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HomeMy WebLinkAbout0169 MARQUAND DRIVE - Health r 169 MARQUAND"D{Nvf,,'� MARSTONS MILLS ` - - - - - - A = 077 037 002 1 1 i 0-7 ? -03-7-bow Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y I�CIL Property Address Owner Owners Name informat�ion is \ _ i ( -1 i required for every - ID 9M.f y 1�'I � 1`� page. City/Town State Zip Code Date of Inspection W m Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information / filling out forms sJ �/00 on the computer, use only the tab 1. Inspector: key to move your cursor-do not Chad Hathaway use the return Name of Inspector key. H.P.S. Company Name P.O.Box 151, Company Address Forestdale Ma 02644 City/Town State Zip Code 774-274-2581 12866 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ,><Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspector's Sign at Date The system inspector shall submi copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ��I have not found any information which indicates that any of the failure criteria described 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: T� 13 System Conditional) Passes: Y Y ❑ 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): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments GM Property Address Owner Owner's Name information is required for every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 L _ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4M Property Address Owner Owner's Name information is required for every page. City1rown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply we I. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ -N Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ElDischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ -E] Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M Property Address Owner Owner's Name information is required for every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ `❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ~[�]' Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ � The system is a cesspool serving a facility with a design flow of 2000gpd- 1 0,000g pd. ❑ .[S The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4 M Property Address Owner Owner's Name information is required for every page. CitylTown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ Q 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? ❑ I Have large volumes of water been introduced to the system recently or as part of this inspection? -,,&L ❑ 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? INq ❑ 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? Nq ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: �© ❑ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): G— Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins•3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments G„M Property Address Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes , No 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 years usage(gpd)): Detail: o C,.�o Sump pump? ❑ YesN No Last date of occupancy: Date e" Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203); gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M Property Address Owner Owner's Name information is required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of 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): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate•on site plan): f �il Depth below grade: feet Material of construction: ❑ cast iron W40 PVC ❑ other(explain). Distance from private water supply well or suction line: h feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: 'concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: ' 1j Sludge depth: . t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owners Name information is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle �\! Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? tape and sludge judge Comments(on pumping recommendations; inlet and outlet tee or baffle condition, structural integrity, liquid.levels as related to outlet invert, evidence of leakage, etc.): pump every 2-3 years as maint. to protect leaching 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments oM Property Address Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments GM Property Address Owner Owner's Name information is required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): i 0 c�rr-7 ��iJ��-� Y V� �7y s��Ja _ Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: T 6 t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17 ( Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M Property Address Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: i ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 'G M Property Address Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M Property Address Owner Owner's Name information is required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 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 0 6;�A a A$3 CI 5 S� �s! JIG t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments GM Property Address Owner Owners Name information is required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells r Estimated depth to high ground water: 90 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers_(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: r Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked Inspection Summary D (System Failure Criteria Applicable to All Systems)completed System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 3 �— COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION „„AFC PARCEL : LOT TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION C) Property Address: 169 Marquand Drive -� Marstons Mills, MA 02648 Owner's Name: Susan McCarty < `n Owner's Address: v 03 o � Date of Inspection: May 5, 2004 cdn r Name of Inspector: (Please Print) James M Ford o co Company Name: James M. Ford or% r Mailing Address: P.O. Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience 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 urther Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: May 12, 2004 The system inspector shall subr y of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 f Page 2 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 169 Marquand Drive Marstons Mills, MA Owner: Susan McCarty Date of Inspection: May 5, 2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health, will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ` ND explain: 2 Page 3 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:p rty 169 Marquand Drive Marstons Mills, MA Owner: Susan McCarty Date of Inspection: May 5, 2004 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of I 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 169 Marquand Drive Marstons Mills. MA Owner: Susan McCarty Date of Inspection: May 5. 2004 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA)or a mapped Zone 11 of a public water supply well 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 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 169 Marquand Drive Marstons Mills, MA Owner: Susan McCarty Date of Inspection: May 5, 2004 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ _ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ _ Was the facility or dwelling inspected for signs of sewage back up? ✓ _ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS, located on site? ✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)]. 5 Page 6 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 169 Marquand Drive Marstons Mills, MA Owner: Susan McCarty Date of Inspection: May 5, 2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 6 Number of bedrooms(actual): 6 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660 Number of current residents: 2 Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes or no): n1a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed approximately 18 years ago-per owner Were sewage odors detected when arriving at the site(yes or no): No 6 r Page 7 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 169 Marpuand Drive Marstons Mills, MA Owner: Susan McCarty Date of Inspection: May 5, 2004 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 32" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1500 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" i Scum thickness: 10" Distance from top of scum to top of outlet tee or baffle: 4" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage. Recommend pumping. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 169 Marguand Drive Marstons Mills, MA Owner: Susan McCarty Date of Inspection: May 5, 2004 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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.): The D-box appeared to be level. No solids were present. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 169 Marpuand Drive Marston Mills, MA Owner: Susan McCarty Date of Inspection: May S, 2004 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 2- 6'x 6'(1000Qal.) leaching chambers,number: leaching galleries, number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): There did not appear to be any signs offailure. The bottom to grade was approximately 10. A video camera was used to inspect the leach pits. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 s Page 10 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 169 Marguand Drive Marstons Mills, MA Owner: Susan McCarty Date of Inspection: May 5, 2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Q I Q I�� A a � a y3 a 3 3 ! "Q 39 y s9 sS- y 10 • Page 11 of l l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 169 Marguand Drive Marstons Mills, MA Owner: Susan McCarty Date of Inspection: May 5, 2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25 +/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: Topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using a Barnstable topographic map and water contours map the maps were showinapproximately 25'+/-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 ASSESSORS MAP 1-3kPARCEL NO• No. -- - Fee----- ---- -------- L� BOARD OF HEALTH TOWN OF BARNSTABLE wo 21ppYicationjorlVei7), AA11ter n5truct ion Permit Appl'c�,tlo is hereby made fora ermit to Construct ( ( ), or Repair ( )an individual Well at: Location — Address Assessors Map and Parcel --Owner-- — -- ---------Address ----- Installer — Driller Address Type of Building Dwelling ----- -- _----------- Other - Type of Building-=---- ------- No. of Persons-- IV -------- Type of Well—, —eK --- Capacity----------------------- Purpose of Well---- --- --- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation un ' ertificat o liance has been issued by the Board of Health. Sig ned d --'`� g -- date Application Approved By 6/ (�7 - ----- date Application Disapproved for the following reasons: _— ---date -- Permit No. — Issued - L--date e—�--- ---------- BOARD OF HEALTH TOWN OF BARNSTABLE Certificate ®f Compliance THIS IS T R�TIFF.Y, That the Individual Well Constructed ( t Altered ( ), or Repaired ( ) by�/�C�—_mod Installer at_ has been installed in accordance with the provisions of the Town of Barnstable Bo rd of Health Private Well Protection Regulation as described in the application for Well Construction Permit Nouw ated---- ---- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE--- - -- Inspector-------- - —_---------—-- OJ7-00,Q-, No. - ----�- Fee---- -------------- BOARD OF HEALTH TOWN OF BARNSTABLE ZppYicat ion-forVefr �Con5tructionPermit 95Jo�5 . M� rw A Is hereby made for a permit to Construct ( ), Alter ( ), or Repair ( )an individual Well at. Location — Address Assessors Map and Farcel Owner-- — --_ —__----- Address ---- — — —r N Installer — Driller Address Type of Building ' Dwelling ---------------__-_ °w�Oth__ Ty..pe of Building---------- r °�1 No. of Per ons------- Type of Well _vx4 --_ Capacity------ —----- — Purpose of Well---- —_—_ r Agreement: � -: ` The undersigned agreesSo install the aforedekc bed�ndividual Z ell in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regul/io�- The undersigned further agrees not to place the well in operation until-a �Verificat o pliance has been issued by the Board of Health. Signed --- -� y date -------- Application Approved By - ( date Application Disapproved for the following reasons: date _-- - Permit No. -- Issued-- - -- --`�-�_--- -----__--___ — date f BOARD OF HEALTH ` TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO C RTIFY,�That the Individual Well Constructed ( 11 Altered ( ), or Repairedby— ( ) Installer athas been installed in accordance with the provisions of the Town of Barnstable Board of i ealth�ated ivate Well Protection 4� Regulation as described in the application for Well Construction Permit No -- -- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE---- _ — Inspector r V 1 BOARD OF HEALTH TOWN OF BARNSTABLE l � Velf Construct ion Permit 1 -�,6 No. $r Fee 2, -------- �..� 1 : Permission is hereby granted ---------------- m a to Construct Al e ( ), or Repair ( ) a I dividual We 1 co' ------ ------------------------------- Street as shown o the a plica ion fqa Pell Construction Permit No.- v 'M -���1��j -____--, Dated- - --T - - - ---------------- - L ------------------ I Board\of Heal DATE th ��� COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS f DEPARTMENT OF ENVIRONMENTAL PROTECTION � ONE WINTER STREET. BOSTON, MA 02108 617.292•5500 'ILLIANI F %k ELD �c Go�cmo: ARGEO PAUL CELLL!CCI DA 3 STD Lt GoNemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A .6 CERTIFICATION Property Address:l 69 Marquand Drive Osterville Address of Owner: 1/0 Date of Inspection: 4/1 6/98 (If different);' �� k►' Name of Inspector:�77 #� I am a DEFappro a syste Inspe eprUrsJAt-to Section 15.340 of Title 5�010 CMR 1SA4> Company Name: J P Macomber & Son Inc- L "'q "p Mailing Address: BOX 66 contervi 1 1 o Mass n'632Oil rqB 8 Telephone Number: 7 5 3338 CERTIFICATION STATEMENT �,`y^ ��.F r Q1 I cen h that I have personally inspected the sewage disposal system at this address and that the int.or�mat on re_:acted txlo s u e u and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper r, a maintenance of on-site sewage disposal systems. The system: asses Conditionally Passes _ Needs Further Evaluation By the local Approving Authority Fads Inspector's Signature: ', Date: The System Inspector s all submit a copy of this inspection report to the Approving Authority within thirty (30) oays of c0mp4e:,n3 tn• 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 a.! s_o- the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to .ne s ver-- o- and copies sent to the buyer, if applicable, and the approving authoriry. INSPECTION SUMMARY: Check A, 8, C, of D. A) SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined ir. 3:0 C -,? ' i 3' Any failure criteria not evaluated are indicated below. COMMENTS. BJ SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repairec 'ne s. completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined-, exD:: r The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Ce- ! ca Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of tr--e 7 ::7 o- the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfdl ,3::cr. r % failure is imminent. The system will pass inspection if the existing septic tank is replaced with a confor-n,n3 s< c '�- as approved by the Board of Health. (revisal 04/75/97) ➢age 1 of 10 DEP on the World Wide Web: hnp itwww.magnet state ma usidep Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORS. PART A CERTIFICATION (COnhnued) ?,open, AOCreWl 69 Marquand Drive Osterville,Mass . O..ner Jessie Spence Dile of InspeC'on 4/1 6/98 -1 SYSTEM CONDITIONALLY PASSES (Continued) , ( kout or high static water level observed In the disttibvt1on Gox is G-e :: Sewage backup or brea _ - neven dlstr but on box. The system will pass pipets) or due to a broken, sealed or u Board of Health) Describe observations: broken pipets) are replaced obstruction is removed dislilbuhon box Is levelled or replaced tiw The system required pumping more than four times a year due to broken or cbs,r ^•cc p =� s e ' ' ,nspe Cl.on .I (with approval of the Board of Health) broken pipets) are replaced Obslrvclion is removeC FURTHER E- ALUATION IS REQUIRED BY THE BOARD OF HLALTH: Cond tons exist whin require funher evaluation by the Board of Health in order to deterr'-e ^r > p 0 C nedllh, wfery and the environment. u SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS •NOT FUNC' rJ"I" '.4'HICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Ajo Cesspool or prrVY is within SO feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a san m.rsn :) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF AP THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND ENVIRONMENT. A) SAS 9 The system has a septic tank and soil absorption system (SAS) and the s 'w :^ n ) 0 'r v,bularY to a surface water supply The system has a septic tank and soil absorption system and the SAS is within d Zone �1 4V The system has a septic tank and soil absorption system and the SAS is —thin 50 1ee� o' i _ The system has a septic tank and soil absorption system and the SAS is less tna•n - pr,vale water supply well. unless a well water analysis for Coliform b3oeria anc '.0 x• e y the well is Iree Irom pollution from that facility and the presence of ammonia nwoge� 3"•_ _ less than 5 ppm Method used to determine distance (approximation no: 3) OTHER SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR-tit PART A CERTIFICATION (continued) Property Address: 169 Marquand Drive Ostervi1 le,Mass. Owner: Jessie Spence Date of Inspection: 4/1 6/98 D) SYSTEM FAILS: You must indicate ewer "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 C:mR 15.303 The b2;i, for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to co-rec' the failure. Yes Nl� Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the disc ipution box above outlet invert due to an overloaded or clogged SAS or cesspoo! _/ Liquid depth in c4upQol is less than 6" below invert or available volume is less than 1/2 day floes. 4/ Required pumping more t n 4 times in the last year NOT due to clogged or obstructed pipe(s) Number of times pumped. 4/ Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply Any portion of a cesspool or privy is within a Zone I of a public well. Any ponion of a cesspool or privy is within 50 feet of a private water supply well. ZAny portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well wi;h no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. EJ LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No AJ/9 the system is within 400 feet of a surface drinking water supply tiq the system is within 200 feet of a tributary to a surface drinking water supply k/ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area • IWPA) or a mapped Zone it of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information (revised 04/25/57) P&g• 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 169 Marquand Drive Osterville,Mass . Owner: Jessie Spence Date of inspection:4/1 6/98 Check if the following have bee) done: You must indicate either "Yes" or "No" as to each of the following: Ye N Pumping inicrmatron was provided by the owner, occupant, or Board of Health. None of the .ystem components have been pumped for at least two weeks and the system has been receiving norn,a' flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of thy: inspection. As built plan, have been obtained and examined Note if they are not available with N/A. The facility o: dwelling was inspected for signs of sewage back-up. The system dDes not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system cc,nponents, wKluding the Soil Absorption System, have been located on the site _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for cond,tion of baffles or tee , material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. — The size and iccau)n of the Soil Absorption System on the site has been determined based on The fauli:v o.,,ner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Sur—ce i risposal System. Existing infer nation. Ex. Plan at B.O.H. Determined in (ne field (if any of the failure criteria related to Part C is at issue, approximation of distance is unaccept.:)le (13.302(3)(b)) (zsvissd 04/25/97) Pag• 4 of 10 I � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 169 Marquand Drive Osterville,Mass . o"nef Jessie Spence Date of Inspection: 4/1 6/98 FLOW CONDITIONS RESIDENTIAL: Design flow.1,76j2 g.p.d./bedroom for S.A.S. Number of bedrooms: f& Number of current residentsU(JC� Garbage grinder (yes or no):1�1 Laundry connected to system (yes or no): °J Seasonal use (yes or no):AXE Water meter readings, if available (last two (2) year usage (gpd): L��� _ i �� �• 0 Sump Pump (yes or no):/14D 6 7'l,rA r. V- Last date of occupancy: YAlkl- COMMERCIAUINDUSTRIAL: Type of establishment: A/A Design flow: 4jll gallons/day Grease trap present: (yes or no)A)—/1 Industrial V,'aste Holding Tank present: (yes or no)&Y Non-sanitary waste discharged to the Title 5 system: (yes or no)d1-114 Water meter readings, if available. A.11? Last date of occupancy:)A OTHER: (Describe) 0 Last date of occupancy: GENERAL INFORMATION PUMPING RECOR S an s ce of information. �r 7 14114% System pumped as part of inspection: (yes or no)XG If yes, volume pumped: :90 allons Reason for pumping: �4a »ten ;0—C16-)IC TYPE OF SYSTEM _Septic tank/distribution box/soil absorption system ,{Cld Single cesspool .IV P Overflow cesspool Privy Shared system (yes or no) (if yes, anach previous inspection records, if any) �! I/A Technology etc. Copy of up to date contract( Chher A� APPROXIMATE AGE of all components, date installed (if known) and source of information: l 2ie:�� Sewage odors detected when arriving at the site: (yes or no) (rwised 04/25/97) Pag• 5 of 10 / SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address169 Marquand Drive Osterville,Mass . Owner: Jessie Spence Date of Inspection: 4/16/98 BUILDING SEWER: (Locate on site plan)Depth below grade w�-+� Material of construction: _ cast iron Y/40 PVC _ other (explain) Distance from water supply well or suction line 1� Diameter Commwts: (condition of joints, v nting, evidence of leakage, etc.( �n 7t; 6 A&Ar T—jo-A V- PEAP 2S SEPTIC TANK:L700Pi )s (locate on site plan) s/ Depth below grade: i� Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age iW Is age confirmed by Certificate of Compliance .41,9 (Yes/No) Dimensions: le G ),otV ZIT i CL:'dQ 5 i7�� Sludge depth:_ Distance from top of sludge to bottom of outlet tee or banle:Q_ Scum thickness:__ Distance from top of scum to top of outlet tee or baffle:_ Distance from bonom of scum to bon of outlet tee or baffle: f How dimensions were determined: Comments: (recommendation for pumping, condit n of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, vidence of leakage, etc.) .10MA2 TALI,, - r` elr GREASE TRAP:&�Ih� (locate on site plan) Depth below grade Material of con struction:4,AconcreteA/LPmetaWAFiberglassNA PulyethyleneaJl9other(explain) 4 - Dimensions: 4- 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:_,d'&q Date of last pumping: Alyt Comments: (recommendation for pumping, condition of inlet and outlet tees or'baffles, depth of liquid level in relation to outlet invert, structural ntegriry, evidence of leakage, etc.) !� is 12)17 (rwised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Properly Address: 169 Margqandf Drive Osterville,Mass . Owner: Date of Inspection: Jessie Spence 4/16/98 SOIL ABSORPTION SYSTEM ;locate on site plan, if possible; excavation not required, but may be approximated by non intrusive metnocsl if not determined to be present, explain: Type leaching pits, number: AA leaching chambers, number: (.l leaching galleries, number: —77 leaching trenches, number,lengih: leaching fields, number, dimensions: overflow cesspool, numbe Alternative system: _ Name of Technology: Zngk Comments: (note condition of soi), signs of hydraulic failure, level of ponding, con i(ion of vegetation, etc.) --- CESSPOOLS: C'�' Rotate on site plan) -'umber and configuration: Depth-top of liquid to inlet inven: R/14 Depth of solids layer AI Depth of scum layer: Dimensions of cesspool: Materials of construction: 9 Indication of groundwater: inflow (cesspool must be pumped as pan of inspection) Comments. (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:�LlG. (locale 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.) Ir•v1•.d 01/15/97) p69• B of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFOR&kATION (continued) Ploperts Address: 169 Marquand Drive Osterville,Mass . °^"e' Jessie Spence Ddle ci r••saecl,on:4/1 6/98 TICNT OR HOLDING TAN'K:&k&�/C-(Tank must be pumped pnu! to. or at hme. of nspeciton) tlo(:a:e o.-) s,te plan) De,-:,) ;,elow grade 6:/ mater'ai o construalon:.Cl—icorscreteVAmetal.P/ Fiberglass,aPc)lyelhyleneANother(explain) '4 --- D-mens'ons A Capac'ry 4JA gallons Design i o.. ^,12 gallons/day Alarm•. .e.el ,Lr —Alarm in wOrking Ordet.(A Yes.V/t Nu Dale 0 prey cus Pumping A COmme^'•s (cone,t,an of nle( tee, condition of alarm and float swathes, etc I DISTRtB ,,TION BOX: ioca:e s 'e plan) Deo:r _ d level above outlet -nven .CJd Com•me':s snot 0 le'ej and drstrib yon is equal, evidence of solids carryover, evidence of leakage into or out of box. : ; r t 91 ) J�d� �ti �!�' v e vo 1C c i O PUMP CHA.�,18ER:Ali2r Iioca:c s,.e plan) .f P�mOs .r ..Orkng order (Yes or NO) y)1� Ali—s c,k ng order (Yes or N'o) -20 Corr, •er:s ,note ;orc,:.on of pump chamber, condition of pumps and appunen,lnces, etc.) D.q. 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORn� PART C SYSIEN% INFORMATION (<onlinued) Propeny Acd(ess:169 Marquand Drive Osterville,Mass . O»ner Jessie Spence Date of Ins�)eclion: 4/1 6/98 SKETCH OF SEWAGE DISPOSAL SYSTEM: :luxe ties to at least two permanent references landmarks or benchmarks ioca:e all wells within 100' (Locate where public water supply comes into house) i � I s r L) SUBSURFACE SENVACE DISP SrSTE•m INSPECTION FOR%� SYSTEM IhIFOI. ON lcontinued) Proper, A dress: 169 Marquand Drive Osterville,Mass . Owner Jessie Spence Date of !nsaection:4/16/98 i De to C:ounowater 0 Feet Tease o ca;e all the methods used to determine High Groundwa.4r ESE a on C .a -•ec irom Design Plans on record G sera ,on of S to ( buning propert observation hole, base-<Or s.mo e�c l ✓z:2m�ne it from IOCdI COnd�I�Ons . ,:n local Board of heahn r;htA Maps p„mping records /i c,' local excavators. Installers _'s -SCS Data De5Cr.:)c ojr own words how you established the High Ground-'Xer'c e.al�cn. Must be co-ple'eC.'; Used Water Contours Map Gahrety & Miller Model 12/16/94 ...rr.-.r.,.-_..__r-i-t-._.rtT—rr-.-rr...:—r.:•.r-.ar:-rar....�-rs-z:rrsr.'.c.rr.. _ ... ... - r.-s—+--cr.r_rT+--T----r- -. .- i TOWN OF Rarncil�T r� WARD OF HEALTH ISUUSURFACF SFHACE DISPOSAL SYSTF,M INSPECTION FORM - PART D - CERTIFICATION .. �. -�t.T.�+l'�.'T:�T.�111TT-�-•.•1-•..�GS'rtT..T•'f'1"'.TT.'TISi�TL!'TT'T.Zi'S.SiiSnTLI"nC:'."QTtTVITrt.r�'TTT'TZTT'mr.+r.-r.-- r-.- .-. -TYPE OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRESS 169 Marquand Rive Osterville,Mass . ASSESSORS MAP , BLOCK AND PARCEL # OwNER' s NAME Jessie Spence PAIN' D - CERTIFICATION NAME OF INSPECTOR Joseph P MAcomber Jr COMPANY NAME J.P.Macomber & Scif Inc. COI.IPANY ADDRESS Box 66 Centerville,Mass . 02632 5 t r e e t Town or City 5tat0 t I P COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 1578 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 _ complet.e as of the time of .-inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : _Zystem PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failui-e criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection which I have conducted has found that the system fails to Protect the public health and the environment in accordance with 'Title 5 , 31O CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature ' f Date One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the DOARD OF (I EAL'I'1I. * IC the inspection FAILED , the owner or operator ehall upgrade the ayetem � iI'hin one year of the date of the inspection , unless allowed or required otherwise as provided in 310 CMR 15 , 305 , partd . doc .S J w cn � THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRON MENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15 .340 and Section 13 of Chapter 21 A of the General Laws. Issued by The Department of Environmental Protection. June 8. 1995 Acting Dlrmor of the itrl�,Zlwi of Water Pollution Control I�- TOWN OF BARNSTABLE LOCATION (09 /Vl/4nMAJ SEWAGE # VILLAGE /'H• /I'l+ IS ASSESSOR'S MAP & LOT Q O INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 1,560 LEACHING FACII.I'I'Y: (type) 9 !'i�C AT (size NO.OF BEDROOMS BUILDER OR OWNER 30JA4 ✓ c(An PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachin�facility) Feet Furnished by �n SPC 1(" �Or 139 I'1 a ys a� 3 Sd 39 Y s9 s� y S 36 i TOWN OF BARNSTABLE 'J.. j/ L ATI�7N �//,4f tei SEWAGE # VILLAGE VZ ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY S7,D LEACHING FACILITY: (type) '�'�� i�`J� (size) NO.OF BEDROOMS BUILDER OR OWNER �il �llCr�- PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of aching f ility /� Feet Furnished by �iG�9� F t f 7 , i a L0 ATION � � � � PERMIT N a 8,�- alp - VILLAGE I N S T A LLER'S NAM R E A ADDESS �7 B U I L D E R OR OWN ER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED v !yo � _ �. �! ... r i � 11/r 0 ,� '�. � / 6 � .c D � 1 �♦ No........S...' 3 FE .........................G THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............. O...W....-0......OF............ ApplirFation for Disposal Works Tonstrnrtinn ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Sy tem at: cation-�Ad,ress kooKd. L....-- o .......-•---------------------------------••-- -- --------- —Address ••• Address aInstaller - ---------------........•--•.......-- ........•-- -----------•------------•---•-- --------- � UType of BuildingSize Lot............................Sq. fq►`� �., Dwelling—No. of Bedrooms......... .............................Expansion Attic ( ) Garbage Grinder q►` aOther—Type of Building ............................ No. of persons----•_-__-__-...____-__-____ Showers ( ) — Cafeteria ( ) OtherLixtures --•--•-•-•------------------•----•-•----•--•••---•---•-•---------•------••---•---••$----•-------••. ----------- W Design Flow........ ......................gallons per person De day. Total daily flow.......... ..._..._.._._..... ons. WSeptic Tank—Liquid capacity.l allons Length..... ....... Width._. 7;L Diameter---------------- Depth...-.•_. x Disposal Trench—N . .................... Widt. .__..�..._._.___ Total Length.... ..... Total leaching area....................sq. ft. Seepage Pit No........ ___--- Diameter....._ '_..... Depth below inlet..-.��`� Total leaching area................' Z Other Distribution box ( ) Dosing tank �) MIS l Qi� S 1.4 Percolation Test Resul s Performed by........ : .e .......................... Date.............. •--•--•---- - --- --• 04 Test Pit No. L. _._._minutes per inch Depth of Test Pit------1_t)_._._.-.__ Depth to ground water......N ..� . fX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-------.......•......... ---------------- .... ....•.•-------•------•-•.............-•-•-•------•-......................................................... O Description of Soil...--------- _ �111-'m..........A Aap........................................................................ --------•-•--••-------•----------- U •------•••--------------•---------------•---•---•••-----•-----------•------------------•-•-••---•-•--•-••-•-•••------------•----•-----------•--•---•-•---•-•---•••---•--•-•----•-•------•---••-•----•--- x I U Nature of Repairs or Alterations—Answer when applicable....__.......................................................................................... --•-------------------------------••---...---•----•---------------------------------.......------------•----------------------------•------•-•---------......--------------------------•-----........_. Agreement: The undersigned agrees to install the afo ibed 1 'ual Se wa Disposal System in accordance with, the provisions of iITI.j 5 of the State San d — e e signe ur ier agrees not to place the system in operation until a ificate o o pliance h ee i e y h b ar he t ._... . Date Application APP d .--•--- ....... . . ........... - ---��,.s ---------------- ---- - ...._..---•---•-- --•----...---•--_..Date Application Disappr ed f o the f l wing reasons---------------------------------•-•-----------------•---------•------------------------.__..--------------...... ......................................... -••............ . ......................................................................................................................................... Date Permit .................................................... Issued....................................................... Date No......................... Fims.......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF....................................................................... ........._......._. App ira#ion for Disposal Works Tontrurtion Frrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .. 0..z...........Kf!h R.U.-WL)........P8 16._.... ...MA.�Ns......UA-1.. 5..................................... Location-Address or Lot A. ......................_.......................................................................... ................................................................................................. Owner Address W Installer Address d Type of Building Size Lot.................... .....Sq. feet aDwelling—No. of Bedrooms____________________________________________Expansion Attic ( ) Garbage GrinderNO p4 Other—Type of Building ............................ No. of persons......._.................... Showers ( ) — Cafeteria ( ) al Other fixtures ----------------------------•-•- ... '5 W Design Flow........ ......................gallons per person er day. Total daily flow--------- ................... Ions. Septic Tank—Liquid capacity gallons Length.__. ------- Width_ t._ Diameter................ Depth... ":-__-- x Disposal Trench—No..................... Widt ................. Total Length------ ff� Total leaching area....................sq. ft. Seepage Pit No......._�...._..__.. Diameter.._._1.4t........ Depth below inlet._..4.f_7..... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing t nk !�I a 9 N,,, `"' Percolation Test Results Performed by....... Date......................... __. !___._._. Test Pit No. 1_ __ __minutes per Inch Depth of Test Pit__________________ Depth to ground water-----&0---------- G14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.....______-____-__.____ 04 .................................. • ODescription of Soil----------- --r b..._........_....___AN-P--•--•--------.._...----------------------••-------------•------------------------------....--•-------•----- x U .................-- ............................................................................................................................................ ---•-•-••------•-••••--••----•---•--•- V Nature of Repairs or Alterations—Answer when applicable............................................................................................... ------------------•------•-----------•---------------------------•--...-----------------------------------------•-- Agreement: The undersigned agrees to install the afo d. ribed Individual Sewage Disposal System in accordance with the provisions of TITLL 5 of the State San e ndersigne fur�her agrees not to place the system in operation until a tificate o Compliance a ee e by h bar of hea°Ith - 1 1 i ' ``7 --5 Signed---- . _---y.-------•--••--•------••-•••••-- ...................... ---� 46:1;� Date Application Ap o ed ............. •• . •••••••�`=._ Date Application Disappr ed for the f l wing reasons:................................................................................................................ P J Date Permit I ••---••------•------------------------------- Issued Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF...... .............................................................................. (9rdifiratr of Tontpliattrr THIS IS TO CERTIFY, That the dividual Sewage Disposal S stem constructed �' ( ) Repaired ( ) L OT InstallerA� n . .. -l_ n.......................................... has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated-................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE .�---------------•-'.;....,�---•---•-......._._. Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH z�'s_ _•----• � 0.........................................OF.............. •----•................-•-----•-•.................................... F E ................ Uisposgt arks T nntrudion frrutit Permissioni ereby d................ . • =_._ . _2 __...----------...------------.......----------...-----•-----..--•-•--• to Construct ) or Repair ( ) an nd'ividual Sewage Dis• sal System L oT ^'Lem [)�A R�'--•• g � t_ iC __ as shown on the application for Disposal Works Construction Permit No... ................ Dated.......................................... ----------------•-------•-•------- - --- - - --•--------•---••-------- . n -------DATE...................... .......................... FORM 1255 A. M. SULKIN, INC.. BOSTON TOWN OF BARNSTABLE UNDAGROUND FUEL AND CHEMICAL STORAGE SYSTEMS _ Tf:'kt k' ♦ q z.. NAME ADDRESS J6 Jc ��!qmA y� VILLAGE /���STOj✓ l L YS' LOCATION OF TANKS: CAPACITY: TYPE OF FUEL AGE: TYPE: OR CHEMICAL 9 A1,:., /i e2 > f//� a? O o2 D �` A/ .YT-/ `/03 (Give same information for any additional tanks on reverse side of card) DATE OF PURCHASE OF EACH: 1. >�' 2. 3. 4. DATE OF FIRE DEPARTMENT PERMIT: TESTING CERTIFICATION SUBMITTED: PASSED DID NOT PASS APPROVED nstab a Conservation Commission Signed Data APPROVED BOAR D OF HEALTH TOWN OF BA 1 SSA BLE Date /— .r t:+ LZIt " e f Ori in!-"J,iot Negotiabl* tia i ill Y&' 1..FK3fi h61 l Foj 17 S P r s No. B3138 Ship e ' ------- ( 4 4 * Carrier's No. t (Name of Carrier) RECEIVED,subject to the classifications,afld tariffs to effect on t Me of the issue of the Blll� f t bding, Y.,,.' y, at AVONs'MASS.' 02322�t j' ' ? 19 1k s From SACHUSMS BNGMRING COee INC. the proDezty de.edlied'.below,III spparsht'good order;eaceDt'ae.rioteQ{aSn/ents and;ciinditions of contents of yync1aties;unk' din);merkcd,consigned.and destined as indicated below, which said car- rier(the word earner being understood throughout}h4 eontraet tta'mdgniity any.perooW or c6rporatioit[In Dnssesslnn ef'thi pro arty trader the dontrart)at•rr,to carry to its usual place of delivery at saiA dec"nallon;it en its own route,otherwise to dellvefi to another'cerNet en'!he[ utlt tV tseid destination:It is mptually agreed, to each carrier f all or,n.•of said property over all or any portion of said route to deKlnation and as to each VV�rty at any tlrrl'e interosteti In all or any'gg aatll properly that every.service lc be performld hereunder shall be sus r n all the lams and conditf nns of the lfmfo— Domestic$traleht all of(,adin set[orlh.(1)Its Olnc4itC.Soulhem;Western and tWnols:.refght�inssiticatlnn in effect on the date_therenf.if this is A rail n azi n.uer shipment,or(t)in the eDPl irable m fn carrier ctaviflcation or tariff It�fs is a motor eaMe[afiipmenl. + �• ,, ,.�'• ' - . Shipper hereby Esrtif iesahat he is familiar w.itfi elF the terms antl rnnditions of the said bill of lading, including those on the back thereof, set fo•th 6i the Massif icavon or tariff which governs the. trampatstron of this#�r � CQndtttttng xe.hgreby e t �ttt bye the shipper_and accepted for himcglf anQthra a wgns. s },� �Hea ingr l oo1 i , c/o° Mr 4Listonr'x Lot 42); Consigned to (Mail or street address at Consignee—For purposes of notification only Marston§ M9'175- MA` Delivery Destination ° state Zip County Address l *To he filled in only when shipper desires and governing tariffs provide for delivery thereof) Route Marquand Drive' Attn) 8i°lodeau Builder a Delivering Carrier —___.__.___.....______Car or Vehicle Initials _ welr.,f t No. Kind of Package,Description of Articles.Special _ � j-. C'lac;' � t � Subject w Section 7 of Conditions of Packages Marks.and Exceptions (subject to o,Rate Coo,r.n I applicable hill nfladin ifthis shipment is In f) p .....Correction) j r ' --��T�' he delivered to the consignee without recourse UG tan on the ronsignor,the consignor shall sign the gallon- following statement: 11' The tamer shall not make delivery of this 1 64 d i a. `-''- - other lawful hature of Consignor) shipment without payment freightofg and all 1 Gage Stick ----_--- —.. _.---___g p prepaid, ._.. i if char ea are t0 be m aid,waste or sea rap I STI - P3 protective system here:"To brlrr aid. 1 Set Installation Instructions I to apply in prepayment of the charges on the . _—_.`---_".-_.-.__--`----_-.'— _ —_--- ----.-__-- ".,rty described hereon. FO taps (one 5" & Four 2 ) --- --- �," � � Agent.or Cashier (T)e signature here acknowledges only the 8,31.8, amount prepaid.) CUST. P. O. *If the shipment moves between two ports by.a terrier by:wate'r,the law requieee that the hill of lading shell state whether it to carrier's or shipper a i, Charges Advanced: weigh). .: car .. c .._ NOTE—Where the rate G deperident on'velue Alppem ere required to state specifically in writing the agreed or declared vaine of the property. $— TM_Ora Or a declared if""of the property Is Mreby speeHlcow started by the stopper to be not excesdinp y ----' '• tth s '.,ith box t� '-------_�}Shipper's imprint in lieu of clamp:not s pave Yfhe fibre boxes deed for Nis shipment mntorei to the speciffcetiotSe set forth fn the bog maker's rrrhficate)here a 1 o re remenke of the of Rtll„f Lading Approved by the Interslnee Co Commerre Commission. lreolideted Freight CLtrerBcebon.. MASSACHUSETT3 EN6INEERIN6 C0 IMC�_Shpper, Per ._. ...__.. �__ ^` ) Agent, Per..._.__._—_.__—__.__-_ Permanent post-office address of sl,; AVON, MASS. 02322 10R4 WilsonJones 1 TOWN OF BARNSTABLE Z a UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS NAME �� r�J �nu � �. ADDRESS'c1�� c VILLAGE�r��� p-j � mw—�. LOCATION OF TANKS: CAPACITY: TYPE OF FUEL AGE: TYPE: _ OR CHEMICAL �• - �&j1 l`Y'�C7 (Give same information for any additional tanks on reverse side of card) DATE OF PURCHASE OF EACH: 1. 2. 3. 4. DATE OF FIRE DEPARTMENT PERMIT: TESTING CERTIFICATION SUBMITTED: PASSED DID NOT PASS 3se i + 7 Jeannine. ►+ iibbard 250`Baxter'Neck Rd Marstons Mi3s Mai 0'2648 ` r • - • • r. 1 g 32 $ersf 'S. Way,' Hyannis - 4 • i urF yam_. •`�.,:T .h'1 r , �r., o ' �.+ ,� • � lr. #i. r �',�yV-� , ;� . - M - �F 3 .., � V h rF.' •,.� - .. '; f'r ! ) p V�yid♦ fix,, 1 `. ' _ �! y 4 Jil , r • • <f •��x � •,s,r A, � I a.F., • y •�f r.. - .� ., e . - A r ,F x 4.+ry — < it'• -~ i • r-r - - T w .. - _ - .y I NAME LOCATION HUBBARD, Jeannine L. 832 Bearse's Way +., nnis y, c, c 'R 600K & PAGE--DATE GRAWED AMOUNT STORED 77/276 May 11, 1973 1,000 a Ions in one undergroum DATE PAID 1974--March 19 A�",R ' 4..R 2 9 3976 APR 2 51977 PR 3 1918 �Y AM E, -14 C l rze>n.t Ftd,C mF i ► ��' 6L3V€ (L 'rO� 4 ?d,1k t?- ldAvE - -TOP OiF F�vwlD. 30 ! :. • y ter: _ _ 7-1 _^ I �1y,f 1! 11 v _ 7 25 Lev 2 a. TLC ( ! hr'Dl'�ir+F.�� v - J ' I l 50C) CaAL_ pro' a-1 A\ T E 5-T i, M>E C�. 5 firc - - I iJOT Td C-A LE � , l 0 + ' l` f =� WAa Eft _ rF t;.Ets T..a T IF ��a ! ;r. �+F' k at)L E trc C L� t _ _ _ _ - - r -r-C) J+.1 n .�C' i 3.✓w•\tL.� rJ 'T: h'�L _ .�'� .. _ 1•= r _ -Fr.a r"7 A E. 3 `'� {"1. t e?`.: w PERG 2�aT� � 2 /tA�� !►.1 5 Ff t7t,M, ti. ; t[? ,b t?F$2 f'V 'T RC F <, Af'PL ICA T IOV lv L • f (,--6 LAC �l -A.c r%A T E. 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