sq. ft. Seepage Pit No_____ ___________ Diameter---APB 0--- Depth below inlet:<!� �...... Total leaching area..G!K,...sq. ft. Z Other Distribution box ( ) Dosing tank Percolation Test Results Performed by.................... ..................................................... Date---------------------------------------- 1.4 Test Pit No. 1................minutes per inch Depth of Test.Pit.................... Depth to ground water_______________________. (� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ --- ---------P - - Description of Soil-------- .....------. ���---- ---- - �. x V --------•--------•--•-•-•-------------------------------•--•------------------------••---------•--- W ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ U Nature of Repairs or Alterations—Answer when applicable-----------------------------------------.----------------------------------------------------.. ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Agreemer t: 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 !b: en issued by oard of health. Si e --•-• -----------•-----------•--------•--- ,del — 7.�:.-- � - Date Application Approved By... '' tw' �=--. "a�,/' Hate Application Disapproved for the following reasons-------------............. ------ ........................................................................... --.-------•--•--•----•------•--•--•---•-•-------------------•-•-••-------•------------------•---------------•---------•-•---•-------••------•-----------------------------•-----------•-•-•----•------•- Date Permit No. - Issued. -7 00' ate -------------J ivo..-- -g FFX ..'2.:.................. THE COMMONWEALTH OF MASSACHUSETTS " BOARD O HEALT Wi ..OF t---... ........ ., ...��-��.---•----� . ... .-• . Appliration for Utsp iial WorkS Tomitrur#inn Pumi# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal S S -/ ---- --._G%!!1-GY=Gc7/J-_ ..... F.sce ... ovation-Address r of No. ...... al.... ---- --- --- ----------------------------------- Lx ` _.uc t�. .__---•-------- /y� ner �fA� dress ............................. lLY .__Y ..... Installer►-1 ............................... Installer Address UType of Building ,/� Size Lot............................Sq. feet /—I Dwelling—No. of Bedrooms.............Y:__-_.._-__-________-__-___-Expansion Attic ( ) Garbage Grinder ( ) 04 Other—T e of Building _______---- No. of persons____________________________ Showers — Cafeteria P-I Other fixtures ...................................................... Design Flow................4-10.....................gallons per person per day. Total daily flow.............. 0?.6---------------------gallons. WSeptic Tank—Liquid capacity?P ngallons Length---------------- Width--"------------- Diameter---------------- Dept]l"-.__-___-_----- x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.____-_�__--__- Diameter...lOb ._ Depth below inlet.... �a....... Total leaching area_.6-_�_�----sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date---------------------------------------- a Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water.................... Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water-__.-_______--__-__-._-_- D Description of Soil______-•__•-.___I_----______ �___._______ °'� V ---------------------------------------•-- ------------------------------------------------------------------------------------------._...---- UW -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 ben issued by-the board of health. ,f Date _. Application Approved BY=''-A4 ..r p -✓ ate Application Disapproved for the following reasons:.......................... -------------------------------------------•-•-•-••------------------- -•---•-•-•--•-----•-•--•------•---•-----••---------•----•-------•---•-•....................••-----------------------•---•--•-----......------------------------•--------•--••--•-----------------•-•--•- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................oF........ ....---................ , . _ . t"Err#ifutt#r of TILImpliana THIS IS TO CEP ,IFY, That the Individua ewage Disposal System constructed ( or Repaired ( ) b --•------------------------------ - Y ----------- -----------------------------•-------- d I staller ;_ -------- ----- has been installed in accordance with the provisions of Artticle XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.....;3-l..4 ........................ dated-------/,2 j9/12 --____-_-_-•••---- ii THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL U ON SATISFACTORY. . DATE----•-----•- - - - ------- ------ 7.7.................... Inspector---------do...--- -------- "--- ----------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...............of ............................... ' 1r.� No.... . ---------- FEE-••--- ......... l larks C #rr#i �trrnti# ---------------------? , Permission is hereby granted-- ______�.:_-C f{ ________. t "`� t ...................... to Construct ( ., or Repair ( ) an Individual Sewage Disposal System ; at No..... - �Gp f r -•-- ,__ �---`- F " --'- 'f --- ---- __._____ a- ._:><f_______mil�'._.c_� n..____1,.J :':p��F �-,,._. -- ----.�_-____. _ __ ._.� �� ___ i . t '- . Street / - % as shown on the application for Disposal Works Construction Permit No l tc t r___•__. Dated r / . !� ;'? Board of Health DATE----------- ---- -n -_...._j--••------•--------•--- r FORM 1255 HOBBS & WARREN:. INC.. PUBLISHERS SYSTEM PROFILE TEST HOLE LOGS TOP FNDN. A t EL. 101.4' ACCESS COVER TO WITHIN 6' OF FIN. GRADE (NOT TO SCALE) r ACCESS COVER (WATERTIGHT) TO ENGINEER: AH OJALA, PE 100.4' MINIMUM .75' OF COVER OVER PRECAST / WITHIN 6' OF FIN. GRADE 2% SLOPE REQUIRED OVER SYSTEM 100.0 WITNESS: NONE I 2' DOUBLE WASHED PEASTONE RUN PIPE LEVEL DATE: 6�/26/02 { M�,GGSROPp �SpN - - FOR FIRST 2' 3' MAX. PERC. RATE = < 2 MIN INCH p5P EXISTING 1000 LOCUS GALLON SEPTIC 98.0' (TEE / 97.23' CLASS I SOILS P# TANK CH- 10 ) GAS 96.83' CO Cl F--1 E� ED ED 4 CI721 $APPLE 97.0' cacso 0 96.4' [`� [] (� Cl © [� [� [� °'`� 3' AT SIDES r MIN m 0 ED Cl O C3 E� CO m 2.5' T ENDS ELEV. V_. a2� (_ % SLOPE) 6' CRUSHED STONE OR MECHANICAL `,o, 2 0 0 0 Cl 0 Cl 0 0 � � 94.4, O A $ COMPACTION. (15.221 [2]) MIN `' g' DEPTH OF FLOW = 4_ 1 ( 9 % SLOPE) ( % SLOPE) 3/4' TO 1 1/2' DOUBLE WASHED ST 7NE SL -� TEE SIZES --- 8„ 1OYR 3/1 a INLET DEPTH =10" PROVIDE SUITABLE TEES AND OUTLET DEPTH = 14' GAS BAFFLE AS'NECESSARY B LOCATION MAP NTS SILT LOAM FOUNDATION- 13' SEPTIC TANK 11' D' BOX 13' LEACH'NG 1OYR 4/6 ASSESSORS MAP 14 PARCEL 3 _ FACILITY 5' 30' 97.4' C1 MED/COS 60" 10YR 4/4 + 99.7 89.4' 4. 100.2 C2 f j MED/cos - - / 2.5Y 6/4 d I + 99.8 00 126" 89.4 -% + 10.E NO WATER ENCOUNTERED NOTES (:7 121 t?� SEPTIC DESIGN: (GARBAGE DISPOSER IS NU" i /1LLk_1ivL V ) t' T .. S i •• i" + 1 0.2 DESIGN FLOW: A_ BEDROOMS (110 GPD) = A Q_G?D 2. MUNICIPAL WATER IS EXISTING + 99.8 L-P 95 USE A 440 GPD DESIGN FLOW 3. MINIMUM PIPE PITCH TO BE 1/8' PER DOT. 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO H- 10. i SEPTIC TANK: 440 GPD ( 2 = 880 TOWN WATER � T T MA WATERTIGHT. 1 P ...JOINTS ❑ BE DE S. PI ❑ LOT 11 '� `'�. USE A NIN. 1000 GAL. SEPTIC TANK 20,320� SQ. FT 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. TH + 99,9- LEACHING: - ENVIRONMENTAL CODE TITLE V. /- + .a o2(39 + 10.83) 2 (.74) 147 7. THIS FLAN IS FOR PROPOSED SEPTIC SYSTEM ONLY AND IS NOT / EXIST. ST --___, �p SIDES: - TO BE USED FOR ANY DTKER PURPOSE. + .6 + 100.6 BOTTOM: 39 x 10.83 (.74) - 312.5 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4' PVC. i� / +.roo9^\ 62160 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT TOTAL: S.F.F GPD INSPECTI❑N BY BOARD OF HEALTH AND PERMISSION OBTAINED PATIO \ 101.4 USE 4) 500 GAL. LEACHING CHAMBERS ACME OR �_ .� FROM BOARD OF HEALTH. + 9 :9 \ EXISTING 100.7 0o EQUAL) WITH 3' STONE AT SIDE AND 2.5' AT ENDS 10, PUMP & REMOVE (OR FILL W/CLEAN SAND) FAILED LEACH PIT +,99.8 DWELLING TOP FNDN = 101.4' CONFIRM EXIST. TANK AT 1000 GAL. MINIMUM CAPACITY 101.0 REPLACE WITH 1500 GAL. IF EXISTING IS LESS THAN 1000 GAL. SEPTIC TANK \ loosPL T. LEGEND _ OF I 101. 100.0 PROPOSED SPOT ELEVATION �� , 4 A SHORE DRIVE I \ 100.2 `\ W + 100.E 3 L LAKE \�° 100x0 EXISTING SPOT ELEVATION IN THE TOWN OF: °� ©o \\ \\ 00 I PROPOSED CONTOUR � ( MARSTONS MILLS) BARNSTABLE o_ \ PREPARED FOR: BORTOLOTTI CONSTRUCTION/KRAVITZ 100 EXISTING CONTOUR \ \\ \ S �,� �°j 20 0 20 40 60 TOWN WATER \\.4_ 00.0 \ \\ �+0�00 ,2 / �,/tom®�99.1 BOARD OF HEALTH / APPROVED DATE I MA SCALE: 1., T 20' DATE: JUNE 17, 2002 _ 99.4 off 508-362-4541 \ / fax 50A 362-98W 4-99.6 pengineering, 9 e en ;rs.H ar q; i rsr tirly� \ �i BENCH MARK - CTR. OF Cg6lWn co ineer n9, inc. / o BASIN. ELEVATION = 99.1 (A SMD) y�?� A R N H. CIVIL ENI JEERS °J�`�' �� C �v�LA O(?+ No.! AN SURV _ YORS .;;��s2 No y 0.4 LN0 939 vain st. yarrlout 1a 02675 � JALA, `., I .L.S. ATE 02 134 4-1199.9 i