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Home My WebLink About0041 FAIRHAVEN LANE - Health 41 Fairhaven Lane Marstons Mills F A = 149 152 No. Fee THE COMMONWEALTH OF MASSACHUSETTS W 11 PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS IYtcatton for Mi ozar * 5tem Congtructton j3ermtt Application is hereby made for a Permit to Construct( )or Repair( an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. i Ins er's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. [7�� oJ_e Type of Building: Dwelling No.of Bedrooms Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow '5 gallons per day. Calculated daily flow ✓ C7 gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs or Alterations(Answer when applicable) pi l— 6)le- rS%E, i-- Date last inspected: Agreement: - The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been is his B =. Signed Date �G� Application Approved by Application Disapproved for the fo owing reasons Permit No. ��.�� Date Issued No. O- Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0[ppYtcation for -Migaal *pgmem Congtruction Permit A ication is hereby made for a Permit to Construct( )or Repair( an On-site Sewage Disposal System at: V t� Location Address or Lot No. ` Owner's Name,Address and Tel.No. a.-7 �.-- Installer's Name-,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No. of Bedrooms _ Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures - Design Flow S gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revisigp Date-.,_.. Title 3 Description of Soil Nature of Repairs or Alterations(Answer when applicable) D 'p i T" U ��--- f' 2 s r- 6v 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 s B h. Signed Date Application Approved by r I Application Disapproved for the fo owing reasons Permit No. V Date Issued THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE. MASSACHUSETTS `Certificate of (Compliance THIS IS TO TIFY,that the On-site§ewage Disposal System installed( )or repaired/replaced(�n,3 36).19?k by r �. for c ,.�.��r.� as has been constructed in accord with the with o Title 5 and the for Disposal System Construction Permit Na dated Use of this system is conditioned on compliance with the provisions set forth below: No. Fee _ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mh5pool *p5tem ConMructton Permit Permission is hereby granted to!:::Zti- lL�i��✓1� to construct( )repair( n--site SSee`wa e,Stem located at and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to i comply with Title 5 and the following local provisions or special conditions. All construction must be completed within two years of the date below. Date: Q ' 46 Approved by i y; 1 f /V N LOT Z 0 9 SF o 4 3 a QO 1,. Q t vE"A I m .,. � 40 V / l o $ Z ni R F d v 1� � 4 ,p� PlST L' )u` .. WATKt I o ISO "F2vNTA .J Ils SE76Ae'KS' J. rr Io 4 u TF_ f?sSUMl�p s,q: r ,j l• /d O�o r Z C� . LuT YIRt�T't"C?r©i✓ R QSBRvs F H P�'"2 .q IF f.LZ, SE C7. �Q Tv�✓ni AYLA N/S 44. Of ALHCRT 7 No: 19367 `; �U rdUFt�E , J' LEGEND k EXISTING SPOT ELEVATION 0,a0 :CERTIFIED PLOT PLAN �a71 EXISTING CONTOUR --- O — ��, 1k .:fit , MNISHED SPOT ELEVATION. .CON.TOUR The location of am existing underground .sewerage, wells, or other utilities shown on this 'planjs: approx- IN imate onlyas- determined from records°and/or' verbal ' informatin. The contractor is res onsible, for the �� ' � 1A, 1'�J '� �+ p rte��sec 1 / � t# A . verification of the existing locations in the field. SCALE, /''_ 40 DATE, J 114/9.S'.LDREDGE ENRINEERINS CO /KGB*a .Y — - — •--------- CLIENT. ._ I CERTIFY THAT THE PROPOSED EAItTERE REGISTER f�5-1 1 4 BUILDING SHOWN ON THIS PLAN .:. JOB NO.�..._...... LAND CONFORMS TO THE ZONING LAWS s' A ,/1 . M V. DR.®Y"�...._._ OF BARNSTABLE , MAS 712 MAIN STREET,:. CH. BY, ---- . ;,.,,. HYANNI S, . MASS. ;/ 2 SHEET._... OF 4DT E REG. LAND SURVEYOR v CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WOOS CONS'F UCI'ION PERIMUF OVI'I'IIOU'I DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated concerning the property located at a`-7 �-�ti��zw. " s meets all of the following criteria: • There are no wetlands within 300 feet or the proposed septic system • There are no private wells within 150 feel 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: DATE: 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). (Dc - , f Town of Barnstable Department of Health, Safety, and Environmental Services Health Division 367 Main Street, Hyannis MA 02601 Office: 508-790-6265 Thomas A.McKean FAX: 508-775-3344.. Db odor of Public Health 1Mt MRN8rAB1�, NMs. t4JA A [ENGINEJER LETTER j -n T0: J ill �r�l 3li/ I (Date) Pa, - �� -+-1-dVCn b-0'1Q_ 1Mz✓s�s Mt(�,,i� �2(�k � ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE_ 5. The septic system owned by you located at Lf( `�,( a V2c) Loa ft_ " was(1S inspected on 2 99 by gz�06SEL Sy4dp6�' a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 C 15:00) due to the following: (`n You are�dire tssional_engineer (PE)-to-design-a-system-that-w111 hdng_ se�tic system in compliance with 310 CMR 15.00, The State Environmental Code, Title 5 within twenty-one (21) days of your receipt of this letter. You are also directed to hire a licensed septic system installer to install the system components within forty- five(45) days of your receipt of this order. You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings, onto the surface of the ground, or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S.. C.H.O. Agent of the Board of Health Town of Barnstable d SENDER: - - —- o ■complete Items 1 and/or 2 for additional services, to ■Complete items 3,4a,and 4b. I also wish to receive the '41 ■Print your name and address on the reverse of this form so that we-can return this following services(for an card to you. OAftach this form to the front of the mailpiece,or on the back if space does not extra fee): LO pemut® ■Write 1. ❑ Addressee's Address Return Receipt Requested-on the mailpiece below the article number. � $ ■The Return Receipt will show to whom the article was delivered and the date 2 ❑ Restricted Delivery N c delivered. 3.i�cle Addressed to. :Ft: Consult postmaster for fee. n �. 4a.Article Number > , c ) ��t�i` �•'? -� 4b.Service TYPe � i ❑ Registered d / ❑ Express Mail Certified ¢o� ❑ Insured c : t ❑ Retum Receipt for Merchandise ❑ CpD . i 7.Date of D`elilive T ° I 5.Received By: "nt Name) c 8.Addressee's A res ( nlyifreque c t and fee is paid) ar g 6.Signs e: d ee o Ag t I P$Form 381 i December 1994 — 10259e-97-a-o 79 Domestic Return Receipt m 4 CO Ir CO 0— w_ c m c kn 0 CD H E a W c d g Q U- 3 Sp LL U L O C ki L N3 °� m wo- 61 67 M d"— a� o a tlf{ d d c2 `� �° o O kn �' U"" E in d >_ p cca m o 0 m d in d y rn D ro S E E E N U OL�Z a V kn cc X ¢o Oi a q 9661.Il,dy'008£wJo=I Sd !4 :p t Town of Barnstable • Department of Health, Safety, and Environmental Services L►artsxee�. II Public Health Division p'EDN1 � P.O. Box 534, Hyannis MA 02601 4. Office: 508-790-6265 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health m April 6, 1998 i David Kelley&Cindy Parker-Kelley 41 Fairhaven Lane Marstons Mills,MA 02648 ORDER TO COMPLY WITH 310 CMR 15.00,THE STATE ENVIRONMENTAL CODE, - TITLE 5. The septic system owned by you located at 41 Fairhaven Lane, Marstons Mills was inspected on ` March 27, 1996 by Robert Bortolotti, a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00)due to the following: The leaching pit was full of wastewater effluent at the time of the inspection. You are directed to hire a licensed professional engineer(PE) to design a system that will bring the septic system in compliance with 310 CMR 15.00, The State Environmental Code, Title 5 within twenty-one(21)days of your receipt of this letter. ,You are also directed to hire a licensed septic system installer to install the system components ,within forty-five(45)days of your receipt of this order. 'You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings, onto the surface of the ground, or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH f Thomas A.McKean,R.S., C.H.O. Agent of the Board of Health q/db/title5e.doc i PAR Real Estate System - General Property Inquiry Help Parcel Id: 149 152- - Account No: 86454 Parent : Location: 41 FAIRHAVEN LANE MM Neighborhood: 19CC Fire Dist : CO Devel Lot : 3 Lot Size : .46 Acres Current Own: KELLEY, DAVID F & State Class : 101 PARKER-KELLEY, CINDY J No. Bldgs : 1 Area: 1712 41 FAIRHAVEN LANE Year Added: MARSTONS MILLS MA 2648 Deed Date : 040196 Reference : 10176230 January 1st : KELLEY, DAVID F & Deed MMDD: 0496 Deed Ref : 10176230 Comments : Values : Land: 21800 Buildings : 93700 Extra Features : Road System: 41 Index: 1987 (FAIRHAVEN LANE ) Frntg: 146 Index: ( ) Frntg: Control Info: Last Auto Upd: 020997 Status : C Last TAGS Update : 071896 Land Reviewed By: Date : 0000 Bldgs Reviewed By: AM Date : 0387 Tax Title : Account : Taken: Account Status : Hold Status : Cancel Press XMT for more data Next screen PAR Action Owners Name Road Index Road Name Parcel Number 149 153 RCV F (GE) 1 Town of Barnstable p INE tp� ° do Regulatory Services 1 snRivsr,►sM Thomas F. Geiler,Director 9q,A '�. ,e� Public Health Division rED N1°r A Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 David F. Kelley & Cindy Parker-Kelley Date: 8/10/02 41 Fairhaven Lane Marstons Mills, MA 02648 FINAL NOTICE ORDER TO COMPLY WITH 310 CMR 15.00,THE STATE ENVIRONMENTAL CODE,TITLE 5. Our records indicate the septic system owned by you located at 41 Fairhaven Lane,Marstons Mills,Ma was inspected on 3/27/96,by Robert Bortolotti a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00)due to the following: Leaching pit was full of wastewater. According to Title V, the owner had two (2) years to repair or replace the system. More than two years has past since the date of this inspection. You were previously notified of the failed septic system. However, the system has not been repaired as required as of this date. Therefore, you are directed to hire a licensed professional engineer (PE) or Register Sanitarian (RC) to design a system that will bring the septic system in compliance with 310 CMR 15.00, The State Environmental Code, Title 5 within twenty-one(21) days of your receipt of this letter. You are also directed to hire.a licensed septic system installer to install the system components within forty-five (45)days of your receipt of this order. You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings, onto the surface of the ground, or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. Failure to comply to this order of the Board of Health, may result in court action against you the owner of this property PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean,R.S., C.H.O. Agent of the Board of Health Town of Barnstable Town of Barnstable Assessors Division Page 1 of 3 THE A DAINSTABUL W 34Y��S4, +a �* A a F m S .. z. " Your Location : Home : Town Departments : Administrative Services :Assessors Division Property Results <<Back-Forward>> Thursday, May 30,2002 F Assessors Division- Property Results Data is based on. Fiscal Year 2002.Assessor's Fiscal Year 2002 Assessed Values database and. is provided for information Tax Information purposes only. Sales History Land and Building Description Construction Details «Search Again Out Buildings & Extra Features - Building Sketch 41 FAIRHAVEN LANE Map/Parcel/Parcel Extension: Mailing Address: 149/152/ KELLEY, DAVID F& Owner of Record: PARKER-KELLEY, CINDY J KELLEY, DAVID F & 41 FAIRHAVEN LANE Property Location: MARSTONS MILLS, MA 02648 41 FAIRHAVEN LANE Parcel ID: 149152 1*i�mapl W-t� \UX 0� Fiscal Year 2002 Assessed Values ^Top Appraised Value Assessed Value Building Value: $ 133,700 $ 133,700 Extra Features: $3,700 $3,700 Outbuildings: $0 $0 Land Value: $47,700 $47,700 Totals: $ 185,100 $ 185,100 Tax Information ^Top Town Tax $ 1,714.03 Tax Rates (per$1,000 of valuation) C.O.M.M. FD Tax $255.44 Town 9.26 Fire District Rates Land Bank Tax $51.42 Barnstable 2.61 C.O.M.M 1.38 Cotuit 1.69 Total: $2,020.89 Hyannis 2.54 W. Barn. 1.54 http://www.town.bamstable.ma.us/ComeOnIn/Department.../resultsk02.asp?MAPPAR=14915 5/30/02 I Town of Barnstable Assessors Division Page 2 of 3 . . '-Total does not include special assessments- vtner Kates Land Bank 3%of Town Tax Due to rounding differences these values are approximate. Sales History !Top Owner: Sale Date: Book/Page: Sale Price: KELLEY, DAVID F & 4/15/1996 10176230 $ 146,000 WEBER, PHILIP J &JENNIFER G 12/15/1991 7803/350 $ 138,000 FIRST FED SVGS BANK OF AMER 11/15/1991 7744/011 $ 135,035 NOONAN, CYNTHIA J 11/15/1986 5382/303 $ 173,450 DACEY, WILLIAM E III TRS 4/15/1986 5000/236 $37,000 DALEY, SEAN TRS 10/15/1984 4293/219 $37,500 NYBERG, PETER& MARJORIE 10/15/1984 4293/209 $23,500 TROTTO, JOHN &CAROL M 9/15/1982 2580/255 $0 Land and Building Description "Top Land Building Lot Size (Acres): 0.46 Year Built: 1986 Appraised Value:$47,700 Living Area: 1794 Assessed Value: $47,700 Replacement Cost: $ 139,320 Depreciation: 9 Building Value: $ 133,700 Construction Details "Top Style: Cape Cod Interior Walls: Drywall Model: Residential Interior Floors: CarpetVinyl/Asphalt Grade: Average Grade Heat Fuel: Gas Stories: 1 1/2 Stories Heat Type: Hot Air Exterior Walls Wood ShingleClapboard AC Type: None Roof Structure: Gable/Hip Bedrooms: 3 Bedrooms Roof Cover: Asph/F GIs/Cmp Bathrooms: 3 Bathrooms Total Rooms: 7 Rooms Outbuildings& Extra Features "Top Code Description Units/SO FT Appraised Value Assessed Value FPL2 Fireplace 1 $2,700 $2,700 BRR Bsmt Rec Room 214 $ 1,000 $ 1,000 Building Sketch "Top Er http://www.town.bamstable.ma.us/ComeOnhi/Department.../resultsk02.asp?MAPPAR=14915 5/30/02 Town of Barnstable Ass--ssors Division Page 3 of 3 jlp-- v k 5 vY 3 P 14.... Sketch Legend BAS First Floor, Living Area FST Utility Area (Finished Interior) UAT Attic Area (Unfinished) BMT Basement Area (Unfinished) FTS Third Story Living Area (Finished) UHS Half Story(Unfinished) CAN Canopy FUS Second Story Living Area (Finished) UST Utility Area (Unfinished) FAT Attic Area (Finished) GAR Garage UTQ Three Quarters Story(Uni FCP Carport GRN Greenhouse UUA Unfinished Utility Attic FEP Enclosed Porch PTO Patio UUS Full Upper 2nd Story(Unfi FHS Half Story(Finished) SFB Semi Finished Living Area WDK Wood Deck FOP Open or Screened in Porch TQS Three Quarters Story(Finished) L ««;..w Back-Forward Home Departments I Town Information ( Contact Town Hall Website Developed and Maintained internally by the Town of Barnstable Information Systems Department Town Hall-367 Main Street- Hyannis,MA-02601-508-862-4000 DISCLAIMER: Although we strive to provide accurate information,we are only human. Flease consult directly with the appropriate department if there is a question of accuracy. Copyright 20010 Town of Barnstable. All Rights Reserved. http://www.town.bamstable.ma.us/ComeOnIn/Department.../resultsk02.asp?MAPPAR=14915 5/30/02 Septic Inspection Information Data Entry Aa a1 4/24/gg S�eptw rispectNNo Assessors Map: 149 Parce 152 Lot: Bus nessS Number; 41 „Address:. Fairhaven Lan— e -� vi"Mager Marstons Mills inspector:; IRobert Bortolotti Iris ect:date 5yst m Status F P 3/271 Commend Pit was full at time of inspection. Permit `,{Repair„Dat Notification Date: 4/9/98 Engllnstallerce Engineer Repair D ae diine7)ate: 5/25/98 .� s. lr IM o ge u] Certified Fee r ostmark Return Receipt Fee 7 M (Endorsement Required) I a t C3 C3 Restricted Delivery Fee /q (Endorsement Required) 0 Total Postage&Fees $ a Z a � � Sent To �'� a David F Kelley & Street, or PO Cindy Parker-Kelley ---------- ---!41 Fairhaven Lane i [� City,State,Z/P+4 i T- 'Marstons Mills, MA 02648 I SECTIONSENDER: COMPLETE THIS SECTION COMPLETE THIS ON DELIVERY J ■ Complete items 1,2,and 3.Also complete A: Receive by(Please Print Clearly) B. D e of D item 4 if Restricted Delivery is desired. ■ Print your name and address on the reverse so that we can return the card to you. C. na ■ Attach this card to the back of the mailpiece, e e ❑Agent or on the front if space permits. ❑Addressee D. Is delivery address differen 166m item 1? ❑Yes 1. Article Addressed to: If YES,enter delivery ad r s below: ❑ No David F Kelley &. Cindy Parker-Kelley 41 -Fairhaven Lane 3. Service Type Marstons Mills, MA 02648 b(Certified Mail ❑ Express Mail All .f; _ - . - � ❑ Registered Of Return Receipt for Merchandise q ❑ Insured Mail ElC.O.D. 7000 1670 0013 -IQ 5 I,10 c.193 4. Restricted Delivery?(Extra Fee) P'Yes 2. Article Number(Copy from service label) r . j PS Form 8811,J61y'1999 `... . . .. Domestic Return Receipt 102595-99-M-1789 " N _. . _ _ .� '•q�' zi W Q o e!,v Vv T11q:COt!VIMO Ad`H OF NASSAq{USEg PUBLIC HEALTH DII/lSiON-BARNb'T�ASLE,IVigSSAC:-' ... fjUSETTS TMS 1S bly the le rap p%a1** installed )or repgired/ laced l✓� -ram cep �withthe p�ovisians the forDisPl S ''L1 ` .use.af this system is condilioned on Xitmfe[' veted in acc arut Na o conzptielice wiihlhg below: dated C z .- l0 N 00 GD s OD LI) aD cm m o m o04 O) O ' I 77 parinquir �. o g Find Map Parcel 149152� Find Owner Parcel ld: 149152 Del_D:'V ---------- Account No: 000864 Parent: 0000000 ` ` Neigl bo hood: 19CC a ._ K _ n Devei Lot- LOT 3 14 Lot Size: .46 Acres ' �. Curr Own: KELLEY, DAVID F& _� _ State C lass: 101 PARKER KELLEY CINDY J No Bldgs 1 Area: 00001712 41 FAIRHAVEN LANE �� 'Year Added 00 MA So MILLS MA 02648� sewer acct 00 0000 000 Deed Date: 040196 ` '� Reference: IOlJ2O� JanuarY tst KYDAVID F& __....� j,Deed,MMt�Y: 0 49 _ 0176230 Values: Land: 000029100 i� Buildin s: _.._ 9 000094400 ExtraFegtures: 0000000000� >� Location 41 FAIRHAVEN LANE Road ndex: 19 77 Frnt 0146 — rq, Fire Dist:7 CO VVV Sec Jndex: 0000 Frntg:, 0000 � ,. _ { } o �, � ��: I °FzKWE r� Town of Barnstable Barnstable ti Regulatory Services Department AMmericaC'dyA BARNSTABLE. MASS. ,Public Health Division m 200 Main Street, Hyannis MA 02601 2007 6 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO May 6, 2008 Cindy Parker 41 Fairhaven Lane Marstons Mills, MA 02648 i ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 41 Fairhaven Lane,Marstons Mills, MA was last inspected on April 25, 2008 by Robert Paolini, a certified septic inspector for the.State of Massachusetts. The inspection of the septic system showed that the system"Failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: Distribution of liquids is not equal, evidence of solids carryover. You are ordered to repair or replace the septic system within two (2) years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. P ORDER OF THE B OF HEALTH V* s McKean, R:S., CHO Agent of the Board of Health 6CERTIFIED MAIL# 7006 2150 0002 1041 9341 Q:\SEPTIC\Letters Septic Inspection Failures\41 Fairhaven LAne.doc TOWN OF BARNSTABLE LIOCATI0N SEWAGE#,�Y= VTJ VILLAGE !0 f" ASSESSOR'S MAP&PARCEL /'z INSTALLER'S NAME&PHONE N0. �Ll �lrJrr� ®i c% S��iL,F SEPTIC TANK CAPACITY I��G� CG %xyial i LEACHING FACILITY:(type)J;/T?'V 'gnL2� 1(s_ize) �X e A.;:1/ NO. OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility feet Private Water Supply Well and Leaching Facility(if any wells exist on site or within 200 feet of leaching facility) feet Edge of Wetland and Leaching Facility(if any wetlands exist within 300 feet of leaching:facility). feet FURNISHED BY 67 , of �p � O Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 41 Fairhaven Lane i- Property Address Cindy Parker Owner Owner's Name information is required for Marstons Mills Ma. 02648 4/25/2008 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this.form. Inspection forms may not be altered in any way. Important: A. General Information When filling out k ` forms on the j computer,use 1. Inspector: �; only the tab key � to move your Robert Paolini cursor-do not Name of Inspector 7 use the return key. Ca ewide Enter rises,LLC ; Company Name r, , P.0>Box 763 Company Address Centerville Ma. 12632 etum City/Town State Zip Code (508)428-4028 S14454 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the-proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further EvWuption by the Local Approving Authority 4/25/2008 Inspec or's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 41 Fairhaven Lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 41 Fairhaven Lane Property Address Cindy Parker Owner Owner's Name information is required for Marstons Mills Ma. 02648 4/25/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: I 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 41 Fairhaven Lane-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 41 Fairhaven Lane Property Address Cindy Parker Owner Owner's Name information is required for Marstons Mills Ma. 02648 4/25/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 41 Fairhaven Lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 41 Fairhaven Lane Property Address Cindy Parker Owner Owner's Name information is required for Marstons Mills Ma. 02648 4/25/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Yz 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. 41 Fairhaven Lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 41 Fairhaven Lane Property Address Cindy Parker Owner Owner's Name information is required for Marstons Mills Ma. 02648 4/25/2008 every page. City/Town State Zip Code Date of.Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. f ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 41 Fairhaven Lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 41 Fairhaven Lane Property Address Cindy Parker Owner Owner's Name information is required for Marstons Mills Ma. 02648 4/25/2008 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(5)] 41 Fairhaven Lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 41 Fairhaven Lane Property Address Cindy Parker Owner Owner's Name information is required for Marstons Mills Ma. 02648 4/25/2008 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: unknown Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2006:102,000 g ( y g (gpd)): 2007:114,000 Sump pump? ❑ Yes ® No Last date of occupancy: 4/25/2008 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 41 Fairhaven Lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 41 Fairhaven Lane Property Address Cindy Parker Owner Owner's Name information is required for Marstons Mills Ma. 02648 4/25/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No 41 Fairhaven Lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 41 Fairhaven Lane Property Address Cindy Parker Owner Owner's Name information is required for Marstons Mills Ma. 02648 4/25/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 16"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): 20'+ Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. I Septic Tank (locate on site plan): Depth below grade: 18"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No --------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000 Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 3 Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? Measured 41 Fairhaven Lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 41 Fairhaven Lane Property Address Cindy Parker Owner Owner's Name information is required for Marstons Mills Ma. 02648 4/25/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump septic tank every 2 years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears to be structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 41 Fairhaven Lane•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 41 Fairhaven Lane Property Address Cindy Parker Owner Owner's Name information is required for Marstons Mills Ma. 02648 4/25/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *.Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No 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.): Box is Ievel.Box has two outlet laterals.Distribution is not equal.Evidence of solids carryover.No evidence of leakage into or out of box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 41 Fairhaven Lane-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 41 Fairhaven Lane Property Address Cindy Parker Owner Owner's Name information is required for Marstons Mills Ma. 02648 4/25/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1-1000 1-600 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy soil.New leaching pit is in hydraulic failure.Old leaching pit is half full.Stain line shows old pit has been in failure. 41 Fairhaven Lane-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 41 Fairhaven Lane Property Address Cindy Parker Owner Owner's Name information is required for Marstons Mills Ma. 02648 4/25/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 41 Fairhaven Lane-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 map Page 1 of 2 Town of Barnstable Geographic Information System Parcel Viewer Custom MapIF Abutters Map Size zoom out J J J!In CIF a 11 IC R 71 AI' I' I f ----------------- 1 1-� �S � J Y41 , , I 5 �l 5 9 20 Feet Set Scale 1" = 20 I Aerial Photos (`nnvrinhf 9nnr._9nn7 T--of Ror—fohlc MA All rinhfc http://www,town.bamstable.ma.us/arcims/appgeoapp/map.aspx?proper yID=149152&map... 4/28/2008 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments o wM 41 Fairhaven Lane Property Address Cindy Parker Owner Owner's Name information is required for Marstons Mills Ma. 02648 4/25/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: Bottom of LP 40' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: As-Built Card ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation well Data.USED:Technical Bulletin 92-000-01 plate#2 annual ranges of groundwater elevations. 41 Fairhaven Lane-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments EaW4 q�revi L/1/ ftperty Address — / C ON ner ON nets Name � h*dred fn is Gl rS rerdf�every A/. page. C@ylrown State ZIP Oode Date of hAecdW Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checidist at the end of the form. In fgm ow� A. General Information on the corrper, use ony theto 1. inspector cu to redo not k /1 cxusor-do� �r /_p / use the return Name of Inspector CD " /,,IL Co Adrtess�(S�/ Gl/LI cdy/rown 5,-, age—� �� State ZIP Code Te1es4iorhMrdw Lbiftse Nsn m B. Certification I certify that I have personally inspected the sewage disposal system at ttus address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a Dias approved system inspector pursuant to Section 1&340 of Title 5(310 1&000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation-by:the Local Approving Authority rq hsW s Sigrrahre Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design tow of 10,000.good or greater,the inspector and the system owner shall submit the,—-- report - report to the appropriate regional office of the DER The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. "**This report only describes conditions at the time of inspection.and under the conditions of.use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. was•9NS ToesoffiWIM I sube0fate Saw ageDispasd siamm•Page+al7 !Commonwealth of Massachuseas Title 5 Offiial Inspection Form ISubsurface Sewage DlWsai System Form-Not for Voluntary Assessments I 1 r�1 a rt H L- /✓ !%Mrty Address Ow ner ON noes Name information is �,� requved for every a.s�hs �Y�S '%�.L_ 0c),6 Y-r / /3 page. ;Cly/rown State Zip Code Date o ftpecton f B. Certification (cunt) Inspection Summary: Check A,B,C,D or E/always corn plete all of Section D _/) System P s: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 'B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y,.N, ND) for the following statements. If"not determined,"please ex Wain. F 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 indcafing that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): Ism-3M 3 ride 50fficial Impection Foart Subsuface Sevrage DLsposal SyOm•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments L/ FGj/rh4v-*h L-// Property Address ON ner Ow ner's Warneinforination is required for every AC'Y-�-IV A page. Qyfrown State Zip Code DWfi of h n B. Cerfificafion (cons.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(coat.): ❑ Observation of sewage backup or break out or high static water level in the.distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 1&303(1)(b)that the system is not functioning in a mannerwhich 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 Sus.3n3 riae50ffidd Impectm Fina 8ubarface Sewagempamai Spew-Page 3of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 'Subsurface Sewage Disposal System Form -Not for Voluntary Assessments LyGtlrnG;l�Lv� L� Property Address C ON net QV oar's Name infonnatieon is d �" requmedforevery liorl(�V page. ay/Town State Zip Code Date of Nsp coon B. Ceitfication (cont.) 2 System will fail unless the Board of Health(and Public Wafter Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well'. Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other. D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ g3e" ' Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6'below invert or available volume is less than%day flow +5ma•3n3 Tbefi kWbnapeolonFormSubeufaeeS9%WDisposalSplem•Pageaofn Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage.(Disposal System Form/-Not for Voluntary Assessments 1 ( / a►l i�l&0e Property Address S4ti ONner Owner's Name information is requvedforevey page. Cdyrrown State Zip Code Date of sp on B. Certification (cola.) Yes No ❑ squired pumping more than 4 times in the last year NOT due to clogged or obstnjcted 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. ❑ L�J Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ L�J 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 certffied laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered A copy of the analysis and chain of custody must be attached to this form.] ❑ e system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. `E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either`yes°or'no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 fleet 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 If of a public water supply well If you have answered"yes'to any question in Section E the system is considered a significant threat, or answered `yes'in Section D above the large system has failed. The owner or operator of,any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5m•3M 3 Title 60f dd hspeelm F am[Stjwrfam Sev%e Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form !Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Grtr�.+{��'1 Property Address Ow ner om ner i;NameInformation is J requaed for every �rjT ws f ✓/ �� Pap. gyf row n State Zip Code Date offispecti6n C. Checklist Check if the following have been done. You must indicate`yes"or"no'as to each of the following: Yes No ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ere any of the system components pumped out in the previous two weeks? ❑ 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 constriction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: 2 J Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): tSrs•ins Td1e50ttidsl I spectionForm SubwAsoe Semmage Disposal System•Page 6or 17 Commonwealth of Massachusetts for-J-919MM-ea W Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth/-Not for Voluntary Assessments g r✓ln�t�'� Z_xz Property Address hf rser ow nets Namorrnation is req}rired for every "6wf4asf page. Qty[Town State Zip Code Date pe bn D. System Information Description: iff- -',1,;4j /0 X,?0 a C' Number of current residents: Does residence have a garbage grinder? ❑ Yes Er No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes L7 No information in this report.) Laundry system inspected? ❑ Yes a No Seasonal use? ❑ Yes Water meter readings, if available past 2 years usage(gpd)): Detail: Sump pump? ❑ Yes/ /v Last date of occupancy: Date Commercial/lrtdusbial Flow Conditions: Type of Establishment: Design flow(based on 310 CM R 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: tsm•3f13 Titles official Impect m Form SubsWace Sewage Disposal Syeem-Page 7of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments R'operty Address QNner hformatio ofeqWre very owner's Namrlr.>!-�-0✓�1 pa". Clylrown State Zip Code Date of n D. System Information (cont) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: ' Source of information: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of S m: 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/Altemative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the UA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(descd be): tSif6.3/13 Me 50f dd UspmOm Form Subsurface Sewage Disposal SyMm•P<ge SaW Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form/-Not for Voluntary Assessments Property Address Ow ner -ON Mes Nameinforfflefim is 2y �y �j� requ�edforevery (/�6 vp ` 3 J� page. Clyfrown State Zip Code Date of D. System Information (font.) Approximate of all components, date installed(i nown)�and,source of information: Were sewage odors detected when arriving at 4 site? ❑ Yes Building Sewer(locate on site plan): C ` Depth below grade: feet Material of constructi;�40 El cast iron PVC ❑ other(explain): I Distance from private water supply well or suction tine: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below de: feet 7en of constr uction::concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) if tank is metal, list age: Years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5M-3ff 3 Tine 50ffical hspecficnFart[Subsufwe S9wgeMgxael Syem-Pap 9of 17 'Commonwealth of Massachusetts Title 5 Official Inspection Form ir .Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments G l7gvev, L 4 r Property Address Ow ner ow nets Name �/f / inforn ation is /' /'lr —7R requiredforevery AL, ti page. City/rown State Zip Code Date of nspe on D. System information (coat.) Septic Tank(cost.) �1 Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): c l ✓`7 r✓! 1P C 0 VyI pvrn Cie c GH a✓2C 4r-e-S Lki- Jo Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 15ins-3n 3 Title 5Offidd Inspection Fam:Subsuface Sewge Disposal System•Page 10 d 17 Commonwealth of Massachusetts :Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �/ Property Address 1 Cw"w Owner's Warne krfomta for is e Al requeedforevery page. Cdylrown State Zip Code Date f fnsA tan D. System Information (coat.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: capacity: gapons Design Flow. gamins per dW Alarm present: ❑ Yes ❑ No Alarm level: Alarm in worldng order. ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No VIM-3M3 Tt0e50ffidd ftr:P,fim Form SubsWam SevegeDisposdl Sys*m-Page ll or 17 F' �I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forr/rn-Not for Voluntary Assessments Gar�16i ve�7 � /v Property address 1 54-1;7 C ON nor ON nets Name d n,/ Information is requiredforevery page. C y rown State Zip Code Date f rnsp coon D. System Information (coat) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Ab Le Gar Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No' Alarms in working order. ❑ Yes ❑ No' Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: {5ms-313 Title 50ffieial Inspection For[Subsuface Sewage Disposal sys*m-Page 12 Q 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Foam-Not for Voluntary Assessments Pbperty Address oN ter Cw WS Name reorrnationis requfired for every page. Cdy/rown State Zip Code Date of p ion D. System Iuz�k mation�(ccoonit.) Type: ❑ leaching pits number. ❑ leaching chambers number. ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovative/aftemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): OAP GH 0,1 C. �Gt,7 C.14 Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction indication of groundwater inflow ❑ Yes ❑ No t5ms•3f13 rt8e50fWd MspectonForm Submstaos SayMemsposal Symtam•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Ow ner C infomaft is Owner's(�arne / 1 requ"veed for every page. Cdylrown State Zip Code Me of D. System Information (coat.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): bns•3N3 rrde50McW bspecbonForm SubSWace S8VMeOral Stem•Page 14 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �i/rAar2 r� L Property Address s �C ON ner ON ner's Name information is required for every /M,✓T page. Clrlrown State Zip Code Date of D. System Information (cons) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate whet is water supply enters the building. Check one of the boxes below hand-sketch in the area below ❑ drawing attached separately g A3 - -71 60, � Pf9h> Ons•31I3 Title 50rfidd Ins peefian Form Subsuface Sexage Disposal SmsEam•P<ge 15 d 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal SystemForm -Not for Voluntary Assessments / l / Q f e�/aV-1 i? L—4 Property Address Ow nor ON ner's Name _I reorrnation is requr�edforevery A4 liL/f TOt�� /� S Lai 6 4Y page. Cityfrown State Zip Code Date of"pecWh D. System Information (coat) Site Exam ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Id E �4-�- Estimated depth to high ground water. feet `oC Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: pate ❑ Observed site(abutting property/observation hole within 150 feet of SAS) Checked with locA Board of Health-explain: O'lti✓l� -J' �S�- I�Okr ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must C�scribe hor you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. tans•3M3 Title5offiew Impecfian Fans Subsuface$riMe Disposal system.Page 16 d 17 e Commonwealth of Massachusetts Title 5 Official e Ins i p ct on Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address / Om ner ON nees Nam�/V/�rj-4.,4gg rniation qua every page. City/Town state Zip Code Date E. Report Completeness Checklist Inspection Summary:A, B, C, D, or E checked LEI Inspection Summary D(System Failure Criteria Applicable to All Systems)completed !rd" Sy tem Information—Estimated depth to high groundwater L'I Sketch of Sewa ge Disposal System either drawn on page 15 or attached in separate file ISM•3M3 TJO&SorbeW Wspectm Form Subsufaoe savage Oisposel sysMm•Page V d 17 W 6 TOWN OF BARNSTABLE L(f'CATION , /'OC /y14✓Ke SEWAGE# 4�ZeO ASSESSOR'S MAP & INSTALLER'S NAME&PHONE NO.• 1✓Ui,c� c4De— SEPTIC TANK CAPACrrY 6- LEACHING FACII.PTY: (type) JD (size) i a NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: �' �� COMPLIANCE DATE: .` r Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by GAS Q, Vf ai IRT � � ` TOWN OF BARNSTABLE � LOCATION 7� !/—�i/` K�dn /7P__ SEWAGE# '�MLAGE// arSk JS M'11S ASSESS 'S MAP &LOT :2NSfeC,-6,2 s NAME&PHONE NO SEPTIC TANK CAPACTTY/Q&�aa/ LEACHING FACILITY: (type) (size) SOD GAG(.. NO.OF BEDRO BUILDER OWNER W, PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) / Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feaof 1 jhi n fa ' ) Al Feet Furnished by QJ �� - � �.r as C� 1� �i�i _I—� u ��,� i ^� f 11J� r p '/� 53�,� �,�� _.,� 461 Ale / COD FAILED NL `I II1W;INC. BORTOLOTTI 765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 508-711-9399 508428-8926 FAX: 508428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: Date of Inspection: , Inspector's Name: Owner's Name and�Ac-ddress: CERTIFICATION SITATIFMENT., I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is.true,accurate and complete as of the time of inspection. The inspection was per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The System: Passes Conditionally Passes ' Needs Further Ev tion By the ocal Aproving Authority Fails Inspector's Signature: Date The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty(30),days of completing this inspection.° If the system is a shared system or'fias 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• A)SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined 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,7upon comple- tion of the replacement or repair,passes inspection. Indicate yes,nor;or not'deternuned(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 sep- tic tank is replaced'with a conforming septic tank as approved by The Board of Health. Sewage backkup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of The Board of Health): -1 - r SUBSURFACE.S WAG DI�SPOSA'I'.SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled 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.OV HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING 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 water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is with a Zone I 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 and volatile organic compounds indicates that the well is free from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D) STEM FAILS: 1/ 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 shoul^contacted to determine what will be necessary to correct the failure. Backup,of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge.or.ponding of efluent 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 clog- ged 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 NM due to clogged or obstructed pipe(s). Number of times pumped -2- I / 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) 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 I of a public well. Any portion of a cesspool or privyis 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 a large system in addition to the criteria above: The design flow of a system is 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 fill compliance with` he groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE, E S ,WAGE DISPOSAL SYSTEM INSPECTION FORM PART B _ CHECKLIST Check if the following have been done: t::�:Pumping information was requested of the owner,occupant,and Board of Health. None of the system components have been pumped for atleast two weeks 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. As-built plans have been obtained and examined. Note if they are not available with N/A. '/The facility or dwelling was inspected for signs of sewage back-up. ` __jZT+.e system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. A11 system components,excluding the Soil Absorption System,have been located on site. _, The septic tank manholes were uncovered,opened,and the interior of the septic tank'was in- spected for condition of baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge,depth of scum. __.AcL'Me size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3- iL a, i, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) ,t✓The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, PART C SYSTEM INFORMATION FLOW CONDITIONS RESIDENTLAL:✓ /� Design Flow: allons Number of Bedrooms:_2 Number of Current Residents: 7 On Garbage Grinder: Laundry Connected.To System:_ Seasonal Use: Water Meter Readings,if ailable:. Last Date of Occupancy: p. r'en v1 t COMMERCIAIJINDUST IAL_ /V( Type of Establishment: Design Flow: = gallons/day,:.Grease Trap.Present: (yes or no) Industrial Waste Holding Tank,.Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of informati System Pumped as part of inspection: If yes,volume pumped: gallons Reason for pumping: TYPE 9F,SYSTEM: eptic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records,if any) Other(explain): ROXIMATE AGE qf al)components date installed(if known)an source of information: ' Sewage odors detected when arriving at the site: -4 Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C I GENERAL INFORMATION (continued) SEPTIC TANK: V Depth below grade: Material of Construction: concrete metal FRP Other (explain) Dimisions: $6"&,2,y,571 Sludge Depth: Scum Thickness: /0/1 Distance from top of sludge to bottom of outlet tee or baffle: 3.� Distance from bottom of scum to bottom of outlet tee or baffle: 2_ Comments:(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to tiet invert,structural integrity' ' evidence of leakage,etc.) o'L R A SR : GREASE Depth Below Grade: Material of Construction: concrete metal FRP Other (explain) Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: 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.) TIGHT OR HOLDING TANK: Depth Below Grade: Material of Construction: concrete_metal_FRP_Other(explain) Dimensions: Capacity: gallons Design Flow: l;allons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm-and•float.switches,etc:) _ . . DISTRIBUTION BOX: / Depth of liquid level above outlet invert: Comments: (note if level and Slistribution is equal,evideXce of solids carryover,evide ce of leakage into or out of box,et .)ny�r)n b&410d1 A Z L62f c 4 61/--- &c)0✓'�i 1.ea el Q vz--. olfM f Q 22 g 4250a►ez?a PUMP CHAMBER: Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) -5- v FORM SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F O PART C SYSTEM INFORMATION(continued) SOIL ABSORPTION SYSTEM(SAS):_ (Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type:. Leaching pits,number: f Leaching chambers, number: Leaching galleries,number: Leaching trenches, number,length: Leaching fields,number,dimensions: Overflow cesspool,number: Comments: (note condition of soil,si s of hydraulic failure level of pon ,condition of ve etadon, rh t/Jenfe-y) CESSPOOLS: .t4le 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(cesspool must be pumped as part of inspection) Comments: (note condition of soilk,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY: Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) -6 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. �✓ 4 q o DEPTH TO GROUNDWATER: Depth to groundwater: // Feet Metho of Determination or Approximation: -7- •ASSESSOR;'S MAP NO. / PARCEL S L%�JCAjION Oc�-e SEWA�G�E� �y� L IT NO. v� 3a'.c L,� ,,� '1 I L L A G E 35 t 4 l V4A1'746V, I N S T A LLER'S NAME j ADDRESS �t1Sca\� V.Sav\ 00 Wt�Sq�o�S iMi, ��5 111UILDER OR OWNER e vk bAvt DATE - PERMIT ISSUED DAT E COMPLIANCE ISSUED �O � , t �� .� � . f �/� '� s �� ASSESSORS MAP NO: !` No...........11 q 41 PARCEL NO.: I F�$.... ?..... THE COMMONWEALTH OF MASSACHUSETTS �--- BOARD F HE LT .rL...........OF..... .- .. .............................. Applirutiun for Biupuuttl 10urkii unitrurtiun Vamit Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal y X .. ... 7 � _,. l Location ddress or Lo ............................ ........................ .....-.� r^r .... c . l.4 r..G.. /�..... Owner Address Installer Address d Type of Building Size Lot.cAr!go_.Q_Q...Sq. feet U Dwelling—No. of Bedrooms........3......................•..__....Expansion Attic Wo Garbage Grinder (/Lim aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixture .-------•----------------------------------------------•-------•-•-------------------------------•--------•-•---------••-•--•------------------------ W Design Flow...........:.__.5.......................gallons per person per day. Total daily flow..........�.:XM................gallons. WSeptic Tank—Liquid*capacity 000gallons Length................ Width................ Diameter-___-__-__-__- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area.--- .----- .sq. ft. Z Other Distribution box ( ) Dosing /� '-' Percolation Test Results Performed by =�-�-.-L!/? K�2Ce��%?-- Date-- G ---... Test Pit No. J 5'S-_-__minutes per inch Depth of- Pit._ .../.. Depth o ground ater...... ......... y� Test Pit No. minutes per inch Depth of Test Pit._J. Depth to ground water.__�1... � -----•---- ...........-••..... ---------------------......................................................... O Description of Soil-- �.'� - •P` ' ? . 'S'O<.�------------------ ........---•-------•------••.. ------ w --... _,q -- -----------------••-•-----•----••....-••••----••-......-••------•-----•••••. ...... UNature of Repairs or Alterations—Answer when applicable............................................................................................... ---------------------------------•--•-----------------•---------------------•-------.....---...........-•--••-•----------------------------------------•---------•-------------------------------..--••- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with the provisions of'LlTLU, 5 of the State Sanitary Code—.The undersigned further a rees Inot to place/�aj( in operation until a Certificate of Compliance has be sued by the a Qf heart Signed•-• --...... .... ... •-- ..................................... ... Application Approved By.....- - .. ° f. ..... Application Disapproved for the following reasons--------------------------------------------------------------------------------••-- --------....-----....---... ...................................•---....--•----------------------------------•--.......--------...------------•..................----.....---•-•-----•---•----•----•--•----•-•----•--------•--------- 40Date PermitNo....•----• ..":. 7..4--- Issued------•-------------------------------------------•---. Date ...�..�.....��.�...«.W. ----------------- --------- THE COMMONWEALTH OF.MASSAC,HUSETTS �' J^°' l............OF..... .... ..yN . .. '�.. ............. Appliration for j3ioposttl lularkii,%vustrurtiOMIJ.'rxmtt` r ;Application is hereby made for a Permit to Construct ("I-) or Repair ( ) an Individual Sewage Disposal Y ya zz ....D .............. Location- ddress or Lot ............................ . .........................` ' 4 �✓._1.. 1 _.. Ownerf f ddress r Installer Address Type of Building Size Lot. O�_A. �'_._Sq. feet U a Dwelling—No. of Bedrooms........ . ...................-•-------_Expansion Attic (-? Garbage Grinder ( p, Other—Type of Building ............................ No. of persons............................ Showers ( ) Cafeteria ( ) p" Other fixturre_s ------------------------•---•••- d .................. Design Flow.._......._:._._,` ......................gallons per person per day. Total daily flow...........Z._.....................-...gallons. WSeptic Tank—Liquid capacityl. Q gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. ..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.--•............._- Diameter.................... Depth below inlet.................... Total leaching area... :....... ft. Z Other Distribution box ( ) Dosing ''' Percolation Test Results Performed by.-- - " t..... =-�"?_.f : • :- Date...x', �"` Test Pit No. . :; _._minutes per inch Depth of�est Pit.._ �(----. -- p p Dept o ground water_ 44 Test Pit No .minutes per inch Depth of Test Pit.. ....... Depth to ground water.. + • ---------••-••.......................................................... O Description of Soil ."" 1 m3 r -----------•---------- �� - - -•---•--•-•--------------- ---- �. --...... _ -----------•-- --•- -•---- ---•---- ••---•-----------•-•--•••-•-••------. V 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 TITLE 5 of the State Sanitary Code—.The undersigned further agrees not to place the/systinoperation until a Certificate of Compliance has bee ued by the cif heap i ned.._ r y S g A" ' ...... ... r �... Dat Application Approved By--- �"� �� " !"...:::. »�/- _�'+ ate Application Disapproved for the following reasons:............................................................................................................. ••••-••-•------------------------••••---......•-•-•----------.:....•-----•-----•--....__.._._........_....---------------•--------------------•--...-------------------••-•--------•-•--•-------.._...••- te Permit No............... " 1 7 t__ Issued.......................................................a Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT ...................................�!......._OF... ..................... i. . Tatif iratr of Tomphaurr X4P IS TO Piff 4FY, That t Individual Sewage Disposal System constructed ( or Repaired ) r 1r Gt. e � Ins ...............................•- at.......Q----- -------- -- -•----=•_-••-- ------_.. .....--- -------- -••--•---cz .. ------. -------- ---- ----------------•------...._...._...----------- has been installed in accordance with the provisions of TI T LF 5 of The lSttate Sanitary Cede s d9scribed in the application for Disposal Works Construction Permit No.__ te: "= ` -.... dad-.-..•....- .�, `�'/ ................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNC ION SATISFACTORY. DATE.................. .f!iP..............•------------•--- Inspector........_..�:71 7x-, THE COMMONWEALTH OF MASSACHUSETTS .. BOARD, F HEAL, H4"70 F.... :r ...�... FEE. ................... Dig o lVor"onstrudiatt prrmit Permission is ereby granted '°"' �' ...... t � t ....................•--------...-----•---......................... .... to Con u #"o .yjair n I divid ewa j is osal,S st at No e pfr � . e 7 ... r ......... ............. .. --- ..._•--•-...... " Street as shown on the lication for Disposal Works Construction Permit NCB-�'ir y'7C __ Dated.__ !.'� ............. ---••-------------- rn._ � .=?G.�. �_._... " Board of Health DATA ---_--- =-- --- ---.. ....._ ..�` ............ FORM 1255 A., ,.SUL'KfN, INC.. BOSTON �f ki • J • �T Z,1 � r5 Al 7/ rk � C t �.n 1 � ^ 4VE �/� - K x ' �,:.�n P.�;r "'• ;.yrx `r- x `� `} fit;_:tk`95� f i7 L.e.r.',' ` t `' vZE. �flT .GiliTtZT/a✓Jjr e x F `3 if � 3s'''• t ,• s-rQ+'` y �rs, ::'ix;r--.:j.: y5,, P i .�.. p 24 s ..� (� ., a, /(�, � /00 � r�.`t ' � .,� a ,�. �-fix r,.' t � • y ,., X��t ///•. 20 ♦_.Y,r .. ��/T.�✓J� � d � fr ) +:y ��.� t t{.r� � ee�� '.e�,� S y._'.f rF sry 4 �.�/�/..,�.G7y�w.L��✓.t • 1o/fir N g TclT " (fit a r r t tv. _ t 7. �LU T r Q�91 r _ ► _ A �' iE a€ ROE4CfRT G s ..�yd.. � 1G= i. / No. 19 ,3 7 c, fST LEGEND-, _a , EXISTING $POT ELEVATION ' 010 CERTIFIED PLOT PLAN EXISTING CONTOUR,---; 0 Y 't * ; rFINISHED .SPOT ELEVATION RINISHEO-CONTOUR --- r0 -�--, `F #'`{ �a fq�2.N•�vE,�__1.�a T NOrrE .,The,.. location of; an exzstin under round sewerage, wed ls.,, ox;other utilities shown ::on this °plan is appx'ox I N mate:-.onl' as determined from'records and/or verbal ' r ` information., The contractor xs •responsible for .the v/ r,ry vera.fication ;of the existing` locations n-.the field ` .' SCALE, = DATE gr6 ' t VLDREDGE ENGINEERING CQ IN CLIENT � v w+tf,k r --- --}�- I CERTIFY THAT THE PROPOSED Q 6'a E6ISTERE {� . REG1.9TERED JOB;N0 ` BUILDING SHOWN ON THIS PL AN` LAND :. CONFORMS TO THE ZONING LAWS s E 0 VEER r , RV z;r DR�.SY` �.��.�-1- 'OF BARNSTA;BLE MAS {: `712 MAI N: STREET �s /SBfoi HYANN15 MA s;� a y 9NEET�.... OF. ...._., DA E : -REG. LAND SURVEYOR � - .,y�.•r-i_ .�,s_by..,.&.x., :." ..:u!o,.w,re"fio-,..,:-4;d. ,....u�.a. -r.,4- ...e+.e.:v�.a.,e.�..i.-h...:r+.€f✓.. :.- _ ,._. �...,_ _ _- -_ ... ....... .,,. El7h�ER' 7`NE 5EP7/C TANK OR 20 Ar M//y: =Ef+c�/lrvG' P/T ARE MORE THAN /2"BE40/N � " `� 1R'AOE� � 2�?"O/AM ETEL' CONG'RETE COVER E /O F7. /N!N Y SJ•/ALL ©E BROUGHT TO GJ;AGE:�.•+NEXTRA � q PNC P/PE i CONC , „ J/E A Y C/ Co R L'L USE7 /N P IF /N OR/VE J / YCDY,ERS , P1� FT. — 2 MiN: CO/VCR�TE AGE GU VER Get O C LEAN SAN LQ t/!O'LEVEL y c ( 4"DIA. ` . �..' 2"LAYER P Y.C. PI PE` /DOe ' .o JIB--'7/B• dr WA M/N.P/7!C/y =- GILL v •o 0 1 • t • : . • i• • s * -D/SF o a•' SHEO $72?%1/L,' • PER JF'T. $E/aT/C Ti4/VK 1 • • . • • • 1 • e a a , v O 4 1 • ,, _ BMX,,. p, f � 8 1 i • • •. f • O -, r Lx a c • l- 0,1 •�FE Ir/✓Z ._.. 4 r fi ryi ;:` +-s ' Y ,.: S Y s r-,j 1 p f •' O TN.1 ♦f f o o WA5NE0 STONE - ' AA - O " dr • • •Jt? PRE A5 S G s t 4 i /��1r 3r7 s a• f • s • •�, i a• • D f�p T EE.p E yJ * : - s �o� ., • • • • ...• f.f a o P/7.OR EVI//V.. ELE�AT/am.s NYERT AT T 4,r Fr.-C PS►c s y ¢90 st Iba �Z' G%AM• C(SE /NLET, SEPT/C Ti4/YK :FT r ETA81/L./�TJON� O/J .L T E 'S C EPT/ .TANK-}' '? uNa JL�ATER TABLE � F%Nd ET D/STR/131/j/AN' BOX FT u. SECT/6N 4* : GRD y= $; ` OtITLETD/STR/B(lTION 6C�X'` 6-7,F�' M SE1�V�46E'O/SPO�SRC_ .S MQ ;' /NLET.LEACH NG Fmm 7/IBUGATIO tia 4 t µ « T -/V DESlGJV `GR�TERI 4 :z J`AW 5l.Q/ : `' ` > v/MENS/oN` NUMBER OF BE�RQOMS, - - _ G�R�AGEO/SPOSAI-UNjT'M/L�¢N a` _ SCJIL. BOG . N TOTAL E3T/M44T'ED /=L'G H/ 3 GAG. 0�4Y. SQtL TEST A�` .SO/� TEJ�"T w NUMBERR OF' 404CNINCe-Pirs l Eck✓:- �c ✓.' -!r o a'TE aF-saiL _TEST`f// 'o r , S/OF LEAC/fJNG PER P/T Srt PT. Q R SfialoK: RESULTS jt/lTNESSED �Y /NCH` ' BOTTOM t.FACN/NG.PER PJT /r_3 ::SQ /C7 2 _ PERCOLAT/D/1i IIRTEAf- TOTAL LERGK/NG �4REA 2 S FT d 'T/ON RA7�'E2 MIN /NCfI' ` (i Q PEJ�Z'COL4 RESERVE LE.4C'N!/1/G ARE/i 26¢ 54 FT ;`d SA�iGt' '' ..ram ''� '• �" .,. ri AL—ERE', x q.` r,. •art ` ! ZJ TA!�/S /1l, 4f ,o9No. ItIliol 01 No.. is TirG'Lt a r s > � �.` $sstt'�`��} ELORE�GE ENGINEER/J1/G G'O.,/NGi -�c ; s g 3 6 E.V 7/2 MAIN' ST., yANNl9, MASS R - _ r ...ALE✓ C�1 r OaTE 9 / ,�'TcSi'. •.:: ,� -/YO GRO UN 'U J•Y,4 TER ENCO t//1/T1�REO Cs./EN r_..1�EEys�"2�� ,.w.. __.. .' S-�+G c : • `// �- G3 ,1-v<+7' .P .qr 464 k JOfs Na.: &5. S/�&Z7�osr.: Z y