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Marstons Mills P
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REVISED 6-14-17, DECK AND ADDITION SIZE
CER TIFIED PL 0 T PLAN
MAHONEY RESIDENCE
CERTIFY THAT THE 96 BOSUN'S WAY
HAVE BEEN LOCATED BY AMF�ELD SURVEY. �`�"��ENTS SHOWN � �f IrgSs9c CENTERWLLE, MA
ti o� G DATE MAY 1, 2017 DRAWN: RBS
ROBB �, JOB #: S317
o SYKES SCALE: 1"=40' DWG. CPP
No. 35418 EASTBOUND
*LAND SURVEYING, INC.
Fs�N/ST No P.O. BOX 442
ROBE SYKES,� P.LS. DATE FORESTDALE, MA 02644
508-477-4511
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MBLU 46-114 �`�'•
96 BOSUN'S WAY
CENTERVILLE, MA
PROP. 16'x23'
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SEPTIC FROM ASBUILT
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HEALTH DEPARTMENT
BUILDER TO CONFIRM
REVISED 6-14-17, DECK AND ADDIPON SIZE
CERTIFIED PL 0 T PLAN
MAHONEY RESIDENCE
1 CERTIFY"THAT THE IMPROVEMENTS SHOWN �.�� of 96 BOSUN'S WAY
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a ROBB �, JOB #. S317
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No. 35418 H EASTBOUND
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P.O. BOX 442
FORESTDALE, MA 02644
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COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, SS DISTRICT COURT
DOCKET NO 0925SU2032
RICHARD MAHONEY )
V. ) SUBPEONA
LISA FIERLY,et al )
You are hereby commanded, in the name of the Commonwealth of Massachusetts to
appear and give testimony in the above captioned matter at the Barnstable District Court on
January 7, :2010 at 9:00 a.m.
Dated at the Law Office of Attorney Richard Gavin Barry the 30th day of December
20V Please direct all inquiries to Lisa Fierley at 1-508-6 - 965.
otary
Commission expi s 4/25/14
FORM30 .C&w HOBBSRWARRENTM THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
is/L—ss-ka.
CITY/TOWN
_ o
DEPARTMENT
2v b \ !L—j- R W S Yam"
ADDRESS 6a) 0//,7 4
671
TELEPHONE
(1 �✓LL�F
Address k`M(�'Cr��S �.\�_—_�Occupant__.
Floor Apartment o. No. of Occupants 6
No. of Habitable Rooms No.Sleeping Rooms_.S
No.dwelling or rooming units_ k- No.Storie
Name and address of owner-: 0 a*_ _ ANC ,J 1�q!> Z5 —0� p�
3, i.¢0{L 'IQ 0- N (yCI-) Remarks Reg. Vio.
YARD ut Bld s.: Fences: 0
Garbage and Rubbish
Containers: f�r�llZ�(.S Z
Drainage g-gv 'Cau Tg^'"t wAA A
Infestation Rats or other:
STRUCTURE EXT. Steps,Stairs, Porches: uL, /0
Dual Egress: and Obst'n.: ,Z `,v p u.0 9-2fjV i
❑ B ❑ F ❑ M Doors,Windows: ® po-Uvtv CV2 qt7
Roof 0ti 1-ga, -4-...1
Gutters, Drains: Li LrjA At h SG"Zvs f_4r-tgCr,0 q/U &--
Walls:
Foundation: DA w14 04z, to GUI_
Chimney: Ir 4.0—> A(-S
BASEMENT Gen.Sanitation: T20 GLC
Dampness: L,
Stairs:
Lighting: st 0 .\10 4/0G
STRUCTURE INT. Hall,Stairway: cZL�x_" t. -i S
Obst'n.:
Hall, Floor,Wall, Ceiling: OU rA U N 2
Hall Lighting: ,vS7/LuG"7 J'0AJ t ,v
Hall Windows: S 9/"1 , IS
HEATING Chimneys: Ala F, �
Central ❑ Y ❑ N Equip. Repair A.10 - ,$ 0
TYPE: Stacks, Flues,Vents: 951.,t(_V1 Aj
PLUMBING: Supply Line: 2wl jvur�
❑ MS ❑ ST ❑ P Waste Line.-
H.W.Tanks Safety and Vent(s)
ELECTRICAL Panels, Meters,Cir.:
❑ 110 ❑ 220 Fusing,Grnd.:
AMP: Gen.Cond. Distrib. Box:
Gen. Basement Wiring:
DWELLING UNIT
Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks .o
Kitchen 13t L--, S i�,6� Kr- / f
Bathroom C 11L �- Cv 3�'� w
Pantry
Den
Living Room
Bedroom 1
Bedroom 2 1 v
Bedroom 3 f lv
Bedroom 4
Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.:
Stacks, Flues,Vents,Safeties:
Kitchen Facilities Sink
Stove
Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.:
Wash Basin,Shower or Tub: -
Infestation Rats, Mice, Roaches or Other: JO
Egress Dual and Obst'n.-
General Building Posted —' o'c js',rtfLLv3
Locks on Doors: r7A c.
r
ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH '
MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE
OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE
AUTHORIZED INSPECTOR. (See Over)
"THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND
PENALTIES F PERJU ?
/�/
INSPECTOR TITLE J10a,C Zq
DATE 7 t 2,411 Oct TIME `!J� 1-1' P.M.
-^T A.M.
THE NEXT SCHEDULED REINSPECTION ` P.M.
u.• }•c.,r .�.� I.k- .i. ,;� S...., F, � '(Jn 7 . .�. '. �.s. ,�., �•re„ cv
,
410.750: Conditions Deemed to Endanger or,Impair Health or Safety
The following conditions, when foundrto exist in residential premises, shall be deemed conditions which may endanger or
impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those
items which are deemed,to always have the potential to endanger or materially impair the health or safety, and well-being of the
occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for
human habitation, any,other violation has the potential to fall within this category in any given specific situation but may not do so
,in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that
other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local
health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to
include affect the Legal obligation of the person to whom the order is issued to comply with such order.
(A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold,to meet the ordinary
needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of'24 hours or longer.
(B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as
prohibited by 105 CMR 410.200(B)and 410.202.
(C) Shutoff,and/or failure to restore electricity or gas.
(D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com-
mon area required by 105 CMR 410.254.
(E) NFailure to provide a safe supply of water.
(F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR
410.150(A)(1)and 410.300.
(G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object,
including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452.
(H) Failure to comply with the security requirements of 105 CMR 410.480(D)
(1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar-
bage, rubbish,filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests
or otherwise contribute to accidents or to the creation or spread of disease.
(J) The presence of Ieadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public
Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.)
,
(K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or
other dangers or impairment to health or safety.
(L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating,
gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352,
so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety.
(M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release
of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105
CMR 410.353.
(N) Failure to provide a smoke detector required by 105 CMR 410.482.
(0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or
knowledge of the owner of said condition or conditions:
(1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven
or any defect that renders either inoperable.
(2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any
defect which renders them inoperable.
(3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of
` generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. `
(4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as
required by 105 CMR 410.503(A)and 410.503(B).
(5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550.
(P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con-
dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner
to remedy said condition within the time so ordered by the Board of Health.
.Citizen Web Request Page 1 of 2
- �aPH -C6 s
Citizen Request Management - Internal Use
Request ID: 27372 Created: 10/27/2009.9 32:42 AM
Siatus: Assigned To Staff Assigned To: Cabot, Jaime
Health Office
Chapter II : Housing
I Anonymous: No Category: Substandard
E.C. Date: 11/10/2009
Created By: Wadlington, Ellen Citations:
Health Office
i Time Worked: 2.50 Response Time: 4.00
i
—' ,Requestor Details:
Email:
Request Location:
96 BOSUN'S WAY
Marstons Mills, Ma 02648
Parcel Number: Map: 046 Block: 114 Lot: 000
Request:
Hot water blew up, no heat because heat is forced hot water; mold in basement, severe.
Have been told it is very toxic for children. Have four children. Unregistered rental.
Request Work History:
Entered on 10/27/2009 4:18:26 PM
by Cabot,Jaime
JAC spoke to who say' s she spent$4500 on Sept. 1st as rental payments and that
she has had many problems with backed up septic leaking dishwasher and toilets that do not
flush. JAC will inspect at 10:00 on 10/28/09
Entered on 11/5/2009 1:02:25 PM
by Cabot,Jaime
JAC issued order letter based on inspection.
Entered on 11/6/2009 1:22:41 PM
by Cabot, Jaime
JAC spoke to Richard and Diane Mahoney they explained situation as a hostile tenant being
evicted. Past tenant had caused property damage per owners, a mold problem in basement which
was corected by a Paul Iverson and Roy Ritchie I explained that there were no building permits on
file for the work and that the unfinished stud walls and electrical work in the basement were
http://issgl2/intemalwrs/WRequestPrint.aspx?ID=27372 11/19/2009
Citizen Web Request Page 2 of 2
violations. JAC asked that the property be registered as a rental and that efforts be made to
correct violations.
Entered on 11/19/2009 3:47:16 PM
by Cabot,Jaime
JAC spoke to Richard Mahoney by phone he states that the trash left outside belongs to the
present tenant and that contractors had not been allowed access to do work. Lisa Fierley states
that the house is infested with rodents and that the situation existed when she moved in and that
she was promised a visit from an exterminator. JAC will re-inspect on 11/30/09 at 10:00am.
-Internal Note History:
System entry on 10/27/2009 9:32:43 AM:
Assigned to Cabot, Jaime
Entered on 11/6/2009 1:22:41 PM
by Cabot,Jaime
Property was rented by a Jean Bowden for the Mahoney's son.
System entry on 11/13/2009 1:27:20 PM:
Request Closed by cabotj
System entry on 11/19/2009 3:11:14 PM:
Request Reopened by cabotj
Entered on 11/19/2009 3:49:53 PM
by Cabot, Jaime
Diane Mahoney 440 725 -0648 History with the Mahoney's on the following properties. 373
Scudder Ave. Hyannisport and 35 Oreo Lane, Centerville
http://issgl2/intemalwrs/WRequestPrint.aspx?ID=27372 11/19/2009
ROBERT DOUGL AS
............................................
122 LIETRllVI cir CENTERVILLE MA 02632
508-42.8-2504 774-836-5482
November 8,2009
Dear Richard and Dianne MAHONEY
BASEMENT MOLD JOB
Two LG Dehumidifiers,two Garden hoses 25'so water can drain outside,twenty sheets of Green board mold
resistant and moisture resistant.Four rolls of mold resistant tape,drywall screws and mud.Vinyl flooring and
new Baseboard.Map insulation will tear down and replace all insulation.One dumpster for all mold infected
material.After Dehumidifiers run for one week,remove all mold infected sheet rock and flooring,put up new
mold resistant green board and paint.Scrape up molded vinyl floor and replace with a new vinyl floor..Take
out broken glass from wood stove,and replace.Fix ripped screens and look for replacement screens where
they're needed. Homeowner pays for Dehumidifiers»I ROBERT DOUGLAS will take care of mold,insulation
paint,clean up and removal.6,500.00. 2,500.00 down Balance do upon completion of job.
I
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Restricted Delivery Fee p �� nW�
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Sen t�
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Certified Mail Provides:,, ,..
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a duplicate return receipt,a LISPS®postmark on your Certified Mail receipt is
required. ,
b For;an additional fee,Fdelivery may be restricted to the addressee or
addressee's authorized aent.Advise the clerk or mark the mailpiece with the
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a 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
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IMPORTANT.Save this receipt and present it when making an inquiry.
PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047
SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY
■"Complete items 1,2,and 3.Also complete A. 8iognaayre
item 4 if Restricted Delivery is desired. ❑Agent
■ Print your name and address on the reverse X Addressee
so that we can return the card to you. B. Received by(Printed Name) C. D to of Delivery
■ Attach this card to the back of the mail iece,
or on the front if space permits. p I �0
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1. Article Addressed to: If YES,enter delivery address below: ❑ No
45 3� �►0n
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ACertified Mail [3Express Mail
zi ❑Registered ❑Return Receipt for Merchandise
❑Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number �7006 2150Y00022 1038 73984�
(Transfer from service laben,
PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540
UNITED STATES POSTAL SERVICE First-Class Mail
Postage&Fees Paid
USPS
Permit No.G-10
• Sender: Please print your name, address, and ZIP+4 in this box •
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Tr HE Town of Barnstable Barnstable
Regulatory Services Department OftwicaC j
�* BARNS-rAULE, D
639- Public Health Division
$prED"hA�a 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTTIFIED MAIL 7006 2150 0002 1038
November 3, 2009
Richard and Diane Mahoney
6835 Morley Rd. l 1
Concord, OH 44077 y qd J
C
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY
CODE II-MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
AND THE TOWN OF BARNSTABLE CODE CHAPTER 170.
The property owned by you located at 96 Bosun's Way, Marstons Mills was inspected
On October 28, 2009 by Jaime Cabot, R.S. Health Inspector for the Town of Barnstable.
This inspection was conducted on the basis of a housing complaint.
The following violations of the State Sanitary Code were observed:
105 CMR 410.500-Owner's Responsibility to Maintain Structural Elements:
Exterior siding has been damaged by animals creating openings for nests. Basement
bulkhead leaks and is a source of chronic dampness "I a4dli &V sj Aj
-e
105 CMR 410.5517 Screens for Windows: Screens not provided for all open able
Windows.
105 CMR 410.552- Screens for Doors: Sliding door in living room has a damaged
screen.
105 CMR 410.351- Owner's installation and Maintenance responsibilities.
Exposed wiring in basement, dishwasher leaks when operated and toilet handle broken.
woodstove has no permit on file at the Building Department.
105 CMR 410.450-Means of Egress: Room under construction in basement lacks
proper egress and lacks approvals from permitting authority.
4v+_10_
105 CMR 410.600 - Storage of Garbage and Rubbish: .-TYZA-'" -h`ti° "' P1G '
Garbage and rubbish left by the previous tenant has been left out for more than 24 hours.
r1+
The following violations of the Town of Barnstable code were observed:
170-4— Certificate of Registration. Rental property is not registered with Town of
Barnstable Health Department.
You are directed to repair the following violations within thirty (30) days of your
receipt of this notice by repairing the damaged siding, applying for a permit for a
wood stove, repairing the leaking dish washer, broken toilet handle, correcting the
exposed wiring and eliminating the source of chronic dampness in the basement.
You are directed to apply for permits to install a five (51)foot cased opening in the
room in the basement that is under construction that does not have proper egress
and is not permitted per Disposal Works Permit 97-423 (approval for a three
bedroom dwelling).
Screens need to be provided for all windows designed to be opened and doors that
open directly to the outside between April first and October cn
p 30 .
You are directed to register the rental properties with the Town of Barnstable
Health Department within ten (10) days of your receipt of this notice.
You are directed to remove the rubbish and garbage that was left in the yard by the
previous tenant within twenty four (24) hours of your receipt of this notice.
You may request a hearing before the Board of Health if written petition requesting same
is received within ten (10) days after the date the order is served.
Non-compliance will result in a fine of$100.00 per violation. Each day's failure to
comply with an order shall constitute a separate violation.
Should you have any questions regarding the above violations, please contact the Town
Health Division and ask to speak with the inspector who performed the inspection.
P7m—a/sM7E
QF TH BOARD OF HEALTH
bean, R.S., CHO .
Director of Public Health
Town of Barnstable
Cc: Lisa Frierley
f
Date: August 25,2006
To: Building File
From: R. Giangregorio
Re: 35 Oreo Lane, Centerville
M&P: 247-140
Zoning: RB
Overlay: AP
David(BOH) identified an addressing problem with this lot when he responded to a
complaint. It appears that there are 2 DUs on this parcel. Frank in Eng would not assign
a new number until the legality of the second unit was confirmed.
A review of the building file shows the following:
• There are 2 structures on MP 247-140..
• Both are identified as sf by Assessing.
• The 2-story primary dwelling)was constructed in 1934 and effectively rebuilt in
1975.
• The 1 1/4 story dwelling was constructed in 1935 and effectively rebuilt,in 1969.
• BOH informs me that there are 2 separate septic systems.
From the age and outside appearance of the secondary unit it is likely this unit was
originally constructed as a garage circa 1930's and converted for residential use in 19
Concrete still butts up against the structure as was common in the 1940's & 50's. (See
BOH pictures taken by David Stanton). _The interior pictures of the unit in question
appear be typical 1970's style.
All building permit applications will"be referred to the ZBA.
I reviewed the file with the BC. He agrees that the burden of proof is on the applicant
because there is not sufficient evidence supporting the theory that the secondary unit was
originally constructed as a sf.
71
07 C-A,,"h
4 %1Z1%5
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
PARCE14
LOT t.o
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A RECEIVED
CERTIFICATION
Property Address: 96 Bosun's Way JUN 2 9 2004
' Marston Mills, MA 02648 TOWN OF BARNSTABLE
Owner's Name: Robert Bolt HEALTH DEPT.
Owner's Address:
Date of Inspection: June 14, 2004
1 �
i
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford C—
Mailing Address: P.O. Box49 2i Ci
Osterville,MA 02655-0049 Lnn a)
Telephone Number: (508) 862-9400
J
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the - formatio6repofad
below is true,accurate and complete as of the time of the inspection. The inspection was perfo ed based-en myj
training and experience in the proper function and maintenance of on site sewage disposal syste s. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
✓ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fa'
Inspector's Signature: Date: June 15, 2004
The system inspector shall sub ' a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 96 Bosun's Way
Marston Mills. MA
Owner: Robert Bolt
Date of Inspection: June 14, 2004
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the "Conditional Pass" section need to be replaced or
repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined",please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
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Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 96 Bosun's Way
Marstons Mills. MA
Owner: Robert Bolt
Date of Inspection: June 14, 2004
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
4
2. System will fail unless the Board of Health(and Public Water Supplier, if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 96 Bosun's Way
Marstons Mills, MA
Owner: Robert Bolt
Date of Inspection: June 14, 2004
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped—
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ Any portion of a cesspool or privy is within a Zone 1 of a public well.
✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.[
No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd-
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA)or a mapped
Zone 11 of a public water supply well
I`you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
f Page 5 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 96 Bosun's Way
Marstons Mills. MA
Owner: Robert Bolt
Date of Inspection: June 14, 2004
Check if the following have been done: You must indicate"yes"or"no"as to each of the following:
Yes No
✓ Pumping information was provided by the owner,occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ _ Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection?
✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ _ Was the site inspected for signs of break out?
✓ _ Were all system components,excluding the SAS, located on site?
✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes No
✓ _ Existing information. For example,a plan at the Board of Health.
✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance '
is unacceptable) [310 CMR I5.302(3)(b)].
5
Page 6 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 96 Bosun's Way
Marstons Mills, MA
Owner: Robert Bolt
Date of Inspection: June 14, 2004
FLOW CONDITIONS
RESIDENTIAL
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
Number of current residents: 2
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage.system(yes or no): n/a [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): ______gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
ndustrial waste holding tank present(yes or,no)
Mon-sanitary waste discharged to the Title 5 system(yes or no):
'Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Unavailable
Was system pumped as part of the inspection(yes or no): No
If yes, volume pumped: _gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Installed 8115197-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 96 Bosun's Way
Marstons Mills. MA
Owner: Robert Bolt
Date of Inspection: June 14, 2004
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC _other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints, venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 12"
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 3"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 12"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage.
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
i
7
Page 8 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 96 Bosun's Way
Marstons Mills. MA
Owner: Robert Bolt
Date of Inspection: June 14, 2004
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: None (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.):
r
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
.Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of I 1
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: _ 96 Bosun's Way
Marstons Mills. MA
Owner: Robert Bolt
Date of Inspection: June 14, 2004
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching chambers,number:
✓ leaching galleries,number: 4 maximizers(per as built card)
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.):
The mazimizers were dry. There did not appear to be any signs offailure The bottom to grade was 4' A video camera was used
for the inspection.
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: None (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
9
~ Page 10 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 96 Bosun's Way
Marstons Mills. AM
Owner: Robert Bolt
Date of Inspection: June 14, 2004
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
3a t3ALk
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10
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Page 11 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property hAddress: 96 Bosun's Way
Marstons Mills. MA
Owner: Robert Bolt
Date of Inspection: June 14, 2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 30 +/- feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: Topographic and water contours maps
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using Barnstable topographic maps and water contours maps the maps were showing approximately 30'+/-to ground water
at this site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
]1
i
7/2/02
DATE : -----------
� R� DCRTV ADDRESS' _QC1_B.0.Shc-II-S--�a-y----------
_--- -
- -Ka-r-st-o-n-s-P4 i 1-�s,-I")-as� .
_ 02648------ ------------
CEIVED
On the above date, I Inspected the septic system at the above Fadidress.
This system consists of the following:
JUL 082002
1 . 1-1.000 gallon septic tank .
2 . 4 Maximizers in series . ( 30 'X10 ' TOwtvOFBARNSTABLE
HEALTH DEPT.
Based on my Inspection, I certify the following conditions:
3 . This is a title five septic system.
4 . The septic system is in proper working order
at the present time .
5 . Stone surrounding the maximizers is presently dry .
SIGNATURE :,,
Name : _ti_�,_ Maco�ber J1r
Company : Jose2h _P _-Macomber-& Son , Inc ,
�ccress : Box 66
_-Cence_rville , _Ma_- 02632-0066
Phone 508- 715- 333.8
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY s
JOSEPH P. MACOMBER & SON, INC.
Tan ks•Cesspools•Leachf lelds
Pumped & Installed
Town Sewer Connectlons
P 0. Box 66 Centerville, MA 02632.0066
775.3338 775.6412
•
COMMONWEALTH OF MASSACHUSETTS
= EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
r
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 96 Bosuns Way
Marstons Mills .Mass .
Owner'sName:pick Mahoney
Owner's Address: 6835 More 1 e y Road
Gnnrnrd (phin44n77
Date of Inspection: 7 f 21/CL2
Name ofInspector: (ppleaseprint oseph P .Macomber Jr .
Company Name: J.P . Macomber on Inc .
Mailing Address: Box 66
Centerville ,Mass . 02632
Telephone Number: 508-7 7 5-3 338
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience i,n 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:
ILIPasses
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fail
Inspector's Signature: Date:X
The system inspector shall mit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner.shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
f
Page 2 of 1 1
i
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:96 Bosuns Way
Marstons Miiis ,mass .
Owner: Dick Mahoney
Date of Inspection:? 2 02
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A System Passes
have.not found any informatio hick indicates that any of the failure criteria described in 310 CMR
15.303 or in 30 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
The septic system is in proper working order at the
present time . Stones are dry within the leaching area .
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass" section need to be replaced or
repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass.
Answer yes, no or not determined (Y,N,ND) in the for the following statements. If"not determined"please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
'A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
/f��P Observation of sewage backup or break out or high static water level in th distribution o ue to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
1G11/ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Propem. Address: 96 Bosuns Way
Marstons Mills .Mass .
Owner: Dick Mahoney
Date of Inspection: 7 (? /02
C. Further Evaluation is Required by the Board of Health:
Conditions exist which requ've further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
I. S,sstem Hill pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the
system is not functioning in a manner wbich will protect public bealtb, safety and the environment:
deb Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the
system is functioning in a manner that protects the public health, safety and environment:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of
surface water supply or rributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone I of a public water supple
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 10, feet but 5 feet or more from a
private water supple yell— Method used to determine distance
'This s\stem passes if the well water analysis, performed at a DEP cenified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that faciliry 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 anached to this form.
3. Other:
3
Page 4 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWACE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:96 Bosuns Way
Marstons Mills ,Mass .
Owoer:Dick Mahoney
Date of lospeclion: 7/2/02
D. System Failure Criteria applicable to all systems:
You must uidicate 'yes" or "no" to each of the following for all inspections:
Yes !"0/
✓l/ackvp 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
_,d/d,V_2 Sutic liquid level in the isrmnbution box bovc outlet inven due to an overloaded or clogged SAS or
/ cesspool 4� / 12� �D'1( A-0
_ V Liquid depth in Q-4is css than 6" below invcn or available volume is less than 'A day now
Rcquircd pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped (5 .
_ y ponion of the SAS, cesspool or privy is below high ground water elevation.
:;� Any ponion of cesspool or privy is within 100 feet of a surface water supply or rributary to a surface
/ water supply.
y ponion of a cesspool or privy is within a Zone I of a public well.
�/ y ponion of a cesspool or privy is within 50 feet of a private water supply well.
u, ponion 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 qualiry analysis. (Tbis system passes If the well water analysis.
pert,rmed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate oitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the soalysis trust be attached to this form,j
X)0(Ycs'No)The system fails. I have determined that one or more of the above failure criteria exist as
described to )10 CMR 15 30). therefore the system fails. The system owner should contact the Boar:
Health to determine what will be necessary to correct the failure
E Large Systems:
To or considered a large system the system must serve a facility with a design now of 10,000 gpd to 15.000
gpd
You must indicate citll 'yes" or"no" to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
des no -
no
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
v the system is located in a nirrogen sensitive area (Interim Wellhead Protection Area — IWPA)or a mappec
Zone 11 of a public water supply well
!f you nave answered "yes" to any question in Section E the system is considered a significant threat, or answered
\es" to Section D above the large system has failed. The owner or operator of any large system considered a
s:en:ftcant threat under Section E or failed under Section D shall upgrade the system in accordance with 3 10 CMR
;04 The system owner should contact the appropriate regional ofT'ice of the Deparrment.
4
Page 5 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 96 Bosuns Way
arstons niiiis ,mass .
Owner: Dick Mahoney
Date of Inspection:7 2 02
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 sys:em received normal flows in the previous two week period ?
YHave large volumes of water been introduced to the system recently or as part of this inspection ?
y _ Were as built plans of the system obtained and examined? (If they were not available note as N/A)
i _ Was the fac liry or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out ?
Were all system components,4xtluding 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 faciiiry owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems ?
The size and Iccation of the Soil Absorption System (SAS)on the site has been determined based on:
Y no
V_ Existing information. For example, a plan at the Board of Health.
Determined Li the field (if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) (310 CfvIR 15.302(3)(b))
Ilf
5
I
l
Page 6 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 96 Bosuns Way
Marstons Mills , Mass .
Owner:Dick Mahoney
Date of Inspection: 7/2/02
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):IL Number of bedrooms (actual):
DESIGN now based on 310 CMR 15.203 (for example: 110 gpd x h of bedrooms):JI X4)d-�CP��.0
Number of current residents: It
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system (yes or no): [if yes separate inspection required)
Laundry system inspected (yes or no):
Seasonal use: (yes or no):
Water meter readings, if available (last 2 years usage (gpd)): If well has .not been
Sump pump(yes or no): tested in the last
Last date of occupancy:
� 12 months. It should be
be done at this time .
COMMERCIAL/WDl7STR1AL
Type of establishment:
Design now(based on 310 CMR 15.203): gpd
Basis of design now (seats/persons/sgft,etc.):tif}
Grease trap present(yes or no): ly
Indusrrial waste holding tank present (yes or no):
Non-sanitary waste discharged to the Title 5 system (yes or no):/y�
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION-
Pumping Records
Source of information: e
Was system pumped as pan of the inspection (yes or no):
If yes, volume pumped: Q gallons -- How was quantiry pumped determined?
Reason for pumping:
T ' OF SYSTEM
OSeptic tank, , soil absorption system
Single cesspool
,U�Overflow cesspool
470— Privy
/115 Shared system (yes or no)(if yes, attach previous inspection records, if any)
/M Innovative/Altemative technology. Attach a copy of the current operation and maintenance contract (to be
WLned from system owner)
ight tank Attach a copy of the DEP approval
.0 Other(describe): �JJ9
Approxi ate aye of all com o ents, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site (yes or no):AO
6
Page 7 of I 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 96 Bosuns Way
Marstons Mills ,Mass .
Owner: Dick Mahoney
Date of Inspection: 7/2/0 2
BUILDING SEWER(locate on site plan)
!J
Depth below grade:
Materials of construction:,ocast iron 40 PVCA�other(explain): lem
Distance from private water supply well or suction line:",vl;"
Comments(on condition of Joints, venting, evidence of leaka e etc.)'
Joints appear tight . No evidence ofgIeakage .The system is
vented through the house vents . -
SEPTIC TANK: Zlocate on site plan) 1 oa.0 f-4 l-6d5
Depth below grade: Aoz
Material of construction: concrete metal 4?dfiberglasslopolyethylene
i other(explain)
If rank is metal list age: Is age confirmed by a Certificate of Compliance (yes or no):Y(attach a copy of
certificate)
Dimensions:
Sludge depth: !�
Distance from top of sl5dge to bottom of outlet tee or baffle:
Scum thickness: 5r�
Distance from top of scum to top of outlet tee or baffle:
Distance from bonom of scum to bottom of outlet tee Qf baffle: /d
How were dimensions determined: �J/Pa9rSL/
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as.related to outlet invert, evidence of leakage, etc.):
Pump the septic tank every 2-3 years . Inlet & outlet tees
are ; n plara _Thp tank is structurally sound and shows no
evidence of )l�e�akage .
GREASE TRAPi�Llocate on site plan)
Depth below grade:
Material of construction:.-ZA) concrete,�J) metal4�gfiberglasseLd!j)olyethylene4other
(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 propping:
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 is not present .
7
Page 8 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 96 Bosuns Way
Marstons Mills Mass .
Owner Dick Mahoney
Date of Inspection: 7/2/0 2
TIGHT or HOLDING TANKA&L8 (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: V
Material of consmruction:,,/,4 concrete 4J�metal d,,L0_fiberglass Iopolyethylene,&�*other(explain):
AlIq
Dimensions:
Capacity: WA allons
Desien Flow: .40 gallons/day
Alarm present (yes or no):
Alarm level: .flA Alarm in working order(yes or no): 4119
Date of last pumping: L
Comments (condition of alarm and float switches, etc.):
Tight or holding tanks are not present
DISTRIBUTION BOXh/gf/e- (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments note i x ' v( f box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box, etc.):
Distribution box is not present .
PUMP CHAMBER-L/drr- (locate on site plan)
Pumps in working order(yes or no):.�i9
Alarms in working order(yes or no):
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Pump chamber is not present .
8
Page 9 of 1 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 96 Bosuns Way
arstons i s , ass .
Owner: Dick Ma Toney
Date of inspection: i 2 0
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, exc vatic�t�rt r0epti�e�)
4— Maximizers Tacked in s one . ( In series 3 1
If SAS not located explain why:
Located ; See page 1
Type
B
leaching pits, number:O
leaching chambers, number:- j oJJc75'5 Visit /ly
�Ub leaching galleries,-number: 6
T_ leaching trenches, number, length: C
AQF leaching fields, number, dimensions:ff
4JL overflow cesspool, number:Q ��
1L innovative/alternat ve system Type/name of technology: >//Je
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
Loamy sand to medium fine sand . No signs of hydraulic failure
or pon ing . of s are ry . ege lllldt .
CESSPOOL St"(cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: Q
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum laver:
Dimensions of cesspool:
Materials of construction:
.Indication of groundwater inflow(yes or no): fX
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
CP�s000ls are not present
PRIVY4&L1 (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.):
Privy is not present .
9
Pagc 10 of I I
O?FICLAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
RFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM TNFOR 'LATION (cminvcd)
p,operrry ^docc,,:96 Bosuns Way
arstons i ass .
Dirk Mahoney
Om of Inlp(clioo:
SX—rTCH OF SEWACE DISPOSAL SYSTEM
Ploridf i lk;cich of the icwcl( d"poiil ly)lcm Inclvding dcl to 11 Ic"I rwo pertnancni rcrcrcncc imunirk, o,
ocncnm�k, l.o<iic cu w<ni Mi�nin 100 (M. Logic whcrc public walcr tvpply cnlcrs the bviloin�.
i 1Sa
Fi� -0 v
Ll
1 — —
I
10
Page 1 I of 1 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 96 3osuns Way
Marstons Mills ,Mass .
Owner: Dick Mahoney
Date of Inspection:7/2.✓0 2
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water IAA)I feet
Please indicate (check)all methods used to determine the high ground water elevation:
Y E Nec
swith
olocalBoard
;of
plans on record - If checked, date of design plan reviewed: 7/2/0 2
bservation hole within 150 feet of SAS)
Health-explain: O b t a i n e d a s b u i l t c a r d
YESChecked with local excavators, installers-(attach documentation)
Y E SAccessed USGS database-explain:h t t p ; 11 t own , b a r n s t a b l e .ma. us .
You must describe how you established the higgh gground water elevation:
Used ; Gahr.ety & Miller Iv'odel . l2/16/94 Ground water elevations above
Sea Level .
Ysed : USGS Observation well data . June 1992 _
Used ; USGS : Tedhni al ulletin . 92-000-1 Plate#2 Annual ranges of ground
water elevate ns . January 1992 .
z0�
4 Maximizers
in series .
*,'eet
Groundwater: t-cet Below Bottom of Pit f?1S ,Groundwater Adjustment 1.8 ft per Frimpter Method
Therefore, the vertical separation distance between the bottoms� J
Of the leaching pit and the adjusted groundwater table is �iG�"v
feet.
11
w
+rrnr+.-n,•r�r--rrrnr mr•ntr+ra�+r.nrr.rr..rr:•.�r+-Tv*r:�n-e+•mn rrr�v .. �,,
TOWN OF Barnstable DOARD OF HEALTH
SU(1SUftFACF 9F,H�OE OI3fUS�L SY3TFM INg[�1FCTION FORM - PART D .- CERTIFICATION 11
0 -TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 96 Bosuns Way Marstons Mills ,Mass .
ASSESSORS MAP , DLOCK AND PARCEL # 046-114
OWNER' s NAME Dick Mahoney
PART D - CERTIFICATION I
NAME OF INSPECTOR Joseph P.Macomber Jr .
COMPANY NAME J.P .Macomber & Son Inccf '
COMPANY ADDRESS Box 66 Centerville ,Mass . 02632
Street Town or City
State LIP
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 790 1578
A
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at,
this address and that the information reported is true , accurate , and
omplete as of the time of :inspection , The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one :
1/` System PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or Lhe environment as defined in 310 CMR 16 , 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form ,
System FAILED*
The inspection which I have conducted has found that the system fails to
Protect the E)tlblic health and the environment in accordance with Title
6 , 3.10 CMR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form ,
Inspector Signature / r Date
awFnecopy of this certification must be provided to the OWNER, the BUYER
d
here applicable ) and the 130ARD OF 11EAL1.11,
* If the inspection FAILED , the owner or"'oporator shall upgrade • the aye tem
within one year of the date of the inspection , unless allowed or required
otherwise as provided in 310 CMR 16 , 305 .
partd . doc
�a �y�TOWN OF BARNSTABLE
LOCATION ����G� �7/J � � SEWAGE # ���
V' LLAGE/%�� ASSESSOR'S MAP & LOT
INSTALLER'S NAME& PHONE
SEPTIC TANK CAPACITY
LEACHING FACILITY: (size) X���� l
NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIAN DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Lea# ng Facility (If any wetlands exist
within 300 fe o le n ) Feet
Furnished b
AfV- WA`{
��-r►w�xew h 6�
—
Fc
. 1
• m
�� f
TOWN OF BARNSTABLE
LOCATION h ea-5-ong !(1j¢J!' SEWAGE #
VILLAG ASSESSOR'S MAP & LOT O — II
INSTALLER'S NAME&PHONE NO.
SEPTIC.TANK CAPACITY / D D y
LEACHING FACILITY: (type)Y AJ/!Z/., -I�Zt'/"S (size),3V`11 7 �ox
NO.OF BEDROOMS /
BUILDER OR OWNER e/I Gail 5 ge Ci✓t o/ ,4vI
PERMIT. /_3/�;�_COMPLIANCE DATE: /ur -
Separation:Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private WaterSupply Well and Leaching Facility (If any wells exist
on site:or.within 200 feet of leaching facility) ltpo Feet
Edge of W- edand and Leaching Facility(If any wetlands exist
within.300 feetXof eaching facty Feet
Furnished`by
9f.
r
y �
ci�t
t� y ��AXJMr7P�S._ _1
i
Q� 2 TOWN OF BARNSTABLE '' l
LOCATION Swis w/a SEWAGE # 91 ` ya3
VILLAGE M• fMl S ASSESSOR'S MAP & LOT Oy6' I
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY I
LEACHING FACIL=: (type) (size)
NO.OF BEDROOMS I� n L
BUILDER OR OWNER 'l4 IJO�T
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leachi g facility)^� [ Feet
Furnished by t U
/�� _ � ..
�+, �� � i
3a 6,��k ,
.. - �c�k �
. q p
r ,
_ �
x
1
TOWN OF BARNSTABLE ' �- �
LOCAt1 ON SEWAGE # C'
VILEAGEIVOtr,ARC S 14 t CIS ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY / D D y
LEACHING FACILITY: (type) Z/1*1/Z?o"S (size),3yl// 7 Ylel�
NO.OF BEDROOMS .3 -// /
BUILDER OR OWNER�Gy /S 9- CO-4 O/ 4AI `,�4 d
PERMPTDATE: �Ef/3 Z.7 COMPLIANCE DATE: / -7
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"'o�ng faci 'ty) Feet
Furnished by y+-s
9b `
vc €its //f�
9 NPR, C 17 X
yo pv C
36
DLO
L0 ,l.C&,T10t, .SEWaCtE PERMIT U0.
IMST&LLERS U&ME ADDRESS
UILDER 5 &MF- ADDRESS
DATE PERMIT ISSUED _ ��- -7L —
D ATE COMPLI &MCE ISSUED y` ��
i
S/
e
1
v+i'
No. 1" 3 Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
---
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
Zipprication for Migozal *potem Construction Permit
Application for a Permit to Construct(�')Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Q` Owner's Name,Address and Tel.No.
p/P Asse�sor�Maarcel 0" /s Ac/k_/e
Installer's Name,Address,and Tel.No. /;7 Old-6 Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Sized 0 ® sq.ft. Garbage Grinder(0)
Other Type of Building,492it_A No.of Persons Showers(/ ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issu`ed/6 t'hiiss Board
Signed �t�%�h:✓2 �i� rS �t�CeN Date f /
Application Approved by .a.w�-,
Application Disapproved for the following reasons
Permit No. / 7 C Date Issued
No. 3 Fee _
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:,T�----
0 : r Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
.r' a
2pprication for �Digpogal*pgtem Congtruction Permit
Application for a Permit to Construct(N)Repair( )Upgrade( ')Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
Assessor'sMap/Parcel /1 Gl / / 1 /� X�5 � r�
Installer's Name,Address,and Tel.No. /;7 6/(/6;� Designer's Name,Address and Tel.No.
Q ! CD°t.5 VCa,
S-o
Type of Building: - "
Dwelling No.of Bedrooms Lot Size /�d 0 sq. ft. Garbage Grinder(0)
Other Type of Building Ajf4tit C No. of Persons 57 Showers( / ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow "__,gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank t Type of S.A.S.
Description of Soil
r
Nature ofiRepairs or Alterations(Answer when applicable)+a +
Date lasthnspected
Agreement:
The undersigned agrees to ensure the constructioq and maintenance of the afore described on-site sewage disposal system _
in accordance with the provisions of Title 5 of the Environmenta o e a d not to place the system in operation until a Certifi-
cate ofiCompliance has been issued 6 this Board of deal
r t( Signed // " `� ' J Date l '
Application Approved by `` Date
Application Disapproved for the following reasons b°!
Permit No. 7. OL Date Issued 'f r
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS M1 l
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( )Repaired ( )Upgraded( )
Abandoned( )by
at W has been constructed in accordance
with the provisions of Title 5 and the for Disposal SyVern Construction Permit No. - t % dated
Installer L Designer
The issuance of this permit shall not be c'` strued as a guarantee that the system will f ct* as designed.
Date a _ Inspector
.�
t THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
='igpogal *pgtem fougtruction Permit
Permission is hereby granted to Construct( )Repair(*>e)Upgrade( )Abandon
System located at
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction cmust be completed within three years of the date of this permit.
Date: _ / 7 Approved by .
NOTICE.*This Form is to be used for the Repair of FhAiled
Septic Systems Only
CERTIFICATION Or SKETCH AND APPLICATION FOR A DISPOSAL
1VQHKS CONS'I'RUC'I'IUN I'ER(111'I' (�VI'1'11UUT DESICNEll PLANSI
/AAr p- , hereby certify that the application for disposal works
construction permit signed by me dated /Z _. concerning the
property located ft ` meets all of the
following criteria:
There are no wetlands within 300 feet of the proposed septic system
• There arc no private wells within 150 feet of the proposed septic system
• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
• There is no increase in now and/or change in use proposed
• There are no variances requested or needed.
SIGNED : 1 DATE: //2—
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted).
av
t
,�oso�5 ltja� i
i
sec., / firms� ,i Cvf Cap
'44 _57 PS L✓t � fiG
0 UXW(
Commonwealth of Massachusetts Jolm Grad
Executive Office of Environmental AffUrS D.E.P. Title V Septic hupector
Department of P.O. Box 2119
P Environmental Protection Teaticket,MA 02536
U,
SUBSURFACE SEWAGE DISPOSAL SYSTEMINSPECTION FOR ,+� 1
PART A 4r
CERTIFICATION J U L 2 5 1997
N
Property Address: 96 Bosuns Way Marstons Mills Address of Owner: TOWN HFAF ARNST.ABLE
Date of Inspection:7123197 (if different)
Name of Inspector:John Graci Andrade
Company Name,Address and Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
_ Passes This inspection is based on criteria defined in Title y
_ Conditionally Passes code 310 CMR 15.303.My findings are of how the system is
performing at the time of the Inspection.My Inspection does
_ Needs Fu er valuation By the Local Approving Authority not Imply any waranty or guarantee ofthe longevity of the
X Fails septic system and any of its components useful life.
Inspector's Signature: Date: 7/23197
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. 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 Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer; if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B,C,or D:
A] SYSTEM PASSES:
_I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system,upon completion
of the replacement or repair, passes inspection.
Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined", explain why not.)
The septic tank is metal, cracked,structurally unsound, shows substantial infiltration or exfiltration,or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved
by the Board of Health.
(revised 11115195)
One Winter Street • Boston,Massachusetts 02108 9 FAX(617)556-1049 9 Telephone(617)292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 96 Bosuns Way Marstons Mills
Owner: Andrade
Date of Inspection:7123197
Sewage backup or breakout or high static water level observed in the distribution box is due to a broken,
settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
_The system required pumping more than four times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
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 the public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)DETERMINES
TI4AT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public water
supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water
supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private
water supply well, unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is
free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm.
3) OTHER
D] SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in
310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be
contacted to determine what will be necessary to correct the failure.
Backup of sewage in facility or system component due to an 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
cesspool.
x SAS is in hydraulic failure.
(revised 11115195)
2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 96 Bosuns Way Marstons Mills
Owner: Andrade
Date of Inspection:7123197
D] SYSTEM FAILS(continued)
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 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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. If the well has.been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria:
_ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 11/15195)
' 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 96 Bosuns Way Marstons Mills
Owner: Andrade
Date of Inspection:7123197
Check if the following have been done:
X Pumping information was requested of the owner,occupant, and Board of Health.
X None of the system components have been pumped for at least two weeks and the and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
Na As built plans have been obtained and examined. Note if they are not available with N/A.
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout.
X All system components,excluding the Soil Absorption System,have been located on the site.
X The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected
for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge, depth of scum.
X The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11115/95)
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 968osuns WayMarstons Mills
Owner: Andrade
Date of Inspection:7123197
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 330 gallons
Number of bedrooms: 3
Number of current residents: 5
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings,if available: n1a
Last date of occupancy: n1a
COMMERCIAL/INDUSTRIAL:
Type of establishment: rda
Design flow:0 gallons/day
Grease trap present:(yes or no) No
Industrial Waste Holding Tank present: (yes or no) No
Non-sanitary waste discharged to the Title 5 system: (yes or no) No
Water meter readings,if available: n1a
Last date of occupancy: n1a
OTHER: (Describe) rda
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System was last pumped in the fall.
System pumped as part of inspection: (yes or no)No
If yes,volume pumped: 0 gallons
Reason for pumping: n/a
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) ( if yes, attach previous inspection records,if any)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source information:
19-20 years.
Sewage odors detected when arriving at the site: (yes or no) No
(revised 11115195)
5
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 96 Bosuns Way Marstons Mills
Owner: Andrade
Date of Inspection:7123197
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 8'
Material of construction:X concreate_metal_FRP_other(explain)
Dimensions: L 8'6'H 5'7"W 4'10"
Sludge depth:1'
Distance from top of sludge to bottom of outlet tee or baffle: 26'
Scum thickness:0
Distance from top of scum to top of outlet tee or baffle:6'
Distance form bottom of scum to bottom of outlet tee or baffle:0
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.)
Septic tank and all components are structurally sound.Recommend pumping septic system every two years for maintenance.
GREASE TRAP:_
(locate on site plan)
Depth below grade: nla
Material of construction: _concrete_metal—FRP_other(explain)
Dimensions: n1a
Scum thickness:nla
Distance from top of scum to top of outlet tee or baffle:nla
_Distance from bottom of scum to bottom of outlet tee or baffle: n1a
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.)
nla
(revised 11115/95)
. 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 96 Bosuns Way Marstons Mills
Owner: Andrade
Date of Inspection:7123197
TIGHT OF. HOLDING TANK:
(locate on site plan)
Depth belcw grade: nla
Material of construction:_concrete_metal_FRP_other(explain)
Dimensions: r9a
Capacity: n1a gallons
Design flow: n1a gallons/day
Alarm leve': n1a
Comments::
(condition of inlet tee, condition of alarm and float switches, etc.)
nla
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: n1a
Comments
(note if level and distribution is equal,evidence of solids carryover, evidence of leakage into or out of box etc.)
n1a
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances, etc.)
nla
(revised 11115195)
7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 95 Bosuns WayMarstons Mills
Owner: Andrade
Date of Inspection:7123197
SOIL ABSORPTION SYSTEM(SAS):X
(locate on site plan,if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
n1a
Type:
leaching pits,number: 1,000 gallon leach pn
leaching chambers,number:n1a
leaching galleries,number: n1a
leaching trenches,number, length: Na
leaching fields, number, dimensions:n1a
overflow cesspool,number:nla
Comments::(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
The leach pit is past the effective depth of leaching.The system is in hydraulic failure.
CESSPOOLS:
(locate on site plan)
Number and configuration: n1a
Depth-top of liquid to inlet invert: n1a
Depth of solids layer: n1a
Depth of scum layer: n1a
Dimensions of cesspool: nia
Materials of construction: nia
Indication of groundwater: nfa
inflow(cesspool must be pumped as part of inspection)
nla
Comments:(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.)
nla
PRIVY:_
(locate on site plan)
Materials of construction: n1a Dimensions: nia
Depth of solids: nla
Comments.�note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
n1a
(revised 11115195)
8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 96 Bosuns Way Marstons Mills
Owner: Andrade
Date of Inspection:7123197
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
K a 06
A � AC
o«µ
�re,n a
4A 13
A(3 lot
y�
cc a3 ,
D C L,
DEPTH TO GROUNDWATER
Depth to groundwater: 12 feet
method of determination or approximation:
USGS Maps and Charts-12+feet
(revised 11115195)
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No.. F�a.. .......................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.0&.*,�..........OF........... tr .: ......................................
A 4 _� �a����trtttt�t� fnr �t � ttl Works Towitrttrt joy t Vani t
Application is hereby made for a Permit to Con r ( ) or Repair ( ) an Individ 1 Sewage Dispo 1
r „ syst
lV _
n-Address 14
Lot No. ./f�A'
O er Ad�ress
W _ ........... .............
.�4u1s! R
Installer Address
QType of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms-----Z.________________________________Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ..!'r - No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Otherfixtures ............. ........................ ............ ------------------------------------- ...........................................
Design Flow.................................. .........gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacity/B�: _gallons Length................ Width_.............. Diameter................ Depth_.--____-_-_---
x Disposal Trench—No........ ........... Width.................... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No.149a Diameter.................... Depth belo inlet____ __ _.._..._. Total leaching area-._-_-- .........sq. it.
z Other Distribution box'( ) Dosing tank ( ) d/2 _
` s (e 7/
aPercolation Test Results Performed by-------------_ ......................................................... -Date....----- ------------_---------------
,� Test Pit No. 1.................minutes per inch Depth of Test Pit.................... Depth to ground water------. --:_--__--_.-. -
fZ4 Test Pit No. 2................minutes per inch Depth of Test Ait-------------------- Depth to ground water._.-_------.----__-__. -
9 ------------- ------- ----
O d. ,;-- . . •. .............
... ` �-• ------ ---------
Description Soil------- E -------� G ..l�r -------- - ---------
----------------------------------------- -----------------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable._..............................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by e board of
Signed. --• ••----• . . ............ —, ^ ...............................
Date
Application Approved By---- - - ------- --• ••• •• - -- - - ---------- --� . ..7_ _
"Date
Application Disapproved for the following reasons:.........................• -----------------------------•....•----.._........................••----•-
..•-----------------------•---------------------------------------------•-------------------------------••-•••••. ---...--••••......-•----••-•--.
Date
Permit No......................................................... Issued...........................................
.............
Date
1------------------------------- ------------------ ------- ----------- ----------- ---- -- -i
No.------.y ... Fas... .......................
' THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............. . _ ._ ._.............OF....................................................................
............
Appliratiort -for Bi,ipoott1 10orkii Towitrurtion Prrotit
Application is hereby`made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
----�ao - ----------------
ddresclion or•A
........... :;a ... .. ....-•.................•---•........... •-•--••-••-------...-------•--•----•--•-•••-----•-•-•-.....-••----•-•-•------...._.........--•---.
O no Address
e -------------•--•-•-----•-----------•---•---
Insa l Address U Type of Building - Size Lot............................Sq. feet
Dwelling—No. of Bedrooms....... _____ ;__________________--___Expansion Attic ( ) Garbage Grinder ( )
a.1 Other—Type of Building -__ :. �. _.. No. of persons____________________________ Showers ( ) — Cafeteria ( )
P4 Other fixtures ------------- ------------- -------------------------------------------
W Design Flow...........................................gallons per person per day. Total daily flow...........................................gallons.
WSeptic Tank—Liquid capacity/ae'_Ogallons Length---------------- Width---------------- Diameter_-_.._-.___-- Deptll_.-._____-----
x Disposal Trench—No. ____.... .......... Width----------------- __ Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No._?� O.:` Diameter.................... Depth below/inlet.... ......... Total leaching area----._.----------sq. ft.
Z Other Distribution box �( ) Dosing tank ( ) �> -
'-' Percolation Test Results Performed b Date........................................
Test Pit No. 1----------------minutes per inch Depth of "Pest Pit-------------------- Depth.to ground water...____.._.__.__-.......
�14 Test Pit No. 2................minutes per inch Depth of Test Pit.__..___.........___ Depth to ground water__.__._.______-_____----
- F`/ t - : -------------
- - - ------- -, . --••••' ..............................------ . -----7 --
-----------
Description of Soll-- � �----,---= �------�--�- �--�- �--�.� ---- - ----------�/
x
W
U Nature of Repairs or Alterations_Answer when applicable.--------------------------------------------------------------------_......_----------_--------
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by to board of health
Signed = �'�. .........
!..=. �•--------�?-..�j_..-.a
f� Date
Application Approved BY /L�'L ''v ff - � *�--------- - G'
Date
Application Disapproved for the following reasons:...........................---------
-----------
•----•--------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD Of HEALTH
GGl..............O F......... ../, �....IG% ii/�,.......................................
Qrrtif irate of ITUMp aurr
TH IS TO CERT F , That th n vidual Sewage Disposal System constructed ( or Repaired ( )
by ..... --� --•----------- ------ --•- ---- --•------- -----------------•---------•••------------•-----------•-----...---•----••------
at.-- •--��.��_..--. . . ._ ___�_--- •.__ .........................................................
n taller
has been installed in accordance with the rovisions of : c�e I of The State Sanitary Ile as esc e in the
application for Disposal Works Construction Permit N ....... .........:�j%!3 _____ dated.... .:. �-- �........_....
THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION pS,ATISFACTORY.
DATE. / �----... Inspector------.---"- D
..--
THE COMMONWEALTH OF MASSACHUSETTS
-� BOARD O HEALTH /
� .. I. �R.............OF VL.��1.12-....... / /
No.......... ............ FEE.-_ ..
�i��o�tt orb
• str�tr " it rrmit
.............................................s reby granted----. G -----
to Constr (� Rpx an div'dual ew osal Sy
at No._ -Or/= Street
as shown on the application for Disposal Works Construction Perm o__ _____ _ ______ Dated..........................................
----------•-•-- . ----�--• -------•••--• -- . .... ............................d eal
DATE.---..C-�•^ - C....---••-------------------------
Boar of H
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
BOARD OF HEALTH
TOWN OF BARNSTABLE
zippritation,fiorWrIt Con$truttion30ertnit
Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair (✓)an individual Well at:
�oSu:N s _ v i5T -----------------------------------------------P---------------------
----------------------
Location — kdress Assessors Ma and Parcel
ra_rl e --- - __q --r-- - --------------- ----------�---------------------
Owner Address
------------
j�'
-- - - - -
Installer — Driller}— Address
Type of Building
Dwelling --------------------------
Other - Ty pe of Build ing No. of
Type of Well ---------—- ---- --- Capacity --- - -
Purpose of WellLHe — — --- --- —
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to
place the well in operation unt'I a Certificate o Complia e has been issued by the Board of Health.
9
Signed ---
date
Application Approved By---� - -------------- ----: ^ datems-
Application Disapproved for the following reasons:---------------------------------------------------------------------------_--------------------__-----_
date
PermitNo.--------W- -------- Issued---------- -------------------------------------------------------------
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
C ertif irate Of Compliance
THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( )
bY--- -- �� '� — — -- —--------------------------Installer — — -- ----—---— —
at— - —— - - — ---4 --U --------------------------------------------------------------------------------------------------
has been installed in accordance with the provisions of!1'te Town of Barnstable Board of
Health Private Well Protection
Regulation as described in the application for Well Construction Permit No. Dated------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE--- —----------------------------------------- Inspector---� -----— --_- - - -- -
1Vo. Fee----a �---
s BOARD OF HEALTH
i
TOWN OF BAR.NSTABLE
i
Appri ationArlVell Coft5truct ion Permit
Application is hereby made for a-rpermit to Construct ( ), Alter ( ), or Repair (Ls)an individual Well at:
------------------------------------------------------------
Location — Address- ]�ssessors Map and Parcel
--e----------------------------------------- =` C ono(s)C1JC _V__�IA I�Jt:1 -
---- — ------
Owner n r Address
staler — Driller / Address° —
Type of Building
Dwelling —sT-- --- - -- -
Other - Type of Building ------------- No. of Persons-------------------------------------------------------
Type of Well -------------- -- Capacity----------------
Purpose of Well---- -------------------------------------- �4
Agreement: 1 .
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to
place the well in operation until a Certificate o Compliaa c�e has been issued by the Board of Health.
Signed- � /rhl--- —
date
Application Approved By-------- =�- , ,
date
Application Disapproved for the following reasons:--------------------------------------------------- - ----------
I
-- Issued---------------------------------------------------------------
date
Permit No.- ------ -------- ---- --------------------- - -------------
f -
T�—^�----�._. date
1
BOARD OF HEALTH
TOWN OF BARNjSTABLE
(Certificate (of eom'Priance
THISAS TO CERTIFY, T at the Individual Well Constructed ( )� Altered ( ), or Repaired ( )
by-6r-1 --- - --- --� � � --.-----------------------—- - �-------------------------------------------------— Installer
at-='---------------- I
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit No. --� �-a ---��---Dated--------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-- ---- —- ---- ----------------------- Inspect r-------------------- - -------- - - ---
I
BOARD OF HEALTH
7
TOWN OF BAR14?TABLE
lVer[ Con5tructionDermit
1
'�1-- l z-7- Fee-
_ti� r_r_
Permission is hereby granted---------—yl�� ----------------------------------------- —------------------
to Construct ( ), Alter ( ), or Repair an Individual Well at:
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as shown on the application for a Well Construction Permit
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Board of Health
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I CERTIFY THAT THIS PLAIN SHOWS
THE ACTUAL.. LOCATION OF THE
STRUCTURE ON THE LAND AND
'III!► T fT CONFORMS WITH THE
BY4LA lS OF THE TOWN
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PLAN of LAND
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FRANK
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FRANK FRANK �*+ CONERY t REN,aN ST
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No. 6232 V No. 5573 q / a�nowmo 040imma a gw�su"VEVOR
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