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Home My WebLink About1301 OLD POST ROAD (CT & MM) - Health 1301 Old Post Road - v Marstons Mills A= 057-033 Commonwealth-of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments °M •'°F 1301 Old Post Rd. Property Address Linda Thomas Owner Owner's Name information is required for Marstons Mills Ma. 02648 3/24/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of LP 27' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: As-Built ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database- explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-,0001 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth-bf Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ° M 1301 Old Post Rd. Property Address Linda Thomas Owner Owner's Name information is required for Marstons Mills Ma. 02648 3/24/2011 every page. Cityrrown 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 r t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 657-a33 Commonwealth of Massachusetts Title 5 Official .Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' r 1301 Old Post Road, Marstons Mills ✓ M -57 P- 33 Property Address p,y John & Cecile Czarnecki Owner Owners Name — _U information is _r. required for every 26 Francis Avenue, Lunenburg MA 01462 November 21, 2018 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information on the computer, use only the tab Troy Williams key to move your Name of Inspector cursor-do not Troy Williams Septic Inspections use the return Company Name key. Hummel Drive r� Company Address South Dennis MA _ 02660 _ City/Town State Zip Code (508) 385- 1300 S1682 _ -- Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 16.340 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 November 21, 2018 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 rInspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - � 1301 Old Post Road, Marstons Mills. _ M -57 P -33 — Property Address John & Cecile Czarnecki _ Owner Owner's Name information is required for every 26 Francis Avenue, Lunenburg MA 01462 November 21, 2018 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Septic tank is H-10 grade and is located under driveway. This was addressed in past inspection and by the town in 2011. It was recommended that tank be replaced with H-20 tank. This was only a recommendation then and also is recommended on this inspection.System meets minimum standards set by Massachusetts DEP at the time of inspection only.This inspection is not a guarantee or warranty on the future working conditions of leaching, pipes, components or the future structural integrity of said components and only represents conditions found at the time of inspection only. 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.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 16 Commonwealth of Massachusetts �n ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1301 Old Post Road, Marstons Mills M -57 P -33 Property Address John &Cecile Czarnecki Owner Owner's Name information is 26 Francis Avenue, Lunenbur MA 01462 November 21, 2018 required for every g page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms.not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR I[ 16.303(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 1301 Old Post Road, Marstons Mills M -57 P - 33 Property Address John & Cecile Czarnecki Owner Owner's Name information is g required for every 26 Francis Avenue, Lunenbur MA 01462 November 21, 2018 _ page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal conform bacteria Indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1301 Old Post Road, Marstons Mills M -57 P-33 Property Address John & Cecile Czarnecki Owner Owner's Name information is 9 26 Francis Avenue, Lunenbur MA 01462 November 21, 2018 required for every _ _ page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/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 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 M ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts �� - -- Title 5 Official Inspection Form } Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1301 Old Post Road, Marstons Mills M -57 P -33 Property Address John & Cecile Czarnecki Owner Owner's Name information is 26 Francis Avenue Lunenbur MA 01462 November 21, 2018 , required for every g --- -- — 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 all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling 'inspected for signs of sewage 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection .Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1301 Old Post Road, Marstons Mills M -57 P -33 v - - Property Address John & Cecile Czarnecki Owner Owner's Name information is required for 26 Francis Avenue, Lunenburg MA 01462 November 21, 2018 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): .3 — Number of bedrooms (actual).- -- -- DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd Description: Number of current residents: 0 -- Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: N/A Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ® Yes ❑ No Water meter readings, if available last 2 ears usage d 17=30,000 gals. g ( y g (gpd)): 16=24,000 gals. Detail Sump pump? ❑ Yes ® No Last date of occupancy: Da easional use 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 9 p Y rY 1301 Old Post Road, Marstons Mills _ M-57 P-33 _ Property Address John & Cecile Czarnecki Owner Owner's Name information is 26 Francis Avenue, Lunenburg MA_ 01462 November 21, 2018 required for every _ —_. — page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/industrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): N/AGallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): N/A -- ---- _ Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: N/A Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: N/A Last date of occupancy/use: N/A Date Other(describe below): N/A 3. Pumping Records: Source of information: No pumping info available. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: - — t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v 1301 Old Post Road, Marstons Mills _ M -57 P- 33 Property Address John & Cecile Czarnecki _ Owner Owner's Name information is g for every 26 Francis Avenue, Lunenbur MA 01462 November 21, 2018 required gage. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Tank, d-box and leaching are original to home built in 1979. Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 5. Building Sewer(locate on site plan): Depth below grade: 18"feet Material of construction: ❑ cast iron ®40 PVC sch 20 pvc ® other(explain): Distance from private water supply well or suction line: feet -- -- Comments(on condition of joints, venting, evidence of leakage, etc.): Flushed lines and found clear through to leachpit at the time of inspection. t5ins .doc•rev.7/26/2018 Title 5 Official Inspection Form: m.Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1301 Old Post Road, Marstons Mills M -57 P=33 Property Address John & Cecile Czarnecki_ _ Owner Owner's Name information is required for every 26 Francis Avenue, Lunenburg MA 01462 November 21, 2018 _ -_ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): 1' _ Depth below grade: feet - Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) H-10 grade If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallon — Sludge depth: 4" ----- Distance from top of sludge to bottom of outlet tee or baffle 2' 8" -- Scum thickness none — Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" -- -- How were dimensions determined? probe/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.): Pvc inlet and concrete outlet tees were found present and in working order. No evidence of leakage or damage was found. Tank was not in need of pumping at this time. Septic tank is H-10 grade and is located under driveway. This was addressed in past inspection and by the town in 2011. It was recommended that tank be replaced with H-20 tank. This was only a recommendation then and also is recommended on this inspection. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts yn Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1301 Old Post Road, Marstons Mills _ M -57 P-33 Property Address John & Cecile Czarnecki Owner Owner's Name information is required for every 26 Francis Avenue Lunenburg MA _ 01462 November 21, 2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: N/A feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: N/A Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A -- Distance from bottom of scum to bottom of outlet tee or baffle N/A Date of last pumping: N/A 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.): N/A 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A — --- Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: N/A----- -- Capacity: N/A _ gallons Design Flow: N/A gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 c � Commonwealth of Massachusetts --- -- , Title 5 Official Inspection Form �a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1301 Old Post Road, Marstons Mills _ M - 57 P -33 Property Address John &Cecile Czarnecki___ Owner Owner's Name information is 26 Francis Avenue Lunenbur MA, 01462 November 21, 2018 required for every � 9 ._ _ page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: N/A -- Alarm in working order: ❑ Yes ❑ No Date of last pumping: N/A Date Comments (condition of alarm and float switches, etc.): N/A "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 level _ 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 found level and in working order. t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1301 Old Post Road, Marstons Mills —__ M -57 P-33 Property Address John & Cecile Czarnecki _ Owner Owner's Name information is 26 Francis Avenue, Lunenburg MA 01462 November 21, 2018 required for every -- - - 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.): N/A * 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: 1 -6'X6' pit with2'of stone ❑ 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.7/26/2018 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 v � 1301 Old Post Road, Marstons Mills _ M -57 P_33 Property Address John & Cecile Czarnecki _ Owner Owner's Name information is g required for every 26 Francis Avenue, Lunenbur MA 01462 November 21, 2018 _ page. City/Town 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.): Soil was sandy. Leach pit was dry on inspection with a visible stain line approx. 18" below inlet invert. No evidence of hydraulic failure or problems in the past were found at the time of inspection. Pit located in in overgrowth and I marked cover with a red reflector. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A _ Depth—top of liquid to inlet invert N/A Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction N/A Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts w� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1301 Old Post Road, Marstons Mills M - 57 P-33 u Property Address John & Cecile Czarnecki Owner Owner's Name information is 26 Francis Avenue, Lunenbur _ MA 01462 November 21, 2018 required for every g page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: N/A Dimensions N/A Depth of solids N/A N/A — — — -- Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A tiinsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �L / 1301 Old Post Road, Marstons Mills _ _ _ M -57 P- 33 Property Address John & Cecile Czarnecki _ Owner Owner's Name information is 26 Francis Avenue, Lunenbur MA 01462 November 21, 2018 required for every — g page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately /,;� I I k i 3•aS 1 �_ Sri' ! 6ro4,�- s7' I ; I i O �. I � � I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts !n - Title 5 Official Inspection Form I o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4, 1301 Old Post Road, Marstons Mills _ M - 57 P - 33 _ Property Address John &Cecile Czarnecki Owner Owner's Name information is required for every 26 Francis Avenue, Lunenburg MA 01462 November 21, 2018 - 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 ground water: 14.0'+ 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: pate ® 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: SDW 253 Zone C 49.1_ 4.1' adjustment You must describe how you established the high ground water elevation: USGS groundwater map shows groundwater to be approx. 27.0' below grade. Groundwater adjustment at the time of inspection was 4.1'. Bottom of leaching at 9.4'was found not to be located in the high groundwater elevation at the time of inspection. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts -- ,� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !/ 1301 Old Post Road, Marstons Mills _ M -57 P -33 Property Address John & Cecile Czarnecki__ _ Owner Owner's Name information is 26 Francis Avenue, Lunenbur _____ MA 01462 November 21, 2018 required for every g —. _ 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 '*. Room k U.S.POSTAGE)>PiTNE'BOWES DFtME�Owa Town of Barnstable Public Health Division BARNSTABLE. ' 200 Main Street ZIP 02601 $ 005,54a MASS. %ED MP'�p`0 Hyannis,MA 02601 tik 0001361475 APR 26 2011 I i L 7006 0810 0000 3525 5415 Y R A ._I_:n,4,n-Thnmas- NXXXIF mm a eta 0z.j0 ./aj. RETURN TO SENDER NO MAIL RECEPTACLE ONAML.E TO PopwARD - 00: 02601400200 0969--034a0-28--4' Nt9R I i COMPLETE .N COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Signature item 4 if Restricted Delivery is desired. X ❑Agent ■ Print your name and address on the reverse ❑Addressee so that we can return the card to you. B. Received by(Pr/nted Name) C. Date of Delivery i ■ Attach.this card to the back of the mailpiece, I or on the front ifs ace e •P permits. ! 1. Article Addressed to: D. Is delivery address different from item 1? ❑Yes If YES,enter delivery address below: ❑No I I I 1VI -Linda Thomas I' 130;1,Old.Post Road Marsns Mills, MA 02648 3. Service Type ❑Certified Mail ❑Express Mali. I ❑Registered ❑Return Receipt for Merchandise 0 Insured Mail 13C.O.D. _--_ j I c 4. Restricted Delivery?(Extra Fee) ❑Yes I 2. Article Number 7006 0 810 0000 3525 5 415 (Transfer from service label , I j •; i j I PS Form 3811,February 2004 Domestic Return Receipt y_ 102595-02-M-1540 1 i S t—T I `�TC?�{t rt t'C T __�- '__ ��_ r Un p M p �. • . . .- m o^ p Postage $ p �YAIVM� p Certified Fee p !/ Postmark p Return Receipt Fee Here (Endorsement Required) ��- p Restricted Delivery Fee 9 O (Endorsement Required) C ?�I 05 Total Postage&Fees �7•SL/ ��s l �O Ln p Sent To/� p wl r froC'Lbr g.----Ss�e n .. 3`freet Apt No: 9 -PO Box N--oo-� Q- d X .............................. City,State, IP+4 :rr r, Certified Mail Provides:o A mailing receipt asjanay)zooz eunr'ooeE Wood sa o A unique identifier for your mailpiece 411.1 • A record of delivery kept by the Postal Service for two years Important Reminders: a Certified Mail mayONLY be combined with First-Class Maile or Priority Mail®. o Certified Mail is not available for any class of international mail. • NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. o For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPSe postmark on your Certified Mail receipt is required. ,r r For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". o If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT: Save this receipt and present it when making an inquiry. Internet access to delivery information is not available on mail addressed to APOs and FPOs. UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid USPS Permit No.G-10 • Sender: Please print your name, address, and ZIP+4 in this box • I Town of Barnstable Public Health Division I 200 Main Street Hyannis, MA 02601 l SENDER: SECTION. DELIVERY ■ Complete items 1,2,and 3.Also complete A. Sign re item 4 if Restricted Delivery is desired. ❑Agent ■ Print your name and address on the reverse ❑Addressee so that we can return the Card to you. B. Received by(Printed Name) C. Date of Delivery ■ Attach this card to the back of the mailpiece, i or on the front if space permits. D. is delivery address different from item 1? ❑Yes 1. Article Addressed to: a�0 1 F If YES,enter delivery address below: ❑No Mr:,-Proctor Ransde � i0 P.G.Box 1398 doy North Falmouth, MA 56- s. Service3e Certified Mail e ❑Mail Express Mail � ❑Registered ❑Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Y 2. Article Number •` I 70 0 5 i , (transfer from service label) _+ ++ 1 V6 01.0 0 ff 0 0151 I PS Form 3811,February 2004 Domestic Return Receipt 1o25s 2-M- IKE Town of Barnstable Barnstable Regulatory Services Department aFamericacitl►1 I 0D +�BARNnABLE. 1639. Public Health Division G°Arf°M 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL # 7006 0810 0000 3525 5415 April 25, 2011 Ms Linda Thomas 1301 Old Post Road Marstons Mills, MA 02648 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 1301 Old Post The septic system located at 1301 Old Post Road,Marstons Mills, MA was last inspected on 3/24/2011,by Robert Paolini, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Passes" under the guidelines of 1995 TITLE 5 (310 CMR 15.00). However, it is recommended that the tank be replaced with a heavy duty (1-120) load bearing tank due to its location beneath a driveway. PER ORDER OF THE OARD OF HEALTH Thomas McKean, R. ., Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures\TEMPLATEI.doc Ln p : Ln t17 Ml OFFICIA-L Ln m Postage $ 026 tM or C3 Certified Fee Retum Receipt Fee Postmark Here (Endorsement Required) Her O Restricted Dellvery Fee � (Endorsement Required) 7y y M Total Postage&Fees J�Q p Se n To `- Street,Apt No.,orP08ox-IVo. I3Q/ __ � r •L-wyiJ�/t .City-state,z Q��.. s.. •.1.�.3 /�4/'1..U��..� Gratified Mail Provides: (aslenaa)zooa eunr'OOee W,o�sd a A marling receipt „rp A A unique identifier for your mailpiece o A record of delivery kept by the Postal Service for two years Important Reminders: n Certified Mail may ONLY be combined with First-Class WHO or Priority Maile. • Certified Mail is not available for any class of International mail. el NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For Valuables,please consider Insured or Registered Mail. q For an additional fee,a Retum Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpieee"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPSe postmark on your Certified Mail receipt is .required. ® For. an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". • if a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and.present it when making an inquiry. Internet access to delivery information is not available on mail addressed to APOs and FPOs. F SHF Town of Barnstable BarBarnstable.t ° T Regulatory Services Department a�j TIARNSTABLE, MASS Public Health Division l� a679. Arf° �A 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL # 7006 0810 0000 3525 5415 April 25, 2011 Ms Linda Thomas 1301 Old Post Road Marstons Mills, MA 02648 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 1301 Old Post The septic system located at 1301 Old Post Road, Marstons Mills, MA was last inspected on 3/24/2011,by Robert Paolini, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system `Passes" under the guidelines of 1995 TITLE 5 (310 CMR 15.00). However, it is recommended that the tank be replaced with a heavy duty(1-120) load bearing tank due to its location beneath a driveway. PER ORDER OF THE OARD OF HEALTH Thomas McKean, , Agent of the Board of Health Q:\SEPTIC\Letters Septic inspection Failures\TEMPLATEI.doc Town of Barnstable Barnstable . . °� Regulatory Services Department j ericaC j + BARNSTABLE. MASS. Public Health Division 1639. m ArfD µAS a • 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL # 7006 0810 0000 3525 5415 April.25 2011 Ms Linda Thomas 1301 Old Post Road Marstons Mills;MA 02648 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 1301 Old Post The septic system located at 1301 Old Post Road, Marstons Mills, MA was last inspected on 3/24/2011,by Robert Paolini, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Passes"under the guidelines of 1995 TITLE 5 (310 CMR 15.00). However, it is recommended that the tank be replaced with a heavy duty (1-120) load bearing tank due to its location beneath a driveway. PER ORDER OF THE OARD OF HEALTH Thomas McKean, , Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures\TEMPLATEI.doc 04/121/2011 12:47 FAX 5084283928 CAPEWIDE IM001/003 Capel de ENTERPRISES,. LLC J.P. MACOMBER & SON To: SOL-f rlS' From: Pages: Subject:' ev L!!te-- ``t— -)-I_ 1 Phone:508-477-8877 Fa)c 548-477-4977 Website: www.CapewideEnterprises.com Email: Rich@CapewideEnterprises.com Joao@CapewideEnterprises.com 04/21/2011 12:47 FAX 5084283928 CAPEWIDE R 002/003 ✓ ,per Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1301 Old Post Rd. Property Address Linda Thomas Owner Owner's Name information 1s required for Marstons Mills Ma. 02648 3/24/2011 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered In any way.Please see completeness checklist at the and of the form. Important A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name P.O.Box 763 Company Address Centerville Ma. 02632 City/Town State Zip Code (508)477-8877 S14454 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CM 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority -Zlil 3/24/2011 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 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. tins•7 i n 0 Trde 6 official Inapedon Fomr Subsuriaos Sewage Disposal System•Page 1 of 17 r 04/21/2011 12:47 FAX 5084283928 CAPEWIDE IM003/003 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1301 Old Post Rd. Property Address Linda Thomas Owrer Owner's Name information equr dfo is Marstons Mills Ma. 02648 3/24/2011 required for every page. C4/rown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time.Septic tank is in driveway.Tank is H10 loading not H2O.Recommend that tank be upgraded to H-20 loading. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for`yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please 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): 15ins•11M0 TU 5 Official Inspedion Form:St6surface Sewage D*xxsal System•Page 2 d 17 i Commonwealth-of Massachusetts • Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1301 Old Post Rd. Property Address Linda Thomas Owner Owner's Name information is required for Marstons Mills Ma. 02648 3/24/2011 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector ' use the return key. Capewide Enterprises,LLC. Company Name t� P.O.Box 763 Company Address Centerville Ma. 02632 City/Town State Zip Code (508)477-8877 S14454 Telephone Number License Number B. Certification 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: ^ 1 ❑ Passes ❑ Conditionally Passes ❑;µFails ® Needs Further Evaluation by the Local Approving Authorityel/W�, /- 3/24/2011 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 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. VV �I t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 l y Commonwealth-of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 1301 Old Post Rd. Property Address Linda Thomas Owner Owner's Name information is required for Marstons Mills Ma. 02648 3/24/2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Septic tank is in driveway.Tank is H10 loading not H2O. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health;will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND) for the following statements. If"not determined," please 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•11/10 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 M 1301 Old Post Rd. Property Address Linda Thomas Owner Owner's Name information is required for Marstons Mills Ma. 02648 3/24/2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 f Commonwealth-of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 1301 Old Post Rd. Property Address Linda Thomas Owner Owner's Name information is required for Marstons Mills Ma. 02648 3/24/2011 every page. City/Town 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 well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® 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 1/2 day flow t5ins•11/10 Title 5 Official Inspection Form: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 1301 Old Post Rd. Property Address Linda Thomas Owner Owner's Name information is required for Marstons Mills Ma. 02648 3/24/2011 every page. CitylTown 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- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system.the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No t ❑ ❑ 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth-of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1301 Old Post Rd. Property Address Lirida Thomas Owner Owner's Name information is required for Marstons Mills Ma. 02648 3/24/2011 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components-pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 1301 Old Post Rd. Property Address Linda Thomas Owner Owner's Name information is required for Marstons Mills Ma. 02648 3/24/2011 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d NA 9 ( Y 9 (gp ))� Detail: Sump pump? ❑ Yes N No Last date of occupancy: NA Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 , •Title 5 Official Inspection Form: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 , 1301 Old Post Rd. Property Address Linda Thomas Owner Owner's Name information is required for Marstons Mills Ma. 02648 3/24/2011 every page. City/Town 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1301 Old Post Rd. Property Address Linda Thomas Owner Owner's Name information is required for Marstons Mills Ma. 02648 3/24/2011 every page. City/Town 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): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 101+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank(locate on site plan): Depth below grade: 1811 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: 1500 gallon Sludge depth: 6" t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ^M 1301 Old Post Rd. Property Address Linda Thomas Owner Owner's Name information is required for Marstons Mills Ma. 02648 3/24/2011 every page. Citylfown 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 26" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 12" 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.): Pump tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound.NOTE:Tank is not H2O loading and is in driveway. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments wM 1301 Old Post Rd. Property Address Linda Thomas Owner Owner's Name information is required for Marstons Mills Ma. 02648 3/24/2011 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.- Not for Voluntary Assessments M ,•'`v 1301 Old Post Rd. Property Address Linda Thomas Owner Owner's Name information is required for Marstons Mills Ma. 02648 3/24/2011 every page. Cityrrown 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 No Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box is Ievel.Box has one outlet lateral.no evidence of solids carryover.No evidence of leakage. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 1301 Old Post Rd. Property Address Linda Thomas Owner Owner's Name information is required for Marstons Mills Ma. 02648 3/24/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy dry soil.No signs of hydraulic failure.Leaching pit was dry at time of inspection.Stain line observed 24" below invert. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 r _ • r Commonwealth of Massachusetts r W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 1301 Old Post Rd. Property Address Linda Thomas Owner Owner's Name information is required for Marstons Mills Ma: 02648 3/24/2011 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 OF THE Tp� Town of Barnstable Barnstable ' °: hy Regulatory Services Department ;edeaC � nARNSTABLE. A MASS*9. N,�� Public Health Division 200 Main Street,Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.GeilerLeach pit is only3f )undwagter,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7005 1160 0000 0191 3035 May 4, 2011 Mr. Proctor Ransden P.O. Box 1398 North Falmouth,MA 02556 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system 1301 Old Post Road, Cotuit MA,was last inspected on 3/24/2011, by Robert Paolini, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Passes" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) However, it is recommended tat the tank be replaced with a heavy duty (H20) load bearing tank due to its location beneath a driveway. PER ORDER OF THE BO OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures\1-1 SAMPLE 60 Day Deadline.doc