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HomeMy WebLinkAbout0261 LAKESIDE DRIVE - Health 2 't Lakeside Drive- - _ Marstons Mills r A = 102 165 , r x l R y •i y Town of Barnstable 59. 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.Alt March 3, 2022 Mr. Joseph Henderson Horsley Witten Group 90 Route 6A, Unit 1 Sandwich, MA 02563 R Dave,` astonsMlsMr iE 61 Lakeside'" Dear Mr. Henderson, You are granted variances on behalf of your client, Amy Hotchkiss, to construct and utilize a NitROE secondary treatment unit with advanced nitrogen reduction technology at 261 Lakeside Drive, Marstons Mills, Massachusetts. The following variances were granted: 310 CMR 15.211:: To install a soil absorption system 9.5 feet away from the foundation of the dwelling in lieu of the twenty (20) feet minimum separation distance required. 310 CMR 15.211:: To install a tank 8.9 feet away from the foundation of the screen porch, in lieu of the ten (10) feet minimum separation distance required. 310 CMR 15.221(7):: To install the soil absorption system 3.8 feet below grade, in lieu of the three (3) feet maximum of soil cover allowed. These variances were granted because the physical constraints at the site severely restrict the location of the septic system components due to the small size of the lot and its close proximity to a pond. 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 Q:WP/Henderson 261 Lakeside Drive Variances Granted NITroe Oct 2022.docx 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 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 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. 9 p [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 hftp://www.mass.gov/eea/docs/dep/water/laws/i-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. Q:WP/Henderson 261 Lakeside Drive Variances Granted NITroe Oct 2022.docx This permission is granted because the proposed plan appears to meet the maximum feasible compliance provisions of the State Environmental Code, Title 5, and the Town of Barnstable Board of Health Regulations. It also appears to meet the nitrogen loading restrictions contained within the State and local regulations with no increase in sewage flow requested at this property at this time. Sincerely ours, hn Norman Chairman I Q:WP/Henderson 261 Lakeside Drive Variances Granted NITroe Oct 2022.docx -DATE: $95.00 FEE*: KAM BARMABLF, Town of Barnstable REC.BY: Board of Health SCHED.DATE: 200 Main Street,Hyannis MA 02601 Office: 508-8624644 // John T.Norman FAX: 508-790.6304 Donald A.Guadagnoli,M.D. Paul J.Cannifl;D.M.D. F.P.(Thomas)Lee,Alternate VARIANCE REQUEST FORM LOCATION Property Address: 261 Lakeside Drive,Marstons Mills Assessor's Map and Parcel Number: 102/165 Size of Lot: 0.17 ac Wetlands Within 300 Ft. yes Business Name: Subdivision Name: APPLICANT'S NAME: Joseph Henderson (Horsley Witten)Phone (508) 833-6600 Did the owner of the property authorize you to represent him or her? Yes X No PROPERTY OWNER'S NAME CONTACT PERSON Name: Amy D. Hotchkiss Name: Joseph Henderson (Horsley Witten Group) 261 Lakeside Drive,Marstons Mills, MA 026AR 90 Route 6A Unit 1,Sandwich,MA 02563 Address: Address: Phone: Phone: (508) 833-6600 EMAIL: jhenserson@horsleywitten.com VARIANCE FROM REGULATION(tncl.Reg.code a) REASON FOR VARIANCE(May attach separate sheet if more space needed) Installation of I/A System 15.211 setback tank to cellar wall lot area 15.211 setback leachfield to cellar wall of area 15.221(7)depth of cover _ pipe length,try' to avoid needing a pump chamber_ NATURE OF WORK: House Addition House Renovation Repair of Failed Septic System Checklist (to be completed by once 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 UA 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: 1)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 Note: 1. Floor Plan Provided by Property Owner. 2. Basement unfinished. AN .. YP -#3 X 7-1 .... ..-- ----------........................... r rT� yl lCommonwealth 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 (NitROEO 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: K1eanTu 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. May_ 12, 2020 Marybeth Chubb, Section Chief 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 617.292-6761. TTY#MassRelay Service 1-800-439-2370 MassDEP Website:www.mass.gov/dep Printed on Recycled Paper Y C KleanTu NitROE 2K Provisional Approval,May 2020 Page 2 of 15 Technology:NitROE®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 headerihose 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:NitROEO 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 i K1eanTu NitROE 2K Provisional Approval,May 2020 Page 4 of 15 Technology:NitROE®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. KleanTu NitROE 2K Provisional Approval,May 2020 Page 5 of 15 Technology:NitROEO 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 actions 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 an Y Y PP g Y g Y Y 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 KleanTu 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.govleealdocsldeplwaterllawsli-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:NitROEO 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 I 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.gov/eea/docs/dep/water/laws/i-thru-z/testsamp.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 I. 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. KleanTu NitROE 2K Provisional Approval,May 2020 Page 9 of 15 Technology:NitROE®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. KleanTu NitROE 2K Provisional Approval,May 2020 Page 10 of 15 Technology:NitROEO 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 used 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 liability 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 costs 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: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. 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 K1eanTu 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 by 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 necessary 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 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. 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:NitROEO 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:NitROEO 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. K1eanTu 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. f September 2, 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 my house. This plan will be submitted to you for approval. Please don't hesitate to contact us with any questions at adhotch@hotmail.com. Amy Hotchkiss 261 Lakeside Drive Marstons Mills, MA 02648 r KleanTu® LLC KleanTu wastewater John R.Smith Treatment P.O. Box 1154 Technologies Edgartown,MA 02539 412-719-5976-Mobile 5.08-627-3072-Office September 2, 2021 I Town of Barnstable Board of Health 200 Main Street Hyannis, MA 02601 RE: Property and System Owner Certification for New NitROE02KS WWTS Enhanced Title 5 Septic System Installation for 261 Lakeside Drive, Marstons Mills, MA 02648;KleanTu Project 80039-2109 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 261 Lakeside Drive, Marstons Mills, MA,a private residence,(the"New System'),featuring the use of a new NitROE® 2KS wastewater treatment system (the "NitROE®2KS Components"). Item IV- #5 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 included with this letter the required certification. Should you have any questions, please do not hesitate to contact me. Sincerely yours, .)nhn R Smitli loci j,aizi.1.1:45 rin l John R. Smith President Enclosure cc: Amy Hotchkiss, Property and System Owner - 1- i September 2, 2021 K1eanTue LLC John R. Smith P.O. Box 1154 Edgartown,MA 02539 Dear Sir: I 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(the"New System")proposed for my private residence at 261 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 owner of the property known as 261 Lakeside Drive,Marstons Mills, MA 02648, I/we hereby certify to the accuracy of all of the following statements: I. I have been provided a copy of the DEP Permit and I agree to comply with all terms and conditions cited therein. 2. I 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,record- keeping,reporting and related matters for the NitROE®2KS Components(collectively,the"O&M Responsibili- ties."). 3. I understand that I must enter into a contract by which my O&M Responsibilities will be fulfilled with KleanTu® or a KleanTu®-approved operator licensed by the Mass DEP as required by the DEP Permit. 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. I understand that I must fulfil my responsibilities to provide written notification of the conditions of the DEP Per- mit to any new owner, as required by 310 CMR 15.287(5). Sincerely yours, h.. )N) Amy Iqo chkiss 2 r KleanTu® LLC John R.Smith KleanTu Wastewater P.O. Box 1154 Treatment Technologies Edgartown,MA 02539 412-719-5976-Mobile 508-627-3072-Office September 2,2021 To: Town of Barnstable Board of Health 200 Main Street Hyannis, MA 02601 RE: Designer Certification for New NitROE02KS WWTS Enhanced Title 5 Septic System Installation for 261 Lakeside Drive, Marstons Mills, MA 02648; KleanTu Project#80039-2109 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 261 Lakeside Drive, Marstson Mills, MA private residence(the"New System'),featuring the use of a new NitROE®2KS wastewater treatment system(the"NitROEO 2KS Components'). The New System was designed by Joseph Henderson,a Massachusetts Registered Professional Engineer with Horsley Witten Group, Inc.(HWG). The NitROE®2K Components are depicted in Site Drawing Project No.: 20112,prepared by HWG and dated September 2,2021. Item IV-#2 of the DEP Permit requires that KleanTu®makes 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 NitROEO 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, c,oh .Inha R Smith(sF'P A,A21 uo: G CDT) John R. Smith President cc: Joseph Henderson, Horsley Witten Group Amy Hotchkiss, Property and System Owner - 1- I i- t n � . , z - � r r Certifl f i * ',max O p ed .� z Ma i _I Fe Extra Services&Fees(check box,add fee as a �sf i ❑Return R Certified Mail� Receipt(hardrgpy) $ appropriate) 0 p ❑Return Receipt(electronic) $ p ❑Certifietl Mail Restricted Delivery $--- U Extra Services&Fees(check box,add fee as a ❑Adult Sin a Po9Utlaik appropriate) Q g ature Required $—'--"'—�— urn Receipt(hardcopy) $ Here ❑Return Receipt❑Adult Signature Restricted Delivery$--'— __ 0 pt(electronic) $ Q Postage ❑Certified Mail Restricted Delivery $ Postmark i `%/ p $ C f\ ) I 0 ❑Adult Signature Required $ Here p rt �r / ❑Adult Signature Restricted Delivery$ $ 0 Post e J r n t 14 BARBERR JOSEPH K&JOANNA T p T \ 10 p S, 14 BARBERRY LANE '\ �O<�a�} Iti MARSTONS MILLS.MA $ C. 02648 p SAND SHORES ASSOC INC '�T ru BOX 342 �Y s MARSTONS MILLS,MA 02648 ,G' • t ' �1 ............... ....................... Obw. ........................................................I 1 7- Zap - -- ------------ :.• , ,- a �£ P I t� x p Certified Mail Feea� ,( 6 i 4• 'j ( n 7 : cp $ rj ,b Y L^6a Certified Mail Fee Q' Extra Services C3 &Fees(check box, as ` ❑Return Receipt add fee P slec copy) $ appropriate) $ ❑Return Receipt(elec - ," Q-• Extra Services&Fees check box,add fee as appropriate) p ironic) tRf $ _ ❑Return Receipt(hardcopy) $ p ❑Certified Mail Restricted Delivery $��— .e - m6ric r� ❑Return Receipt(electronic) $ pAs ark p ❑Adult Signature Required ❑Certified Mail Restricted Delivery $ ❑Adult Signature Rasii,cted Delivery$�"- - _ j•• 1Here p Postage Q El Signature Required $ -- p ❑Adult Signature Restricted Deli 0 $ O Postage C3 Total Post \ \y _ Q Sent To C RK. C� ollLL -� Tot �� ` �1 I11 HERTHA B&ROONEY,JAMES E J $ Q Siieeiairo%ROONEY.JAMES E O Se'DEROSIER.ROGER&CELESTE M M1 251 LAKESIDE DR ____ ru 'SW%DEROSIER.ROGER&CELESTE TRS city sta'teMARSTONS MILLS.MA 02648 295 LAKESIDE DRIVE • ,------ �` �;I MARSTONS MILLS.MA 02648 -------------- O Q Certified '� !q f u° Mai)Fee t cp $ Extra Services t � ❑Return Receip(ha dcocp)kbox,'add/ea as a co ORetumReceipt ate $�` +�\ ❑Certified ( c£ronic) ❑Atlult Signature estdcta Delivery $��_ QAdult Si Required $'—� \,• Postmark nature Restricted D �j' Here p Postage elivery$,�'�—� I BOLTON.WILLIgNI "\`I 'd ����. SANDRA 285 FAKES' E DR REALTY TRUST T .� MARST ESI E DR TRUST RS MILLS.MA 02648 ................. ' y • • 1 © Complete items 1,2,and 3. A. Signature is Print your name and address on the reverse so that we can return the card to you. X ❑Agent 0 attach this card to the back of the mailpiece, ���,,'celv�dbyPrj� r 5' Q Addressee cr on the front if space permits. B. calvedted Nam � C. Date of Delivery 1. Article Addressed to: - D. Is delivery address different from item 1? ❑Yes If YES,enter delivery address below: ❑No DEROSIER.ROGER&CELESTE M VV \o %GEROSIER.ROGER&CELESTE TRS 295 LAKESIDE DRIVE MARSTONS MILLS.MA 02648 O J� gg III I'III'I IIII III I I�IIIII I IIII I I I II I II II II III 3. Service Type O Priority Mail Express®O Adult Signature I J141glstered Mall- O Cer it Signature Restricted Delivery ❑Re Istered Mail Restricted 9590 9402 6257 0265 0727 63 0 Certified Mtified ail Restricted Delivery 0 Delivery natre ConfirmatonTm 2. Article Number ❑Collect on Delivery ❑Signature Confirmation (transfer from service label) 0 Collect on Delivery Restricted Delivery Restricted Delivery 7020 0640 0001 9808 1077 ""Rd Mail id Mail Restricted Delivery PS Form 3811,July 2020 PSN 7530-02-000-9053 Domestic Return Receipt P i^5� i DATE: 2/11 /02---- PROPERTY ADDRESS: 2-61 Lakeside Drive - --------------------- Marsto -------- ------- ------- ------------------------ On the above date, I Inspected the septic system at t 9:BARNSTABLE ddr ss. This system consists of the following: 1 . 1 -1 000 gallon septic tank. MAR 2 . 1 -Distribution box, 3 . 1 -4 'X 10J leaching pit. TOWN OFHEAL Based on my Inspection, I certify the following conditions: 4 . This is a title five septic system. ( 78.. Code ) 5. The septic system is in. proper working -order . at the present. ( Dry at time of inspection. ) 6 . Pit is under the `tool shed. 7. Cut out flooring and installed trap door.This gives a service access.- SIGNATURE Name:_J_p_ Macomber �)r�______ Company: Joseph-P. Macomber-& Son , Inc . Address: Box 66 -------------------- _-Centerville , Ma ._02632-0066 Phone: 508-775-3338 I THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY gr JOSEPH P. MACOMBER & SON, INC. Tan ks-Cesspools-LeachfleIds Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775.3338 775.6412 • ♦ �--\ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAJRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 261 Lakeside Drive Marstons Mills ass. Owner's Name: Robert &Nula Dykes Owner's Address: T 507 Venice F on a 34285 Date of Inspectlon:2/1 1 /02 Name of Inspector: (please print) Joseph P.Macomber Jr. Company Name: J.P.Macom er & Son Ind Mailing Address: Box 66 Centerville,Mass. 02632 Telephone Number: 50R-775—'V1'A8 CERTIFICATION STATEMENT I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: Passes _ Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fa 151 f Inspector's Signature: 0� Date: l`ate The system inspector shall s mit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and u"iider the conditions of use at that time..Tbis inspection does not-address-how the system will perform in the future under the same.or differeot conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 261 Lakeside Drive Mars tons i s, ass. Owner: Robert & Nu la Dykes— Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: A b have not found any information hich indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic-system is in pro er working order at the present time. B. System Conditionally Passes: A10 One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. ,00 The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. 'A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: AIP Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: a The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 261 Lakeside Drive Marstons Mills,Mass. Owner: Robert & Nula D kes Date of Inspection: 2 11 02 C. Further Evaluation is Required by the Board of Health: A16 Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health,safety and the environment: ,0 Cesspool or privy is within 50 feet of a surface water 100 Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: /fb 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. ,fLd The system has a septic tank and SAS and the SAS is within a Zone I 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 !Z=, feet or more from a private water supple well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 261 Lakeside Drive Marstons Mills,Mass. Owner: Robert & Nula Dykes Date of Inspection: 2/1 1 /0 2 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No / _ �,�ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool s� Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or logged SAS or cesspool Static liquid level in the distribution box above out invert due to an overloaded or clogged SAS or cesspool is'4flgf Liquid depth inressped 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 0 _ y portion of the SAS,cesspool or privy is below high ground water elevation. �y portion of cesspool or privy is within ]00 feet of a surface water supply or tributary to a surface water supply. OAny y portion of a cesspool or privy is within a Zone 1 of a public well. y portion of a cesspool or privy is within 50 feet of a private water supply well.portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303.therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large 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. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes 1/the ./ system is within 400 feet of a surface drinking water supply — Y the system is within 200 feet of a tributary to a surface drinking water supply _ Zthe system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well T If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 1 1 s OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 261 Lakeside Drive Marstons Mi11s,Mass. Owner:Robert & Nula Dykes Date of Inspection: 2/1 1 /0 2 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes Now ✓ Pumping information was provided by the owner, occupant, or Board of Health XWere any of the system components pumped out in the previous two weeks ? -ZHas the system received normal flows in the previous two week period ? Have large volumes of water been introduced to the system recently or as part of this inspection ? Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out ? Were all system components,excluding the SAS. located on site? ..; . .. Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition _0�1of the affles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ? _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yv no Existing information. For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)J 5 Page 6 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:261 Lakeside Drive mars tons i s, ass. Owner: Robert & Nuia y es Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms): Number of current residents: 0 Does residence have a garbage grinder(yes or no): -Ve) Is laundry on a separate sewage system(yes or no) [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no): Water meter readings, if available(last 2 years usage(gpd)): 2 0 0 0—1 3 6. 9 9 ga 11 on s P.D. 5 0. 0 0 0 0 Sump pump(yes or no): 4 2001 =26000 gallons=71 .24 GPD Last date of occupancy: p/ C O M M E R C IA L/IND U S TRIA L Type of establishment: 4Ulf Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no):&y Non-sanitary waste discharged to the Title 5 system(yes or no):,Vd Water meter readings, if available: AIX Last date of occupancy/use: OTHER(describe): A�14 GENERAL INFORMATION Pumping Records j Source of information: ,( Was system pumped as part of the inspection(yes o no): If yes, volume pumped: O allons--How was quantity pumped determined? Reason for pumping: TY� OF SYSTEM r Septic tank, distribution box,soil absorption system Ale Single cesspool J4Overflow 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 systqm owner) _424)T ight tank 6V Attach a copy of the DEP approval 4UG they(describe): A proxim to a e of all com onents date installed if knownland source of informat'o Were sewage odors detected when arriving at the site(yes or no): 6 Page 7 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:261 Lakside Drive Marstons Mills,Mass. Owner:Robert & Nula Dykes Date of Inspection:2/11 /02 BUILDING SEWER (locate on site plan) Depth below glade: .Materials of construction. ca t tort 40 PVC mother(explain): Distance from private water supply well or suction line: Alt- Comments (on condition of jousts, venting, evidence of leakage, etc.): Joints appear tight.No evidence of leakage.The system is vented through the house vent. SEPTIC TANK: Azoocate on site plan) Depth below glade: lf Material of construction: /�cancrete 4?,, netal 4kfiberglassyyDolyethylene 4 other(explain) .f)> If tank is metal list age: Is age confirmed by a Certificate of Compliance (yes or no):/1/29 (attach a copy of certificate) ,r Dimensions: Sludge depth: J Distance from top of luege to bottom of outlet tee or baffle: Scum thickness: ?.t�.�� Distance 5om top of scum to !op of outlet tee or baffle: Distance fiom bonom of scum to bonom of outlet'tee or baffle: How were dimensions dvertrined: AbO.W1194 Comments (on pumping recoTmendations, inlet and outlet tee or baffle condition,-structural integriry, liquid levels as related to outlet inven, evidence of leakage, etc_): Pump the septic: tank, every 2=3. years.The inlet & outlet tees are in' place,'The tank is 'structurailX -sound and shows no eviden of leakage. GREASE TRAP4k4locate on site plan) Depth below grade: &/9 Material of construction4?e concrete4&metal�9 fiberglass�✓jDolyethylenW,* other (explain): AAA Durensions: 160 Scum thickness: t401 Distance from top of scum to top of outlet tee or baffle: Distance from bonom of scum to bonom of outlet tee or baffle: Date of last pumping: B�O Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integriry, liquid levels as related to outlet invert, evi,'er.ce of leakage, etc.): Grease trap is not present- 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:261 Lakeside Drive Marstons Mills,Mass. Owner: Robert & Nula Dykes Date of Inspection: 2/1 1 /0 2 TIGHT or HOLDING TANK(b,&,(tank must be pumped at time of inspection)(]ocate on site plan) Depth below grade:_A Material of construction:,concrete hW metal VJ _fiberglass dig Aolyethylene�jd2—other(explain): Dimensions: ,lJ� Capacity: gallons Design Flow: 414 gallons/day Alarm present(yes or no):�) Alarm level:*1 Alarm in working order(yes or no): 40 Date of last pumping: A)tI Comments(condition of alarm and float switches,etc.): ; Tight or holding tanks are not present DISTRIBUTION BOX:Zif present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box has one lateral.No evidence of solids carry over.No evidence of leakage into or out of the box PUMP CHAMBER (locate on site plan) Pumps in working order(yes or no): ILO Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): Pump chamber is not present 8 Paze 9 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 261 Lakeside Drive mars tons s, ass. Owner:Robert & Nula Dykes Date of Inspection: 2 1 1 02 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) 1 -4 'X10 ' Precast leaching pit. ( 2 ' of stone ) If SAS not located explain why: Located; See page 10 Type _�/leaching pits, number: L!V X4 0 leaching chambers, number: 0 fit)leaching galleries,number: 8 _4kL leaching trenches,number, length: O d2Q leaching fields,number,dimensions: ,UD overflow cesspool,number: C) innovative/altemative system Type/name of technology: - J Comments (note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): Loamy sand to hnnPV fine Gand.No signs of hydraulic failure or ponding.Soils are dry.Vegetation is normal . The leaching pit is presently dry. CESSPOOLSAW (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n Depth—top of liquid to inlet invert: A,�j Depth of solids layer: '64 Depth of scum laver: Dimensions of cesspool: Materials of construction: 10 Indication of groundwater inflow(yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Cesspools are not present PRIVY4�(locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Privy is not present. 9 Page 10 of I I OFFICLAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:261 Lakeside Drive ars ons i ass. Owocr: Robert & Nula Date of Inspeetioo: 2 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. r 10 JAN-24-200? : 2 :51 PM 7285646. 74d49 508 428 3132 P. 02 TOWN OF BARNSTAUS ^^r Q r y j LOCATION o�W t ��, �1�L. R�y!✓ SEWAGE A►_ VILLAGE S ASSESSOR'S MAP 4 LO ' INSTALLER'S NAME & PHONt NAY..- `�f w SEPTIC TANK CAPACITY LEACHING FACILITY:(type)21 (size) b 0 NO. OF BEDROOMSPRIYATQ WELL OR I WATE _ i nn s� + BUILDER OR OWNER j DATE PERMIT 133UED: 40 DATE COMPLIANCE ISSUED: i i VARIANCE GRANTED: Yes No i I:� I Fz BOG I . Page I 1 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 261 Lakeside Drive Mars tons MiiisMass. Owner: Robert & Nula Dykes Date of Inspection: 2 1 1 02 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water '217 feet Please indicate (check)all methods used to determine the high ground water elevation: Obt ' ed fr stem design plans on record - If checked,date of design plan reviewed: bserved site abutttnfproge bservation hole wit in 150 feej of SAS) ecked with local Board of Health-explain 14,, ram .ufi A,-"'Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Used: Gahrety & Miller Model. Grondwater level above sea level- Used; USGS Observation well data June 1992 USED; USGS Annual ranges of around water 1PVP1 92_nnn_1 P1 r un Leaching Pit Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method Therefore,the vertical separation distance between the bottom Of the leaching pit and the adjusted groundwater table is 4 feet. 11 +•r.rnA�n.•.7r•T tt1►Ta.R•n1i...s'9.na'.nfnmrlr+ �er/r►*�'11n+fRr\1fa/�r�rt�qrT .T7rrr�-fin+--'..t r TOWN OF Baanstable I30ARD OF HEALTH SUBSURFACE SEHAGF DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION «•Te`1�T•1•:• —T.ti��.�rr�tt+n•ri.Tn lw►Jrs'+rin'7en:rAl r1VTT'.RRtR�T���w1r1RAAAIA'wr� twn► .fir r+-•r•�. �..� -TYPE OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRESS 261 Lakeside Drive Marstons Mills,Mass. ' ASSESSORS MAP, BLOCK AND PARCEL # 102-165 OWNER' s NAME Robert & Nula Dykes PART D - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber Jr. COMPANY NAME Joseph P. Macomber & San Inc COMPANY ADDRESS P.O. Box 66 Centerville Ma 02632 Street Town or Clty State t I P COMPANY TELEPHONE (508 ) 775 - 3338 FAX ( 508 ) 790 - 1 578 m V CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and omplete as of the time of The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . C;�� ne : System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public healLh or the environment as defined in 310 CMR 16 , 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILEll The inspection which I have con t7cted has found that the system fails to ! Protect the public health and the environment in accordance with Title 5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form , "e ZInspector Signature Date ' /A� On 6 copy of this ce ification must be provided to the OWNER, the BUYER where applioable ) and the 130ARD OF HEAL1'll. If the inspection FAILED, the owner or..,op operator shall u* i i P pgrade ' the system within one year of the date of the inspection , unless allowed or required otherwise as provided in 3.10 CMR 16 . 305 . partd .doc TOWN OF BARNSTABLE ''` r,OCATION�' )PAW'Wo, ,D'Klee, SEWAGE # 'Vii LACE eg/ !�13'- ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. G SEPTIC TANK CAPACITY c LEACHING FACILITY: (type) �`' ����� �/�Cs4sj' �ize) NO. OF BEDROOMS BUILDER OR OWNER PERMIT DATE: 71 COMPLIANCE DATE: 19—'zp f"5�/ Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland >0A, 43c aching Facility (If any wetlands exist within 300 fe '��facili Feet Furnished b i '4w• • l Ktlt6 C TOWN OF BARNSTABLE LOC�;T10N !� �, -���L SEWAGE #_`I�t VILLAGE y ASSESSOR'S MAP d LO INSTALLER'S NAME & PHONE NO ��CQ,� SEPTIC TANK CAPACITY � � > � LEACHING FACILITY:(type)�p 1 (size); NO. OF BEDROOMS PRIVATE WELL OR L�WATE BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No �, A= oo ck, 1 'F= 36� '113 No....... _... Fms ........._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE "StablbJ_ A R co o �, Appliration for Dhipaii al Works Tarn i' r�ai�iton�L Application (is her by made for a Permit to Construct ( ) or Repair ( an diva Sew�agepDisposal� System at,lD \ ..... a ��� • _ ... ....- •- - -----•--_----- ---- ---- ---- ------------•-------••--------- -- ••--•-- o�.�ades or I o No. V t - ti L w r Addr ss + -------- ------------- ---- Installer Address d Type of Building Size Lot............................Sq. feet V Dwelling—No. of Bedrooms.___________ ______________Expansion Attic ( ) Garbage Grinder ( ) a`4 Other—T e of Building No. of ersons____________________________ Showers — ( ) YP g --------•---------•--------- P ----------------------------•--•---•-----•--------. ( ) Cafeteria P Other fixtures _____________________ ---------------------------------- ------------._...._..__ Ions. - w Design Flow____________________________________________gallons per person per day. Total daily flow.._.._._.__.______._. gal WSeptic Tank—Liquid capacity___-________gallons Length................ Width................ Diameter................ Depth................ _ x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water...................... 44 Test Pit No. 2________________minutes per inch Depth of.Test Pit---_................ Depth to ground water........................ P4 ---•----•---•----------------•-•-••-•--•--•---------------------•••---------.........----------•••••......................................................­ 0 Description of Soil-•-•.......................................•-•-•------•-•----------•---••--•---......................................................--................................ x c, w x ---------- ----- -- ----------- ------------------ U f Repairs r rations—Answer when applicable . ...... ..... . .. ..._.....__._._ ._ .L — ----- _X ---------:0 N -p--k�-------- jam r am` Agreement: 1 The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Enviro e I Code— undersigned further agrees not to plat the system in operation until a Certificate of Compli bee ue b the board of health. Siged -------- ---- ------- .............. Application et� l Approved BY . . . ............. ............. -- ........ ........ ...... . . ........... 1ef / Application Disapproved for the following reasons- ----- ---------- --- -------------------..........................--.......... ........................................... ...................................................... ..-.. --------------------------—.--...................--'----------.----'------'..................----'------............-----'----'--'---. ............---'Dare--................ j _ 7 Permit No. ....... ....-1---- --- �jl �----------------- Issued -----...g.� . t rNo........ .J.. / FEB............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE App irtt#ion for Bispmal Works Tort t Uri#ins exuti# Application is hereby made for a Permit to Construct ( ) or Repair an dividu Sewage Disposal System at• 1 r (D... � �Y ....:. �j Ma . ........ ............................... ............. _-~- o o ddres r I o No. Y er Addre InstallerAddress-� Type of Building Size Lot............................Sq. feet �-, Dwelling—No. of Bedrooms.............3..........._.._.__........Expansion Attic ( ) Garbage Grinder ( ) Wa Other—Type of Buildin No. of persons............................ Showers YP g --------•-----------------•- P ( ) — Cafeteria ( ) dOther fixtures -------•--------------------------------------•------•--•--...-•-•--- ..._.. ..... W Design Fiow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation-Test Results -Performed bY.......................................................................... Date............. ------------------------- Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water....................... 44 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ P+ --•---•-------------------------•------•.......--••-•••--------.....--------..........---•----------......................................................... ODescription of Soil..............................................:.::—.......... - x x --- ------ U —Nature-of Repairs rE rations—Answer when applicable_---u- i:- ,..f2� Z_...... . ............ ------------- _._ n- -----------------• d. - -' �? -_--••-----�C�--\-� - ` ��'-`------- "a Q�{�C!M��',�.. Agreement: IThe undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environ.. e 1 Code— _ e undersigned further agrees not to place the system in operation until a Certificate of Compli been is ue b the board of health. Sign--------- - ---------- n ...... .... -----.G.................-----. .. ..-----e- A��lication Approved BY = _ i.. - 1 /I Application Disapproved for the followingreasons: / ------..............................................�-----------------------------.................................. 1----- ------------------ ........ ------------------- - - ---- --------qj 1. D- PermitNo. ...- ..973---------------- Issued .------.. ` ...�.L... .......Da........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Trr#if ratr of Coxnlalianre THYn'S VER(1FY,-_T-hwv-_die Individual Sewage Disposal System constructed ( ) or Repaired ( ►� ) by --.......-- ..-� � i .-...:.- - - -------------- --------.....-------------------------------------------------- -------------- "In at --------------------2 ------....---- ^a `- �\- J .:�- , - has been installed in accordance with the provisions of TITLE 5 f The Environmental V i ed in .the application for Disposal Works Construction Permit No- ------ -- --- ... . .. .. ....... --,/... .__:.j.1------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BIONST ED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. - .. ..... Inspector ............./----...--.:........... ..�....------_-..`- ----�'...-I---.._.... , ti l DATE- � i . r.�� ,! p THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH G� '. TOWN OF BARNSTABLE No.....` FEE........................ �i��ro�tt�ork� �i #r�r#imr�t rr�i# Permission is hereby granted.._:..tv------- ..........�a \ ...................................................... to Constr.ict ( or Rep�ai�r ( - :Individual Sewage Disposal S stex �( / 9/ ........ f �et �1 Y.. 'ated lJ ll� !.I..... as shown on the application for Disposal `t�orks Construction Pmit No.............. ......... .._. i .............. _ -----------------•------------.....---.Board of Health DATE.........................-•----------�-�----... --------------------------- FORM 36508 HOBBS&WARREN.INC..PUBLISHERS ��