HomeMy WebLinkAbout0237 MOCKINGBIRD LANE - Health �C237 Mockingbird Lane
Marstons Mills P
A = 029 018
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART'A
CERTIFICATION
Property Address: 237 Mockingbird Lane
Marston Mills:MA 02648
Owner's Name: Kathy Harrington
Owner's Address:
Date of Inspection: April 13, 2006
Name of Inspector: (Please Print) James M. Ford
Company Name: James M.Ford !
Mailing Address: P.O.Box 49.
Osterville,MA 02655-0049
Telephone Number: (508)862-9400 ? :'
CERTIFICATION STATEMENT , w
I certify that I have personally inspected the sewage'disposal system at this address and that thecmformation_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 amea)DEP=
I
approved:system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: r, 2
✓ Passes
Conditionally Passes
Nee urther Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: April 13, 2006
The system inspector shallu 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.
Notes and Comments Original Leach Pit is under the shed and newer Leach Pit is Partly under the Fish pond.
**"This report only describes conditions at the time of inspection,and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page I
,
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 237 Mockingbird Lane
Marston Mills. MA
Owner: Kathy Harrinjzton
Date of Inspection: April 13, 2006
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
15.363 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 infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if.(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
.ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 237 Mockingbird Lane
Marston Mills. MA
Owner: Kathy Harrington
Date of Inspection: April 13, 2006
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.
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 and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 237 Mockin bird Lane
Marston Mills, MA
Owner: Kathy Harrington
Date of Inspection: April 13, 2006
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z dayflow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_ ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well.
✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either."yes"or"no"to each of the following:
(The following criteria apply to large systems in addition.to the criteria above)
Yes No
the.system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone 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.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 237 Mockingbird Lane
Marston Mills, MA
Owner: _ Kathy Harrington
Date of Inspection: April 13, 2006
Check if the following have been done: You must indicate"yes"or"no"as to each of the following:
Yes No
✓ Pumping information was provided by the owner,occupant,or Board of Health
_ ✓ Were any of the system components pumped out in the previous two weeks?
✓ _ Has the system received normal flows in the previous two week period? .
✓ Have large volumes of water been introduced to the system recently or as part of this inspection?
✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?.
✓ _ Was the site inspected for signs of break out?
✓ _ Were all system.components,excluding the SAS,located on site?
✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,.depth of sludge and depth of scum?
✓ — Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
✓ _ 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(3)(b)].
5
Page 6 of 1.1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 237 Mockingbird Lane
Marston Mills. AM
Owner: Kathy Harrington
Date of Inspection: April 13, 2006
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: 3
Does residence have a garbage grinder(yes or no): Yes
Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings,if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occuvied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): apd
Basis of design flow(seats/persons/sgft,etc):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Pumped in 2004 per owner
Was system pumped as part of the inspection(yes.or no): No
If yes,volume pumped: _gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records,if any)
Innovative/Alternative technology.,Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
original
g nal to 1983 pit was added in 1997-per as-built
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 237 Mockingbird Lane
Marston Mills MA
Owner: Kathy Harrington
Date of Inspection: April 13, 2006
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron 40 PVC other(explain):
Distance from private water supply well or suction line
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TA 'NK: v (locate on site plan)
Depth below grade: 1-5
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 gal.
Sludge depth: 2"
Distance from top.of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 8"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 10"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet.invert,evidence of leakage,etc.):
Tees were present. The liquid level was even with the outlet invert There did not appear to be any signs of leakage
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal —fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top.of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert, evidence of leakage,etc.):
' 7
Page.8 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 237 Mockingbird Lane
_ Marston Mills ,MA
Owner: _ Kathy Harrington
Date of Inspection: April 13, 2006
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened).(locate on site plan)
)
Depth of liquid level above outlet invert: Even
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.):
No solids were present
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.)-
8
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 237 Mockingbird Lane
Marston Mills. AM
Owner: Kathy Harrin-aton
Date of Inspection: April 13, 2006
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 2-6'x 6''0000 gal.) 2'stone per info
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
Innovative/alternative system Type/name of technology:
Commments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
The original leach pit#3 was under the shed and used camera to inspect The newer pit#4 was partly under the ash pond and
had]'of water on the bottom The scum line was approxunately Y up from the bottom There did not appear to be any signs of
failure. The bottom to trade was approximately 9 5'
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: None (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM.INFORMATION(continued)
Property Address: 237 Mockingbird Lane
Marston Mills. MA
Owner: Kathy Harrington
Date of Inspection: April 13, 2006
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.
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10
• . Page I I of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 237 Mockingbird.Lane
Marston Mills.MA
Owner: Kathy Harrin¢ton
Date of Inspection: April 13, 2006
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to gro-.ind water 50+/- feet
Please indicate(check)all methods.used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed,
Observed site.(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours mans
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using Barnstable topographic and water contours maps the snaps were showing approximately 50'+1-to ground water at this
site.
This report has been prepared only for the septic system and components described.herein. This septic system has been
inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will
function properly in the future. There have been no warranties or guarantees, either expressed,written or implied,
relating to the septic system, the inspection, this report and/or any components of the septic system which have not
been located and inspected
11
f
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
MAP
PARCEL, ; O 1
LOT 1'6u= ,
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 237 Mockingbird Lane
Marstons Mills
Owner's Name: Mark&Carol Baker
Owner's Address: ��(;Eo��
Date of Inspection: 8/14/2003 % 5 2003
p�G
Name of Inspector: (please print) Kevin J.Sullivan HEA 5pRNSTABLE
Company Name: Ready Rooter GOWN ITN oEpT.
Mailing Address: P.O.Box 371
Sandwich,MA 02563
Telephone Number: (508)888-6055
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(310 CMR 15.000). The System:
asses
Conditionally Passes
Needs Further Evaluation by the Local Authority
Fails
Inspector's Signature: Date: 3
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.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Page 2 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 237 Mockingbird Lane
Marstons Mills
Owner: Mark&Carol Baker
Date of Inspection: 8/14/2003
Inspection Summary:Check A,B,C,D or E/ALWAYS complete all of Section D
C. 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 Zreta
ontional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement r,as approved by the Board of Health,will pass.
Answer yes,no or not determined (Y,N,ND)in the the following statements.If"not determined"please
explain.
The septic tank is metal and over 20 years old'* the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltratio or tank failure is imminent.System will pass inspection ifthe
existing tank is replaced with a complying septic as approved by the Board of Health.
*A metal septic tank will pass inspection if it is Ily sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old i vailable.
ND explain:
Observation of sewage backup orb out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settl or uneven distribution box.System will pass inspection if(with
approval of Board of Health):
roken pipes)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumpi more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM_INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 237 Mockingbird Lane
Marstons Mills
Owner: Mark&Carol Baker
Date of Inspection: 8/14/2003
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the 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 determi in accordance with 310 CMR 15.303(l)(b)that the
system is not functioning in a manner which w' protect public health,safety and the environment:
_Cesspool or privy is within 50 feet of a s water
—Cesspool or privy is within 50 feet of a dering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water S pplier,if any)determines that the
system is functioning in a manner that protects the public health,sat and environment:
_The system has a septic tank and soil absorption system(SA 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 in a Zone 1 of a public water supply.
—The system has a septic tank and SAS and the SAS. within 50 feet of a private water supply well.
The system has a septic tank and SAS and the S is less than 100 feet but 50 feet or more from a
private water supply welly*. Method used to d e distance
"This system passes if the well water analysis, rformed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitr en is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the anal y s must be attached to this form.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 237 Mockingbird Lane
Marstons Mills
Owner: Mark&Carol Baker
Date of Inspection: 8/14/2003
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_,Z 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
— -Z'Static liquid level in the distribution box above outlet invert due to and overloaded or clogged SAS or
cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less than %z day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
_ - Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
_ Any portion of a cesspool or privy is 50 feet of a private water supply well.
_ 7ZAny portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
rQQ (Yes/No)The system fails. I have determined that one or more of the above 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 a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to criteria above)
yes no
_ the system is within 400 feet of a surface d ' ' g water supply
— the system is within 200 feet of a tributary a surface drinking water supply
the system is located in a nitrogen sensi ve area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone U of a public water supply well
If you have answered"yes"to any question' Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system as failed.The owner or operator of any large system considered a
significant threat under Section E or fail under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should con the appropriate regional office of the Department.
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 237 Mockingbird Lane
Marstons Mills
Owner: Mark&Carol Baker
Date of Inspection: 8/14/2003
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
Pumping information was provided by the owner,occupant,or Board of Health
,Were any of the system components pumped out in the previous two weeks?
Has the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of this inspection?
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
Were all system components,excluding the SAS,located on site?
Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the battles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
__Z_ Was the facility owner(and occupants if different than owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
Existing information.For example,a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)]
Page 6 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 237 Mockingbird Lane
Marstons Mills
Owner: Mark&Carol Baker
Date of Inspection: 8/14/2003
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): L4 Number of bedrooms(actual):_ 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):_qjp 6,P.t�".
Number of current residents:—4L_
Does residence have a garbage grinder(yes or no): `Ccs,
Is laundry on a separate sewage system(yes or no):A-"b[if yes separate inspection required]
Laundry system inspected(yes or no):—
Seasonal use:(yes or no):.Ajcj
Water meter readings,if available(last 2 years usage(gpd)):_Qg c.:�,k 7,Q 6.
Sump Pump(yes or no):
Last date of occupancy:
COMMERCIAU/INDUSTRIAL
Type of establishment:
Design flow(based on 310 Xpresemator
Basis of design flow(seats/p
Grease trap present(yes or
Industrial waste holding tanr no):—Non-sanitary waste discharg system(yes or no):Water meter readings,if av
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: „�...,r— _ `,�,�� �7 ; 3 rz, ^ r S.
Was system pumped as part of the inspection(yes or no):jn2c:D
If yes,volume pumped: — gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
-,Zfeptic 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:
Were sewage odors detected when arriving at the site(yes or no): d0:7
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 237 Mockingbird Lane
Marstons Mills
Owner: Mark&Carol Baker
Date of Inspection: 8/14/2003
BUILDING SEWER(locate on site plan)
Depth below grade: 42� /7
Materials of construction:_cast iron-\,A PVC other(explain):
Distance from private water supply well or suction line: 1?/
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:'Zoocate on site plan)
Depth below grade: %'/ toco„ /
Material of construction: ncrete_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:
Sludge depth:
Distance from the top of sludge to bottom of outlet tee or baffle:
Scum thickness: "1 -0
Distance from top of scum to top of outlet tee or baffle: ,•
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined: 1 wa aft-- yV"%zfsA6ca ,-
Comments(on pumping recommendations;inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
.
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construction: concrete m _fiberglass___polyethylene other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outl t tee or baffle:
Distance from bottom of scum to botto of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommen tions,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence f leakage,etc.):
f
Page 8 of l I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 237 Mockingbird Lane
Marstons Mills
Owner: Mark&Carol Baker
Date of Inspection: 8/14/2003
TIGHT or HOLDING TANK: (tank must be pum at time of inspectionxlocate on site plan)
Depth below grade:
Material of construction:_concrete metal glass__polyethylene_other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallon ay
Alarm present(yes or no):
Alarm level: Alarm in wo mg order(yes or no):
Date of last pumping:
Comments(condition of alarm d float switches,etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:_Cn!
Comments(not if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
k -
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber ndition of pumps and appurtenances,etc.):
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 237 Mockingbird Lane
Marstons Mills
Owner: Mark&Carol Baker
Date of Inspection: 8/14/2003
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number: '':;L
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.):
CESSPOOLS: (cesspool must be p ped 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 in w(yes or no):
Comments(note condition 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,sign of hydraulic failure,level of ponding,condition of vegetation,etc.):
i
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 237 Mockingbird Lane
Marstons Mills
Owner: Mark&Carol Baker
Date of Inspection: 8/14/2003
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.
C
3
F3
0 1-
° tZ3
Page 11 of 11
' a
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 237 Mockingbird Lane
Marstons Mills
Owner: Mark&Carol Baker
Date of Inspection: 8/14/2003
SITE EXAM
Slope
Surface water
Check cellar.
Shallow wells
Estimated depth to ground water'_�feet
Please indicate(check)all methods used to determine the high ground water elevation:
V"Obtained from system design plans on record—If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with the local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You mast describe how you established the high ground water elevation:
` TOWN OF BARNSTABLE
LOCATIONpZJ I �1�10Lk1,AT6ir2 /4At SEWAGE# Cn' 1,
VILLAGE_ M. r/V IJJ S ASSESSOR'S MAP&PARCEL CJa-�'j � d/F
INSTALLERS NAME&PHONE NO.
SEPTIC TANK CAPACITY Cf ZJ'Un
F EACHING FACILITY:(type) a. I_i-r5 (size) a�AL
(INO.OF BEDROOMS y
OWNER -�A����c'T'a�
PERMIT DATE: 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 leaching facility) Feet
FURNISHED BY p,., �, Fp/l
1
roo-� IIi�,
t �C
1
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y a3 W7
O a
a 33 3�
o s 3 417 S3
s�-
TOWN OF � G
I T!, /
r J7 ®C �f?G 7NSTABLE
SEWAGE #
LG i �►' tri+T
\/)F.LAGE / /; �`o/�./`l�� 5 ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY /0®y
dUCHING FACILITY: (type) (size) 06
NO.OF BEDROOMS
BUILDER ORPWNNgV
PERMIT DATE: `— —�7 COMPLIANCE DATE: / 2_
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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
a
r
��
1
4
��
�"'
��
TOWN OF STABLE
LOCATION
7 ��C / i/ � SEWAGE # 9 T l?
VII,LAGEr2/`��5/`�i�5 ASSESSOR'S MAP & LOT�Z��O���
INSTALLER'S NAME&PHONE NO. G0//
SEPTIC TANK CAPACITY /0_0
[6
LEACHING FACILITY: (type) / S (size) /O U
NO.OF BEDROOMS
BUILDER OR /CAI^
PERMIT DATE: E7 COMPLIANCE DATE: l
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
M site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist Feet
within 300 feet of leaching facility)
Furnished by
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No. �� /�°.S A Fee-6
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
2pplication for 33topooar *p6tem Cottgtruction Permit
Application is hereby made for a Permit to Construct( )or Repair an On-site Sewage Disposal System at:
Location Address or Lot No. Z 37 Aftz �,W- Owner's Name,e,,°Addres annTTeel.No.
Assessor's Map/Parcel �� /� �/ Ill��'-_ � "
Installer' Name,Addres ,and Tel.No. Designer's Name,Address and Tel.No.
j� i
7 >!- ?3Yf
Type of Building:
Dwelling No.of Bedrooms Garbage Grinder(-to
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow /!C) gallons per day. Calculated daily flow gallons.
Plan Date / — 3 Number of sheets Z11 Revision Date
Title
Description of Soil
Nature of R vairs or Alterations(Answer when plic ble)
6QGI� V-/r 0-
irk err®��
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 b o of H lth.
Signed Date le
Application Approved by Date nEZ77
Application Disapproved for the following reasons
Permit No. ��� / Date Issued
No. �-- /
Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION TOWN OF BARNSTABLES MASSACHUSETTS
Zipprication for Migogal bpgtem Congtruction permit
Application is hereby made for a Permit to Construct( )or Repair( w)�an On-site Sewage Disposal System at:
Location Address or Lot No. J/ !?, Owner's Name,Address and Tel.No.
Assessor's Map/Parcel d�s f�/rj / S f'/
Installer' Name,A dress,and Tel.No. Designer's Name,Address and Tel.No.
7
Type of Building:
I Dwelling No.of Bedrooms Garbage Grinder
Other Type of Buildings/ 1°r/G�' No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow C4 gallons per day. Calculated daily flow gallons.
Plan Date / `/ - 3 Number of sheets Revision Date
Title
Description of Soil
Nature of R pairs or Alterations(Answer when pplic4ble) �15���� �'�`' �
i
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 b 3gard of H th.. ----
Signed Date
Application Approved by 9' Date
Application Disapproved for the following reasons
Permit No. /'" Date Issued
--------------------------------------- -
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Dispos�ay�system ins�t�alied( ,)or epaired/replaced( on
by InstallerG
at 2 3 45G' O // /4. 'ell I as been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Date Inspector ------_
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYS-
TEM WILL FUNCTION SATISFACTORY.
No. -----------------------`®! � Fee "°�' �'�r✓
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
30ion5 Y *pgtem Congtruction 3permit
Permission is hereby anted to
to construct( )repair(t4an On-site Sewage System located at No.# T12
Street
and as described in the above Application for Disposal System Construction Permit. V Z-
No. Date.
The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions.
All construction t be completed within-three years of the date below.
Date: Z__ Approved by
Boara of Health
A,Ortdel4 of
��E., HYDt,er e R
lo.i 103.7/
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125.00*+ 19
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N0.281l14 Q ry �0� �4 A�S.�ML C Fi.?irEc rvn•Y vtil`CQ• I
Np SUR��y k. N U a i;.IL r'LA,rsE
C� /25 .00
�-- s 8 y ' 49' �-O'• w
LEGEND CERTIFIED PLOT PLAN
EXISTING SPOT ELEVATION OxO
EXISTING CONTOUR ---- 0 _-- PH14 b .o
FINISHED SPOT ELEVATION [Q WEI, - L0r/37 l'IaKln►GeIRv lea"E MRasTONSP1us
FINISHED CONTOUR 0 �i 66 4' w IN
o SSG S T S
APPROVED , BOARD OF HEALTH S�nNA
DATE AGENT SCALE, 1" 30'. DATE, -A4t419 85
eLbI—?E—DGE ENGINEERING CD. IN CLIENT(eeni,ne- I CERTIFY THAT THE PROPOSED
EGISTERE REGISTE-RED JOB NO. 81002- BUILDING SHOWN ON THIS PLAN
CIVIL LAND CONFORMS TO THE ZONING LAWS
ENGINEER SURVE OR DR. J D OF BARNSTAILE, MASS. A-5
As Nca1L•D
712 MAIN STREET, CH- BY, Jam—..
H Y A N N I S, M A$S. O1.2o 83
- .:�--
SHEETS OF 3. DATE AM LAND SURVEYOR
NOTICE:This Form is to be Used for the Repair of Failed
Septic Systems Only
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
,711"Zelll",
I,� I-F✓ , hereby certify that the application for disposal works
construction permit signed by me dated If 7 , concerning the
property located at Zv 7 /�4 �1T �// `�i a/5�®�5 >eets all of the
following criteria:
//Fhere are no wetlands within 300 feet of the proposed septic system
here are no private wells within 150 feet of the proposed septic system
e observed groundwater table is 14 feet or greater below the bottom of the leaching facility
ere is no increase in flow and/or change in use proposed
There are no variances requested or needed.
SIGNED: DATE: JC l�6 -7
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
j xert