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HomeMy WebLinkAbout0074 BARBERRY LANE - Health 6 V�M � II IL �� J �� �� co m ca '. co Postage $ nj Certified Fee 0 I,PostPnark b 0 Return Receipt Fee 1. Here 0 (Endorsement Required) l p O J� Restricted Delivery Fee O (Endorsement Required) ri0 Total Postage&Fees rl Sent To 0 Street,Apt No.; //�2 r%- --PO Box N------/!P - l a Cd};State,ZIP Certified Mail Provides: e A mailing receipt o A unique identifier for your,mailpiece e A recor�of delivery kept by the Postal Service for two years Important Reminders: In Certified Mail may ONLY be combined with First-Class Mail®or Priority Maile. a Certified Mail is not available for any class of international mail. e NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. a For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. o For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". e If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT,Save this receipt and present it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 «T Town of Barnstable Barnstable Regulatory Services Department IARNSTABtE i679• Public Health Division "" 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,.Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7012 1010 0000 2847 8384 January 12, 2017 HOBBS, HENRY A.JR& JOAN F 1103 WATER LILY WAY LELAND,NC 28451 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 74 Barberry Lane, Marstons Mills, MA was inspected on 12/31/2016 by Sean M. Jones, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Single cesspool and the leaching pit or cesspool with high liquid level, <12" below inlet(per Town Code 360-9.1). You are ordered to repair or replace the,septic system within two (2)years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH omas cKean, R.S., CHO. Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\74 Barberry Lane Marstons Mills.doc Town of Barnstable � w • HARN57'AHL.F MAS& ,�� J. Regulatory Services Department '�Ea ram Public Health Division 200 Main Street,Hyannis MA"02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 5/11/16 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) _ An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1)YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). O 2 YEAR DEADLINE CRITERIA Single Cesspool ❑Any"conditionally passed systems" (broken cover,relocation of a pipe, relocation of a driveway due to H-10 components, etc) L eaching pit or cesspool with high liquid level, <12"below inlet(per Town Code §360-9.1) ❑ Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER Repair deadline: WSEPTIMDEADLINES TO REPAIR FAILED SYSTEMS.doc Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 74 Barberry Lane Property Address a-a Henry &Joan Hobbs Owner Owner's Name information is �/ required for every Marstons Mills Ma 02648 12/31/2016 page. City/Town State Zip Code Date of Inspection h7 !'t7 IX 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 A. General Information S� aa�g f out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection Company Name 74 Beldan Ln. Centerville Ma 02632 Cltyrrown State Zip Code 774-248-4850 smjonestitle5@gmail.com S14522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority 12/31/2016 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 DG� VS Commonwealth of Massachusetts u . Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 74 Barberry Lane Property Address Henry &Joan Hobbs Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/31/2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: . ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): (Sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 r... Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments yVO,r 74 Barberry Lane Property Address Henry &Joan Hobbs Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/31/2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts F L: Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 74 Barberry Lane Property Address Henry&Joan Hobbs Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/31/2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ® ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded ❑ C' or clogged SAS or cesspool ® ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts v W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M a 74 Barberry Lane Property Address Henry &Joan Hobbs Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/31/2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 74 Barberry Lane Property Address Henry&Joan Hobbs Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/31/2016 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ E 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: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 6 of 17 f Commonwealth of Massachusetts H W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4M < 74 Barberry Lane Property Address Henry &Joan Hobbs Owner Owners Name information is required for every Marstons Mills Ma 02648 12/31/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: unknown Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 74 Barberry Lane Property Address Henry &Joan Hobbs Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/31/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? 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) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 74 Barberry Lane Property Address Henry&Joan Hobbs Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/31/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: unknown Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts G r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 74 Barberry Lane Property Address Henry&Joan Hobbs Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/31/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? 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: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts a vJ Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 74 Barberry Lane Property Address Henry&Joan Hobbs Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/31/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts H W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .'4 74 Barberry Lane Property Address Henry &Joan Hobbs Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/31/2016 page. City/Town State Zip Code Date of Inspection D. System information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): 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. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 74 Barberry Lane Property Address Henry &Joan Hobbs Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/31/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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 (cesspool must be pumped as part of inspection) (locate on site plan). Number and configuration 1 Depth—top of liquid to inlet invert water level into riser, 3"below grade Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Foam:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 74 Barberry Lane Property Address Henry&Joan Hobbs Owner Owner's Name information is Marstons Mills Ma 02648 12/31/2016 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Cesspool was found to be full into riser 3" below grade, unknown if there is any overflow off of this cesspool. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I 74 Barberry Lane Property Address Henry&Joan Hobbs Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/31/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 74 Barberry Lane Property Address Henry&Joan Hobbs Owner owner's Name information is required for every Marstons Mills Ma 02648 12/31/2016 page. City/Town , State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to 9 P Y 9 p Y 9 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 A� �I 1 131 3g I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments t 74 Barberry Lane Property Address Henry &Joan Hobbs Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/31/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 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: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 74 Barberry Lane Property Address Henry &Joan Hobbs Owner Owner's Name information is required for every Marstons Mills Ma 02648 12/31/2016 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked E Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 No. � J Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS �4pftLatlon for Misposal *pstrm ConstCUCtlon VPrmit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) Complete System ❑Individual Components Location Address or Lot No. Own is Name Address,and Tel.No. �y C3c-r+oa.ry 1�� I -(e.,�t• c�b�S Assessor's Map/Parcel a S�pn N►Q%I% y In taller's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. ec'l'lZrw�� t► 3 (��J YG,r,..�v� �,� e,�,.G \AMas Q.a MOX L(o tl n i aci 4 oo dij 6 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) ;j33 gpd Design flow provided 3.9a gpd Plan Date L,(,(i I('3� l� Number of sheets Revision Date Title Size of Septic Tank f,ST)U �Q Type of S.A.S. L ( (0 C C p&,6A S �9 l Description of Soil /D� g-X o )c i n C) d P e Nature of Repairs or Alterations(Answer when applicable) 'q 1k%Lr-,CA 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 Certificate of Compliance has been issued by this Board of Health. Si ed Date twin 7 Application Approved by Date Application Disapproved by Date for the following reasons Permit No. J l Q Date Issued No. P" / Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE,AASSACHUSETTS Yes 01pplitation for Misp` al 6pstrm Construttion AErmit ` r Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) Complete System ❑Individual Components Location Address or Lot No. �� � 'I tr „.owner's Name,Address,and Tel.No. 11ob�S Assessor's Map/Parcel � S}OA M ` S Installer's Name,Address,and Tel.No. 4 � Designer's Name,Address,and Tel.No. SC0kk'VrGV—J� k i 3 ri r ft" �, ev-c HaG.S Q.G, MOX 1 to Type of Building: Dwelling No.of Bedrooms Lot Size (, sq.ft. Garbage Grinder( Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures n Design Flow(min.required) (� gpd Design flow provided 35.�. t .� gpd Number of sheets Plan Date ' 1'� ' i Revision Date Title } f Size of Septic Tank / O � �(�QnX Type of S.A:S' !9, , (0 c I^CA, Description of Soil _ /r)4LOX Mr. / x ] i n Ck. d re n^ i'1 P \ S CA^—Z) Nature of Repairs or Alterations(Answer when applicable) �Rn c CS�J Ra 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 Certificate of Compliance has been issued by this Board of Health. Si ed Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. o Date Issued G g THE COMMONWEALTH OF MASSACHUSETTS ` BARNSTABLE,MASSACHUSETTS Certifitate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(� Upgraded( ) Abandoned( )by `d C(-,k\ TX 'gry—y. at -14�3 c r 6cr r,,i �UA C M M,-,)k 1c, has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No„--I( ` G e 2 dated Installer !S r C S� M �r � Designer V . #bedrooms Approved design flow "? — gpd The issuance of this permit sh 11 notZ//,? construed as a guarantee that the system w' 1 functi d si ed. Date ���(p Inspector --------------------------------------------------------------------------------------------------------------------------------------- No. 9:2/7 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal 6pstem ConstrUttion 'ermit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at �l d 5QCk-7{1-r\( [�d� l�rn rsAx)nt ►A 3 11, and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be/completed*ithin three years of the date of this permit. Date G/ /j,9/1 / Approved by Towle of Barnstable Regulatory Services Richard V. Scali,Interim Director Public Health Division t834 r Thomas McKean,Director '200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: / o'er f Sewage Permit# 00f /tom Assessor's Map\Parcel /0d ld' Designer: 1�f{�1.� il. kA ks, Installer: SdAV-M Address: `� 0.- CSC t( Address: its oL-th, C?Aei-4007�t ®Z C> On u t t x t�? T l� K was issued a permit to install a (date) (installer) septic system at 744 Uc n,e, M M t based on a design drawn by (address) S"�tk6!i-3 S,F&Fdated U/ 13 1-7 (designer) ✓ I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box andlor septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State& Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required)was inspected and the soils ?� were found satisfactory. I certify that the system referenced above was constructed i nce with the terms of the I\A approval letters (if applicable) (Installer's Signature) 1 (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. 0ASeptieDesigner Cenification Form Rev 8-14-13.doc 9/15/2020 ShowAsbuilt(1653x2338) TOWN OF BARNSTABLE LOCATION' Lc,-�__SEWAGE'# VILLAGE_�jcs-sk� \ j /ASSESSOR'S MAP&PARCEL /CUa—/Fi'7y_ INSTALLER'S NAME&PHONE NO. 0 i SEPTIC.TANK CAPACITY, ��"Q_( 1_L_�s.n - 14)0 O R ox-, LEACHING FACILITY.:(iype) t Ci(o C (iCrf (size) yy N. O.OF BEDROObfS OWNERO�rrlC?S PERMIT.DATE; . Lk LI"Fw l 1-7.. COMPLIANCE DATE: W I9G 1 17 Separation Dcscance Between'the. Maximum Adjusted Groundwater Table to the Bottom of Leaching:Facility N A. FoeC Private Water Sgpply Well and Leaching".Facility(If any wells existon �} site or within 200 k:6,of leaching facility) WA- -Feet. Edge;of Wetland and Leaching Facihty,(If any wetlands exisf-within 300 feet of leaching.facility) AA Feet FURNISHED BY 14 Alt i , A3- xw c ew-eo`F t3.J Ik. t44 4 https://itsqldb.town.barnstable.ma.us:8431/Home/ShowAsbuilt?mp=102187&sq=1 1/1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 74 Barberry Lane Property Address Terri Ann Milligan Owner Owner's Name / information is Marstons Mills y Ma 02648 9-8-2020 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information on the computer, Daniel Hawkins use only the tab key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. 374 Route 130 I Company Address Sandwich Ma 02563 City/Town State Zip Code iasio (508)477-0653 S114324 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. 0 Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Dan Hawkins Digitally signed by Dan Hawkins Date:2020.09.15 14:22:00-oa'oo' 9-8-2020 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 t � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments tl 74 Barberry Lane u Property Address Terri Ann Milligan Owner Owner's Name information is Marstons Mills Ma 02648 9-8-2020 required for every page. City/Town 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 system was in working order at the time of inspection. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 74 Barberry Lane Property Address Terri Ann Milligan Owner Owner's Name information is Marstons Mills Ma 02648 9-8-2020 required for every 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 �w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,.� 74 Barberry Lane u Property Address Terri Ann Milligan Owner Owner's Name information is Marstons Mills Ma 02648 9-8-2020 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 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No El El clogged of sewage into facility or system component due to overloaded or clogged SAS or cesspool El El due 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 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 74 Barberry Lane Property Address Terri Ann Milligan Owner Owner's Name information is Marstons Mills Ma 02648 9-8-2020 required for every page. Citylfown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ O Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ❑ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow ❑ ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ 0 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. ❑ a Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ El 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.] ❑ a The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ a 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 74 Barberry Lane ul Property Address Terri Ann Milligan Owner Owner's Name information is Marstons Mills Ma 02648 9-8-2020 required for every 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 Q ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ 0 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 recent) or as art of ❑ 0 9 Y Y P this inspection? 0 ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ El Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs ns of break out? ❑ P 9 El ❑ Were all system components, excluding the SAS, located on site? El ❑ 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: 0 ❑ Existing information. For example,a plan at the Board of Health. ❑ 0 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 C� Commonwealth of Massachusetts p Title 5 Official Inspection Form f. ji; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , � 74 Barberry Lane Property Address Terri Ann Milligan Owner Owner's Name information is Marstons Mills Ma 02648 9-8-2020 requited for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 3 3 Number of bedrooms (design): Number of bedrooms (actual): 352/GPD DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Description: 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes No Does residence have a water treatment unit? ❑ Yes ❑i No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes RI No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? - ❑ Yes ❑g No See below Water meter readings, if available(last 2 years usage(gpd)): Detail: 2019- 3,000gallons 2018-4,000gallons Sump pump? ❑ Yes ❑■ No Last date of occupancy: 2 weeks Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 74 Barberry Lane Property Address Terri Ann Milligan Owner Owner's Name information is Marstons Mills Ma 02648 9-8-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA 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: Owner- not since time of install 2017 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: 15insp.doc•rev.712612018 Tito 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 74 Barberry Lane Property Address Terri Ann Milligan Owner Owner's Name information is Marstons Mills Ma 02648 9-8-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: 0 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: 2017 Were sewage odors detected when arriving at the site? ❑ Yes 0 No 5. Building Sewer(locate on site plan): 21211 Depth below grade: feet Material of construction: ❑ cast iron ❑■ 40 PVC ❑ other(explain): Town water Distance from private water supply well or suction line: feet Comments(on condition of joints,venting, evidence of leakage, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 74 Barberry Lane Property Address Terri Ann Milligan Owner Owner's Name information is Marstons Mills Ma 02648 9-8-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 14rr Depth below grade: feet Material of construction: ❑■ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No 1 Dimensions: 500gallons 411 Sludge depth: 3211 Distance from top of sludge tobottom of outlet tee or baffle Orr Scum thickness NS Distance from top of scum to top of outlet tee or baffle NS Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): The tank was in workingorder at the time of inspection. The tank is not in need of pumping P P P 9 at this time but should be pumped every two years for maintenance. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 74 Barberry Lane Property Address Terri Ann Milligan Owner Owner's Name information is Marstons Mills Ma 02648 9-8-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): NA Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: NA Material of construction: ❑ concrete ❑ 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 r c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 74 Barberry Lane u Property Address Terri Ann Milligan Owner Owner's Name information is Marstons Mills Ma 02648 9-8-2020 required for every 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): o„ Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The d-box was in working order at the time of inspection. 15insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 c Commonwealth of Massachusetts �= Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 74 Barberry Lane Property Address Terri Ann Milligan Owner Owner's Name information is Marstons Mills Ma 02648 9-8-2020 required for every 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.): NA * 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: (4)LC6 chambers R leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 74 Barberry Lane V Property Address Terri Ann Milligan Owner Owner's Name information is Marstons Mills Ma 02648 9-8-2020 required for every 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.): The SAS was in working order at the time of inspection. Leaching was dry when viewed. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): NA 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.7126/2018. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 c Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 74 Barberry Lane Property Address Terri Ann Milligan Owner Owner's Name information is Marstons Mills Ma 02648 9-8-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): NA 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 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form �11 Subsurface Sewage Disposal System Form Not for Voluntary Assessments 74 Barberry Lane V� Property Address Terri Ann Milligan Owner Owner's Name information is Marstons Mills Ma 02648 9-8-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑■ hand-sketch in the area below ❑ drawing attached separately TOWN OF RA STA aJ_E LOCATION r? -' SEWAGE a. 2617 VILLAGE C� g. j� �:\L� ASSESSOR'S MAP&PARCEL_ZQ;�= ' INSTA.LLER'S NAME&Pi ION£N0. .. icy -r _ 1 �?q_ SEPTIC TANK CAPACPt'Y 1 !K:o ) g�X= t�1, cQ t3 t4st r LEACHING FACILITY;(type)L4 t r C_, s:��,��b<r-r (size) l40 i.+ae 3'S(j L. ?e b+a•O 2�. NO..OF.BEDROOMS._ txcQ OWNER. �a%t©S PERmi-i-T>A`rE: �' �{ S�l _._ _._.— COMPLIANCE DATE:_ %_4 I;a(. { \? Separation Distance Between the:Maximum.Adjusted Groundwater Table to the Bottom of Leaching Facility d`A JM Feet. private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet.of leaching facility) 1;V`y A Feet Edge of Wettansi and Leaching Facility(If any wetlands exist within ,,��{{ 300 feet of leaching facility) �I'T Feet . FURNIS14ED BY IL a.-- _ I A 31,= iU{ _ 34 E C1 S - o l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 c , Commonwealth of Massachusetts Title 5 Official Inspection Form I. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 74 Barberry Lane Property Address Terri Ann Milligan Owner Owners Name information is Marstons Mills Ma 02648 9-8-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑■ Check Slope ❑■ Surface water ❑■ Check cellar ❑� Shallow wells Estimated depth to high ground water: No GW @ 120"feet Please indicate all methods used to determine the high ground water elevation: 0 Obtained from system design plans on record 4-13-2017 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: A plan on file at the local Board of Health was used to determine high groundwater. 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 c Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u� 74 Barberry Lane Property Address Terri Ann Milligan Owner Owner's Name information is Marstons Mills Ma 02648 9-8-2020 required for every 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: III For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 II Town of Barnstable P# 15 2G1 J Department of Regulatory Services s » ar��, F Public Health Division Date a 1 im 200 Main Street,Hyannis MA 02601 " rEll MXt Date Scheduled Time Fee P Lv 6 e" Soil Suitability Assessment for Sewage Disposal Performed-By:' t � r � Wltncssed'By: c •a r ,y41r.,4,S LOCATION&•GENERAL MFORMATION Locatlon Address j• � Owner's Name H 4�,X r - Address Assessor's Map/Parcel: 9//,S-7 Engincer'e Name NEW CONSTRUCnON REPAIR Telephone# Land Use A-Yi-7 3lopcs(96) Z- Surface Stones f` Distances$-om: Open Water Body `— ft Possible Wot•Arca ft Drinking Water Well —I ft Drnlhage Way T"'"" ft Property Line 1 = ft Other T ft I ' I SKETCH:(street name,dimensions of lot,exact locations of test holes&porn tests,locate wetlands?a proximlty, to holes) v Tlet Parent material(geologic) D th to Bedrock Depth to Oroundwater. Standing Water In Hole: Weeping tYotn Pit Foos Estimated Seasonal High Oroundwater DETERMINATION FOR SEASONAL-RIGH WATER TA LE ! _ Method Used: di/s - DO th Observed standing in obs.hole: - In, Depth to sell mottles: Do�th to weeping from side of obs,hole: ___in, Oroundwater Adjustment ft. Index Wcli•# Roading Date: Index Wall level _ Adj,dhetdr Adj.C)rtaundwater•Level„_ PERCOLATION TEST bate 3 z f I .ume Observation Hole# Tlmo at 9" Depth of Pero ��r, Time at 6" Start Pro-soak Time @ C c, Time(9"-6") End Pro-soak Rate Mtn./Inch . Z Site Suitability Assessment: Site Passed SitF Fallod: Additional Testing Needed(Y/N) original: Public Health Division Observation Hole Data To Be Completed on Hack— L------ ' ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conseirvation Division at least one(1)week prior to beghming. Q:ISBPTICIPBRCFORM.DOC i ,/( !�J DEEP.OBSERVATION HOLE LOG Hole# Depth from Solt Horizon Sall Texture Shcl Color Sall. Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stonei;Boulders. Isistancy,%]Qrwail yo .3z DEEP OBSERVATION Hole HOLE LOG # Depth from Soil Horizon . Soll Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. s .32 L5 IU L S1G DEEP OBSERVATION HOLE LOG Hole# Depth from Sol Horizon Soil Texture Soil Color Sall •Other. Surface(In.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.. Consistency,%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from. Soil Horizon Soil Texture Sall Color Soll Other Surface(In.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders, Flood Insurance Rate Map: Above 500 year flood boundary No— Yes Within 500 year boundary No Yes Within 100 year flood boundary No. Yes Denth of NeturaUv Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed thrpughout the area proposed for the soil absorption system? `( If not,what is the depth of haturally occurring pervious material? Certificatl°�' I certify that on (date)I have,passe'd the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the required trainin a ertise and experience described In 10 CMR 15.017. Signature --' Date Y 7 Q.\3HFrrlL BRCPORM.DOC TOWN OF BARNSTABLE r� LOCATION � C[��1P_rry Lc,.e, _SEWAGE# o2617—1 VILLAGE ASSESSOR'S MAP&PARCEL /O;I-- INSTALLER'S NAME&PHONE NO. V-7c-cN6L_ SEPTIC TANK CAPACITY 1_t_n n - /-/.;1 0 f) R 0 LEACHING FACILITY: (type) U i:,C C_Vx pA%try (size) /Q is,c �Y�l L �c NO.OF BEDROOMS ���` OWNER A6;jT0.S PERMIT DATE: LA [ �,� COMPLIANCE DATE: (, 1-7 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility _MA Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) WA Feet Edge of Wetland and Leaching Facility(If any.wetlands exist within ,�i 300 feet of leaching facility) If .'t; A Feet FURNISHED BY, P L r i, A Fro evt 13 A3 �g 2-'7 C I, ,ACCESS COVERS MUST BE WITHIN 9 MINIMUM. INVERT ELEVATIONS : DES f GN CR l TER f A : GENERAL NO TES : 6" OF FINISH GRADE 3' MAX/MUM COVER 102.47 FIRST 2' TO INVERT AT BUILDING: 99.4 DESIGN FLOW: BE LEVEL MIN 2. OF PEASTONE INVERT IN SEPTIC TANK: 98.75 3 BEDROOMS AT l l0 G.P.D. PER !. THIS PLAN IS FOR THE DESIGN AND CONSTRUCTION 92.9 OR F I L TER FABR 1 C INVERT OUT SEPTIC TANK- 98.5 BEDROOM EQUALS 330 G.P.D. OF THE SEWAGE D 1 SPOSAL SYSTEM ONLY. !8 98.7 INVERT IN DIST. BOX: 98. 17 �41AM 4 /P �� 98.5 98.0 o DOUBLE WASHED STONE INVERT OUT D!ST. BOX: 98.0 NO GARBAGE GRINDER 2. VERTICAL DATUM IS ASSUMED. FOR BENCH MARKS /2' SET. SEE SITE PLAN. 98.75 . GAS �/ 98. !7 0 97.9 °c 96.9 INVERT 1N LEACH CHAMBER: 97.9 BAFFLE SEPTIC TANK REOUI RED: 3 OUTLET 4 LC-6 LEACHING CHAMBERS BOTTOM OF LEACH CHAMBER: 96.9 330 G.P.D. X 20OX - 660 GAL. J. ALL CONSTRUCTION METHODS AND MATERIALS AND D-BOX W/3.5' STONE AROUND. 10'w x 38'1 x 12'd ADJUSTED GROUND WATER: N/A SEPTIC TANK PROVIDED: 1500 GAL. MIN. MAINTENANCE OF THE SEPTIC SYSTEM SHALL 1500 GAL H-20 OBSERVED GROUND WATER: N/A CONFORM TO MASS. D.E.P. TITLE 5 AND LOCAL SEPTIC TANK 6* CRUSHED STONE OR BO T TOM OF TEST HOLE t: 91.2 SOIL ABSORPTION SYSTEM REQUIRED: BOARD OF HEALTH REGULATIONS. COMPACTED BASE DESIGN PERC RATE ! 5 M I N/I NCH NPROF ! L E : NOT TO SCALE SOIL TEXTURAL CLASS - I 4. ALL SEPTIC SYSTEM COMPONENTS LOCATED UNDER EFFLUENT LOADING RATE - 0.74 GPD/SF AREAS SUBJECT TO VEHICULAR TRAFFIC OR GREATER 330 GPD / 0.74 GPD/SF - 446 S.F. REQUIRED THAN 3' IN DEPTH SHALL BE CAPABLE OF WITH- STANDING H-20 WHEEL LOADS. PROVIDED. 4 LC-6 LEACHING CHAMBERS W/3.5' STONE AROUND. A-476 S.F. 5. ALL SEWER PIPE SHALL BE SCHEDULE 40 PVC OR 476 S.F. x 0.74 - 352 G.P.D. APPROVED EOUAL. SOIL TEST P l T DA TA s 6. SEPTIC TANK AND D-BOX SHALL BE REINFORCED PRECAST CONCRETE OR APPROVED POLYETHYLENE. INDICATES �_ INDICATES BOTH SHALL BE WATERTIGHT. D-BOX SHALL BE WATER PERCOLATION = OBSERVED TEST = GROUNDWATER TESTED FOR LEVEL WHEN THERE IS MORE THAN ONE ' TP sl Ps15293 TP •2 OUTLET. +103.0 HORIZON TEXTURE COLOR HORIZON TEXTURE COLOR o" 101.2 0" I0I.2 7. BEFORE CONSTRUCTION CALL "DIG-SAFE`. I LOAMY IOYR LOAMY IOYR / A SAND 3/4 A SAND OY 1-888-916-SAFE AND THE LOCAL WATER DEPT. 9- - - - - - - - - - - - - - - - 100.5 /0" - - - - - - - - - - - - - - - 100.4 FOR LOCATION OF UNDERGROUND UTILITIES. LOAMY IOYR LOAMY IOYR �) I SAND 5/6 SAND 5/6 \ I +r0` 6 32- - - - - - - - - - - - - - - - 98.5 32-- - - - - - - - - - - - - - - - 98.5 8. SEPTIC SYSTEM INSTALLER SHALL NOTIFY THE MEDIUM IOYR MEDIUM IOYR I l 32.39� i �� saNO s/4 C� saNO s/4 DES 1 GN ENG l NEER TWO DAYS PR l OR TO CONSTRUCTION OF THE SYSTEM TO ALLOW FOR SCHEDULING OF THE 4 LC-6 PRECAST / LEACHING CHAMBER �� CONSTRUCTION INSPECTIONS. L0 / l 5� \W�3.5- STONE AROUND 6' 46' 9. EXISTING CESSPOOL TO BE PUMPED DRY AND sr� l2. 064- S.F. BACKF I L L ED. / \ Fllg y to 1 \ TP*/ 120" NO WATER 9/.2 120" NO WATER 91.2 \ BM. CORNER BOTTOM STEP D BPX 2 EL-102.12co DATE: MARCH 2/. 20/7 TP*2 = TEST BY: STEPHEN HAAS i WITNESSED BY: DONALD DESMARAIS b \ 101.4 PERC RATE: C 2 M/N/I NCH O � b O I O Q O 1 EXISTING 20- . io of DWELLING +101-3 I1. I500 GALLON p / 10, _ SEPTIC TANK y CESSPOOLO � 100.7 100.7 ONA _ _ zrc q SHED : ' 37 y UP 586-3 1� `1 Z� SEPT / C SYSTEM DE� S / ON 74 BARBERRY LANE . MAP 1 02 . PARCEL l 87 BARNS TABL E . CMARSTONS MI LLS ) MA PREPARED FOR LEGEND H ,7 N R Y H O B B S LAKES 1 DE OR L OCU� CB CONCRETE BOUND -W VA TER LINE SCALE ! " - 20 ' APR l L 13 . 2017 SHUBAEL HYDRANT POND 6AS L INE STERHEN A . HAAS OHW-- �VER HEAD WIRES R I NO INC LIGHT POST E N G I NEE -`E UNDERGROUND ELECTRIC LINE P . (D . B o x 1 6 -T- UNDERGROUND TELEPHONE L I NE l j/��>�j� %l �� South D e n n i s , MA 02660 c -CTV- VNDERGROUND CABLEVISION LINE G!'`'` /���I ` ( 508 ) 362-8 132 +40.4 POT ELEVATION ------- 1XISTING CONTOUR LOCUS MAP 0 I 0 20 40 4 _ MOPOSED CONTOUR JOB NO: l 7-009 f f I II