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HomeMy WebLinkAbout0035 BLUEBERRY LANE - Health 35 Blueberrya]�- ane Marstons Mills i Commonwealth of Massachusetts 1 6-2-1 10' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a 'e 35 Blueberry Lane Properly Address Margo O'Brien 35 Bluberry Lane Realty LLC f.• Owner Owner's Name O?� information is required for every Marstons Mills Ma. 02648 3/1/2016 . page. Citylrown State Zip Code Date of Inspection C. 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. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Raymond Dumas use the return Name of Inspector key. Dumas Landscape Const. �y Company Name 564 Old Stage Rd. Company Address r� Centerville Ma. 02632 Cityrrown State 508-778-0249 S1437 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 wig 3/1/2016 In or'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•3113 Ute 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 �J# US Commonwealth of Massachusetts Title 5 Official lnsp ection Dorm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Blueberry Lane Property Address Margo O'Brien 35 Bluberry Lane Realty LLC Owner Owner's Name information is required for every Marstons Mills Ma. 02648 3/1/2016 page. Cityrrown 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: ® 1 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): t5ins.3113 Title 5 Official hispeaion Forth:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts -- - Title 5 Official Inspection Dorm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Blueberry Lane Property Address Margo O'Brien 35 Bluberry Lane Realty LLC Owner Owner's Name information is required for every Marstons Mills Ma. 02648 3/1/2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cant.) ❑ 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.3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Blueberry Lane Property Address Margo O'Brien 35 Bluberry Lane Realty LLC Owner Owner's Name information is Marstons Mills Ma. 02648 3/1/2016 required for every page. Cityfrown State Zip Code bate 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 town overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/day flow t5ins•3/13 Title.5 Official Inspection Fow Subsurface Sewage.Disposal Systern•Page 4 of 17 Commonwealth of Massachusetts Tabs 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 35 Blueberry Lane Property Address Margo O'Brien 35 Bluberry Lane Realty LLC Owner Owner's Name informations required for every Marstons Mills Ma. 02648 3/1/2016 _ Page Cityfrown state Zip Code Date of Inspection B. Certification (cunt.) Yes No ❑ ® 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. ❑ ® 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. ❑ N 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 ❑ El the system is located in a nitrogen sensitive area(Interim Wellhead Protection .Area—IWPA)or a mapped Zone If 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 35 Blu_ebq"Lane Property Address Margo O'Brien 35 Bluberry Lane Realty LLC Owner Owner's Name information is required for every Marstons Mills Ma. 02648 3/1/2016 page. City,tTown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner,occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example,a plan at the Board of Health. ❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms). 330 t5 ns•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Dorm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Blueberry Lane Property Address Margo O'Brien 35 Bluberry Lane Realty LLC Owner Owner's Name information is Marstons Mills Ma. 02648 3/1/2016 required for every page. City/rown State Zip Code Date of Inspection D. System Information Description: 1500 gallon septic tank, D-box and 2-500 gallon chambers with 4 ft. of stone as per as built sketch as per compliance dated 10-3-1996 Number of current residents: 2 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: 2015 33000 gallons 2014 29000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: Date ed now 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: t5ms-3l13 Title 5 Official h spection Forth:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 official inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Blueberry Lane Property Address Margo O'Brien 35 Bluberry Lane Realty LLC Owner Owner's Name information is Marstons Mills Ma. 02648 3/1/2016 required for every page. City/Town state Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 3/2016 Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? 1500 gallon tank Reason for pumping: Maintanance 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): 1500 gallon pre cast septic tank, D-box and 2 500 gallon chambers with 4 ft of stone t5ins-3113 Title.5 Official Inspection Form:Subsurface.Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 official inspection Dorm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Blueberry Lane Property Address Margo O'Brien 35 Bluberry Lane Realty LLC Owner Owner's Name information is Marstons Mills Ma. 02648 3/1/2016 required for every 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: System installed Oct. 1996 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 44 inches below top of foundation fbet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: Town water comes in right front of house Comments(on condition of joints,venting, evidence of leakage, etc.): all good Septic Tank(locate on site plan): 44 Depth below grade: eet inches below grade Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallon Sludge depth: 6 inches t5un.3l13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts TiVe 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Blueberry Lane Property Address Margo O'Brien 35 Bluberry Lane Realty LLC Owner Owner's(dame information is required for every Marstons Mills Ma. 02648 3/1/2016 page Citylrown 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 approx 30 inches Scum thickness 6 inches Distance from top of scum to top of outlet tee or baffle 8 inches Distance from bottom of scum to bottom of outlet tee or baffle 12 inches How were dimensions determined? dip stick ruler Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Pumped tank for maint 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•W13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Blueberry Lane Property Address Margo O'Brien 35 Bluberry Lane Realty LLC Owner Owner's Name Information is Marstons Mills Ma. 02648 3/1/2016 required for every page_ Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): PVC tees look good 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•W 3 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 35 Blueberry Lane Properly Address Margo O'Brien 35 Bluberry Lane Realty LLC Owner Owner's Name information is required for every Marstons Mills Ma. 02648 3/1/2016 Cilyrrown page_ State Zip Code Date of Inspection D. System Information (cunt.) 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.): D-Box Level, some carryover so we pumped the septic tank 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: Located 2-500 gallon chambers as per as built plan t5ins•3f13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts -- Title 5 official lnspectoon Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Blueberry Lane Property Address Margo O'Brien 35 Bluberry Lane Realty LLC Owner Owner's Name information is required for every Marstons Mills Ma. 02648 3/1/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Precast Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): All good Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ® No t5ins•3113 Title 5 Official Inspection Forth: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 35 Blueberry Lane Property Address Margo O'Brien 35 Bluberry Lane Realty LLC Owner Owner's Name information is Marstons Mills Ma. 02648 3/1/2016 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): all good 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.): t5ms•3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Ville 5 official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Blueberry Lane Property Address Margo O'Brien 35 Bluberry Lane Realty LLC Owner Owner's Name information required for every Marstons Mills Ma. 02648 3/1/2016 r for Cityrrown page. 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 le Commonwealth of Massachusetts Fills 5 Official pnsp ection [dorm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Blueberry Lane Property Address Margo O'Brien 35 Bluberry Lane Realty LLC Owner Owner's Name information is required for every Marstons Mills Ma. 02648 3/1/2016 page. Cltyfrown 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: Greater than 14 It below bottom of leaching chambers 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: Daatete 6 D ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: As per plan at Board of Health ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Records at Board of Health Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5fns-3(13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 official Inspection form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 35 Blueberry Lane Property Address Margo O'Brien 35 Bluberry Lane Realty LLC Owner Owner's Name is equired ron for every required Marstons Mills Ma. 02648 3/1/2016 page. Cdyfrown State Zip Code Date of Inspedion E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ms•31`13 Idle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Aloa 41 toll (1:11, ev i dO 1 7 Q �s r CERTIFICATION OF SKETCII AND APPLICATION FOR A DISPOSAL 1VORKS C 0NS'I*ItU '-*1lUN 1'E;It1111,I tIVI*1-110U'I' DESIGNED PLANS] hereby certify that the application for disposal works construction.p B permit signed by me' dated ��Z-9<�f� concerning the property located at � i'1'r' ��� �, ' l-5 meets all of the following criteria: v✓ T ere arc no nctlands within 300 tcct of the proposed]septic system Vicre arc no privale«•ells within 1;0 feet of the proposed septic system vic observed groundn•nicr tnbie is i d fecc or greater below the bottom of the leaching facility T'ere is no increase in now and/or change ?n use proposed There are no variances requested or needed. SIGNED : DATE:. LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER iAltach a sketch plan of the proposed system. Also if the licensed installer posesses A certified plot plan, this plan should be submiticdl. TOWN OF BARNST.ABLE _ lr Av. �SEWAGEO rv- 3! DWALLEWS NAM AP90NENa SEM TANK CAPACITY oSiv 6 q a LEACHING FACII T!'Y:{s�pe} o taa,1` ; rt t t {si�oe) l•1t��lJ���D NO OFmmoobls_r.�! suanFx oR� .deJt/r9DlX�Is PFRIIGTDAIE- 14 COMPLIANCE DAZE: ' Distm�oe Baevap flee: bum Adjusted Canuodw our Table and Bottom of I=chins Faceb'ly Fea Pow water supply well and Lis Facility (If any wells grist an site or within 200&a of hsrrhueg facility) Fed Edse of Worland mdi cachuos Facility(if any wedoods exist within 3W tat of facility) Eby S�cvh� i3At k 6 ' 3MtL 1 J O N�FF Sf�mL Ataex•J 314't.V Health Complaints 14-Oct-05 Time: 4:24:00 AM Date: 10/7/2005 Complaint Number: 18509 Referred To: DAVID STANTON Taken By: ELLEN J. WADLINGTON Complaint Type: NUISANCE CONTROL REG. 1 RUBBISH Article X Detail: UNSANITARY CONDITIONS Business Name: Number: 35 Street: BLUEBERRY LANE / Village: MARSTONS MILLS Assessors Map_Parcel: 102- -f 6 b Complaint Description: bags of trash along driveway for the last week, scattered by animals; neighbor reporting has been picking up trash for a week.Owners in Sandwich, Daniel and Margo O'Brien 508-888- 1676. Complainant spoke with owner and was told tenants being evicted and owner's atty advised them not to go near property so can't claim harassment. Complainant says now it's been 2 weeks and trash stinks and is all over road. Actions Taken/Results: DS WENT TO SAID LOCATION AND SPOKE WITH TENANT. THERE WAS NO TRASH ALL OVER THE ROAD. THE TENANT CLAIMS THAT SHE CLEANED IT UP. THE TENANT STATED THAT THE TRASH COMPANY WAS COMING TODAY. THE HAVE TWO CONTAINERS OUTSIDE, AND SOME BAGS THAT ARE COVERED OVER WITH A HEAVY CANVAS PAINTERS DROP CLOTH. NO FURTHER ACTION REQUIRED. Investigation Date: 10/13/2005 Investigation Time: 2:20:00 PM 1 Health Complaints 14-Oct-05 2 A5ASSUK5 MAC' NU: r L- 2 :i `' PARCEL NO.: V,LLACL INSTA LLER'S NAME A ADIDRESS B U I L D E R OR OWNER D AT E P E R M I T I S S U E D DATE C0MPLIAN-CE ISSUED M STifi o(�t�'C At TOWN OFBARNSTABLE �/ / 1ILLACGIE "PON 3� �� kets' /4• SEWAGE # P6' ! 3e.��'�6 rd'� Obi��� ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. ���f�'� � Cadl<S ����✓� '�' SEPTIC TANK CAPACITY %5'0® 6 A L 0"1 a LEACHING FACILITY: (type) 5 a V L its s s$tj e.1 1.j (size)015'1-`A I N' Wh .� NO.OF BEDROOMS BUILDER OR� S PERMIT DATE: COMPLIANCE DATE: .��"� - " Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished bye 8ACK 6 ' NovSe— 3`F-A L L d0 13 31 � a f5-q- 39' G ,, No. .. Feea THE COMMONWEAL H OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Z[ppYication for Mi5po0al *p5tem Conotruction Permit Application is hereby made for a Permit to Construct( )or Repair( V<an On-site Sewage Disposal System at: Location Address or Lot No. �' � jrl l Owner's Name,Address and Tel.No. Assessor's Map/Parcel ��1J�/,.5),—ew6 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 Garbage Grinder(-W Other Type of Building /&3j�?effle-,O No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow l/le�l gallons per day. Calculated daily flow 3�® gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs or Alterations nswer whe applicable vim' A�1 ���A Q'�C��o Q - oar L �� wIr Date last inspected: Agreement: The undersigned agrees to ensure the construction of the afore described on-site sewage disposal system in accordance with the provisions of Tide 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued this He / Signed Date `Z�. Application Approved b < Alz&d Date Application Disapproved for the following reasons Permit No. Date Issued 4W- No Fee THE COMMONWEAL H OF MASSACHUSETTS. . � PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MAS9AC�FIUSETTS 2pplicatton for ;Dtgpoga1 *pgtem Congtructton Permit Application is hereby made for a Permit to Construct( )or Repair( w1lan On-site Sewage Disposal System at: Location Address or Lot No. J p t— / �y` Owner's Name,Address and Tel.No. J Assessor's Map/Parcel 44'f/ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. f Type of Building: Dwelling No.of Bedrooms_ 3 p Garbage Grinder(,�aQ Other Type of Building IPSidioHiB No.of Persons Showers( ) Cafeteria( ) OtheQF,h tunes Design Flow 4/4 gallons per day. Calculated daily flow 33Q gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs or Alterations(Answer when applicable) D 4v Date last inspected: Agreement: The undersigned agrees to ensure the construction nxo ads .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 bV this f_ Heal Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued X__:� [3 ——————————————————————————————————————— THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certtf irate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced( on by Installer �� yi' at_ Sr`�i�f Title�5 o r.�✓ / has been constructed in accordance with the provisions o and/the for,Disposal System Constructio 'e • 't No. dated VJ /.fig ram^ /- Date Inspector. or THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYS- TEM WILL FUNCTION SATISFACTORY. ——————————————————————————————————————— No. �QZ —�©� Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS &!6pogal *pgtem Comgtructton j3ermtt Permission is hereby granted to Z&Z/ &&7�I/, to construct( )repair( ./an On-site Sewage System located at No.# 4 /��/,f- 01il y AW. Sweet and as described in the above Application for Disposal System Construction Permit. FW o �lS- P The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within three years of the date below. Date: �' 10" Approved by of Heal r Y, CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONS FRUCTION 1'I?1t1111-1' (%V1'1.11OUT UESIGNEU PLANS) hereby certify that the application for disposal works -_....._. construction permit signed by me dated g-12,71e , concerning the property located at ��� �C� �h, ✓�� -5 meets all of the following criteria: ,ITlT4. icre ire no wcilands within 300 feet of(he proposed septic system Ycre arc no private wcils within 150 feet of the proposed septic system —Ulic observed gronndivater table 's i 9 rec!or greater below the bottom of the leaching racility Y T'ere is no incrc tse in how and/or chance n use proposed There are no variances rcauested or needed. SIGNED : DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER IAttach a sketch plan or the rroposed system. Also irthe licensed installer posesses a certified plot plan, this plan should be submilled-l. r - t �-_e��y, w+ a..., - :y.>"` .,�.4,'' J'.. }:s2 z;�..r- �- .aa- so:`uji�' t „�-::'•�'t-. JJr ti.�.r. .. Yam. .`F r.=T�1 a - r 1'- w oy � I � F" / 5j 4t-- S 3 Lu;-A�rtrc UJ