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HomeMy WebLinkAbout0320 LONG POND ROAD - Health 320 Long Pond Road, Marstons Mills A=029 - 029 i� it r 9 i Commonwealth of Massachusetts Title 5 Official Inspection Form �} Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 320 Long Pond Rd Property Address Zabusky Owner Owner's Name information is required for every Marstons Mills MA 02648 10/2/20 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. Inspector Information 51* f 0(q Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 City/Town State Zip Code 508.272.6433 13010 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 10/2/20 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 320 Long Pond Rd Property Address Zabusky Owner information is Owner's Name , required for every Marstons Mills MA 02648 10/2/20 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 320 Long Pond Rd � Property Address Zabusky Owner information is Owner's Name required for every Marstons Mills MA 02648 10/2/20 page. CityrFown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ElY ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 320 Long Pond Rd Property Address Zabusky inform Owneration is Owner's Name required for every Marstons Mills MA 02648 10/2/20 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4 System Failure Criteria Applicable to All Systems: Y pp Y You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 320 Long Pond Rd Property Address Zabusky Owner information is Owner's Name required for every Marstons Mills MA 02648 10/2/20 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. = ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes • No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 c Commonwealth of Massachusetts �e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 320 Long Pond Rd Property Address Zabusky inforrn Owneration is Owner's Name required for every Marstons Mills MA 02648 10/2/20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for aU inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 320 Long Pond Rd Property Address Zabusky Owner information is Owner's Name required for every Marstons Mills MA 02648 10/2/20 page. Cityfrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description:. 3 bedroom permit and plan on file at BOH Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d well water 9 ( y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Occupied Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �o 320 Long Pond Rd Property Address Zabusky Owner information is Owner's Name required for every Marstons Mills MA 02648 10/2/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Pumped 2017 per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 320 Long Pond Rd Property Address Zabusky Owner information is Owner's Name required for every Marstons Mills MA 02648 10/2/20 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1991 per BOH record Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 5. Building Sewer(locate on site plan): 6' Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10'feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev.7/26/2018 Tdle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form j/ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 320 Long Pond Rd Property Address Zabusky inform Owneration is Owners Name required for every Marstons Mills MA 02648 10/2/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) 6. Septic Tank(locate on site plan): 5'6" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) H-10 septic tank appears to be structurally sound, inlet and outlet covers to 12"of grade If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500g Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle >12" Scum thickness trace-1/2" Distance from top of scum to top of outlet tee or baffle >2" Distance from bottom of scum to bottom of outlet tee or baffle >2" How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping suggested every 3yrs to prolong the life of the system t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 320 Long Pond Rd Property Address zabusky Owner information is Owner's Name required for every Marstons Mills MA 02648 10/2/20 page. City(rown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments u 320 Long Pond Rd Property Address Zabusky Owner information is Owner's Name required for every Marstons Mills MA 02648 10/2/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box was video inspected no adverse conditions observed t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 320 Long Pond Rd Property Address Zabusky Owner information is Owner's Name required for every Marstons Mills MA 02648 10/2/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 320 Long Pond Rd Property Address Zabusky Owner information is Owner's Name required for every Marstons Mills MA 02648 10/2/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Pit"C" as depicted on pg. 16 is in hydraulic failure with effluent to the bottom of the invert, pit"D" has 6"of effluent at this time, sidewalls are clean above the current level, no indication of past hydraulic failure, it is 7'6" below grade, cover raised to 6" 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts ro Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 320 Long Pond Rd Property Address Zabusky Owner information is Owner's Name required for every Marstons Mills MA 02648 10/2/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts �a (o Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 320 Long Pond Rd Property Address Zabusky inform Owneration is Owner's Name required for every Marstons Mills MA 02648 10/2/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Z 1 tn C�_ '37b C 433 S(gx t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts ,9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 320 Long Pond Rd Property Address Zabusky inform Owneration is Owner's Name required for every Marstons Mills MA 02648 10/2/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high round water: >12 p g g feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 1989 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: 4' seperation per 1991 compliance ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: TOPO mapping shows the site at 86'msl and nearby surface water at 50'msl You must describe how you established the high ground water elevation: See above Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 I i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments v 320 Long Pond Rd Property Address Zabusky inform Owneration is Owner's Name required for every Marstons Mills MA 02648 10/2/20 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification.,: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria) and 6(Checklist)completed ® D. System information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included i t5insp,doc•rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 18 of 18 r c , Commonwealth of Massachusetts N F Title 5 Official Inspection Fo Ld/-� Subsurface Sewage Disposal System Form -Not for Voluntary 1 320 Long Pond Rd , � Property Address I`I1 Zabusky �i" Owner Owner's Name information is required for every Marstons Mills MA 0264� Op page. Cityrrown State Zip Coj D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(act al): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: 3 bedroom permit and plan on file at BOH � 3 -(� i�A X J Prl_ Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal.use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d well water 9 ( Y 9 (gp ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Occupied Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 ,�of.aa'� +o��. CERTIFICATE OF ANALYSIS Page: 1 Barnstable County Health Laboratory 13�sst��ysc�/ Report Prepared For: Report Dated: 6/6/2008 Howard Zabusky Order No.: G0846625 320 Long Pond Road Marstons Mills, MA 02648 Laboratory ID#: 0846625-01 Description: Water-Drinking Water Sample#: Sampling Location: 320 Long Pond Rd.Marstons Mills,MA Collected: 6/6/2008 Collected by: H.Zabusky Map 029 Parcel 029 Received: 6/6/2008 Test Parameters ITEM RESULT UNITS RL MCL Method# Tested pH 6.8 pH-units 0 SM 4500 H-B 6/6/2008 Water sample meets the recommended limits for drinking water of all the above tested parameters. T Approved By: (Lab D' ctor) � I CC 0— d C:, m N c� o a ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 }� CERTIFICATE OF ANALYSIS Page: 1 L in fi Barnstable County Health Laboratory-rrs�CHus"� Report Dated: 6/16/2004 RECEIVED Report Prepared For: Order o.: iLT15ftG4 Jennifer Visco uI`I 1 388 Old Oyster Rd. TOWN OF BARNSTABLE Cotuit, MA 02635 HEALTH DEPT. Laboratory ED#: 0425606-01 Description: Water-Drinking Water Sample#: 25606 Sampling Location 320 Long Pond Marstons Mills MA Collected: 6/10/2004 Collected by: J-Visco Received: 6/10/2004 i Routine ITEM RESULT UNITS RL MCL Method# Tested LAB: IC Lab Nitrates 2.1 mg/L 0.1 10 EPA 300.0 6/11/2004 LAB: Metals Copper 0.3 mg/L 0.1 1.3 SM 3111B 6/14/2004 Iron BRL mg/L 0.1 0.3 SM 3111B 6/14/2004 Sodium 17 mg/L 1.0 20 SM 3111B 6/14/2004 LAB: Microbiology Total Coliform Absent P/A 0 Absent 309 6/10/2004 LAB: Physical Chemistry Conductance 130 umohs/cm 1 EPA 120.1 6/10/2004 pH 6.1 pH-units 0 EPA 150.1 6/10/2004 Water sample meets the recommended limits for drinking water of all the above tested parameters. / Approved By: %�' ( Director) RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 of DATE7-1 S PER: • BARMABIL _ `"" Town of Barnstable t679• �� REC. BY r/ Board of Health e36�Main Street,Hyannis MA 02601 Office: 508-79-6265 Susan 0.Rask,R.S. FAX: 508-79,0-6304 r ., 2 IF Sumner Kaufman,M.S.P.H. Ralph A.Murphy,M.D. VARIANCE REQUEST FORM_ LOCATION Property Address: Q. 4--dVa PoNA Assessor's Map and Parcel Number: Size of Lot: Wetlands Within 300 Ft. Yes Subdivision Name: No Business Name: APPLICANT CONTACT PERSON Name: � T�4"� Name: `k Address: Address: t " ", a Ph on(5 a'-'7 Phone: Vk FA h02 I 4aO " c� -F(a C% FAX: VARIANCE R (sl Reg.)s•) (May attach If m space need ) ,v. ON lC tecklist(to be completed by office staff-person receiving variance request application) Four(4)copies of plan submitted(including septic system plans and/or restaurant floor plans) Applicant understands that the abutters must be notified 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 submitted(for grease trap variances only) Variance request application fee collected(no fee for lifeguard modification renewals,grease trap variance renewals(same owner/leasee onlyl,outside dining variance renewals(same ownedleasee only),and variances to repair failed sewage disposal systems(only if no expansion to the building pmpoaedn Variance request submitted at least IS days prior to meeting date VARIANCE APPROVED Susan G.Rask,R.S.,Chairman NOT APPROVED Sumner Kaufman,M.S.P.H. REASON FOR DISAPPROVAL Ralph A.Murphy,M.D. Q:/WP/VARIREQ - tiJi23i1994 111:21 FP.OM Town of Barnstable TO J 94205762,P.02 TOWN OF BARNSTABLE BUILDING DEPT. 0 .DEB 2 31194 E c E I v E .0. 8,94 "Per 4.4 k%c �htXPt COO AWMV- �vP ��pQ.Maes ) �r lu u t1� 0 L 'Cau ati-w- 0 V V .j COOIL.�.c w) • A ��Qu1OM0m7- NOT 1v CC01"i /23i1994 11:21 FROM Town of Barnstable TO 94205752,P.02 ' . j r'd R- -�'y-L.. / t--'t`' i.TC-i�-��► L TOWN OF BARNSTABLE BUILDING DEPT. p M 2 3 '199 E c E I v .0. .8,94 1 N 16 SOW 3 c.e�P &Atrr...r r F cot �► 'P e: 1.4006C N r V COO AaTC - ' o* � �11X'� dd C�O�Maes ) QC �f 0 0 „ F{{ a v G a d v � C;:o1C«,..c..� � H • A ��lK.C.1- v gay 4 �c.00Q tic) . 20' qu t 0 ME�+'r No 'W t'C"C-j J TOWN OF BARNSTABLE 1/ o/Zo �OaG AIM RVKE) ryQ LUCA?1ON SEWAGE # 91- c3 f 0 VILLAGE 1�4;ILA ASSESSOR'S MAP & LOT�;Z INSTALLER'S NAME & PHONE NO. iY►21�ie' . � SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) 16&0 cA,&j V NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER ____4*,,,,4 Z DATE PERMIT ISSUED: n _►�(n 91 DATE COMPLIANCE ISSUED: - 71 VARIANCE GRANTED: Yes No I/ r I� � ay.�,_ ,q..� ^ � � � ,. � � � � � y� �� � No......q./._._�/0 = FES. 1 .. ..._... ......._ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH U TOWN OF BARNSTABLE Appliration for Diipu, al Works Tomitrnrttnn Errant Application,i hereby mad fo a qP *t to Co struct ( ) or Repair ( ) an Individual Sewage Disposal Systemat: 3-® 1a .....----- o. 116 1Q...... ..Ll1 `/' v- - rot+N . sflrls s'... --------------------• .. Owner Address W Installer Address d Type of Building Size Lot............................Sq. feet V Dwelling—No. of Bedrooms........ _...............................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons____________________________ Showers — Cafeteria a' Other fixtures ____________________________ _ W Design Flow.............. ......................gallons per person per day. Total da�il flow........... ...................galJons. WSeptic Tank—Liquid capacityl -gallons Length__1 O_V__ Width__.._ .___ Diameter________________ Depth...... ._0 L� x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................Sq. ft./� Seepage Pit No_______ _________ Diameter........In—_._. Depth below inlet......... Total leaching area_ A.scf-€t-�qr � Other Distribution box ( Dosing tank (. ) II ff W Percolation Test Results Performed by-----LA :e, f�_____________________i Date... -_� ."! _ __________.... a Test Pit No. 1_ '____minutes per inch Depth of Test Pit_._ ._________ Depth to ground water___ __ _________- G14 Test Pit No. 2...i4n:jk_.minutes per inch Depth of.Test Pit____J.�..j.'..... Depth to ground water.....kN."...- 9 - ........-•-------------------• ...:................................................................................................................. ODescription of Soil---------------�. .......��.: ......................----------------------•-------------•---------=-------------------•-----......-•-----• x V -----------••------ --------------------------------------------- -•------------------------------------ -------- --------------------------------------------- •------ ---------------- W U Nature of Repairs or Alterations=Answer when applicable............................................................................................... ..------•----------------------------------•--------•------•---._...-----------------......-----------------...--------------------------------------.................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed -..---...- - to Application Approved By -- -.-. . . . . ... ........ .. ---.-..-.- ...-. t-----.----- --.-.-- -.....................-........ . ..� to ...---..... Application Disapproved for the following reasons- --------------------- ------- ------ - ---------------------------------- --- --------------- ----------- ----- / Date Permit No. t '�. '76 ---. .---- Issued .---.-- (J ......... .... ....-'--- .--�..--.--...-.-.--.---- 1 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Di"vs al Works Tomitrurtinn ramit Application is,�by ma 0 P : nit,�to�ruct ( ) or Repair ( ) an Individual Sewage Disposal System at: , ! ��(J : ---..................................................... QSTI 'j _.._I Gar,.......-...I......----------.....................----------................. LT ion- ddress �y� or Lot N .. �.. / 'I'_... $u':EK1-� v C/= ! Y WOwner Address a ........................................................ > Installer Address Type of Building Size Lot............................Sq. feet I—, Dwelling—No. of Bedrooms........3..._....._•....................Expansion Attic ( ) Garbage Grinder ( ) a ,. Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ----------------- -------- Design Flow...............5.r'_'_......................gallons per person pert day. Total daily flow..........333�...._..._......_._.gall ns. t 1° t t WSeptic Tank—Liquid capacity_l .gallons Length___(_0..f/�� Width.... .. ��. Diameter______________ Depth...... ..D-. y Disposal Trench—No..................... Width._.................... Total Length___._._.._______.___ Total leaching area.................... ft. p Seepage Pit No.......`2--------- Diameter.........t_5�.1.._.. Depth below inlet.._..._."...... Total leaching area...�.(_�.!k.sq:i;. � Z Other Distribution box (� Dosing tank ( ) aPercolation Test Results. Performed by.....L?!4---t--- v��?!.................................. Date....2-.1L ......--.... Test Pit No. L. 6 Z....minutes per inch Depth of Test Pit.... `�_....... Depth to ground water•-_ _____________. 44 Test Pit No. 2---L-2.minutes per inch Depth of Test Pit----- ------- Depth to ground water--__------- ----•--•--•-------------------- ••-•--------••---••-•-------•-•---....-•••-----......------......-----------------'--•----.......----•---...----.-•--- O Description of Soil................ ..... � _ . x -------•------------------------------------------------------------------------------------------ w U Nature of Repairs or Alterations—Answer when applicable._____........................•._._.....__._.................................__................. ,. . ----------------------------------------------•------------•-----------------------.......----•--------•.....-••---------•--•---••-•-----------------•-•••••----------•------------------........_--•••. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed ...... ... - �' -=------------------------- Application Approved BY ? ����� -----------...................................-------------------- r� ' `�/J w D are Application Disapproved for the following reasons: . .. . ..... .......-- ... ,....... ....a - te.................. Date Permit No. ✓-3--- ...... ........ Issued .. 1 ----- .....................-- Dace 7- ..--------------- - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Certifi a e of Tontlatia ce THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by ---- --------------- Installer i at ........... '.. D... ... ........ .............................. has been installed in accordance with the prov dons of TITLE 5 he S� t onmental Code as described in the application for Disposal Works Constructs Permit No. .......Z.j' �g��v.... dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTI , SAT FACTORY. `DATE.. .......................------------------- Inspector ....................... YO ..---.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No.... ... ......v.... FEE........ Permission is Pereby granted......................---••----•-••-•--•-••--.---•-•--•••----•-------•................•---••- to Construe or e atr an dIn,ividual e r e Dis,oS stemP ( a P Y mat No. r 1- fi�"� ' •- ----'-s.-0-�------ ...... A � as shown on the application for Disposal r Permit q/ 4 pp posal Works ks Construction Per t No. l.___._�__,�Dated_.._._�l_S�!..�.....r...�_.... •----•-•-----•----------•--------- .................................................................... ---...----••..............•-•---•--••-•---•----............................... Board of Health DATE_ - FORM 36508 HOBBS}WARREN.INC..PUBLISHERS l lee lJ ,r 1-141 7 of. • 3l , t 2 Pi 5 . i Nm D 'AC aw s w / Y rP �p yMftT +. R n 6/16/2020 ShowAsbuilt(1700X2800) TOWN OF A NS�ABLE N� / LUCA:'ION SEWAGE 9 F1- 378 VILLAGE An nls 14 lf,e ASSESSOR'S MAP G LOT{ 9 u )-� INSTALLER'S NAME G PHONE NO, fim a r d IlA SEPTIC TANK CAPACITY /SOO LEACHING FACILITY:(tnm) Z (size) NO.OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER , ,a DATE PERMIT ISSUED: 91 DATE COMPLIANCE ISSUED; - �I VARIANCE GRANTED: Yes No L/ a "p I https://itsqldb.town.barnstable.ma.us:8431/Home/ShowAsbuilt?mp=029029&sq=1 1/1 , , w,l4wm»1/�eY+Srt•,.Y•NAAW�. 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