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HomeMy WebLinkAbout0045 AUDREYS LANE - Health 45 AUDREYS LANE, MARSTON MILLS: j, r f Commonwealth of Massachusetts ORB-- OS-69 Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 45 Audreys Lane Property Address Daniel &Judith Wood Owner Owner's Name / information is Marstons Mills V Ma 02648 9/18/2020 required for every i page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling opt forms �A. Inspector.Information 6 490 on the computer, use only the tab Sean M. Jones key to move your Name of Inspector cursor-do not use the return S.M.Jones Title V Septic Inspection key. Company Name 74 Beldan Lane ICI Company Address _. Centerville Ma 02632 � City/Town State Zip Code 774-248-4850 smjonestitle5@gmail.com, SI4522 1 sm sean@ onestitle5.com License Number B. Certification I certify that:I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems:After conducting this inspection I have determined that the system: 1 ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approvin ority 4. ❑ Fails 9/18/2020 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 has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 �-, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v : 45 Audreys Lane Property Address Daniel &Judith Wood Owner Owner's Name information is required for every Marstons Mills Ma 02648 9/18/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The property located at 45 Audreys Ln Marstons Mills is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and 3 500 gallon precast leach chambers. Although the system was found to be in proper working condition at the time of inspection this report does not guarantee future performance under similar or increased usage. I 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional.Pass' section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND).for the following statements. If"not determined," please explain.r 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. [1,Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts �Y Title 5 Official Inspection -Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 45 Audreys Lane Property Address Daniel &Judith Wood Owner Owner's Name information is required for every Marstons Mills Ma 02648 9/18/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass.inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further.Evaluation is Required by the Board of Health: ❑. Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 Audreys Lane Property Address Daniel &Judith Wood Owner Owner's Name information is Marstons Mills Ma 02648 9/18/2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 1.00 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System'Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No."to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 45 Audreys Lane Property Address Daniel &Judith Wood - Owner Owner's Name information is required for every Marstons Mills Ma 02648 9/18/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow El ® 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. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ The system fails. I have determined that one or more of the above failure® criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 Audreys Lane Property Address Daniel &Judith Wood Owner Owner's Name information is required for every Marstons Mills Ma 02648 9/18/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the-previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components,excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® El 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)] t5insp doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments `J 45 Audreys Lane Property Address Daniel &Judith Wood Owner Owner's Name information is Marstons Mills Ma 02648 9/18/2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. 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 gpd Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes E No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes Z . No Water meter readings, if available (last 2 years usage (gpd)): Detail: .Sump pump? ❑ Yes ® No Last date of occupancy: 3/2020 Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 45 Audreys Lane Property Address Daniel &Judith Wood Owner Owner's Name information is required for every Marstons Mills Ma 02648 9/18/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings,.if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 _ Commonwealth of Massachusetts. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4� 45 Audreys Lane Property Address Daniel &Judith Wood Owner Owner's Name information is required for every Marstons Mills Ma 02648 9/18/2020 page. CityTTown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: system repaired 8/1999 per town records, tank original 1975 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron: Z 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 in good condition, no leakage, vented through roof. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 45 Audreys Lane Property Address Daniel &Judith Wood Owner Owner's Name information is required for every. Marstons Mills Ma 02648 9/18/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 1 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) I If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes ❑ No Dimensions: 1000 gallons Sludge depth: 5° Distance from top of sludge to bottom of outlet tee or baffle _ 3 211 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 10.1 How were dimensions determined? Opened covers and took measurements 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 does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance.Water level was even with outlet, tank was not leaking and was structurally sound. t5insp.Joc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 45 Audreys Lane Property Address Daniel &Judith Wood -. Owner Owner's Name information is required for every Marstons Mills Ma -02648 9/18/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: El concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete El metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1 45 Audreys Lane Property Address Daniel &Judith Wood Owner Owner's Name information is required for every Marstons Mills Ma 02648 9/18/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0il 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.): Distribution box was video inspected and found level and in good condition with no rot. Water level was even with outlet invert with no signs of past backup. t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 I� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal.System Form - Not for Voluntary.Assessments 45 Audreys Lane Property Address Daniel &Judith Wood Owner Owner's Name information is required for every Marstons Mills Ma 02648 9/18/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): .... If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 3 x 500 gals ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: Eloverflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/23/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 45 Audreys Lane Property Address Daniel &Judith Wood Owner Owner's Name information is required for every Marstons Mills Ma 02648 9/18/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching facility was located and excavated. Chambers were dry at time of inspection with a stain line approx 6"from bottom. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert_ Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction_ Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .�� 45 Audreys Lane Property Address Daniel &Judith Wood Owner Owner's Name information is required for every Marstons Mills Ma 02648 9/18/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Insp ection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 45 Audreys Lane Property Address Daniel &Judith Wood Owner Owner's Name information is required for every Marstons Mills Ma 02648 9/18/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 0 _ 0 Z A- Zy 6 AZ 2- 2 7 A3 : y3 �3 A s0 6 r3 y �S t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I" Subsurface Sewage.Disposal System Form -Not for Voluntary Assessments v% 45 Audreys Lane Property Address Daniel &Judith Wood - Owner Owner's Name information is required for every Marstons Mills Ma 02648 9/18/2020 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground 12'+ d 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: Groundwater was.established by accessing town of Barnstable groundwater contour maps.. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u� 45 Audreys Lane Property Address Daniel &Judith Wood Owner Owner's Name information is required for every Marstons Mills Ma 02648 9/18/2020 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Hclding Tank-Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 4. I : �oFIWKWE ti Town of Barnstable o� Inspectional Services IIARNSTABLE. Public Health Division QED MA'S s Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 August 12, 2019 Daniel Wood 215 Church Street West Barnstable, MA 02668 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY CODE II — MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE CODE CHAPTER 170. The property owned by you located at 45 Audrey's Lane, Marston's Mills, MA, was inspected on August 12, 2019 by Timothy B. O'Connell, R.S., Health Inspector for the Town of Barnstable. This inspection was conducted due to complaint received at the Health Division. The following violations of the State Sanitary Code were observed: 105 CMR 410.500— Owners Responsibility to Maintain Structural Elements Chipping paint observed on the ceilings in multiple rooms within the dwelling unit. 105 CMR 410.501- Weathertight Elements. Observed that siding is being replaced and the dwelling unit is not currently weathertight. Also observed a mold like substance within the attic. You are directed to correct the State Sanitary Code violation listed above within thirty (30) days of your receipt of this notice by replacing siding; by ensuring structure is weathertight and free from all sources of chronic dampness; by removing any mold like substances in attic and by repairing any chipping paint. Y6u may request a hearing before the Board of Health if written petition requesting same is received within ten (10) days after the date the order is served. Non-compliance will result in a fine of$100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. Should you have any questions regarding the above violations, please contact the Town Health Division and ask to speak with the inspector who performed the i+,�pection. PER ORDER OF THE BOARD OF HEALTH Th'o c ean;'R:S., CHO Director of Public Health Town of Barnstable Cc: Brian Hollis, Occupant PI The Law Office of DAVID V. LAWLER, PC 540 Main Street, Suite 8 Hyannis, MA 02601 Telephone: (508) 778-0303 Facsimile: (508) 778-4600 962 Main Street Email Address: Osterville, MA 02655 david@dlawlerlaw.com Tel:(508)428- 0542 September 9, 2019 Thomas McKean, Director Town of Barnstable Public Health Division 200 Main Street Hyannis, MA 02601 Re: 45 Audrey's Lane, Marstons Mills, MA Owner: Daniel Wood Dear Director McKean: Please be advised that I represent Daniel Wood, the owner of the property at 45 Audrey's Lane, Marstons Mills, MA. After numerous attempts to coordinate access to the property for the purpose of conducting repairs as indicated by the Barnstable Board of Health's correspondence dated August 12, 2019. The owner's representative was denied access to the property. As previously arranged by my client who had a builder at the subject premises to complete the work. However, the tenant left a note denying access to the contractor. Moreover the tenant had previously cut the power while the homeowner was having outdoor repairs taking place.. It's quite apparent that the tenant is refusing reasonable access to the conduct the repairs as ordered by the Board of Health. I will be in contact with you to discuss future handling. Thank you for your courtesies in this regard. ;David 7/Ver Cc: Brian Hollis and Brenda Nemec Town of Barnstable o� Inspectional Services =AF3VSTABLL �$ b 9- Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 August 12, 2019 Daniel Wood 215 Church Street Wes: Barnstable, MA 02668 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY CODE II — MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE CODE CHAPTER 170. The property owned by you located at 45 Audrey's Lane, Marston's Mills, MA, was inspected on August 12, 2019 by Timothy B. O'Connell, R.S., Health Inspector for the Town of Barnstable. This inspection was conducted due to complaint received at the Health Division. The following violations of the State Sanitary Code were observed: 105 CMR 410.500— Owners Responsibility to Maintain Structural Elements Chipping paint observed on the ceilings in multiple rooms within the dwelling unit. 105 CMR 410.501- Weathertight Elements. Observed that siding is being replaced and the dwelling unit is not currently weathertight. Also observed a mold like substance within the attic. You are directed to correct the State Sanitary Code violation listed above within thirty (30) days of your receipt of this notice by replacing siding; by ensuring structure is weathertight and free from all sources of chronic dampness; by removing any mold like substances in attic and by repairing any chipping paint. You may request a hearing before the Board of Health if written petition requesting same is received within ten (10) days after the date the order is served. Non-compliance will result in a fine of$100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. Should you have' any questions regarding the above violations, please contact the Town Health Division and ask to speak with the inspector who performed the inspection. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., CHO Director of Public Health Town of Barnstable Cc: Brian Hollis, Occupant • Citizen Web Request Page 1 of 3 .� 49 titiS ¢�Bt2 @�Gar— `�+�+^-r»^'..�„»,. __ ✓y�7.��"' ?r� � . Monday,August 12 2019 A,plication Center Logged In As: oconnelt Citizen Request Management Logoff Route to Users Search Requests Create Requests Request Information Request ID: 70186 Created: 8/9/2019 8:49:33 AM Status: Assigned To Staff Assigned To: O'Connell,Timothy Health Office Anonymous: No Request Category: Chapter II : Housing Substandard edit Routine work: No Estimate: No edit Date scheduled: edit Estimated 8/23/2019 Change Estimated Jul August 2019 se[) Completion Completion Date: Sun Mon Tue Wed Thu Fri Sat Date: 28 1 29 30 1 31 1 2 3 4 5 6 7 8 9 to 11 12 13 14 15 16 17 • 18 19 20 21 22 23J 24 25 26 27 28 29 30 31 1 2 3 4 5 6 7 Created By: Soto, Kathryn Priority: Medium edit Health Office Citation Numbers: edit Requestor Information Requestor Request Parcel Number Map: 028 Block: 056 Lot: 0 0 Tenant reports multiple issues at property: paint chipping on several ceiling areas, water damage/stains, severe black Parcel Lookup mold, patches of floor damaged, blocked access doors/egress and front door area open underneath looking into basement. Unregistered rental for eleven years. Email: sandwichpools@yahoo.com Edit Requestor Information https://itsgldb.town.barnstable.ma.us/CitizenRequest/WRequest.aspx?ID=70186 8/12/2019 I Health Master Detail Page l of 1 Logged In As: TOWN\oconnelt Health Master Detail Monday,August 12 2019 Application Center Parcel Lookup Selection Items Parcel Septic Perc Well Fuel Tank Parcel: 028-056 Location: 45 AUDREYS LANE, Marstons Mills Owner: WOOD, DANIEL 3 &JUDITH A Business name: '__s f_._ Business phone:(� _ 11 _ _ _ ._ .._- .._.. _.. _ _- — _ Rental property: ❑ Deed restricted: ❑ _.__Number of bedrooms : - 0y 1 Contaminant released: ❑ Fuel storage tank permit: ❑ Save Parcel Changes Return to Lookup Parcel Info Parcel ID: 028-056 Developer lot:LOT 4 Location:45 AUDREYS LANE Primary frontage: 125 Secondary road: Secondary frontage: village:Marstons Mills Fire district:C-O-MM Town sewer exists at this address: NO Road index:0050 Asbuilt Septic Scan: 028056 Interactive map: p Town zone of contribution:GP (Groundwater Protection Overlay District) state zone of contribution:IN Owner Info owner: WOOD, DANIEL J &JUDITH A Co-owner: Streeti:215 CHURCH STREET Street2: city:WEST BARNSTABLE state:MA zip: 02668 country: Deed date: 11/15/2017 Deed reference:30899/208 Land Info Acres: 0.46 use: Single Fam MDL-01 zoning:RF Neighborhood: 0105 Topography:Above Street Road:Paved Utilities:Septic,Gas,Public Water Location: Construction Info lEuildi-I N .ea.Bui1 Gross Are<L.kin,. Aree Bedrooms l8ath,oanis 1 1975 2272 1056 3 Bedroom 1 Full-0 Half Buildings value:$116,700.00 Extra features: $24,700.00 Land value: $105,000.00 http://issgl2/intranet/healthMaster/HealthMasterDetail.aspx?ID=028056 8/12/2019 2 • TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date (� t "— Time: In Out Owner Tenant Address � � � Address A FT 0 � �I Compliance Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities 6. Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Iv V� Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17. Temporary Housing 18. Driveway Width 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms Number of Vehicles A (m Number of Persons Allowed max Person(s) Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here 4-10 TOWN''OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date O Time: In Out Owner V V'C.� :h, Tenant Address Address "Y 1 Compliance Remarks or Regulation# Yes NO0 Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities ,/ 6. Heating Facilities r 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 4'1 11. Space and Use v 12. Exits U ;k 13. Installation and Maintenance of Structural y,' V/ Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal Ig 1 16. Sewage Disposal I ` 17. Temporary Housing 18. Driveway Width , J` 19. Number of TenantvObserved PART 11 >� F 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms Number of Vehicles Allowed (max), ; Number of Persons Allowed (max) ,r Persons Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here'` r COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS } d DEPARTMENT OF ENVIRONMENTAL PROTECTION 3(l D,� SYBv nrLr ILL TITLE 5 OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION operty Address: ( fAG l'e 'LG h�e— `$ner's Name: a N on wner's Address: 2 L s►+� Date of Inspection: Name of Inspector: lease print) rk Company Name: vi O — T EG _ Mailing Address: O O E� 9L4Od- Telephone Number• O — *55 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 CAM15.000). The system: I/ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: OAZ1 Date: 0� 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. Title 5 Inspection Form 6115 2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: `-t- dry L..o,ne- ar f 4h /yl 0,ZZ Owner: ( 1 0(9 Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sy Passes: I have not found an information which indicates that an of the failure criteria described in 310 CMR Y Y 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 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 hispection if(with approval of 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: LZ� 14 -S 14,4 h Owner:_"'o Date of Inspection: / C. Further Evaluation is Required by the Board of Health: /V 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 CN M 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: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: v►Cr 2 S a A-C� Owner: �Od Date of Inspection: 08 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ ckup 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 ,.etogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or /xesspool VI squid 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 /tunes pumped . _ I/ y 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. V Any portion of a cesspool or privy is within a Zone 1 of a public well. (/�rhy 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.] (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 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. 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 io 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 yoiu have nswered"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. n Page 5 of 11 OFFICIAL. INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 7S N Gre S �lrs*on /yi¢ L-902,�qy Owner:. (1104 Date of Inspection: / Check if the following have been done-You must indicate"yes"or"no"as to each of the following: Yes o Pumping information.was provided by the owner,occupant,or Board of Health Xereany 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) l/ 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'raffles 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 //'' L/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)] Page 6 of I 1 OFFICIAL, INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION II �� Property Address: lid/$ L,aA-e-, 99 Owner: L✓Oo Date of Inspection: ItLOW CONDITIONS 0o" RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CND 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage g=inder(yes or no): *10 Is laundry on a separate sewage system(yes or no):/VO [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no): &V Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):�n Last date of occupancy: COMR7ERCLAL/I14DUSTRIAL Type of establishment: Design flow(based on 310 CIVIP_ 15.203): gpd. 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: 2 ;- Q(,✓w,i Was system pumped as part of be inspection(yes or no)-," If yes,volume pumped: :gallons--How was quantity pumped determined? Reason for pumping: TYP �taTdi:E Septi bution 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,rdate installed(if known)and ifo �on:�� Were sewage odors detected when arriving at the site(yes or no): gg� 7l Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: z4v re S L--a n, Owner oo Date of Inspection: �7 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.): b SEPTIC TANK:_(locate on site plan) Depth below grade: 1-3 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: "-X Sludge depth: <,2 02 9 </ Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: LASS /// 6 r/ Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to boltpf outlet or baffle:_ How were dimensions determined: /'° �e /'Sa jG6­1G C Comments(on pumping recommendations,inlet an outlet tee or baffle condition,structural integrity, liquid levels as Fated to outlet invert,evidence o leakage,etc.): �n /!O/T 1✓ G b��iS >111"71 /09 %OO Ci O✓" r /O GREASE TRAPe(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.): T:al.. C T—____..____ r•_ i i. i...,.... '7 Page 8 o=11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /7 H ✓y s� a � Owner- t✓o v Date of Inspection: / Q TIGHT or BOLDING 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): Dimens_ons: 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:Zff present must be opened)(locate on site plan) Depth of liquid level above outlet invert:k!10 Gr(-- Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakag . ' to or ut of bqx,etc.): 4h / 1--�.y�/ /did so l��r /lip �-e��•� PUMP CHAMBER:L(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.): Page 9 of 11 OFFICIAL. INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL., SYSTEM INSPECTION FORM PAIN C SYSTEM INFORMATION(continued) Property Address: `7' 14y c� ,e- s LG� �/�i9' OoC-t� Owner: In/'Oo Cli- Date of Inspection: 4/ (y SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: 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:AL/(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:klocate 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.): ( - Page 10 cf 11 OFFICIAL, INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORIMATION(continued) Properh,Address: !� rG S LtiYYi Owner: t0 Date of Inspection: / 0 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. a r � rj 1 3 � to L /'/'" /kv 9�s.�� Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM PART C S/ 471 SYSTEM INFORMATION(continued) Property address: y fi►G'� �R''4_11 Owner: Date of Inspection: / 11 SITE EXAM 9 d` Slope g Surface water �Q Check cellar ( �� Shallow wells /► Estimated depth to ground water &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: served site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: 11,74'&15: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You mu�_describe ow y u established the hi h ground water elevation: ro �fW c„ of i2c a-�ao� /S q /f 0 r i Town of Barnstable �FTHE 1p� o Regulatory Services snxxsrnsLE. ; Thomas F. Geiler,Director 9� 1MA & ,eg A,Fo3�A Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER 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 or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations 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 Works Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. Q:\SEPTIC\Disclaimer Private Septic Inspections.DOC TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE / ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 1 0 6 ~cS4 -7 2 " $ SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 3 ^ s— �` (size) — 3 NO.OF BEDROOMS L/ BUILDER OR OWNER "f PERMITDATE: !���` f 7 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching v Feet Private Water Supply Well and Leaching Facility (If any wells e on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands ezi Feet within 300 feet of leaching facility) Furnished by 1� O b� a TOWN OF BARNSTABLE r� /f LOCATION ��) /`6 U[�� �� U'� 6�.� SEWAGE # VfLLAGE `j S ASSESSOR'S MAPS& LOT INSTALLER'S NAME&PHONE NO. 77LVII z' v SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 3 " S" 2 <� (size) NO.OF BEDROOMS BUILDER OR OWNER l✓° �"© `� PERMTTDAT'E: 16 g g COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Le/e ' Feet Private Water Supply Well and Leaching Facility (If any on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands e within 300 feet of leaching facility) Feet Furnished by 1 _ _ �0. No. Fee $5 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01pplication for Mid aal *pgtem Conttruction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components L cation Address or Lot No. Owner's Name,Address and Tel.No. �5 Audreys Lane , Marstons Mills Dan Wood Assessor's Map/Parcel MA Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service PO Box 1089, Centerville, MA Type of Building: Dwelling No.of Bedrooms_*4— Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Sand. Nature of Repairs or Alterations(Answer when applicable) new Title-5 leach system. 1)—'hnx and 3 leach ohambprs. 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 's B d of Health. Signe Date Application Approved by 11 Date Application Disapproved for the following reasons Permit No. Date Issued ,fryer t ///� � ff�•� II • � No. y, _._. Fee $50 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZippYication for 30i5pozar *pztem Con.5truction Permit , { Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) O Complete System ❑Individual Components L,oc tion Address or Lot No. Owner's Name,Address and Tel.No. 4.5 Audreys Lane, Marstons Mills Dan Wood Assessor's Map/Parcel MA Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service PO Box 1089, Centerville, MA Type of Building: Dwelling No.of Bedrooms_kj� Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title IN Size of Septic Tank Type of S.A.S. Description of Soil Sand t 4W Nature of Repairs or Alterations(Answer when applicable) new Title-5 leach system. D-box and 3 leash chambers, r� 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- -�. date of Compliance has been issued byt is Byarazdof Health. x ` I Sign, Date Application App`ro"ved by / l9 Date ® Application Disapr,prro,�ed for the following reasons Permit No. IVY Date Issued ——————-———————------------------------- THE COMMONWEALTH OF MASSACHUSETTS Wood. BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( ) Repaired (X )Upgraded( ) Abandoned( )by Wm.—E E . Robinson q P nt i r. q ary i e e at Mills, constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Wm. E. Robinson S r. Designer o The issuance of this perinit sh ill of e construed as a guarantee that the sy a ill function as des g ed. l Date l/i Inspector � ` /� a� / A I I ., No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEAL Q:IKLS:ION, ARNSTABLE., MASSACHUSEF7S%- Mitpo5ar *pgtem Construction Permit Permission is herebyfgranted to Construct( )Repair(X )Upgrade( )Abandon( ) System located at 45 Aud.reys Lane, Marstons Mills, MA 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. D Provided:Construed o must le�completed within three years of the date of t pe t . Date: :I Approved by i ����✓i/�- S o i 1/6/99 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) I, William E . Robinson,E, hereby certify that the application for disposal works construction permit signed by me dated go/ , concerning the property located at 45 Aud.reys Lane , Marstons Mills, MAmeets all ofthe following criteria: • The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • e soi 's classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • Where no wetlands within 100 feet of the proposed septic system • `There are no private wells within 150 feet of the proposed septic system ��ere is'no increase in flow and/or change in use proposed • re are no variances requested or needed. •bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W.Elevation +the MAX.High G.W. Adjustment. _ �l DIFFERENCE BETWEEN A and B SIGNED : L �^�-" DATE: g � [Sketch proposed plan of system on back]. q:health folder:cert Old v' e 1�44t "�45- TOWN OF BARNSTABLE LOCATION AVDf2r�6S 4-4wc SEWAGE # 7-5" VILLAGE MA-P—�'TZ?NS M/LCS ASSESSOR'S MAP & LOT Zg INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO. OF BEDROOMS_ R/IVATE WEL OR PUBLIC WATER BUILDER OR OWNER '/► '" �"�� DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No rf` 3 � Alt n e-0 �2p, �✓ oc� rc.� Ar dal 4 fa�. .s No.. �'�._...� Fs$.: ...Cl.................. THE COMMONWEALTH OF MASSACHUSETTS OARD OF HEALTH ...... . ...,dgZ421_-----.OF....... _. .. .._..................------------------------- Apphration -for Di_qpuittl -'1Vvrkfi C onfitrurtion Vrrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Indivi 4alew -e is oral System at: / Location-Address or Lot N . Owner Address Installer Address d Type of Buildings Size Lot............................Sq. feet U Dwelling—�No. of Bedrooms______________ _Expansion Attic Garbage Grinder 0-4 Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( /) — Cafeteria ( ) Q' Other fixtures _.._._.__........................................... W Design Flow.._.___.....................................gallons per person per day. Total daily flow.........................................---gallons. W Septic T:utk—Liquid capacity/0-0__gallons Length.......4..... Width------ Diameter................ Depth.--_-__-_--- x Disposal Trench—No_____________________ Width-------------------- Total Length-------------------- Total leaching -area----------.---------sq. ft. Seepage Pit No--------------------- Diameter.................... Depth beloyv inl _... ....... Total le chin ---sq. ft. Z Other Distribution box ( ) Dosing tank , ���k — � /. aPercolation Test Results Performed by._: u� .- �9 ._ k✓ 1 ..... Date...?/.�!__l_-7�-----__.__.. a Test Pit No. 1......�:L....minutes per inch Depth of "lest Pit____________________ Depth to ground water...__...____.__---__-- (_, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ °' ...... ------------•------------------------------------------------------------ 0 Description of Soil-----0.- 40-......L0S... ..'o-------V•- D 4.r------------ ------------- V --•--------------------------------- �2 ' �'�' t✓__�ts�trd ..6,00 .-.--------f.� J�c�-la�uts .. .�' �. �! ------------ W -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- UNature 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 been ' s ed by the boa d of he h. Sign ----- m.. ' Date a Application Approved By____ �� _^.S_=_..................... Date Application Disapproved for the following reasons:------------------------------------------------------------------------------------- .......................... •-••---•-••--------------------------••--•---•---•---•----------•------...-•-•----•-•-••---•-----------• ------- �-. � Date PermitNo......................................................... Issued.----- ........................... ........... Date r f No.._._.......................... ....�... THE COMMONWEALTH OF MASSACHUSETTS "BOARD CIF HEALTH . .. r`7-VV%.........OF.....600-4YV....._.............................:.. Appliraatioat -for Difi ooaal Eorks Tonfitrurtion Perattit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual ewpge/Dis oral System at: .� l ... '. --•---------------------------•----..... --------------------�C�?.... ............... ............= `` Location-Address or Lot No. ............................................ Owner Address ----------------- Installer Address d Type g Sq. feet T e of Building Size Lot________________________ _ _ Dwelling''-=No. of Bedrooms-_............ .........................Expansion Attic (/Uf Garbage Grinder (' ' `PL4L4 Other—Type of Building ............................ No. of persons____________________________ Showers f — Cafeteria Q' Other fixtures ----------------------------------------------------------------------------------------------------------------------------------------------------- d W Design Flow............................................gallons per person per day. Total daily flow------------------------------------------.-gallons. WSeptic Tank—Liquid capacity/ »---gallons Length_______ ______ Width-----�------. Diameter................ Depth---.-.-__.----- x Disposal Trench—No- ___________________• Width.................... Total Length.................... Total leaching area-..-----__-_.-._____sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet-----________---__ Total leaching g area_________________sq. tt. z Other Distribution box ( ) Dosing tank ( ) Lt —T r✓ Y Percolation Test Results Performed '' J - Date ` I' al Test Pit No. 1.......2.....minutes per inch Depth of Test Pit.................... Depth to ground water-------- ........... w Test Pit No. 2................minutes per inch Depth of Test Pit------_............. Depth to ground water-•.-_-_---__-...___--.-. 9 r ------------------------------------------------------------------------------•-------•------------------•------------------------------------ D Description of Soil----rA. V )------ --•.... /�—��Cr�J6- S1(• a -- - r J--- •C ---1Lr:r�7 y '-, % T;j J W UNature 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 been Cued by the bo d of he xth. Sign /! 2.�Cr 'J J/ / } -----•- ......._-- -•-•---•-• ...._ / ✓ / : Date Application Approved By--- _.._____. 't ............................._. -. --------------------------------------- Date Application Disapproved for the following reasons--------------------•----.....-•---••-•--•-••---.............----•-•--------.........--•---•-•-•••---..._......-- -•--•-.-•--••••-•-••----------------------------------------•--•..........------------------••-•-••-----.••---------•....--------......----•------•..........---•----------....-•-------.------_-•.••--- Z_:Date PermitNo......................................................... Issued-•--.5~.............................-�...... Date t THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �2. .. ..............0 F.....,. :�. c,.�l � � � .�,� CIertifirate of Tilutpiiatatrr THISIIS TO'CERTIFY, That the Individual Sewage Disposal System constructed (4-7or Repaired ( ) W by.... l� ='cr a ,r y 1l..... L .......---•-•------ . ------- / _ _ r / � Installer � at (� rf+l '1 �! �isa.n _/. /"/t.,•I ............................................. ---- ----- ---- - �. •---------------- ---- �--- ---- -- has been installed in accordance with the provisions of Article XI of The State Sanitary Code as descriyekin the application for Disposal Works Construction Permit No.--_./.t^_---------- -_ -------- dated..-.-E----:".-:?............................. THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......-----• q .2�J ---•--------------------- Inspector----•-..dtl- D4�- •--•-•---•------ ------•-••---------------•---- THE COMMONWEALTH OF MASSACHUSETTS {� ✓,,� BOARD O-' HEALTIA ! �.. ....... CC. % --tl No............ FEE... <•1 Uinpoijaj Works Toatotrudion ramit 1 Permission is hereby granted. `= !'�, rr.-� ``' ''� .+:_. x'".'...-•-------•------.....-•---•--•-••--•-----•---------------- - -- - ! to Constmict (�) or Re air ( ) an Indiy�dual Sew e Disposal" System at No.• �. r l ! ? ..ram ra.:....., .._ = l-�/- .` e f . f ! _�4r" ' Street as shown on the application for Disposal Works Construction _Permit No._t _•_; ated__ ..-.�_ ._____.._._ Board of Health DATE.. , ---------------------------------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS a I s .�• � � X�w �1 _ •TEST'____ �,_' - � _ �e.A,� �. s / I O J �r� 6r AJf/EO Sr/a �E 2D� All O b Y Sox 93=� •o N 1 ,'� �a�� ,�i zfl.t a Oil I . .,.��+ rat }t,•h,.., sr-sr .�.s•.' `° ` LA. /a �iPo�oS�p•.` s •'SG�2.LE J /"_-�® ' DFaTE� ' 7 25 7S ]i�ST //oL� ,�EScx7'S'; r�. a� �CF3^/ .L�TOOiL- d Z`Z� ���, fZ - iJ8""/YY` LL�N COA/rS8 si"/9ivG3,`".a11 � = HE'CEBY� CENT/FY THAT TL/E BV/LD��c/�r� ,vJi.c// CM .SAWC)AVA.1 O,tJ TN/s A-L Ai A./ /S L OC TEa C>A/ TL•/E FAB /A .�i.5 sa/oW.V HE�BoM �a/D THgT iT .. s '"-f . COA�/FO AL'4-f TO TAvl—'-- BY LFJN/S O� T/,/E 7WA.1 OF BA�.vSTi4BL �(� OF �A b ya`�' �'�C . �, �' -•° 'ARNE H° r* OJALA #26348 ti y,� � �r•�. G�i,Va /Sci�V6Yo�5 -- z 20fJ77E 6.4^-YL��' OCJT�/, MASS• DfiYlz C�EGr. L �1r!o. s, .°r- v � 4