HomeMy WebLinkAbout0251 LAKESIDE DRIVE - Health 251 Lakeside Drive, Marstons Mills
A=
UFC i293Q
N�.2. 53LY
W46TINOB, MN
��
i
i
i
R:r
o�TME
Town of Barnstable
Board of Health
200 Main Street, Hyannis MA 02601
Office: 508-862-4644 John Norman,Chairrman
FAX: 508-790-6304 Donald A.Guadagnoli,M.D.
F.P.(Thomas)Lee,P.E.
Daniel Luczkow,M.D.At
March 3, 2022
Mr. Joseph Henderson
Horsley Witten Group
90 Route 6A, Unit 1
Sandwich, MA 02563
Dear Mr. Henderson,
You are granted permission on behalf of your clients, Ronald Palma and Juanita Sweet,
to construct and utilize a NitROE secondary treatment unit with advanced nitrogen
reduction technology at 251 Lakeside Drive, Marstons Mills, Massachusetts.
You are reminded the following requirements are provided within the MA Department of
Environmental Protection (DEP) Provisional Use Approval Renewal letter for this
particular technology, dated May 12, 2020:
(1) Thirty (30) days prior to submitting an application for a DSCP, the Company or its
representative shall provide to the Approving Authority a certification, signed by
the owner of record for the property to be served by the unit, stating that the
property owner: a) has been provided a copy of the Provisional Use Approval
and all attachments and agrees to comply with all terms and conditions; b) has
been informed of all the owner's costs associated with the operation including
power consumption, maintenance, sampling, recordkeeping, reporting, and
equipment replacement; KleanTu NitROE 2K Provisional Approval, May 2020
Page 11 r of 15. Technology: NitROE® 2KS & 2KM WWTS c) understands the
requirement for a contract with a company approved operator and has been
provided a current list of all approved operators; d) agrees to fulfill his
responsibilities to provide a Deed Notice as required by 310 CMR 15.287(10)
and the Approval; and e) agrees to fulfill his responsibilities to provide written
notification of the Approval conditions to any new owner, as required by 310
CMR 15.287(5).
(2) Prior to the issuance of a Certificate of Compliance by the Approving Authority: a)
In accordance with 310 CMR 15.021(3), the System Installer and Designer must
Q:WP/Henderson Horsley Witten Group IA approval 251 Lakeside Drive Marstons Mills Nov 20 3,1,docx
certify in writing that the System has been constructed in compliance with 310
CMR 15.000, the approved design plans, and all local requirements, including
any local approving authority site-specific requirements;
(3) Prior to issuance of the Certificate of Compliance and after recording and/or
registering the Deed Notice required by 310 CMR15.287(10), the System Owner
shall submit the following to the Local Approving Authority: (i) a certified Registry
copy of the Notice bearing the book and page/or document number; and (ii) if the
property is unregistered land, a Registry copy of the System Owner's deed to the
property, bearing a marginal reference on the System Owner's deed to the
property. The Notice to be recorded shall be in the form of the Notice provided by
the Department
(4) Prior to the use of the System, the System Owner shall enter into an O&M
Agreement with a qualified contractor and submit the Agreement to the
Approving Authority and the Company. The Agreement shall be at least for one
year.
(5) The wastewater effluent shall be sampled and analyzed/tested quarterly if this
facility is utilized year-round. Sampling shall include pH, BOD5, TSS and Total
Nitrogen, unless otherwise stated. Flow shall be recorded at each inspection.
[Note:a)Year-round facilities shall be inspected and effluent sampled quarterly;b)Seasonal properties shall
be inspected and effluent sampled a minimum of twice per year,with at least one annual sample taken 30 to
60 days after seasonal occupancy and a second sample taken no less than 2 months after the first sample;
and c) After 12 rounds of monitoring, sampling may be reduced to TN only quarterly. Reduced sampling
shall also include Field Testing of System wastewater when determined necessary by the operator, see DEP
Field Testing Protocol at http://www.mass.gov/eea/docs/deptwaterAawsA-thru-z/testsamp.pdf]
(6) A copy of the wastewater analyses, wastewater flow data, field testing results,
and System Operator O&M reports and inspection checklists shall be maintained
by the Company. It is recommended the System Owner also maintain copies of
these items.
All of the other conditions listed in the MA Department of Environmental Protection
(DEP) Provisional Use Approval Renewal letter to KleanTu LLC dated May 12, 2020
shall be adhered to.
This permission is granted because the proposed plan appears to meet all of the
provisions of the State Environmental Code, Title 5, Town of Barnstable Board of Health
Regulations It also meets the nitrogen loading restrictions contained within the State
and local regulations with no increase in sewage flow requested at this property at this
time.
Sincere) yours,
0 /�_,�
ohn Norman, Chairman
Q:WP/Henderson Horsley Witten Group 1A approval 251 Lakeside Drive Marston Mills Nov 201!Aocx
1� DATE:
$95.00 FEE*: v
BARMABM =
MAt3S. Town of Barnstable REC.BY: �s
Board of Health SC ED.DATE: �d1y
200 Main Street, Hyannis MA 02601
Office: 508-8624644
�j�� /l, John T.Norman
h-✓'
FAX: 508-790-6304 r 111601 Donald A.Guadagnoli,M.D.
Paul J.Canniff,D,M.D.
F.P.(Thomas)Lee,Alternate
VARIANCE REQUEST FORM
LOCATION
Property Address: 251 Lakeside Drive,Maisons Mills
Assessor's Map and Parcel Number: 102/166 Size of Lot: 0.17 ac
Wetlands Within 300 Ft. Yes Business Name:
Subdivision Name:
Henderson (Horsley Witten Phone (508) 833-6600
APPLICANT'S NAME: Joseph ( Y )
Did the owner of the property authorize you to represent him or her? Yes X No
PROPERTY OWNER'S NAME CONTACT PERSON
Name:
Ronald Palma&Juanita Sweet Name: Jospeh Henderson (Horsley Witten Group)
Address: 251 Lakeside Drive, Marstons Mills Address: 90 Route 6A Unit 1, Sandwich, mA 02563
Phone: Phone: (508) 833-6600
EMAIL: jhenderson@horsleywitten.com
VARIANCE FROM REGULATION uncl.Reg.code s) REASON FOR VARIANCE(May attach separate sheet if more space needed)
Installation of IA System
NATURE OF WORK: House Addition House Renovation LJ Repair of Failed Septic System LJ
Checklist (to be completed by office staff-person receiving variance request application)
Please submit first four on list as S collated packets.
A. Five(5)copies of the completed variance request form
B. Five(5)copies of MA DEP approval letters for Innovative/Altemative septic system(when proposing an I/A system or
secondary treatment unit(S.T.U.).
C. Five(5)hard copies of engineered plan submitted(e.g.septic system plans)and one(1)electronic version submitted to email:
healthatown.bamstable.ma.us *(Pool Plan—5 hard copies)
D.Five(5)copies of labeled dimensional floor plans submitted.(e.g.house plans or restaurant kitchen plans)and one(1)electronic
version.
A completed seven(7)page checklist confirming review of engineered septic system plan by submitting engineer or RS.
Signed letter stating that the property or business owner authorized you to represent him/her for this request
Applicant must notify abutters by certified mail at least ten days prior to meeting date at applicant's expense(for Title V and/or
local sewage regulation variances only).
Full menu—Five(5)copies of full menu submitted(for grease trap variance requests only).
Fee Submitted*$95.00 for the following variances: 1)New construction, 2) Septic repairs with increase in flows, and 3)New
owner/new lessee applying for food, pool or body art variances. Exemptions from Variance Fee: I) Septic repair without an
increase in flow and variances granted at the counter,2)Monitoring Plans,and 3)Temporary Food(not a"variance").
Variance request submitted at least 15 days prior to meeting date
VARIANCE APPROVED John T.Norman
NOT APPROVED Donald A.Guadagnoli,M.D.
REASON FOR DISAPPROVAL Paul J.Canniff,D.M.D.
Q:\Application Forms\VARIREQ Rev Jan 1-2020.docx
MAIL-IN REQUESTS
Please mail the variance fee amount of $95.00 (if applicable), along with the documents listed
below, to the following address: Checks payable to: Town of Barnstable.
Town of Barnstable
Public Health Division
200 Main Street
Hyannis, MA 02601
For septic.systerrl variance requests, each of five packets must'include;
1) Variance Request Form,
2) Letter for the Board.with further information on the reason for the septic
variance request (Optional),
3) MA DEP Approval letters for proposed Innovative Alternative (I/A) septic
system or a proposed secondary treatment unit (S.T.U.)
4) Engineering plans,
5) Floor plans.
In additional to the five septic packets above include one copy of the seven (7) page checklist,
the authorization letter, copy of abutters notice, and fee, if applicable (see checklist below).
Please send one electronic submission using a PDF or jpg of the engineering plan and floor
plans to email: health(Dtown.barnstable.ma.us. (Total email must be less than 10 megabytes.)
For grease trap variance requests, each of five packets must also include a full menu. (see
checklist below).
Checklist Please submit rirst four on list as 5 collated packets.
X Five(5)copies of the completed variance request form
B. Five(5)copies of MA DEP approval letters for Innovative Alternative septic system(when proposing an I/A or
secondary treatment unit
C. Five(5)hard copies of engineered plan submitted(e.g.septic system plans)and one(1)electronic version submitted
to email: health@barnstable.ma.us
D. Five(5)copies of labeled dimensional floor plans submitted(e.g.house plans or restaurant kitchen plans)and
one(1)electronic version submitted to email: health@town,bamstable.ma.us
A completed seven.(7) page checklist, confirming all required items are on the engineered septic system plan
submitted by engineer or registered sanitarian.
Signed letter stating that the property or business owner authorized you to represent him/her for this request
Applicant must notify the abutters by'certified mail at least ten days prior to meeting date at applicant's expense(for
Title V and/or local sewage regulation variances only).
Full menu-Five(5)copies of full menu submitted(for grease trap variance requests only)
Fee Submitted*$95.00 for the following variances: 1)New construction,2)Septic repairs with increase in flows,3)
New owner/new lessee applying.for food,pool or body art variances. Exemptions from Variance Fee: 1) Septic
repair without an increase in flow and variances granted at the counter. 2)Monitoring Plans, and 3) Temporary
Food(this.is not a variance).
Variance request.submitted at least 15 days prior to meeting date.
For further assistance on any item above, call (508) 862-4644
Email: health(cDtown.barnstable.ma.us
Back to Main Public Health Division Page
TRANS. NO.:
CITY/TOWN: Marstons Mills
APPLICANT: Horsley Witten Group
ADDRESS: 251 Lakeside Drive,Marstons Mills
DESIGN FLOW: 330 gpd
REVIEWED BY: DATE:
N/A OK NO
GENERAL 2
Legal boundaries denoted [310 CMR 15.220(4)(a)]
Street, Lot,tax parcel number and lot number noted on plan [310
CMR 15.220(4)(u)]
Locus Provided [310 CMR 15.2204(t)]
Plan proper scale? (1"=40' for plot plans, 1"=20' or fewer for
components) [310 CMR 15.220(4)]
Easements shown [310 CMR 15.220(4)(b)]
System located totally on lot served [310 CMR 15.405(1)(a)for
upgrades]- if not, a variance is required [310 CMR 15.412(4)]
Location of impervious surfaces (driveways, parking areas etc.)
[310 CMR 15.220(4)(d)]
Location all buildings existing and proposed 310 CMR
15.220(4)(c)]
Location and dimensions of system components and reserve
areas. [310 CMR 15.220(4)(e)]
System Calculations [310 CMR 15.220(4)(f)]
daily flow
septic tank capacity (required andprovided)
soil absorption system (required andprovided)
whether system designed for garbage grinder
North arrow [310 CMR 15.220(4)( )]
Existing and ro osed contours [310 CMR 15.220(4)(g)]
Location and log of deep observation holes (existing grade el. on
each test) [310 CMR 15.220(4)(h)]
Names of soil evaluator and BOH representative [310 CMR
15.220(4)(h) and (i)]
Location and date of percolation tests (performed at proper
elevation?) [310 CMR 15.220(4)(i)]
Percolation test results match loading rate? [310 CMR 15.242]
Certification statement by Soil Evaluator [310 CMR 15.220(4)0)]
Observed and Adjusted groundwater(method for adjustment
given or indicated) [310 CMR 15.103(3) and 310 CMR
15.220(4)(n)]
Address 251 Lakeside Drive,Marstons Mills �'� Sheet 1 of 7
N/A OK NO
Location of every water supply,public and private, [310 CMR
15.220(4)(k)]
within 400 feet of the proposed system location in the case
of surface water supplies and gravel packed public water supply
within 250 feet of the proposed system location in the case
within 150 feet of the proposed system location in the case
of private water supply wells
Location of all surface waters and wetlands located up to 100 ft.
beyond setbacks listed in 310 CMR 15.211 and any catch basins
located within 50 ft. [310 CMR 15.220(4)(1)]
Water lines and other subsurface utilities located [310 CMR
15.220(4)(m)] (if water line cross see 310 CMR 15.211(1)[1])
Profile of system showing invert elevations of all system
components and the bottom of the SAS [310 CMR 15.220(4)(o)]
Stamp of designer [310 CMR 15.220(1) and 310 CMR 15.220(2)]
Stamp of Registered Land Surveyor(required if construction
activities within 5 ft. of lot line) [310 CMR 15.220(3)]
Test Holes adequate (two in each of the primary and reserve
unless trenches as permitted in 310 CMR 15.102(2) or as
approved for an upgrade under LUA at 310 CMR 15.405(1)(k)]
Test hole adequate to demonstrate four feet of suitable material?
[310 CMR 15.103(4)]
Test Holes adequate to confirm adequate groundwater separation?
[310 CMR 15.103(3)]
Benchmark within 50-75' of system [310 CMR 15.220(4)( )]
Materials specifications noted? [various sections of 310 CMR
15.000]
System components not> 36" deep (unless Local Upgrade
jApproval or LUA requested) [310 CMR 15.405(1(b)]
251 Lakeside Drive, Marstons Mills
Address Sheet 2 of 7
251 Lakeside Drive
Provided by
Homeowner
UNDRY BATH
2"x 57"
KITCHEN 5' "x 5'7'-
' 14'6"x 9'6"
GARAGE "
16'4"x 20'10" to
LIVING ROOM PRIMARY BEDROOM
11'3°x 13'9" 12'8"x 14'9"
i
i
1
3
i
I
Ttit Fl3W 1k- INgn�,:3 ttn4td t-��oWefim�Lihc fmn n(Ih p1ouMY:nd Ay�rol nt<`�I'h;Ny'nspt4i#I:f 4'�t �p.Inl�g�f te;ll yaennwlf p'4'Pt�?y cteKl:pia. F16PIan
z"ap?'19ht s 7821 fingMal$u5N4335/Yzmc,lnc AA r=9hi rs;ttsEO
First Floor
f
l
i
i I
j
DECK i
w
BATH BATH W,L5.
7 511 5' 0'
'GREAT ROOM 4
22'2 x 20'10"
t 07,
FAMILY ROOM
14'10"x 16'11" EN SUITE BEDROOM
1218"x 1416"
I
BALCONY I_ BALCONY
T%,i1m,mfloor Plan Int<"d<0fo,epro,e"1I/x Ibw WiM Ptcr',ertkLM mjy"tec[metN1 l<pi<,a="C or
tfN:agrt•R t1.pl"n<IPY=s='xii01<. Flo Plan OeM,Wht C=1 All—h�tivamc:p SYftRMsl"k.nu¢gllt=,Ped.
Second Floor
LOFT
16'4"x 10'9"
HALL,, I
l9„x.31
ATTIC/MECHANICAL.S
11'8"x 9'11" T
BEDROOM
i 12'8"x 165
I
I
I
OPEN TO BELOW I
I
i
i
I
I
'n VRbW- no A'fl,;i -!oleo.iP rp�r _.c tcx5w.f� P P�;tY aM-uY�.I eCetiw-'y te�ykn,lnanaM.�:,pnl,of Secn-'�vi et MM.atnF�sy nf.nuur�We.
F16PIan
Loft Area
V
Y
f
a
BAT
I X I u
ELECTRICAL ROOM STORAGE
12'4„ x 20'1" �. 15'4" x 9'1"
OFFICE STORAGE
9'8" x 10.631 10'2" x 10'6"
Rls flM1idaa Nape ait, rMe�J lO r<p<fCnl dtr lb:v pf VM km4:Y and YMt Kt.UYaIN((.1a. SWa ehpMtiMvr a/aaGf!Ip�T U:6C 01op^_*t/a.atehule. C�Ory��y�
COPY IUh3 o 2033 33na I 01.1-1 SysRms,1nu-1 d!/h(;;«yanaC r r n
Basement
KleanTu® LLC
KleanTu Wastewater P.O. Box John R.Smith
math
Treatment
1154
Technologies Edgartown,MA 02539
412-719-5976-Mobile
508-627-3072-Office
November 4, 2021
To: Town of Barnstable Board of Health
200 Main Street
Hyannis,MA 02601
RE: Designer Certification for New NitROE®2KS WWTS Enhanced Title 5 Septic System Installation
for 251 Lakeside Drive,Marstons Mills,MA 02648;KleanTu®Project No.80053-2111
Dear Members of the Board: - - -
Kindly refer to the following: (i)the Mass DEP Provisional Permit issued to KleanTu®LLC(DEP Transmittal
No.:X285590;Issued May 12,2020)(the"DEP Permit");and(ii)the Enhanced Title 5 Septic System design for
the 251 Lakeside Drive,Marstons Mills,MA,private residence(the"New System"),featuring the use of a new
NitROE®2KS wastewater treatment system(the"NitROE®2KS Components"). The New System was designed by
Joseph Henderson, a Massachusetts Registered Professional Engineer with Horsley Witten Group, Inc.(HWG).
r The NitROE®2K Components are depicted in Site Drawing Project No.: 20112,prepared by HWG and dated
November 8,2021.
Item IV-#2 of the DEP Permit requires that KleanTu®make certain certifications to the Town of Barnstable Board
of Health(the"Board")pertaining to the design of the New System.
Accordingly, KleanTu®LLC hereby certifies to the Board that(i)the New System design, solely as it relates to the
NitROE®2KS Components and their incorporation into the New System,conforms with the design specifications
required by the DEP Permit and(ii)the NitROE®2KS Components are able to perform the proposed wastewater
treatment for the New;System.
Sincerely yours,
Jaw K F (Nw5,202110:08 EDT) -
Jaw FL
Vice President
Engineering and Operations
cc: Joseph Henderson, Horsley Witten Group
Ronald Palma and Juanita Sweet, Property and System Owner, ,
I
- 1-
I
KleanTu® LLC
John R.Smith
KleanTu Wastewater P.O.Box 1154
Treatment
Technologies Edgartown,MA 02539
412-719-5976-Mobile
508-627-3072-Office
November 4,2021
Town of Barnstable Board of Health
200 Main Street
Hyannis,'.VIA 02601
RE: Property and System Owner Certification for New NitROE®2KS WWTS Enhanced Title 5 Septic System
Installation for 251 Lakeside Drive,Marstons Mills, MA 02648;KleanTu Project 80053-21 l 1
Dear Members of the Board:
Kindly refer to the following: (i)the Mass DEP Provisional Permit issued to KleanTu®LLC(DEP Transmittal
No.X285590; Issued May 12,2020(the"DEP Permit"); and(ii)the Enhanced Title 5 Septic System proposed for
251 Lakeside Drive,Marstons Mills,MA,a private residence,(the"New System'),featuring the use of anew NitROE®
2KS wastewater treatment system(the"NitROE®2KS Com orients").
Item IV- 45 of the DEP Permit requires that KleanTu®LLC provide to the Town of Barnstable Board of Health(the
"Board")a certification that the owner of the property of record has agreed to certain specific matters with respect to the
New System.
I have inc_uded with this letter the required certification.
Should you have any questions, please do not hesitate to contact me. My cell#is 412-491-0122.
Sincerely yours,
Jaw K.F (Nov 5,X 21101.13 EDT) .. ..
Jaw Fu
Vice President
Engineering and Operations
Enclosure
cc: Ronald Palma and Juanita Sweet, Property and System Owners
- 1-
f
November 4,2021
K1eanTuo LLC
Jaw Fu - -
P.O. Box 1154
Edgartown,MA 02539
Dear Sir:
I refer to the following: (i)the Mass DEP Provisional Permit issued to K1eanTuo LLC (DEP Transmittal No.X285590;
Issued May 12, 2020(the"DEP Permit");and(ii)the Enhanced Title 5 Septic System(the"New System")proposed for
our private residence at 251 Lakeside Drive,Marstons Mills,MA 02648,featuring the use of a new NitROE®2KS
wastewater treatment system(the"NitROE®2KS Components").
By signing this letter and delivering it to you,as the owners of the property known as 251 Lakeside,Marstons Mills,MA
02648, I/we hereby certify to the accuracy of all of the following statements:
1. I have been provided a copy of the DEP Permit and I agree to comply with all terms and conditions cited therein.
2. 1 have received estimates of all homeowner's costs associated with the operation of the NitROE®2KS
Components including power consumption and equipment replacement,as well as maintenance, sampling,
recordkeeping, reporting and related matters for the NitROE®2KS Components(collectively,the"O&M
Responsibilities").
3. I understand that I must enter into a contract by which my O&M Responsibilities will be fulfilled with K1eanTue
LLC or a K1eanTue LLC-approved operator licensed by the Mass DEP as required by the DEP Permit.
it
4. 1 understand that I must provide a Deed Notice to the Town of Barnstable Board of Health as required by
310 CMR.15.287(l0)and the DEP Permit.
5. 1 understand that I must fulfill my responsibilities to provide written notification of the conditions of the DEP
Permit to any new owner,as required by 310 CMR 15.287(5).
Sincerely yours,
Date:
Aanita
ma
Date:
et
-2-
KleanTu® LLC
Mean Wastewater John R.Smith
Treatment P.O.Box 1254
Technologies Edgartown,MA 02539
n _ .
412-719-5976-Mobile
508-627-3072-Office
CONTRACT No.80053-2111 for 251 Lakeside Drive,Marstons Mills MA 02648
November 4,2021
Mr. Ronald Palma and Ms.Juanita Sweet
251 Lakeside Drive
Marstons Mills, MA 02648
RE: NitROE02K WWTS Installation for 251 Lakeside Drive;Marstons Mills,MA;KleanTu®Job No. 80035-2111
Dear Ron and Juanita:
KleanTu®LLC is pleased to provide this contract document for a NitROE®2K Waste-Water Treatment System
(WWTS)to be installed at 251 Lakeside Drive,Marstons Mills,MA. The main purpose of the NitROE®2K
WWTS is to serve as a supplemental upgrading of a new Title 5 septic system. A new NitROE®2K WWTS tank
will be inserted in between the gravity flow path of a new septic tank and a new leaching chamber. The purpose of
the NitROE®2K WWTS is to significantly reduce total nitrogen(TN)from the sanitary wastewater flow prior to
permitted discharge to the new Title 5 leaching chamber. In addition to significantly reducing TN,the NitROE®2K
WWTS enhancement will produce a highly treated wastewater effluent with significantly reduced levels of organics
and suspended solids as well.
NitROE®ENHANCED TITLE 5 SEPTIC SYSTEM OVERVIEW
The NitROE®2K WWTS to be installed is specified in Site Drawing Project No. 20112,prepared by Horsley
Witten Group Inc.(HWG)dated November 8,2021.
With reference to this site drawing,wastewater will first be collected into your existing 1,500-gallon septic tank.
After solids separation in the septic tank,wastewater will then gravity flow into a NitROE®2K WWTS tank for
enhance total nitrogen reduction. From there,the significantly treated wastewater will gravity flow into a new
leaching chamber.
�I
KleanTu® LLC
KleanTu Wastewater John R.Smith
Treatment P.O.Box 1154
Technologies Edgartown,MA 02S39
412-719-S976-Mobile
508-627-3072-Office
CONTRACT No.80053-2111 for 251 Lakeside Drive Marstons Mills MA 02648
REGULATORY REQUIREMENTS
The NitROE®2K WWTS will be installed and operated under a Mass DEP Provisional Permit granted to KleanTu®
LLC(DEP Transmittal No.X285590; issued May 12,2020). Specific regulatory items that need to be addressed
are summarized below. It is to be noted that various actions among the site owner,the site design engineer,the
installer,and KleanTu®LLC must be followed and respectively documented. The majority of the documentation
required will be provided by the Barnstable Clean Water Coalition(BCWC)with input from KleanTu®.
Furthermore,these Mass DEP regulatory requirements pertain to respective actions from project initiation through
to NitROE®2K WWTS start-up and yearly operation.
A. Obtaining a Disposal System Construction Permit(DSCP). This is issued by the local Board of Health
(BoH)after completion of the following:
1. Submittal of the site engineering design and DSCP application to the local BoH. Normally this is
done by the Design Engineer.
2. Along with the DSCP application,to comply with Section IV-1 of the Provisional Permit,the
BCWC,with input from K1eanTue LLC,will provide to the local BoH,a certification letter that
the site owner:
i. Has been provided a copy of the Provisional Use Approval and agrees to comply with
all terms and conditions cited herein.
ii. Has been informed of all owner's costs associated with operation&maintenance
(O&M)activities with the operation of the New NitROE®2K WWTS Enhanced Title 5
Septic System to be installed,including power consumption,maintenance,sampling,
recordkeeping,reporting,and equipment replacement.
iii. Understands the requirements for a O&M contract to be in place with.KleanTu®LLC,
or with their designated and trained entity,and that the NitROE®2K WWTS operator
must.be licensed by the Mass DEP as stipulated in KleanTu®LLC's Provisional Permit.
iv. Agrees to fulfill their responsibilities to provide a Deed Notice,and file with the local
Registry of Deeds,as required by 310 CM 15.287(10)and with the Approval by the
local BoH.
v. Agrees to fulfill their responsibilities to provide written notification of the Approval
conditions to any new owner,as required by 310 CMR 15.287(5). .
-2-
f
KleanTu® LLC
-KleanTu Wastewater John R. Smith
Treatment P.O.Box 1154
Technologies Edgartown,MA 02539
412-719-5976-Mobile
508-627-3072-Office
CONTRACT No.80053-2111 for 251 Lakeside Drive,Marstons Mills,MA 02648
3. Along with the DSCP application,to comply with Section IV-2 of the Provisional Permit,the
BCWC,with input from KleanTu®LLC,will provide to the local BoH,with a copy to the
Designer and the Site Owner,that the site-specific design conforms to Provisional Permit
requirements and that the proposed use of the NitROE®2KM WWTS is consistent with the unit's
capabilities and all KleanTu®LLC requirements.
B. Executed Operation& Maintenance Contract In-Place. To comply with Section 1V-4 of the
Provisional Permit,thirty(30)days prior to installation of the NitROE®WWTS,the BCWC,with input
from KleanTu®LLC,will provide to the local BoH,a copy of a signed O&M contract for a minimum
period of one year,between the site owner and KleanTu®LLC,or their designated approved operator,who
has been properly trained and certified by KleanTu®. In this regard,in addition to signatory execution of
this Contract document,the site owner will also be required to sign and thus execute an O&M contract for
start-up and the first 12 months of operation and monitoring.
C. Obtaining a Certificate of Compliance(COC). This is issued by the local Board of Health(BoH)after
installation,local BoH inspection and sign-off,and completion of the following to comply with
Sections IV-5 and 1V-6 of the Provisional Permit citing the following:
1. A local BoH inspector,the installer and the designer all need to sign the COC and thus certify, in
writing,that the NitROE®2K WWTS was constructed in compliance with both the Provisional
Permit and Mass DEP 310 CMR 15.000 requirements,and that any changes to the design plans are
reflected in as-built drawing and/or notes. The completed COC then needs to be filed with the
local BoH.
2. The BCWC,with KleanTu®LLC input,will submit a written certification letter to the local BoH,
and copy the site owner,that the:
i. NitROE®WWTS has been constructed and installed in compliance with approved site
design plans,the Provisional Permit requirements,Mass DEP 310 CMR 15.000 and local
BoH requirements.
ii. NitROE®WWTS was constructed and installed under direct supervision and oversight by
KleanTu®LLC personnel,and that KleanTu®LLC also did the installation of the aeration
system,bacterial seeding of the tanks,and installation of other pertinent items such as
risers and access ports.
-3-
KleanTu® LLC
KleanTu Wastewater John R.Smith
Treatment P.O.Box 1154
Technologies Edgartown,MA 02539
412-719-5976-Mobile
508-627-3072-Office
CONTRACT No.80053-2111 for 251 Lakeside Drive,Marstons Mills,MA 02648
D. NitROE®WWTS Site Inspections and Monitoring. To comply with Section III B, items 13-36 of the
Provisional Permit related to Operation and Maintenance(O&M), KleanTu®LLC,or a designated
representative entity trained by KleanTu®LLC,will be responsible for doing the appropriate number of
site inspections,along with sampling and analyses for specific wastewater treatment parameters,and for
reporting respective results to the Site Owner,the local BoH and the Mass DEP. Initially the required
number of site visits and monitoring will be done on a quarterly basis,per the Provisional Permit
requirements. Once a General Permit is issued,then the site inspections and monitoring will be reduced to
a semi-annual or annual basis. In any event,the site owner will be required to have contracts in place with
KleanTu®LLC,or their designated representative, for O&M, including the monitoring and reporting
required.
INSTALLATION ACTIVITIES AND PRICE
For installation of the enhanced NitROE®2K WWTS,the task activities to be carried out,along with their
respective prices,are provided in the table below.
IT IS TO BE NOTED THAT ALL OF THE COSTS CITED WILL BE COVERED BY THE
BARNSTABLE CLEAN WATER COALITION(BCWC)PER AN AGREEMENT THEY HAVE WITH
THE SITE OWNER
An electronic copy of the NitROE®WWTS Installaton Manual is provided along with this Contract proposal. This
document serves to identify the various activity responsibilities among the site owner or the BCWC,the installer
and KleanTu®LLC. Of particular note, it is the responsibility of the site owner to identify and make the installer
aware of any buried utility lines such as gas,electrical,and cable; here Dig Safe can be contacted to provide this
service at no cost(http://www.dipsafe.com),but they only identify public utility lines and not any private lines.
As cited in the Table 1 below,the contract price for KleanTu®LLC to provide the task activities cited is$12,500.
This also cites that the site owner is also responsible for the engineering and installation services to be done by
others.
Additionally,it is to be noted that the BCWC will arrange for and pay for additional site-specific activities related
to:
1. Providing a dedicated electrical service and a four-receptacle GFI outlet box in a location near the NitROE®
2KS tank locations:
2. Filing a notarized deed restriction with Barnstable County and paying the filing fee as well as-obtaining a
copy of the deed restriction document for the local BoH. A deed restriction to be executed is provided with
�^ this contract proposal.
1
-4-
KleanTuO LLC
KleanTu Wastewater John R.Smith
Treatment P.O.Box 1154
Technologies Edgartown,MA 02S39
® 412-719-5976-Mobile
508-627-3072-Once
CONTRACT No.80053-2111 for 251 Lakeside Drive Marstons Mills MA 02648
Table 1.KleanTu°Price of Title 5 Enhancement via NitROE®2KS WWTS Enhancement
for 251 Lakeside Drive,Marstons Mills,MA 02648
ONE 2,000 GALLON NitROE TANK(N-ASST20M-H10)
(KleanTu®Project No.80053-2111)
KleanTu°
Task Categories and Description Price
(Covered
by BCWC)
Task 010-Project Management,Engineering and Permitting
Includes overall project management coordination inducting review and input to the site engineering
design,local BoH and MassDEP permitting interactions,and ensuring that all work is done in a manner
protective of workers and the environment. Note:BCANC is responsible for site design engineering and local $0
BoH nteractions including obtaining all permits and final certification. BCWC is also responsible for filing
"Notice of Alternative Sewage Disposal System"with Registry of Deeds and pay$105 fee,with KleanTu'
providing review and coordination.
Task 020-Procurement and Field Fabrication of ONE Concrete Tank
Includes providing one2,000-gallon NitROE®2KS H-10 tank at a price of$12,500. These prices include all
media,access riser ports and covers near or to surface:aeration assembly w/air pump and installed air $12,500
tubing,and faux rock for air pump enclosure.
Task 030-Tank Delivery and Installation Oversight
Installation oversight and air-line hook-up of delivered NitROE®Tank,including remote sensing unit
connection to homeowner Wi-Fi network. Note:BCWC is responsible for procurement and sewer piping
connections of septic and NitROE®tank,procurement and installation of leach chambers and all piping i in $0
connections,providing electrical service(120V• 20 amp)and outlet boxes to location selected by site owner
for running air pump. NOTE:TASK ACTIVITIES PROVIDED BY KLEAN TU AS IN-KIND SERVICE.
TASKS 010-030 TOTAL THRU INSTALLATION $12,500
Task 040-Start-Up and Monitoring,Operation&Maintenance(MOM)Per MassDEP Provisional Permit
and Barnstable BoH Requirements
Includes NitROE®WWTS bacterial seeding,system star-up,bi-monthly visits,quarterly sampling and
analyses by MA certified lab,recordkeeping and reporting required by MassDEP,and operational oversight $0
for 1st year to address issues that may arise. MOM for subsequent years will be$500-$1,300 depending
on MassDEP and Barnstable BoH requirements. Note: 1st five years of MOM to be covered by BCWC
subsequent years to be determined to be borne by the homeowner.
Note: Final Grading and Some Landscaping to be Provided by BCWC
-5-
KleanTu® LLC
�1 KleanTu Wastewater
John R.Smith
Treatment P.O. Box 1154
Technologies Edgartown,MA 02539
412-719-5976-Mobile
508-627-3072-Office
CONTRACT No.80053-2111 for 251 Lakeside Drive Marstons Mills MA 02648
SCHEDULE
Barring unforeseen circumstances,KleanTu®LLC will have the NitROE®WWTS tank ready for installation in
December 2021,with the actual date to be finalized with the site owner and their installer.
PAYIIIIENT SCHEDULE
All KleanTu®LLC costs to be paid by the BCWC under separate contract with KleanTu®LLC.
WARRANTY
KleanTu®LLC guarantees NitROE®2K WWTS specific equipment and materials to properly operate for a period
of one year. This is contingent that the NitROE®2K WWTS is installed per the engineering design and that the
NitROE®2K WWTS receives typical sanitary wastewater(as defined per Title 5)and is within the design flow and
does not exceed 330 gallons per day(gpd).
�i
SITE ACCESS
By signing this contract,site owner agrees that KleanTu®LLC and BCWC designated personnel will be allowed
access to the site for the purpose of performing routine MOM activities associated with the NitROE®2K WWTS.
CONTRACT ACCEPTANCE
KleanTu®LLC looks forward to working in partnership with the BCWC and for providing direction and oversight
for installing and operating a NitROE®2K WWTS to enhance your upgraded Title 5 septic system.
By accepting this contract,you also agree to comply with the regulatory requirements cited on pages 2 and 3 of this
contract document. Specifically,that you agree to yearly MOM contracts with KleanTu®LLC,or their designated
representative,to begin when the BCWC no longer covers yearly MOM activities. And that you also will work
with the BCWC to file the appropriate paperwork with the Registrar of Deeds so that it is identified that you have a
NitROE®WWTS enhanced Title 5 septic system operating on your property.
1
-6 -
KleanTu® LLC
^�P 1 KleanTu Wastewater John R.Smith
Treatment P.O.Box 1154
Technologies Edgartown,MA 02539
412-719-5976-Mobile
508-627-3072-Office
CONTRACT No. 80053-2111 for 251 Lakeside Drive,Marstons Mills,MA 02648
To accept this contract so that work may continue as planned,please sign below. Also,please contact Zenas"Zee"
Crocker at zcrocker@bcleanwater.org. at Barnstable Clean Water Coalition with any questions or comments.
Sincerely,
Sk..k4 ,
Jaw K.-u(Nov 5,202110:10 EDT)
Jaw Fc
Vice President
Engineering and Operations
Name: Ronald Palma Signature: Date:
1114ti1
AyAdl
Name: Juanita Sweet Signature: OW2177/Date:
i
-7-
KleanTu® LLC
John R.Smith
KleanTu Wastewater P.O. Box 1154
Treatment
Technologies Edgartown,MA 02539
- - 412-719-5976-Mobile
{R) 508-627-3072-Office
CONTRACT No.80053-2111-040 for 251 Lakeside Drive Marstons Mills .MA 02648 .
November 4,2021
Mr. Ronald Palma and Ms. Juanita Sweet
295 Lakeside Drive
Marstons Mills, MA 02648
RE: NitROE®2K.W WTS Start-Up and Monitoring,Operation,and Maintenance(MOM)for 251 Lakeside
Drive,Marstons Mills,MA 02648; K1eanTu6 Job No. 80053-2111-040
Dear Ron and Juanita:-::
In concert with the Barnstable Clean Water Coalition(BCWC),KleanTu®LLC is pleased to submit this
"Contract"to provide Start-Up and Monitoring, Operation,and Maintenance(MOM)oversight services:for up to
five years from the NitROEO 2K Waste-Water Treatment System(WWTS)installation date at 251 Lakeside
Drive,Marstons Mills,MA.
f The main purpose of the NitROEO 2K WWTS is to enhance your Title 5 Septic System for the purpose of
significantly reducing total nitrogen(TN)from the sanitary wastewater flow. In addition to significant TN
reduction,the NitROEO enhanced Title 5 septic system will also produce a highly treated effluent low inorganic
carbor.constituents(measured as BOD5)and low in total suspended solids(TSS)levels.
Please note that entering into a yearly MOM contract is a requirement of KleanTu®'s Massachusetts Department
of Environmental Protection(DEP)Provisional Permit(DEP Transmittal No.: X285590;issued May 12,2020).
As this is the first year of operation, start-up services are also provided. As cited in Section IV-4 of the
Provis_onal Permit,yearly OM&M contracts must be in place to ensure proper operation and consistent treatment
performance. In this regard,this contract also provides budgetary price estimates for subsequent years of MOM.
CONTRACT DETAILS AND PRICE PROJECTIONS
As cited in Table 1,regarding start-up and MOM services, it is to be noted that the BCWC will provide for and
cover all costs associated with MOM,including sample collection and analyses for the first five years of
operation.
BCWC intends to work with The Massachusetts Alternative Septic System Test Center(MASSTC)and the U.S.
Environmental Protection Agency(US EPA)to cover all MOM costs for a total period of five years as part of the
Shubael Pond Innovative and Alternative Septic System Project. After this initial five years,.MOM related costs ,
will be the responsibility of the homeowner.
- 1-
f
KleanTu® LLC
ecoco
Wastewater John R.Smith
Treatment P.O. Box 1154
Technologies Edgartown,MA 02539
412-719-5976-Mobile
508-627-3072-Office
CONTRACT No.80053-2111-040 for 251 Lakeside Drive Marstons Mills MA 02648
All MOM activities, including monitoring and sample collection,will be performed or directly supervised by a
System Operator that has been certified at a minimum Grade Level IV by the Board of Operators of Wastewater
Treatment Facilities,in accordance with Massachusetts regulations 257 CMR 2.00. Specific to any KleanTu®
LLC Contract,the System Operator will be John R. Smith,Certificate No.: 1914.
Electronic copies of the Provisional Permit and the NitROE®2K WWTS MOM Manual are provided along with
this contract proposal.
Table 1. Scheduled(Routine) Yearly MOM Deliverables and Pricing for New NitROEO2KS WWTS for
251 Lakeside Drive,Marstons Mills,MA. '
Time Deliverables Price per Period
Period ($)
December 2021 . Start-Up including bacterial seeding and monitoring at least once every $0
to .2 weeks during the 1"8-weeks of operation to ensure that NitROE®2K (All related MOM
'} November 2022 WWTS is properly functioning. costs to be paid for
(12 months) . Provide and Review an OM&M Manual to homeowner and address any by the BCWC)
and all related questions.
• Monthly Sample Collection and Analyses beyond what is required by
the Mass DEP Provisional Permit.
• Respond to Homeowner issues,concerns and questions.
• Monthly Inspection and Quarterly Monitoring Updates to
Homeowner.
(NOTE:All NitROE®WWTS Components Covered Under Warranty)
December 2022 . Sample Collection and Analyses with minimum per Mass DEP $0
to Provisional Permit. y (All related MOM
November . Respond to Homeowner issues,concerns and questions. costs to be paid for
2027 by the BCWC)
(5 years) ' Quarterly Inspection and Monitoring Updates to Homeowner.
December 2027 . Quarterly Inspection and Sample Collection per Mass DEP General $600-$1,200
and Permit conditions. (Projected Range of
beyond . Covers Maximum of 4 site calls per year. Yearly Contract to
• Yearly Update to Homeowners. be covered by the
(NOTE: O&M Calls(>4)andlssues Addressed per Table 2 Items)
Homeowner)
t These terms are expected to be modified(e.g.,monthly monitoring)as a result of the Shubael Pond innovative and Alternative
Project with all relevant MOM cost covered by BCWC,MASSTC and US EPA.
-2-
KleanTu® LLC
John R.Smith
i KLeanTU Wastewater P.O. Box 1154
Treatment Ed artown,MA 02539
Technologies g
412-719-5976-Mobile
o. 508-627-3072-Office
CONTRACT No.80053-2111-040 for 251 Lakeside Drive Marstons Mills MA 02648
As the NitROE®2K W WTS moves through the Mass DEP permitting process from Provisional Permit Use to
General Permit Use,'fable 1 reflects that the associated price for yearly MOM significantly decreases. This
OM&M price reduction is primarily due to the fact that the Mass DEP requirements for inspections and sampling
and analyses move from quarterly(under the Provisional Permit)to yearly under a General Use Permit. At this
time, it is not known if a General Use Permit will be issued in year 2022 or 2023 as that decision rests with the
Mass DEP.
It is also cited in Table 1 that this l"year contract, 3nce executed, runs from December 2021 -November 2022,
anticipating use immediately after installation. As--he NitROE®2K WWTS operation then moves into December
2022,a new contract will need to be executed with each renewal for a minimum 1-year period.
In ad6tion to the pricing of scheduled MOM activities cited in Table 1,Table 2 provides non-scheduled and
non-routine MOM activities and associated price estimates,with anticipated timeframes as to when such MOM
activity may be needed and thus the cost incurred. While KleanTu®LLC has designed and utilized equipment to
provide low maintenance operation and treatment,-able 2 is provided so the system owner has some sort of idea
what costs may be incurred in future years associated with non-routine MOM activities.
While the BCWC will cover the first five years of MOM support,it is to be noted that all the items cited in
Table 2 will need to be covered by the homeowner as respective issues and situations arise after this initial
five-year period.
The only cost estimate in Table 2 that will be incurred each year is the electrical cost associated with the
continuous operation of one(l)120-watt air pump required to enhance and maintain the appropriate level of
biological processes required. This yearly electrical cost will be borne by the homeowner,along with periodic
pumping of their septic tank as required.
-3-
KleanTu® LLC
John R.Smith
KleanTu Wastewater P.O. Box 1154
Treatment Ed artown MA 02539
Technologies g
412-719-5976-Mobile
508-627-3072-Office
CONTRACT No.80053-2111-040 for 251 Lakeside Drive Marstons Mills MA 02648
Table 2. Non-Routine MOM Items and Projected Price Estimates for New NitROE®2KS WWTS
Replacement Items for 251 Lakeside Drive,Marstons Mills,MA
Item Description Price Estimate
Air Pump • One(1) 120 W air pump. $210
Electrical . Total daily electrical usage measured at—2.9 kWhr/day/pump. per Year
Usage . Cost/day at$0.20/kWhr x 2.9 kWhr/day=$0.58/day.
Non-routine • After 12-month warranty period,troubleshooting site calls(more $120
Troubleshooting than 4/year)will be charged at$120/hr with ] hour minimum. per Hour
Visits
• KleanTu®will determine when this is needed based on scheduled $200- $300
site visits. (for EST Septic
Septic Tank • Pump out to be done by no_l-KleanTu®contractor with estimated Tank Pumped
{` (EST) Pump Out price=$200- $300/EST tank. out every
• Exact time period is site-specific with estimate of every 3-8 years. 2-3 Years)
(NOTE: This pump out cost would need to be done even if this was a
conventional Title 5 septic system)
• Replacing remote sensing snit and probes=$360. $360
Replace Remote •. Exact time period is variable with estimate of every 8-10 years. (Every
Sensing Probes (NOTE: For remote sensing operation, 8710 Years)
and Unit Wi-Fi connection-rom homeowner is needed)
• Air pump repair and/or replacement. $500
Replace Air . Exact time period range is variable with estimate of every 5-8 (Every
Pump years. 5-8 Years)
•. Replace all air tubing=$800. - - - - $800
Replace Aeration . Exact time period is variable with estimate of every 0-20 years. (Every
Tubing - 10-20 Years)
Replace Wood e Replace all wood chips=$ ,000. $1,000
Chips . Exact time period is variably with estimate of every 20-30 years. (Every
20-30 Years)
Replace . Limestone Addition=$1,600. $1,600
Limestone . Exact time period is variable with estimate of every 20-30 years. (Every
20-30 Years)
-4-
f
KleanTu® LLC
John R.Smith
KLQanTu Wastewater P.O.Box 1154
Treatment
Technologies Edgartown,MA 02539
412-719-5976-Mobile
CR) 508-627-3072-Office
CONTRACT No. 80053-2111-040 for 251 Lakeside Drive Marstons Mills MA 02648
PAYMENT TERMS
Even though there is no site owner cost for the first five years of MOM,the contract still needs to be signed and
executed by the site owner as it is a confirmation that he/she accepts responsibility for associated MOM costs in
subsequent years.
Contracts executed for subsequent yearly time periods will need to be signed by October of the respective contract
time period with the entire contract amount paid at that time.
After the five-year period,all related MOM costs will be borne by the homeowner/system owner cited herein.
CONTRACT ACCEPTANCE
To execute this contract,and comply with Mass DEP Provisional Permit Requirements,please sign below to
acknowledge acceptance of this proposal and mail original with your signature,or e-mail pdf copy of this page
with your signature,back to me.
Please contact Zenas"Zee"Crocker, zcrocker(a,bcleanwater.ore,of Barnstable Clean Water Coalition with any
questions or comments.
Thank you,
s. k
Jaw i ON Nov 5,202110:12 EDT)
JawFu
Vice President
Engineering and Operations
SYSTEM OWNER SIGNATURE
Name: Ronald Palma
Signature: .Date: Y ( 12—t
Name: Juanita Sweet
Signature: Date:
-5-
1
November 4, 2021
Town of Barnstable Board of Health
200 Main Street
Hyannis, MA 02601
Sirs,
This letter is to verify that I have authorized Horsley Witten to design plan for an alternative
septic system to be installed at our house. This plan will be submitted to you for approval.
Please don't hesitate to contact us with any questions at juanita.m.sweet@gmail.com or
ronpalma@me.com.
Ron Palma
Juanita Sweet
251 Lakeside Drive
Marstons Mills, MA 02648
McKean, Thomas
From: McKenzie, Marybeth
Sent: Wednesday, November 17, 2021 10:37 AM
To: 'Joe Henderson'
Cc: McKean,Thomas
Subject: 251 Lakeside Dr. MM
Hello Joe,
Tom wanted me to contact you in regards to the review of 251 Lakeside Dr.for the BOH meeting.There are just two
things that were noted:
Please verify that the basement rooms noted "Storage", but have egress are "unheated storage". Due to the egress they
could be considered bedrooms by Title V standards.The office and other room do not show any windows so they are all
set.
The other item is that the disclosure Notice in the Deed of property will have to be submitted prior to the COC being
issued.
If you have any questions please feel free to contact me.
Thank you,
Marybeth McKenzie R.S.
Town of Barnstable
Health Inspector
508-862-4644
1
Commonwealth of Massachusetts
Executive Office of Energy &Environmental Affairs
Department of Environmental Protection
One Winter Street Boston, MA 02108.617-292-5500
Charles D.Baker Kathleen A.Theoharides
Governor Secretary
Karyn E.Polito Martin Suuberg
Lieutenant Governor Commissioner
PROVISIONAL USE APPROVAL RENEWAL
Pursuant to Title 5, 310 CMR 15.000
Name and Address of Applicant:
K1eanTu LLC.
300 Old Pond Road, Ste#206
Bridgeville,PA 15017
Trade name of technology and models:
NitROE® Waste-Water Treatment System (NitROE® WWTS) with unit sizing for design flows up to
2000 gpd (NitROE® 2KS WWTS and NitROE® -2KM WWTS) (hereinafter the `System' or the
`Technology'). Owner and Operator manuals, installation manual, schematic drawings illustrating the
System models and the technology inspection checklist are part of this Certification.
DEP Transmittal No.: X285590
Date of Issuance: May 12,2020,
Expiration date: May 12,2025
Authority for Issuance
Pursuant to Title 5 of the State Environmental Code, 310 CMR 15.000, the Department of Environmental
Protection (hereinafter "the Department") hereby issues this Provisional Approval to: KleanTu LLC,
located at 300 Old Pond Rd., Ste 206 in Bridgeville, PA (hereinafter "the Company"), NitROE® 2KS
WWTS and NitROE® 2KM WWTS (hereinafter "the Technology" or "System") for use in the
Commonwealth of Massachusetts subject to the conditions herein. Sale and use of the Technology is
subject to compliance by the Company, the Designer, the System Installer, the Operator, and the System
Owner with the terms and conditions herein. Any noncompliance with the terms or conditions of this
Certification constitutes a violation of 310 CMR 15.000.
1 949voil-
May 12,2020
Marybeth Chubb, Section Chief J Date
Wastewater Management Program
Bureau of Resource Protection
This information is available in alternate format.Contact Michelle Waters-Ekanem,Director of Diversity/Civil Rights at 617-292-5751.
TTY#MassRelay Service 1-800-439-2370
MassDEP Website:www.mass.gov/dep
Printed on Recycled Paper
i
J
KleanTu NitROE 2K Provisional Approval,May 2020 Page 2 of 15
Technology:NitROEO 2KS&2KM WWTS
I.PURPOSE
Subject to the conditions of this Approval and any other local requirements,the purpose of this Approval
is to allow installation and operation of at least 50 on-site sewage disposal systems utilizing the
technology .in Massachusetts in order to conduct a performance evaluation of the capabilities of the
Technology during the first 3 years of operation of each system, in accordance with Title 5 — 310 CMR
15.286 (7),Provisional Approval of Alternative System.
The specific goal of the Performance Evaluation is to determine if the Technology is capable of
consistently meeting the concentration limits for total nitrogen (TN) of less than 11 milligrams per liter
(mg/L) for installations with design flows less than 2,000 GPD in the effluent discharged to the soil
absorption system. In areas subject to nitrogen loading limitations, increases in the discharge rate per acre
may be allowed when the nitrogen concentration discharged to the soil is reduced.
The Company is responsible for oversight and sampling of the systems during the Performance
Evaluation. The System Owner has responsibility for continued oversight and sampling of the system if
the property served was allowed to increase the discharge rate per acre above 440 gallons per day per acre
(gpda) in an area subject to Nitrogen Loading Limitations. The System Owner will be required to repair,
replace,modify or take any other action as required by the Department or the local approving authority, if
the Department or the local approving authority determines that the System is not capable of meeting the
required reduction in nitrogen in the effluent.
With the other applicable permits or approvals that may be required by Title 5, this Approval authorizes
the installation and use of the Alternative System in Massachusetts. All the provisions of Title 5,
including the General Conditions for all Alternative Systems (310 CMR 15.287), apply to the sale,
design, installation, and use of the System, except those provisions that specifically have been varied by
this Approval.
II.GENERAL DESCRIPTION OF THE TECHNOLOGY
The NitROE ® 2KS or 2KM WWTS (the `System') is installed in series between a Title-5 system septic
tank and a soil absorption system constructed in accordance with 310 CMR 15.100 — 15.279, subject to
the provisions of this Approval to accommodate design flows of less than 2,000 GPD.
The System is comprised of two-unit processes which are sequentially performed in two different
chambers. The first chamber is aerated, via an external air pump and airline header/hose arrangement, to
achieve both organic carbon reduction along with the biological conversion of ammonia-N to nitrate-N.
From the Aeration Chamber, the wastewater then gravity flows into a Denitrification Chamber where, in
the presence of natural organics from wood chips, bacteria mediate the conversion of nitrate-N to inert N
gas that exits to the atmosphere via the Title 5 system vent piping. Depending on design flow and
availability of local tank structures, the sequential Aeration and Denitrification process steps can be
performed in the same single tank, which is NitROE®2KS WWTS, or each process could be performed
in its own separate tank with the overall NitROE® WWTS comprised of multiple tank combinations,
which is NitROE®2KM WWTS.
The use of the Technology under this Approval requires:
• Disclosure Notice in the Deed to the property;
• Certifications by the Company,the Designer, and the Installer;
• System Owner Acknowledgement of Responsibilities;
KleanTu NitROE 2K Provisional Approval,May 2020 Page 3 of 15
Technology:NitROE®2KS&2KM WWTS
• A certified operator under contract for periodic inspection and maintenance;
• Periodic sampling;
• Recordkeeping and reporting; and
• An external power supply
III.CONDITIONS OF APPROVAL
A. Basis for Conditions.
1. The term "System" refers to the Technology in combination with any other components of an
on-site treatment and disposal system that may be required to serve a Facility in accordance
with 310 CMR 15.000.
2. The term "Approval" includes the Special Conditions, Standard Conditions, General Conditions
of 310 CMR 15.287,and the approved Attachments.
3. Items required by this Approval include:
a) Performance Evaluation Plan (PEP) with sampling and analysis requirements and
approved by the Department. The PEP must be submitted to the Department for review
and approval within 60 days of issuance of this Approval and meet the requirements of
the Department's Guidance for the Preparation of Performance Evaluation Plans
<2,000 GPD;
b) Minimum System installation requirements;
c) Company schematic drawings and specifications;
d) Owner's Manual, including information on substances that should not be discharged to
the System;
e) Operation and Maintenance manual, including but not limited to, operator qualification
requirements, inspection requirements, sampling and analysis requirements,
recordkeeping requirements, and/or reporting requirements; and
f) MassDEP Operation and Maintenance (O&M) checklist and I/A technology inspection
checklist.
B. Special Conditions
1. Department review and approval of the System design and installation is not required unless
the Department determines on a case-by-case basis pursuant to its authority at 310 CMR
15.003(2)(e)that the proposed System requires Department review and approval.
2. System installations must meet the specific siting conditions for Provisional Use provided in
310 CMR 15.286(4)and the facility must meet the siting requirements of this Approval.
3. Any System for which a complete Disposal System Construction Permit Application is
submitted while this Approval is in effect, may be permitted, installed, and used in accordance
with this Approval unless the Department,the local approval authority, or a court requires the
System to be modified or removed or requires discharges to the System to cease.
4. The System Owner shall provide access to the site for purposes of sampling the System in
accordance with the Company's technology Performance Evaluation Plan approved by the
K1eanTu NitROE 2K Provisional Approval,May 2020 Page 4 of 15
Technology:NitROEO 2KS&2KM WWTS
Department, in addition to providing access for performing inspections, maintenance, repairs,
and responding to alarm events.
5. The System Owner shall ensure that no permanent buildings or structures, other than the
System, are constructed in the area for the installation of all the components of a fully
conforming Title 5 system with a reserve area. The area for a fully conforming Title 5 system
with a reserve area shall not otherwise be disturbed by the System Owner in any manner that
will render it unusable for future installation of a fully conforming Title 5 system.
6. The Department has not determined that the performance of the System will provide a level of
protection to public health and safety and the environment that is at least equivalent to that of a
sanitary sewer system.
If it is feasible to connect a new or existing facility to the sewer, the Designer shall not
propose an Alternative System to serve the facility and the facility Owner shall not install or
use an Alternative System.
When a sanitary sewer connection becomes feasible after an Alternative System has been
installed,the System Owner shall connect the facility served by the System to the sewer within
60 days of such feasibility and the System shall be abandoned in compliance with 310 CMR
15.354, unless a later time is allowed in writing by the Department or the Local Approving
Authority.
7. The control panel including alarms shall be mounted in a location accessible to the System
Operator.
8. For any System that does not flow by gravity to the SAS, the System shall be equipped with
sensors and high-level alarms to protect against high water due to pump failure, pump control
failure, loss of power, or system freeze up. The control panel including alarms and controls
shall be mounted in a location always accessible to the operator (or service contractor).
Emergency storage capacity for wastewater above the high level alarm shall be provided equal
to the daily design flow of the System and the storage capacity shall include an additional
allowance for the volume of all drainage which may flow back into the System when pumping
has ceased.
Instead of providing emergency 24-hour storage,an independent standby power source may be
provided for operation during an interruption in power. With any interruption of the power
supply the source must be capable of automatically activating in addition to manual start up
capability. The standby power must be sufficient to handle peak flows for at least 24 hours and
sufficient to meet all power needs of the System including, but not limited to, pumping,
ventilation, and controls. Standby power installations must be inspected and exercised at least
annually and all automatic and manual start up controls must be tested. Standby power
installations must comply with all applicable state and local code requirements. Provided that a
standby power installation complies with these requirements, no variance is required to the
provisions of 310 CMR 15.231(2).
9. System unit malfunction and high water alarms shall be connected to circuits separate from the
circuits to the operating equipment and pumps.
10. All System control units,valve boxes, conveyance lines and other System appurtenances shall
be designed and installed to prevent freezing per the Company's recommendations.
K1eanTu NitROE 2K Provisional Approval,May 2020 Page 5 of 15
Technology:NitROE®2KS&2KM WWTS
11. Any System structures with exterior piping connections located within 12 inches or below the
Estimated Seasonal High Groundwater elevation shall have the connections made watertight
with neoprene seals or equivalent.
12. In compliance with 310 CMR 15.240(13), a minimum of one (1) inspection port shall be
provided within the SAS consisting of a perforated four inch pipe placed vertically down into
the stone to the naturally occurring soil or sand fill below the stone. The pipe shall be capped
with a screw type cap and accessible to within three inches of finish grade.
Operation and Maintenance
13. Inspection, operation and maintenance (O & M), sampling, and field testing of the System
required by this Approval shall be performed by a System Operator with the following
qualifications:
a) is an approved System Inspector in accordance with 310 CMR 15.340;
b) has been trained by the Company and whose name appears on the Company's current
list of qualified operators; and
c) has been certified at a minimum of Grade Level IV (four) by the Board of
Registration of Operators of Wastewater Treatment Facilities, in accordance with
Massachusetts regulations 257 CMR 2.00. The name of the Operator shall be
included in the O&M agreement required by paragraph B (14).
14. Prior to the use of the System, the System Owner shall enter into an O&M Agreement with a
qualified contractor and submit the Agreement to the Approving Authority and the Company.
The Agreement shall be at least for one year and include the following provisions:
a) The name of the qualified Operator that appears on the Company's current list of Service
Contractors;
b) The System Operator must have the qualifications specified in paragraph B (13);
c) The System Operator must inspect the System in accordance with the Approval and
anytime there is an equipment failure, System failure, or other alarm event;
d) In the case of a System failure, an equipment failure, alarm event, components not
functioning as designed or in accordance with the Company specifications,or violations of
the Approval, procedures and responsibilities of the Operator and System Owner shall be
clearly defined for corrective measures to be taken immediately. The System Operator
shall agree to provide written notification within five days describing corrective measures
taken to the System Owner,the Company, and the local board of health;
e) The System Operator shall determine the cause of total nitrogen effluent limit violations if
they occur and take corrective actions in accordance with the approved O & M Manual;
and
f) Procedures and responsibilities for recording quarterly or monthly wastewater flows must
be defined, see paragraph B (32)"Flow Metering".
15. At all times, the System Owner shall maintain an O&M Agreement that meets the
requirements of paragraph B (20).
16. The System Owner and the System Operator shall properly operate and maintain the system in
accordance with this Approval, the Designer's operation and maintenance requirements, and
the requirements of the local approving authority.
K1eanTu NitROE 2K Provisional Approval,May 2020 Page 6 of 15
Technology:NitROE®2KS&2KM WWTS
17. Upon determining that the System has failed, as defined in 310 CMR 15.303, the System
Operator shall notify the System Owner immediately.
18. Upon determining that the System has failed, as defined in 310 CMR 15.303, the System
Owner and the System Operator shall be responsible for the notification of the local approving
authority within 24 hours of such determination.
19. In the case of a System failure, an equipment failure, alarm event, components not functioning
as designed or in accordance with the Company specifications, or any violations of the
Approval, the System Owner and the System Operator shall be responsible for the written
notification of the local approving authority and the Company within five days describing
corrective measures taken.
20. Within 60 days of any site visit, the System Operator shall submit an O&M report and
inspection checklist to the System Owner and the Company. The O&M report and inspection
checklist shall include, at a minimum:
a) for a System failing,any corrective acticns taken;
b) wastewater analyses,wastewater flow data, and field testing results;
c) any violations of the Approval;
d) any determinations that the System or its components are not functioning as designed or
in accordance with the Company specifications; and
e) any other corrective actions taken or recommended.
21. By September 30th of each year, the System Owner and the Service Contractor shall be
responsible for submitting to the local approving authority all monitoring results with all
O&M reports and inspection checklists completed by the System Operator during the previous
12 months.
22. By September 30th of each year, the Service Contractor shall be responsible for submitting to
the Company copies of all O&M reports including alarm event responses, all monitoring
results, violations of the Approval, inspection checklists completed by the Service Contractor,
notifications of system failures, and reports of equipment replacements with reasons during the
previous 12 months.
23. A copy of the wastewater analyses, wastewater flow data, field testing results, and System
Operator O&M reports and inspection checklists shall be maintained by the Company. It is
recommended the System Owner also maintain copies of these items.
24. The System Owner shall notify the Approving Authority in writing within seven days of any
cancellation,expiration or other change in the terms and/or conditions of the O&M Agreement
required by Paragraph B(14).
25. The System Owner and the Service Contractor shall maintain copies of the Service
Contractor's O&M reports, inspection checklists, and all reports and notifications to the LAA
for a minimum of five years.
26. The System may only be installed to serve facilities where a fully conforming Title 5 system
with a reserve area exists on-site or could be built on-site in compliance with the design
standards for new construction of 310 CMR 15.000, and for which a site evaluation in
K1eanTu NitROE 2K Provisional Approval,May 2020 Page 7 of 15
Technology:NitROE®2KS&2KM WWTS
compliance with 310 CMR 15.000 has been approved by the Approving Authority. A fully
conforming Title 5 system may include other approved alternative technologies in accordance
with the conditions imposed on the alternative technologies.
27. Subject to the provisions of this Approval, the Technology shall be installed in a manner
which neither intrudes on, replaces a component of, or adversely affects the operation of all
other components of the System designed and constructed in accordance with the standards for
new construction of 310 CMR 15.200- 15.279.
Effluent Limit and Monitoring Requirements,
28. For the new construction, unless the facility meets a TN effluent limit of 11 mg/1 or less, the
system shall not be designed to receive more than 440 gallons of design flow per day per acre
(gpda) in an area that is subject to the Nitrogen Loading Limitations of 310 CMR 15.214. If
the facility does not meet with the Nitrogen Loading Limitations pursuant to the aggregation
provisions of 310 CMR 15.216, the System Owner shall repair, replace, modify or take any
other action as required by the Department or the local approving authority to meet the total
nitrogen concentration limits in the effluent.
Violation of the TN concentration in the System effluent shall not require notifications as
required in paragraphs B(18)and(19).
29. Prior to.Department approval of the Company's Performance Evaluation Plan, the Company
shall be responsible for the following monitoring requirements for all System installations that
are subject to a total nitrogen concentration limit in accordance with paragraph B (28).
Sampling shall include pH, BOD5, TSS and Total Nitrogen, unless otherwise stated. Flow
shall be recorded at each inspection, see"Flow Metering" section below.
a) Year-round facilities shall be inspected and effluent sampled quarterly;
b) Seasonal properties shall be inspected and effluent sampled a minimum of twice per year,
with at least one annual sample taken 30 to 60 days after seasonal occupancy and a second
sample taken no less than 2'months after the first sample;and
c) After 12 rounds of monitoring, sampling may be reduced to TN only quarterly. Reduced
sampling shall also include Field Testing of System wastewater when determined
necessary by the operator, see DEP Field Testing Protocol at
http://www.mass.zovleealdocsldep/water/laws/i-thru-zltestsamp.pdf.
Properties occupied at least 6 months per year are considered year-round properties.
Properties occupied less than 6 months per year are considered seasonal properties.
30. During the Performance Evaluation period, the Company shall follow the monitoring
requirements specified in the Performance Evaluation Plan for installed Systems.
31. After the three (3) year Performance Evaluation period by the Company and approval by the
Department, and until this Approval is modified, terminated, or superseded by a General Use
Certification, the System Owner shall comply with the following monitoring requirements if
the System is subject to a total nitrogen concentration limit in accordance with paragraph B?
(28)•
KleanTu NitROE 2K Provisional Approval,May 2020 Page 8 of 15
Technology:NitROE®2KS&2KM WWTS
a) Year-round properties shall be inspected and sampled for at least the TN parameter a
minimum of twice/year, at least 5 months apart and with at least one sample taken
between December 1 and March 1 of each year. Field testing shall be completed as
determined necessary by the System operator, see DEP Field Testing Protocol at
http://www.mass.govleealdocsldeplwaterllawsli-thru-zltestsamp.pdf.
Water meter readings shall be recorded at each inspection, see"Flow Metering"below.
b) Seasonal properties shall be sampled for at least the TN parameter a minimum of
twice/year. At least one annual sample must be taken 30 to 60 days after each seasonal
occupancy. A second sample must be taken no less than 2 months after the first sample.
Field testing of the System shall be completed as determined necessary by the operator.
Water meter readings shall be recorded at each inspection, see"Flow Metering"below.
32. Flow Metering - At a minimum, for all systems installed prior to this Approval, water meter
flow data shall be recorded each time the system is inspected and sampled by the System
Operator. For systems installed after the effective date of this Approval, wastewater flow data
shall be recorded each time the system is inspected and sampled by the System Operator and
may be based on:
a) actual metering data of wastewater flow to the system; or
b) water meter data for the total facility with metered non-wastewater flows, if available,
subtracted from the total facility water usage.
33. Field Testing: Turbidity, pH and Apparent Color - Turbidity, pH, DO and apparent color shall
be measured and/or recorded in the field when'when determined necessary by the operator.
See applicable sections of the Department's Field Testing Protocol at
http://www.mass.govleealdocsldepLwater/laws/i-thru-zltestsamp.pdf.
34. At a minimum,the System Operator shall inspect the System:
a) two times per year;
b) in accordance with the approved O&M manual, the Designer's operation and maintenance
requirements, and the requirements of the local approving authority; and
c) any time there is an alarm event,equipment failure, or system failure
35. The System Operator shall collect samples and obtain analysis results from an approved lab,
perform field testing required by the Approval and submit results within 60 days of the site
visit to the System Owner.
36. If the Company successfully demonstrates the effectiveness of the System to reduce nitrogen
loadings during the Performance Evaluation period, a minimum of three years, the System
Owner shall operate the System subject to the requirements of the General Use Certification, if
issued, for this technology.
C. Special Conditions Specific to the Company
1. The Approval shall only apply to model units with the same model designations specified in
this approval and meet the same specifications, operating requirements, and plans, as
provided by the manufacturer at the time of the application. Any proposed modifications of
the units shall be subject to the review of the Department for coverage under the Approval.
K1eanTu NitROE 2K Provisional Approval,May 2020 Page 9 of 15
Technology:NitROEO 2KS&2KM WWTS
2. Prior to submission of an application for a DSCP, the Company shall provide to the Designer
and the System Owner:
a) All design and installation specifications and requirements;
b) An operation and maintenance manual, including:
i) an inspection checklist;
ii) recommended inspection and maintenance schedule;
iii)monitoring(i.e. water use and power consumption)and sampling procedures, if any;
iv)alarm response procedures, if any,and troubleshooting procedures;
c) An owner's manual,including proper system use and alarm response procedures, if any;
d) Estimates of the Owner's costs associated with System operation including, when
applicable: power consumption, maintenance, sampling, recordkeeping, reporting,-and
equipment replacement;
e) A copy of the Company's warranty; and
f) Lists of Designers, Installers,and Service Contractors.
3. The Company shall implement the Performance Evaluation Plan, as submitted and approved
by the Department, and shall be responsible for all data collection and submissions to the
Department until a final determination on the Performance Evaluation has been made by the
Department.
4. Until a final determination has been made by the Department on a completed Performance
Evaluation, the Company shall submit to the Department an annual report by February 15th
of each year that includes the following:
a) a table of all sample data collected for all systems installed to date and all information
required by the Department as part of the approved Performance Evaluation Plan;
b) status of preparation of a Performance Evaluation Plan if not yet provided to MassDEP, or
any recommended changes to the approved Performance Evaluation Plan;
c) a list of pending applications for system installations which have been submitted to local
approving authorities;
d) identification of any System after start-up in violation of the Approval or not in
compliance with any performance criteria at the time of the annual report, the reasons for
the noncompliance and the status of any corrective actions that are needed; and
e) any recommendations and requests for changes to the system monitoring and reporting
plan or the performance criteria of the Approval.
The report shall be signed by a corporate officer,general partner or the Company
owner.
(Service Contractor records submitted to the Company should not be included with the
annual report to the Department,but shall be made available to the Department within
30 days of a request by the Department.)
5. The Company shall institute and maintain a program of Installer training and continuing
education that is at least offered annually. The Company shall maintain and annually update,
and make available the list of qualified Installers by February 15th of each year. The
Company shall certify that the Installers on the list have taken the training and passed the
Company's training qualifications.
K1eanTu NitROE 2K Provisional Approval,May 2020 Page I-)of 15
Technology:NitROE®2KS&2KM WWTS
6. The Company shall institute and maintain a program of Designer training and continuing
education, as approved by the Department. The Company shall maintain and annually update,
and make available the list of qualified Designers by February 15th of each year. The
Company shall certify that the Designers on the list have taken the training and passed the
Company's training qualifications.
7. The Company shall institute and maintain a program of Operator training and continuing
education, as approved by the Department. The Company shall maintain and annually update,
and make available the list of qualified Operators by February 15th of each year. The
Company shall certify that the Operators on the list have taken the training and passed the
Company's training qualifications.
8. The Company shall not sell the Technology to an Installer unless the Installer is trained to
install the System by the Company.
9. Prior to its sale of any System that may be u3ed in Massachusetts,the Company shall provide
the purchaser with a copy of the Approval with the System design, installation, O&M, and
Owner's manuals. In any contract for distribution or sale of the System, the Company shall
require the distributor or seller to provide the purchaser of a System for use in Massachusetts
with copies of these documents,prior to any sale of the System.
10. Within 60 days of issuance by the Department of a revised Approval, the Company shall
provide written notification of changes to the Approval to all Service Contractors servicing
existing installations of the Technology and all distributors and resellers of the Technology.
11. The Company shall provide written notification to the Department's Director of the
Wastewater Management Program at least 30 days in advance of the proposed transfer of
ownership of the Technology for which the Approval is issued. Said notification shall include
the name and address of the proposed owner containing a specific date of transfer of
ownership,responsibility,coverage and liab_lity between them.
12. The Approval shall be binding on the Company and its officers, employees, agents,
contractors, successors, and assigns, including but not limited to dealers, distributors, and
resellers. Violation of the terms and conditions of the Approval by any of the foregoing
persons or entities, respectively, shall consTitute violation of the Approval by the Company
unless the Department determines otherwise.
IV. CERTIFICATION AND NOTIFICATION REQUIREMENTS
1. Thirty (30) days prior to submitting an application for a DSCP, the Company or its
representative shall provide to the Approving Authority a certification, signed by the owner
of record for the property to be served by the unit, stating that the property owner:
a) has been provided a copy of the Provisional Use Approval and all attachments and
agrees to comply with all terms and conditions;
b) has been informed of all the owner's casts associated with the operation including power
consumption, maintenance, sampling, recordkeeping, reporting, and equipment
replacement;
K1eanTu NitROE 2K Provisional Approval,May 2020 Page 11 of 15
Technology:NitROEO 2KS&2KM WWTS
c) understands the requirement for a contract with a company approved operator and has
been provided a current list of all approved operators;
d) agrees to fulfill his responsibilities to provide a Deed Notice as required by 310 CMR
15.287(10)and the Approval;and
e) agrees to fulfill his responsibilities to provide written notification of the Approval
conditions to any new owner,as required by 310 CMR 15.287(5).
2. Upon submission of an application for a DSCP to the Approving Authority, the Company
shall submit to the Approving Authority, with a copy to the Designer and the System Owner,
a certification by the Company or its authorized agent that the design conforms to this
Approval and that the proposed use of the System is consistent with the unit's capabilities and
all Company requirements. The review shall include evaluation of the need for installation of
water meter(s) at each facility. An authorized agent of the Company responsible for the
design review shall have received technical training in the Company's products.
3. The System Designer shall be a Massachusetts Registered Professional Engineer, or a
Massachusetts Registered Sanitarian provided that such Sanitarian shall not design a system
with a discharge greater than 2,000 gallons per day.
4. Thirty (30) days prior to delivery of the treatment unit to the site for installation, the
Company shall provide to the Approving Authority a copy of a signed contract for a
minimum period of one year with a Company approved Operator and the initial
Owner/Occupant of the property.
5. Prior to the commencement of construction,the System Installer must certify in writing to the
Designer and the System Owner that (s)he has taken the Company's training, passed the
Company's training qualifications,and is listed on the Company's list of Installers.
6. Prior to the issuance of a Certificate of Compliance by the Approving Authority:
a) In accordance with 310 CMR 15.021(3), the System Installer and Designer must certify
in writing that the System has been constructed in compliance with 310 CMR 15.000,the
approved design plans, and all local requirements, including any local approving
authority site-specific requirements;
b) In accordance with 310 CMR 15.021(3), the Designer must certify in writing that any
changes to the design plans have been reflected on as-built plans which have been
submitted to the Approving Authority by the Designer;
c) As a condition of this Approval, the System Installer and Designer must certify to the
Approving Authority in writing that the System has been constructed in compliance with
the terms of this Approval;
d) An authorized agent of the Company must certify to the Approving Authority in writing
that the installation was done by a qualified Installer approved by the Company and the
installation conforms to this Approval. The authorized agent of the Company responsible
for the inspection of the installation shall have received technical training in the
Company's products; and
e) Prior to signing any agreement to transfer any or all interest in the property served by the
system, or any portion of the property, including any possessory interest, the System
Owner shall provide written notice, as required by 310 CMR 15.287(5) of all conditions
contained in the Approval to the transferee(s). Any and all instruments of transfer and
any leases or rental agreements shall be included as an exhibit attached thereto and made
KleanTu NitROE 2K Provisional Approval,May 2020 Page 12 of 15
Technology:NitROE®2KS&2KM WWTS
a part thereof of a copy of the Approval for the System. The System Owner shall send a
copy of such written notification(s) to the Local Approving Authority within 10 days of
such notice to the transferee(s).
V. STANDARD CONDITIONS
1. The provisions of 310 CMR 15.000 are applicable to the design, installation, use and
operation of a System utilizing an approved or certified alternative technology, except those
provisions that specifically have been varied'Dy the conditions of this Approval.
2. The design, installation, and use of the System must conform to the terms and conditions of
the Approval and the Department approved attachments.
3. The facility served by the System and the System itself shall be open to inspection and
sampling by the Department and the local approving authority at all reasonable times.
Standard Conditions Applicable to the System Owner.
4. This Approval shall be binding on the System Owner and on its agents, contractors,
successors, and assigns. Violation of the terms and conditions of this Approval by any of the
foregoing persons or entities, respectively, shall constitute violation of this Approval by the
System Owner unless the Department determines otherwise.
5. The System Owner shall obtain all necessa-y permits and approvals required by 310 CMR
15.000 prior to the installation and use of the System in Massachusetts.
6. The System is approved for the treatment and disposal of sanitary sewage only. The System
Owner shall not introduce any\wastes that are not sanitary sewage into the System. The
System Owner shall dispose of wastes generated or used at the facility that are not sanitary
sewage by other lawful means.
7. Prior to issuance of the Certificate of Compliance and after recording and/or registering the
Deed Notice required by 310 CMR 15.287(10), the System Owner shall submit the following
to the Local Approving Authority: (i) a certified Registry copy of the Notice bearing the book
and page/or"document number; and(ii) if the property is unregistered land, a Registry copy of
the System Owner's deed to the property, bearing a marginal reference on the System
Owner's deed to the property. The Notice to be recorded shall be in the form of the Notice
provided by the Department.
8. The System Owner shall at all times have the installed System properly operated and
maintained in accordance with.the most recent O&M provisions of this Approval for the
alternative technology and in accordance with any additional requirements of the Approving
Authority. The most recent O&M provisions of this Approval for the alternative technology
are available from the Department.
9. The System Owner shall furnish the Department any information that the Department
requests regarding the System,within 21 days of the date of receipt of that request.
Standard Conditions Applicable to the Designer
KleanTu NitROE 2K Provisional Approval,May 2020 Page 13 of 15
Technology:NitROE®2KS&2KM WWTS
10. The Designer shall be a Massachusetts Registered Professional Engineer or a Massachusetts
Registered Sanitarian, including when designing systems for repair, provided that such
Sanitarian shall not design a system to discharge more than 2,000 gallons per day.
11. Prior to the application for a DSCP,the Designer shall provide the System Owner with a copy
of this Approval.
Standard Conditions Applicable to the Company
12. This Approval shall be binding on the Company and its officers, employees, agents,
contractors, successors, and assigns. Violation of the terms and conditions of this Approval
by any of the foregoing persons or entities, respectively, shall constitute violation of this
Approval by the Company unless the Department determines otherwise.
13. The Company shall include copies of the Approval with each System that is sold. In any
contract executed by the Company for distribution or re-sale of the System, the Company
shall require all vendors, distributors, and resellers to provide each purchaser of the System
with copies of the Approval.
14. The Company shall make available, in printed and electronic format, the approved
Attachments and any approved updates associated with the Approval, to the System Owners,
Operators, Designers,Installers,vendors,resellers,and distributors of the System.
15. The Company shall submit to the Department for approval any proposed updates or changes
to the Attachments to the Approval.
16. The Company shall notify all System Owners, resellers, and distributors of changes to the
Approval within 60 days of issuance by the Department.
17. The Company shall notify the Department's Director of the Wastewater Management
Program at least 30 days in advance of the proposed transfer of ownership of the Technology
for which the Approval is issued. Said notification shall include the name and address of the
proposed owner containing a specific date of transfer of ownership, responsibility, coverage
and liability between them. All provisions of the Approval applicable to the Company shall
be applicable to successors and assigns of the Company, unless the Department determines
otherwise.
18. The Company shall furnish the Department any information that the Department requests
regarding the Technology within 21 days of the date of receipt of that request.
19. If the Company wishes to continue the Approval after its expiration date, the Company shall
apply for and obtain a renewal of the Approval. The Company shall submit a renewal
application at least 180 days before the expiration date of the Approval, unless written
permission for a later date has been granted in writing by the Department. Upon receipt of a
timely and complete renewal application, the Approval shall continue in force until the
Department has acted on the renewal application.
Reporting
K1eanTu NitROE 2K Provisional Approval,May 2020 Page 14 of 15
Technology:NitROE®2KS&2KM WWTS
20. All notices and documents required to be submitted to the Department by the Approvalshall
be submitted to:
Director
Wastewater Management Program
Department of Environmental Protection
One Winter Street- 5th floor
Boston,Massachusetts 02108
Rights of the Department
21. The Department may suspend, modify or revoke the Approval for cause, including, but not
limited to, noncompliance with the terms of the Approval, non-payment of any annual
compliance assurance fee, for obtaining the Approval by misrepresentation or failure to
disclose fully all relevant facts or any change in or discovery of conditions that would
constitute grounds for discontinuance of the Approval, or as necessary for the protection of
public health, safety, welfare, or the environment, and as authorized by applicable law. The
Department reserves its rights to take any enforcement action authorized by law with respect
to the Approval and/or a System utilizing the Technology against the Company,the Designer,
the System Owner,the Installer,and/or the Operator of the System.
VI. GENERAL CONDITIONS
Title 5 Regulations 310 CMR 15.287: "General Conditions for Use of Alternative Systems Pursuant to
310 CMR 15.284 through 15.286"
"The following conditions shall apply to all uses of alternative systems pursuant to 310 CMR 15.284
through 15.286:
1. All plans and specifications shall be designed in accordance with 310 CMR 15.220.
2. Any required operation and maintenance, monitoring and testing plans shall be submitted to
the Department and approved prior to initiation of the use. Monitoring and sampling shall be
performed in accordance with a Department approved plan. Sample analysis shall be
conducted by an independent U.S. EPA or Commonwealth of Massachusetts approved testing
laboratory, or an approved independent university laboratory, unless otherwise provided in
the Department's written approval. It shall be a violation of 310 CMR 15.000 to omit from a
report or falsify any data collected pursuant to an approved testing plan.
3. The facility served by the alternative system and the system itself shall be open to inspection,
and sampling by the Department and the Local Approving Authority at all reasonable times.
4. The Department and/or the Local Approving Authority may require the owner or operator of
the system to cease operation of the system and/or to take any other action necessary to
protect public health, safety,welfare and the environment.
5. The owner or operator shall provide written notice to any new owner or operator that the
system is an alternative system. Such notice shall include notice of the general conditions and
any special conditions applicable to the system and its owner.
KleanTu NitROE 2K Provisional Approval,May`2020 Page 15 of 15
Technology:NitROE®2KS&2KM WWTS
6. The owner or operator, or the proponent of the alternative system, shall obtain and provide
the Department with a determination from the board of certification of operators of
wastewater treatment facilities established pursuant to M.G.L. c. 21, § 34A as to whether a
certified operator is required for operation of the alternative system. The Department shall
waive this requirement if it has on file a determination for the alternative system, and shall
notify the owner,operator,or proponent of the determination.
7. It is a violation of 310 CMR 15.000 to install, construct, or operate an alternative system
except in full compliance with the written approval and 310 CMR 15.287.
8. The Department may require the issuance of a groundwater discharge permit pursuant to 314
CMR 5.00(groundwater discharge program)for any alternative system.
9. The system owner shall maintain an operation and maintenance contract with a
Massachusetts certified operator where one is required by 257 CMR 2.00, or otherwise with a
person qualified to operate and maintain the system in accordance with the Department's
written approval.
10. Prior to obtaining a Certificate of Compliance for installation of a new or upgraded system,
the system owner shall record in the chain of title for the property served by the alternative
system in the Registry of Deeds or Land Registration Office, as applicable, a Notice
disclosing both the existence of the alternative on-site system and the Department's approval
of the system. The system owner shall also provide evidence of such recording to the Local
Approving Authority.
KleanTu® LLC
John R.Smith
j KleanTu Wastewater P.O. Box 1154
Treatment
Technologies Edgartown,MA 02539
412-719-5976-Mobile
(R� 508-627-3072-Office
November 4,2021
Mr. Ronald Palma and Ms.Juanita Sweet
251 Lakeside Drive
Marstons Mills,MA 02648
Joseph Henderson
Horsley Witten Group
90 Route 6A, Unit l
Sandwich,MA 02563
RE: Installer Certification for New NitROE®2K WWTS Enhanced Title 5 Septic System Installation
for 251 Lakeside Drive,Marstons Mills,MA 02648;KleanTu Project No. 80053-2111
Dear Ron and Juanita:
Kindly refer to the following: (i)the Mass DEP Provisional Permit issued to KleanTu®LLC(DEP Transmittal
No.: X285590; Issued May 12,2020)(the "DEP Permit");and(ii)the Enhanced Title 5 Septic System proposed for
a private residence located at 251 Lakeside Drive, Marstons Mills, MA(the"New System'),featuring the use of a
new N;tROE®2KS wastewater treatment system(the"NitROE®2KS Components").
Item IV #5 of the DEP Permit requires that the system installer 11ak,certain certifications to both of you pertaining
to the installer's qualifications as to its installation of the NitROE®2KS Components. KleanTu®LLC
acknowledges that the installer will be trained and certified prior to installation. In addition,KleanTu®LLC hereby
certifies that KleanTu®LLC personnel will be onsite to supervise the installation of the NitROE®2KS
Components. Such supervision will ensure that the NitROE®2KS Components are installed in a manner that
conforms with KleanTu®LLC's design and operating requirements.
Please contact me with any questions or comments regarding this certification. My cell#is 412-491-0122.
Sincerely yours
Jaw K.�i5,20
Jaw Fu
Vice President
Engineering and Operations
cif
Commonwealth of Massachusetts 8a - r(P(P
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
251 Lakeside Drive
Property Address
Hertha Clark and James Rooney
Owner Owner's Name
information is required for every Martons Mills ✓ MA 02648 04/26/2021
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information '1
on the computer,
use only the tab Michael T Bisienere
key to move your Name of Inspector
cursor-do not Cape Septic Inspections
use the return Company Name
key.
52 Rivers End Road
r� Company Address
Teaticket Ma. 02536
City/Town State Zip Code
r 508-280-3356 S13938
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
Inspectors Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
a
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
` Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
251 Lakeside Drive
Property Address
Hertha Clark and James Rooney
Owner Owner's Name
information is required for every Martons Mills MA 02648 04/26/2021
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Please read the bottom of the first page of this report. This statement is from the Ma. DEP. This home
was inspected under the Ma. DEP and The Town of Barnstable's guidelines. This three bedroom
home has an H-10 1500 gallon septic tank with an H-10 D-Box feeding (2) leaching chambers with
stone. At the time of the inspection the leaching was dry although had visible staining on the
sidewalls but no visible failure criteria was found.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
I `
Commonwealth of Massachusetts
Title 5 Official Inspection Form
<; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
251 Lakeside Drive
Property Address
Hertha Clark and James Rooney
Owner Owner's Name
information is required for every Martons Mills MA 02648 04/26/2021
page. CityrTown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
251 Lakeside Drive
Property Address
Hertha Clark and James Rooney
Owner Owner's Name
information is required for every Martons Mills MA 02648 04/26/2021
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
t I'
This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
< Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
251 Lakeside Drive
Property Address
Hertha Clark and James Rooney
Owner Owner's Name
information is required for every Martons Mills MA 02648 04/26/2021
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
251 Lakeside Drive
Property Address
Hertha Clark and James Rooney
Owner Owner's Name
information is required for every Martons Mills MA 02648 04/26/2021
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate yes or"no"for each of the following for all inspections..
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage backup?
® ❑ 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?
E ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
F 4 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
251 Lakeside Drive
Property Address
Hertha Clark and James Rooney
Owner Owner's Name
information is required for every Martons Mills MA 02648 04/26/2021
page. CitylTown State Zip Code Date of Inspection
D. System Information
1. 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 plus
GPD
Description:
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d town water
9 ( Y 9 (gP ))�
Detail:
In 2020-48,000 gallons were used and in 2019-56,000 gallons were used.
Sump pump? ❑ Yes ® No
Last date of occupancy: occupied
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
+� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
251 Lakeside Drive
Property Address
Hertha Clark and James Rooney
Owner Owner's Name
information is required for every Martons Mills MA 02648 04/26/2021
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present. El Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: Per owner apx 3 years ago
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
251 Lakeside Drive
Property Address
Hertha Clark and James Rooney
Owner Owner's Name
information is required for every Martons Mills MA 02648 04/26/2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
1999
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 15"feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: town water
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Water was flushed and came freely.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
251 Lakeside Drive
Property Address
Hertha Clark and James Rooney
Owner Owner's Name
information is required for every Martons Mills MA 02648 04/26/2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 811
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
I
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
H-10 1500 gallon
Sludge depth:
3"
Distance from top of sludge to bottom of outlet tee or baffle
33"
Scum thickness
1"
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
13"
How were dimensions determined?
sludge judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co.
based on the future use of the home. At the time of inspection the liquid level was at working level
and the tee's were in place.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
i-
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
e
251 Lakeside Drive
Property Address
Hertha Clark and James Rooney
Owner Owner's Name
information is required for every Martons Mills MA 02648 04/26/2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
F; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
251 Lakeside Drive
Property Address
Hertha Clark and James Rooney
Owner Owner's Name
information is required for every Martons Mills MA 02648 04/26/2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑' Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
o,.
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
At the time of the inspection the liquid level was at working level and there were no visible signs of
leakage or solids carryover.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
0
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
h Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
251 Lakeside Drive
Property Address
Hertha Clark and James Rooney
Owner Owner's Name
information is required for every Martons Mills MA 02648 04/26/2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 2
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
y Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
251 Lakeside Drive
Property Address
Hertha Clark and James Rooney
Owner Owner's Name
information is required for every Martons Mills MA 02648 04/26/2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding; damp soil, condition of
vegetation, etc.):
At the time of the inspection the leaching was dry although had visible staining on the sidewalls but
no visible failure criteria was found.
III
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
i
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
251 Lakeside Drive
Property Address
Hertha Clark and James Rooney
Owner Owner's Name
information is required for every Martons Mills MA 02648 04/26/2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
251 Lakeside Drive
Property Address
Hertha Clark and James Rooney
Owner Owner's Name
information is required for every Martons Mills MA 02648 04/26/2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
i
I
_F7 d II
r c qto 0 o� o
r--: y10
p•i SS0
.� �cc -
��_r`�lG Fill'!
t5insp.doc-rev.726Y2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
I�
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
251 Lakeside Drive
Property Address
Hertha Clark and James Rooney
Owner Owner's Name
information is required for every Martons Mills MA 02648 04/26/2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
I
® Check cellar
® Shallow wells
Estimated depth to high ground water: 8 plus feet
feet i
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 i
® Observed site (abutting property/observation hole within 150 feet of SAS)
I
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
I augered a hole at a lower elevation and shot it with a transit to show 4 plus feet of sepertation.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
-� 251 Lakeside Drive
Property Address
Hertha Clark and James Rooney
Owner Owner's Name
information is required for every Martons Mills MA 02648 04/26/2021
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost.$30.00 for 4-years). A business certificate ONLY REGISTERS YOUR NAME in town [which
you must do by M.G.L.-it does not give you permission'to ope.rate.) Business Certificates are available at the Town Clerk's Office, 1' FL., 367
Main Street, Hyannis, MA.02601 (Town Hall) _
+ S Fill in pleasa:
` APPLIGANT-S YOUR NAME_ _!e MJ0,L P211
BUSINESS YOUR HOME pp,,DDRESS:
S68 27-6 1-476 Ors fa,� '
TELEPHONE # Home Telephone Number 7 76 167.6
NAME OF NEW.BU9'1dVE:uS Q
TYPE Op WSINESS: ;M
IS THIS A-NOME OQOQPAT ?ION ,� S j�p. C
Have you been given a}?p:r.'oval frbrn the building:diviso�i? 105 NO
ADDRESS OF'BUSINESS MAP/PARCEL NUMBER__A
When starting a new business there are several•things you must do in order.to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information.you Inay need-. You MIDST GO TO 200 Main St. - (corner of Yarmouth
Rd, &Main Street), to make sure you have the appropriate.permits and licenses required to legally operate your business in this town.
1. BUILDING COMMISSIONER'S OFFICE
This individual has been informed-of any permit requirements that pertain to•this type of business.
Authorized Signature*
COMMENTS:
2. BOARD OF HEALTH
This individual ha e infor e of permit equire nts that pertain to this type of busirie.ss.
1
Authorized S- ature**
COMMENTS: .
3: CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature.*
COMMENTS:
P. 1
COMMUNICATION RESULT REPORT ( SEP.10.2003 9:11AM )
TTI BARNSTABLE BOARD OF HEALTH
FILE MODE OPTION ADDRESS (GROUP) RESULT PAGE
----------------------------------------------------------------------------------------------------
994 MEMORY TX 915089987554 OK P. 4/4
----------------------------------------------------------------------------------------------------
REASON FOR ERROR
E-1) HANG UP OR LINE FAIL E-2) BUSY
E-3) NO ANSWER E-4) NO FACSIMILE CONNECTION
Town of Barnstable
R� .
I xNawl. I gulatory Services
um
SOXV.�, ' Thomas F. Geiler,Director
Public Health Division
Thomas McKean,Director
200 Main Street, Hyannis,MA 02601
t
DATE: bo
NUMBER OF PAGES TO FOLLOW:
TO: r FROM: jam, rw c
PHONE: PHONE: (508)862.4644
FAX PRONE: FAX PHONE; (508)790.6304
cc:
��"�'OI•o� Town of Barnstable
IIAJU'M = Re '
,��, . Regulatory y Services
r
Thomas F. Geiler,Director
Public Health Division
Thomas McKean,Director
200 Main Street, Hyannis,MA 02601
DATE: j(�
NUMBER OF PAGES TO FOLLOW:
TO: A
FROM: .---
ica �'In CIA C-4ze-11
PHONE: PHONE: (508)862-4644
FAX PHONE: FAX PHONE: (508)790-6304
cc:
NOTES/COMMENTS:
2�, a S CU Dc""r�
Q:OEALTH\Fax Form.doc
McKean, Thomas
From: McKean, Thomas
Sent: Tuesday, August 05, 2003 3:44 PM
To: Traczyk, Art
Cc: Broadrick, Tom
Subject: 251 Lakeside Drive Marstons Mills/ Response to Your Memo dated August 3, 2003
Number of Bedrooms Determination
The Health Division does not utilize assessor's information to determine the number of bedrooms existing within a
particular dwelling. In accordance with the training provided by the Massachusetts Department of Environmental
Protection, Health Division professional staff are instructed to utilize the permanent record-disposal works construction
permit number of bedroom information when determining the number of bedrooms allowed at a particular site.
July 15, 1999- Date of Disposal Works Construction Permit Application to Repair a Failed Septic System
According to the permanent septic system record on file, the septic system was repaired on July 29, 1999 at the above—
referenced address. According to the septic system installer Randolf Harnois (on the application form), the home already
consisted of three (3) bedrooms in 1999. Also, according to the as-built card completed by septic installer Randolf
Harnois, the home already consisted of three (3) bedrooms.
September 10, 2002 -Date of Application for Sign-off of Building Permit Application
According to the building permit application form completed by the applicant James Rooney, the home already consisted
of three(3) bedrooms existiing.
The building permit application also reads as follows: "change a first floor bedroom back to a garage; convert two
bedrooms into one."
A health inspector approved this application for an addition with the stipulation that the home remain at"three bedrooms
only."
August 5, 2003 - File Review
I reviewed the floor plans on file at the Building Division. The floor plan shows a bedroom proposed on the first floor, a
bedroom and a "loft" on the second floor, and a "library room"within the attic. We consider the library room as a
"bedroom," per the definition contained within Title 5, due to the privacy provided there on a separate floor. The loft room
appears to be open to the family room area and does not afford privacy. Therefore, I counted a total of three bedrooms on
the floor plan.
I suggest the ZBA should also subpoena the person who completed the disposal works construction permit application,
Randolf Harnois, and the person who completed the building permit application, James Rooney, to testify in regards to the
number of bedrooms which existed at this property prior to the demolition.
1
Town of Barnstable
Planning Division
Thomas A.Broadrick,Director t ;
Planning,Zoning&ffmoric Pmervadon
Memorandum
Date: August 03,2003
To: Tom Perry,Building Commissioner
Thomas McKean,Director of Health
From:
Traczyk,Principal Planner
File letters-2003-M-PerrryMckean on Clark.doc
Request: Your attendance at the September 03,2003 Zoning Board of Appeals hearing on
the Clark/Rooney Appeal 2003-98 and 99—251 Lakeside Drive,Marston Mills,
Assessor's Map 102,parcel 166
On behalf of Daniel M. Creedon, Chairman of the Zoning Board of Appeals,I am
requesting your attendance at the 7:30 P.M.,September 03,2003, continuance'of the above
referenced appeals. The appeals are that of Hertha B. Clark and James E. RooneyJr. seeking
a zoning special permit and variance to permit the demolition and reconstruction of a single-
family dwelling on a non-conforming undersized lot.
The Board's concerns were for:
• the Health Divisions approval of the reconstruction and the on-site septic system for
a three-bedroom dwelling when the Assessors' record indicates that the existing
structure was a two-bedroom dwelling, and
• the issuance of an as-of-right Building Permit that resulted in the demolition of the
entire dwelling.
On behalf of the Chairman and the Board Members I wish to thank you in advance for your
assistance and participation in resolving these issues.
Copy. Attorney Patrick M.Butler
Thomas Geiler,Director,Health,Safety&Environmental Services
Daniel M.Caeedon,Zoning Board of Appeals Chairman
ZBA File 2003-98&99
June 13,2003
Mr.Thomas Perry
Barnstable Building Commissioner
o f Barnstable
Town o (�
Hyannis,MA.02601
Dear Mr.Perry,
v�
I am writing to you regarding the property at 251 Lakeside Drive, Marstons Mills. There are a few concerns to all members of d.
Shores Association. A permit has been issued for a three bedroom home to Mrs.Thertha Clark and James Rooney at 251 Lakeside Drive,^
Marstons Mills,MA. /vJ'
This Pero rty is located directly across from Shubel Pond. Others in our development have been limited to a two bedroom home due to lot
P
size and the Act of Contribution. A third bedroom could only be permitted with the addition of a Nitrate Septic System. Mr.Rooney
himself spoke of having a six bedroom sober house on that property once it is completed. We question how a two bedroom home is torn
down.to the foundation and a permit is issued for a three bedroom home on that same foundation without input from the Zoning Appeal
Board and or the Board of Health.
Mr.Rooney is aware of our concerns,as we addressed these with him at our board of director's meeting. Our annual meeting for the Sand
Shores Association will be held at our beachfront on June 28,2003 At this time,all of these questions will be raised again and the officers
and board of.directors would like to clear up.any concerns regarding a sober house as told to the members by the owner and the issue
regarding the bedrooms.
Attached you will find that the house is listed as.a two bedroom on the Assessor's Map. Therefore,we as an Association are asking you to
look into these concerns and respond back to us by June 23,2003. You can contact the board of directors at the following address: Sand
Shores Association,PO Box 342,Marstons Mills,MA.02648. We appreciate you time and hope to clear up all concerns of this property.
Sincerely,
Officers,Board of Directors Michelle Atcheson,President
And Members of Sand Shores Association Scott Halligan,Vice President
Louise Panton,Treasurer
JoAnne Weekes,Secretary
cc: Thertha Clark and James Rooney
Mr.John Klimm
Mr. Gary Blazis
Susan Rask, Board of Health
Daniel Creedon,Zoning Board of Appeals
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map Parcel
Date Iss
Health Division I
/Application Fee
Conservation Division �l V r
C' Permit Feed` 3
Tax Collector p
�l
Treasurer ��1
SEPTIC SYSTEM MUST BE G v
Planning Dept. INSTAUM IN COMPUANCE
Date Definitive Plan Approved by Planning Board V=T=5
Historic-OKH
Preservation/Hyannis EWRONMENTAL CODE ANO
Street Address �l�Z
Project St , IIIIIIS
Village Td " I-
x T
Owner
ddress � L
Telephone 0 "` d d
t
,CHs -�i' �v LOFT
Permit Request P R —
• C A�� ' �I
Raa
o��1l 13,4TN_i^J /IMEnI` `/
` proposed
�� �Totalew / - �"
Square feet: 1st floor:existing proposed 2nd floor: existing Q P P
Zoning District Flood Plain Groundwater Overlay
IMC7uJG4
Project Valuation QnTa/du Goo Construction Type
Lot Size Grandfathered: ❑Yes ❑No If yes,attach supporting documentation.
Dwelling Type: Single Family Two Family ❑ Multi-Family(#units)
Age of Existing Structure S Historic House: ❑Yes [ No On Old King's Highway: QYes Flo
g _.
Basement Type: �ull ❑Crawl ❑Walkout ❑Other
Basement Unfinished Area(sq.ft)
Base
Basement Finished Area(sq:ft.) ✓ ;-%'� new fir,
new f Half:existing rr.
Number of Baths:e Full:existing ! r
Number of Bedrooms: existing_ new
Total Room Count(not including baths):existing
new �Z_— First Floor Room ount x�
Heat Type and Fuel: WGas ❑Oil ❑Electric ❑Other
Central Air: El No Fireplaces: g laces: Existing J New Existing wood/coal stove: El Yes El No
�
Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size
Attached ❑existing El new size She4existing ❑new size Other:
garage:
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes ❑No If yes,site plan review#
Current Use Proposed Use
BUILDER INFORMATION
Name ���-� oode N Telephone Number
, / /i)C �/`°/c0� License#
Address' �
�kl�1 _4
L IL Home Improvement Contractor#
Y
f Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
om, b b
SIGNATURE D
� ,
- TOWN OF BARNSTABLE 1/l
LOCATION .2,I LAIer sr& A� SEWAGE # "' 7/ •�
,,,,'VIL!LAGE, A � ASSESSOR'S MAP & LOTAL' -,-
INSTALLER'S NAME&PHONE NO. tf+U Ce-S�- Vz `Y
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) 14F,Ac, C 4s (size) .2—S?Q c A-//
NO. OF BEDROOMS
BUILDER OR OWNER'
PERMITDATE: �V COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of ching facility) ` Feet
Furnished by Vr,9 gew P
5
0.0 C -
L7
- . o•/ss1 a- {��
co p9bU -{�
o�
ih
- r
TOWN OF BARNSTABLE
�:0CATION rj �i/ � �—w SEWAGE #�
:VILLAGL_ .5 ASSESSOR'S MAP & LOT�"� {�
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY ;4
LEACHING FACILITY:(type) (size) /QQ0 4AAn
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER ��
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes_ No
r
i
. � � �"..
�� '� � � � �
� � � �
"�
�° yv!'
�'� � � �
I � '� �
� � �
.�5�� �.
��---�►
, Fee S~�
No.
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLEs MASSACHUSETTS yV/'
n
0(opYication for �igozar 6potem con 56t tction Permit
Application for a Permit to Construct( )Repair O Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lotjf�/p t(//�� /J //fj �/(�' Owner's Name,Address and Tel.No.
Assessor's Map/Parcel/o c2 _ / A)
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
04/ _1--jj C, -
Type of Building:
Dwelling No.of Bedrooms_ Lot Size sq.ft. Garbage Grinder( )
Other Type of Building tjn PeS. No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 1�0 gallons per day. Calculated daily flow ` gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of 95FZ
ode and not to place the system in operation until a Ce 'fi-
cate of Compliance has been ' ed by t '
Signed Date
Application Approved by Date /F✓
Application Disapproved for the following reasons
Permit No. Date Issued �`
No. / Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
4 Yes
V
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
application for Migpo,!6A-1 6p errY C40n!truction hermit
f ,, IY . , ._ - -. __ ._ _
Application for a Permit to Construct( )Repair O Upgrade( )Abandon(� ) `0 Complete System ❑Individu`alt Components
Location Address or Lot Owner's Name,Address
and
/Tel.No.
Assessor's Map/Parcel; _
Installer's Name,Address,and Tel.No. Designer's Name,:Address and Tel.No.
( oAl St✓v C1►o Aj ..J ,u C. w
Type of Building:
Dwelling No.of Bedrooms A Lot Size sq. ft. Gar age Grinder( )
Other Type of Building , No.of Persons Sho ers( ) Cafeteria( )
Other Fixtures
Design Flow Q gallons per day. Calculated daily flow gallons.
Plan Date Number of sl eet'__n Revision Date
Title s
Size of Septic Tank Type of S.A.S.
Description of Soil I
VA
of Repairs or Alterations(Answer when applicable)
I VA
Date last inspected-
Agreement: -- s
The undersigned��rues toy'ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance the pr'i�visions of of thie:E vironmeQtat rode and not to place the system inioperation.until -Ce 'fi-
cate of Compliance has been i ed by thi e , ,
Signed Date
Application Approved by l Date% �+
Application Disapproved for the following reasons
j
Permit No. Date Issued ;' X"s;
THE COMMONWEALTH OF MASSACHUSETTS —
BARNSTABLE,.MASSACHUSETTS
Certificate of Compliance
THIS IS TO C- e On i Sewage Disposal System Constructed( )'Repaired (X)Upgraded( )
Abandoned( )by
at t r S o,s !✓r S has been constructed in accordanc f
with the provisionp pf Title 5 and the for Disposal System Construction Permit No. dated A
Installer rt9 . d 0C t o!J ��C; Designer S4 40'e—
The issuance of this permit shall not_be construed as a guarantee that the sysgm will functio designed.
Date ' Inspector
---------------------------------------
No. Fee 4%
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Miooar *raem Construction 3permit
Permission is hereby granted to Construct( )Rep ( )Upgrade( )Abandon
r. `# System located at �r�
LY)PirsTovr rdl. f(s
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this R&4riit.
Date: ` � " / Approved b- q/I�dl r
ty
7eo- �Yt/
` yq'O
,c eG G
t � r30.0
S
TOWN OF BARNSTABLE
LOCATION' LAIM 6afre SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT��_.
INSTALLER'S NAME&PHONE NO. 1G*1d Cc-S�- �Z "Y
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) L i4. Lj-t(size) e2`,n
+ • NO.OF BEDROOMS
BUILDER OR OWNER f{ �
PERMITDATE: '7f X15 Pg COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of ching facility)f� Feet
1/6/99
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only. -
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
r
LhAI'A)o rs hereby certify that the application for disposal works
construction permit signed by me dated concerning the
property located at e meets all of the
following criteria:
The failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
There are no wetlands within 100 feet of the proposed septic system
There are no private wells within 150 feet of the proposed septic system
There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.,
The bottom of the proposed leaching facility will not be located less than five feet above the
ma,dmum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor
method when applicable]
• If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed
leaching faciliry will not be located less than fourteen(14) feet above the maximum adjusted
groundwater table elevation,
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information)
B) G.W. Elevation +the MAX. High G.W. Adjustment .
DIFFERENCE_BETWEEN A and B
c
SIGs D : L�2✓��-4 DATE: /
(Sketch proposed plan of system on back].
q:health folder:cent
f-� ( eA0
CI �
c
FOR
M
OF PHONED
PHONE � RETURNED
AR CODE NUM ER �YOUR:CALL
MESSAGE
EXTENSION
L--
'.WILL GALL
^ AGAIN
f CAME TO
.SEE YOU
SIGNED SEE YOU
- �r iv rsai-gsoos
CO
00
#241 I
I r
\\ 1 z I VLLJ
c
La
CO
`\
LO J
M
G G to m
PROPOSED AIR PUMP o' i `. •N o
FINAL LOCATION TO BE 9 = •>
FIELD DETERMINED i I ;
❑ [3-0-0- U N780 05'25"E 1 1 ► o a `„
} 100.00'
IN,
v =
\ T"
m
NITROE 2KS 2,000 / WASTEWATER NOTES 12. PROVIDE WATERTIGHT SEALS BY USE OF NON-SHRINK GROUT AT ALL c 3 w
GALLON TANK ° POINTS WHERE PIPES ENTER OR LEAVE ANY CONCRETE STRUCTURES. *�
BENCHMARK: \ / � a p
INV. IN=57.71 SPIKE SET \ EXISTING\ / o
INV. OUT=57.46 P�� WATER _ 1. ELEVATION, PROPERTY LINE AND E)CISTING CONDITIONS ON THIS PLAN 13. USE SCH. 40 PVC PIPING WITH WATERTIGHT JOINTS UNLESS y
EL = 59.66 o O '^
SERVICE ` / ARE BASED ON A SURVEY CONDUCTED BY THE HORSLEY WITTEN OTHERWISE NOTED ON PLAN. ALL PIPE SHALL BE PLACED ON A i- w a Y
�\ t GROUP, INC. IN OCTOBER, 2021. COMPACTED FIRM BASE. c m Cr
2. UNLESS OTHERWISE NOTED, ALL SYSTEM COMPONENTS AND 14. ALL STONE TO BE DOUBLE-WASHED AND FREE OF DIRT, DUST,AND ° d N
z , m , CONSTRUCTION METHODS SHALL BE IN ACCORDANCE WITH THE STATE FINES. ,c 33 Q °>
- 22.1l' Q \ N ENVIRONMENTAL CODE AND THE RULES AND REGULATIONS OF THE W 5,
10.30 (n 0o Ln LOCAL BOARD OF HEALTH. `� �o 1 N
ti a
15. THE CONTRACTOR IS RESPONSIBLE FOR PROVIDING OPERATIONS AND >+ ° ° M
MAINTENANCE INFORMATION FOR THE SEPTIC SYSTEM TO THE c ° M M
V) M O
O O z 3. THIS PLAN IS INTENDED TO ADEQUATELY PROVIDE THE INFORMATION ENGINEER, IF NECESSARY. i *° ° °D °p z
��
N a
�� a o0 00
4 SCH 40 PVC , <C W NECESSARY TO LAYOUT AND CONSTRUCT THE PROPOSED SEWAGE O
° � o �soo io
L=20', S=1.0% "'I ` ❑ DISPOSAL SYSTEM REPRESENTED ON IT AND SHOULD NOT BE USED = ti °' Co h "' °
I z , o w FOR ANY OTHER PURPOSES. 16. UNSUITABLE SOIL MUST BE REPLACED WITH TITLE 5 SAND AS
SPECIFIED IN 310 CMR 15.255(3). ANY ADDITIONAL AREAS THAT ARE
251 LAKESIDE DRIVE O I EXISTING GAS FOUND TO HAVE UNSUITABLE MATERIAL SHALL BE REPORTED TO THE U)
SERVICE ° 4. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE ENGINEER ENGINEER.
S9 ( cn 3 BEDROOM DESIGN - \ , AND/OR THE LOCAL BOARD OF HEAILTH BOH STAFF.
O I 17. ALL SEPTIC COMPONENTS SHALL BE INSTALLED WITH MAGNETIC �-
o5. PRIOR TO CONSTRUCTION,THE CONNITRACTOR SHALL COORDINATE WARNING TAPE.
/ \ ` 1 G W ° WITH THE PROPERTY OWNER AND ENGINEER ON THE CONSTRUCTION 0
4" SCH 40 PVC ' I / / I BEACH SITE ACCESS AND MATERIAL STOCK PILE AREAS. 18. ALL SEPTIC TANKS SHALL BE APPLIED WITH 2 COATS OF DAMP I---
L=25', S=0.5% ) ` ❑, / / I �/ PROOFING OR BITUMINOUS MATERIAL. (� L7
C)
DECK / ] z LL 6. TRENCH SAFETY SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR z
�., / PAVED O INCLUDING ANY LOCAL AND/OR STATE PERMITS REQUIRED FOR THE 19. THE CONTRACTOR SHALL RESTORE ALL SURFACES EQUAL TO THEIR W
❑- ❑ ❑ ` i ❑ TRENCH WORK. THIS WORK MAY BE REQUIRED TO TAKE PLACE ORIGINAL CONDITION AFTER CONSTRUCTION IS COMPLETE. AREAS
/ DRIVE 1 i zo W OUTSIDE OF NORMAL HOURS OF OPERATION FOR THE FACILITY. THE NOT DISTURBED BY CONSTRUCTION SHALL BE LEFT NATURAL. THE _1 = z
0 Q CONTRACTOR SHALL PLAN ACCORDINGLY. CONTRACTOR SHALL TAKE CARE TO PREVENT DAMAGE TO SHRUBS, J U `t
Ab - TREES, OTHER LANDSCAPING AND/OR NATURAL FEATURES. WHEREAS
7. THE CONTRACTOR SHALL REPORT ANY DISCREPANCIES FOUND IN SITE G �-
i ,n \ � . THE PLANS DO NOT SHOW ALL LANDSCAPE FEATURES, EXISTING (f)
`') m EXISTING 1500 GALLON .,,✓ W CONDITIONS FROM THOSE SHOWN ION THE PLAN TO THE DESIGN CONDITIONS MUST BE VERIFIED BY THE CONTRACTOR IN ADVANCE OF (/) I-
L`rn (0 SEPTIC TANK TO REMAIN \♦ ENGINEER. THE WORK. Z Q LL
a� INV. IN=58.16
z INV. OUT=57.91 ~~�`. I \ ❑ 8. FAILING TO PROPERLY INSPECT OR;PUMP THE SEPTIC TANKS AND 20. ALL UNPAVED AREAS DISTURBED BY THE WORK SHALL HAVE A b
TREATMENT SYSTEM OR CHANGES TO EFFLUENT FLOW,-GRADING, OR MINIMUM OF 4-INCHES OF LOAM INSTALLED AND BE SEEDED WITH W I""
PROPOSED DBOX CLEANOUT .,, _ LANDSCAPING, EITHER ON-SITE OR ADJACENT TO THE SITE, MAY GRASS SEED AS SHOWN ON THE PLAN AND/OR DIRECTED BY THE V) W
INV. IN=57.33 VGA �,\ I RESULT IN IMPROPER FUNCTIONING OF THE SEPTIC AND LEACHING ENGINEER. THE CONTRACTOR SHALL BE RESPONSIBLE FOR WATERING Q W
(� J
W INV. OUT=57.16 N780 05'25"E UGE ! ❑ SYSTEM(S). ANY LOAM AND SEEDED AREAS UNTIL LAWN GROWTH IS ESTABLISHED J Q00
0 100.00, 565/15 AND APPROVED BY THE ENGINEER AND/OR OWNER. cc
EXISTING DBOX EXISTING I 9. CALL"DIGSAFE"AT LEAST 72 HOUR,S PRIOR TO COMMENCING
L1J I CONSTRUCTION AT 1-888-DIG-SAFE AND ANY OTHER APPLICABLE 21. AN INNOVATIVE &ALTERNATIVE TREATMENT SYSTEM IS PROPOSED N U) W
INV. IN=57.37 UNDERGROUND I 1 AGENCIES TO FIELD VERIFY LOCATIIONS OF EXISTING UTILITIES. FOR THIS SITE. THE SYSTEM MUST BE INSTALLED AND MAINTAINED IN
Q 4" SCH 40 PVC INV. OUT=57.20 ELECTRIC ° z Q
c.� ACCORDANCE WITH THE DEPARTMENT OF ENVIRONMENTAL
'-I = ' - ° TO BE REMOVED w
( )
L 5 S 1:0/° 10. THIS ON-SITE WASTEWATER TREATMENT SYSTEM IS NOT DESIGNED
1 � PROTECTION.(DEP) PROVISIONAL USE APPROVAL.
N ' 1 /`� ' FOR USE WITH A GARBAGE GRINDEIR. m W
EXISTING LEACHING
CHAMBERS(2}. PLUG �N �' ° 11, THE OWNER SHALL HAVE THE SYSTFEM INSPECTED AND HAVE THE.
EXISTING INLETS(2). 1 SEPTIC TANK PUMPED EVERY 3-8 WEARS.
w CORE NEW INLETS(2).
M INV. EL. 57.14 777//7TP-� \•� cv d + ° GENERAL NOTES:
a a
06 #26 153" 1. NITROE 2KS TANK TOP TO HAVE THREE-24",TWO-12"HOLES AND
TOTAL TANK LENGTH MULTIPLE 4' HOLES WITH RISERS AND COVERS FOR MAINTENANCE
Q OUTSIDE WALL TO OUTSIDE WALL OUTLET TROUGH(OT) AND SAMPLING.
2, OR THE 24"HOLES;PROVIDE 24"DIA.ADS PIPE(CORRUGATED) O
p//�� CU
GRAPHIC SCALE �.. � • • • . ,. ,. .Q . : . , • . : ,.. _ WITH POLYLOK(OR EQUIVALENT)COVER(OR EQUIVALENT
Cl) TANK WALL Y w CONCRETE RISER AND COVER)TO 12"BELOW GROUND SURFACE
(1) 10 0 5 10 20 40 THICKNESS ¢ a AND SECURE TO TANK TOP. C
V AT TOP 3. FOR THE 12"HOLES;USE ADS PIPE(CORRUGATED)AND POLYLOK _ co
_J (3 TYP) 06 (OR EQUIVALENT)COVERS TO 12"BELOW GROUND SURFACE AND N U.) 00
Q MIDDLE a.. w 0 0 co
40 p i- SECURE TO TANK TOP. N
w INLET ROUE $ 4. PROVIDE FOUR 4 DIA.SAMPLING PORT(1"BELOW GROUND N I 04
U (in feet) ° TROUGH SU RGED (MT) DENT ICATI a SURFACE)WITH 6"PLASTIC ROUND BOX AND COVER TO BE FLUSH a -O .°�.' <
;L_, p 17
cn EFFLUENT W .- 00
o
�- 1 INCH = 10 FEET FROM SEPTIC (IT) A N AM 0 WITH GROUND SURFACE. �. O N LO
Y 0 TANK C BE (DC) 5. FOR EXISTING SEPTIC TANK;PROVIDE 2"DIA.SAMPLING PIPE THAT L •� Xo
(n 81 zz O 0 S C) IS CEMENTED OR ANCHORED TO THE TANK TOP AND EXTEND 2" CL m �
V BELOW THE TANK TOP AND BE POSITIONED 6-12"FROM THE EDGE �' co O
FFLUENT TO OF THE OUTLET END OF THE SEPTIC TANK OR IN THE SEPTIC TANK o_ m U ao n O a
DBOX CONCRETE OUTLET COVER.ON THE TOP SIDE OF THE SEPTIC TANK,
THE 2"DIA.SAMPLING PIPE SHOULD EXTEND TO 2"BELOW THE
m GROUND SURFACE AND HAVE A 6"DIA.PLASTIC ROUND BOX AND
E- COVER AT GROUND SURFACE.
o TANK WALL
THICKNESS
O AT BOTTOM
(� (4 112"TYP) s .. .
o ZONING & RESOURCE PROTECTION NOTES
v 1. PARCEL ID: 102/166 LOT SIZE: 0.17 AC
CL
'p O
2. OWNER OF RECORD: RONALD PALMA&JUANITA SWEET
6"PLASTIC BOX AND COVER WITH 4" `"
SEE NOTES 3 AND 4(TYP)
3. ADDRESS: 251 LAKESIDE DRIVE, MARSTONS MILLS SEE NOTES 3 AND 4(TYP) MONITORING PIPE;SEE NOTE 2 AND 4(TYP) o 8a co
Y SEE NOTE 2(TYP) > N 'L,0, to 2 CR
4. THE LOCUS IS IN LOCATED IN FLOOD ZONE X(AS SHOWN ON F.LR.M. MAP GROUND SURFACE P EL.59.8 MIN 24"ACCESS HOLE WITH COVER SEE NOTE 2(TYP). o Chi
25001 C0542J DATED JULY 16, 2014). RISER TO WITHIN 3"OF SEE NOTE 2(TYP) °O
n
•-, FINISHED GRADE ¢ a
\I/ a1/-\f/ EL.58.9 MIN 5 1/2"TANK TOP(TYP) TO SOIL a N csi � o Z
-� Lo
5. THE SITE IS LOCATED IN A WELLHEAD PROTECTION DISTRICT. I-1 I = I ABSORPTION SYSTEM ; L o -S
III LOAM AND SEED.I 11_ ^ - (SAS) Z O a o x °'
�-- __-_- -_ - EL.58.87 ,o M = M m
PROVIDE PLASTIC -EL.58.08_^_. co _ a �- o
N WASTEWATER
�+ p �+ �+ �+ IRRIGATION BOX TO - CLEAN
- - - - - - - :a ..: , , •• :, .. :. , ;
00 V VAti7TE V VATER INSTALLATION I INSPECTION NOTES GRADE 4-INCH PVC I --BAGKFILL- - - - - - - EFFLUENT FROM SEPTIC ae'StATICWATERDEPTH EFFLUENT Registration:
O THREADED CAP - - - - - - - - -
TANK =
- _ - _ a-
- - - - - - -
F 4 HOURS ADVANCE
1. THE CONTRACTOR SHALL PROVIDE A MINIMUM O 2
NOTICE TO THE ENGINEER AND LOCAL BOARD OF HEALTH FOR ANY --
_ _-_ a
- - _ _ _ w
13F
INSPECTION. _ FLOW FLOW_ _. -. - I p
1' - - - - - - - - - 6„OF 3/4" a g i'"w z^ ca .IOSEI°Ff E.
�_, - - -- - - SUBMERtGED DENITRIFICATION CHAMBER = O o ¢w
C 2. ALL WASTEWATER COMPONENTS SHALL BE INSPECTED BY THE ENGINEER - EL.56.58 ' .. _ _ _ p -_ COMPACTED 0 w n = }- _
0 > AERATI10N 0 (DC) ' } o F a
CRUSHED � 0 = W
•i _ I-
zIYf a
AND THE LOCAL BOH REPRESENTATIVE PRIOR TO BACKFILLING. AT A PROVIDE ADAPTER TO Q -0 0 CHAMBIER p 0 I >z L ,
STONE BASE F.- .-� 0 �.-. w z
MINIMUM THE FOLLOWING ITEMS SHALL BE INSPECTED: JOIN SEWER OR LATERAL 45 DEGREE PVC BEND AT - III I 0 °u_ o (SAC)) � Z j �w
2.1. SYSTEM COMPONENTS BASE AND INSTALLATION PRIOR TO BACKFILL To 4-INCH ELBOW THE END of LINE wYE I I I LO - � Li° o o o
2.2. LEAKAGE TEST ON PRECAST TANKS (MIN. 24 HR) CONNECTION FOR w I i I ( I- ! I -
N J J w z
2.3. START UP TEST OF SYSTEM WITH ALL COMPONENTS INSTALLED AND LINE w - o y It
p �'w az so AL
0
0 NOTES: z� t9
O FUNCTIONING AS DESIGNED Ct�
1. PROVIDE 3 OUTLET DISTRIBUTION BOX INSTALLED ON LEVEL
v 2.4. FINAL INSPECTION OF BACKFILLED SYSTEM STABLE BASE: EL.53.12 �... . .•. •' ;.•: KleanTu LLC Project Number: Sheet:
2. BLOCK ONE OUTLET. TANK BOTTOM
N 3. THE CONTRACTOR SHALL BE RESPONSIBLE TO MAINTAIN UP-TO-DATE AS-BUILT 3. INSTALL FIRST 2 FEET OF OUTLET PIPES LEVEL. THICKNESS 4" 12"CRUSHED AGGREGATE OR APPROVED 20112 1 Of
DRAWINGS AND NOTES INDICATING THE HORIZONTAL AND VERTICAL LOCATION 4. INSTALL SPEED LEVELERS(OR EQUAL)ON OUTLET PIPES. MATERIAL;ON LEVEL,COMPACTED AND
STABLE BASE
o WITH TWO TIES OF ALL SYSTEM COMPONENTS INSTALLED. THESE AS-BUILT PROPOSED H-10 DISTRIBUTION BOX DETAIL TANK WALL THICKNESS AT BOTTOM(4")
DRAWINGS AND NOTES WILL BE UTILIZED BY THE ENGINEER FOR THE TANK WALL THICKNESS AT TOP(3") Sheet Number:
TYPICAL CLEANOUT DETAIL ACME PRECAST OR EQUIVALENT NitROE 2KS 2,000 GALLON WASTEWATER TREATMENT SYSTEM (WWTS)
N PREPARATION OF RECORD PLANS. NOT TO SCALE NOT To SCALE N-ASST20M-H10 W V V
t6 NOT TO SCALE