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HomeMy WebLinkAbout1471 OLD POST ROAD (CT & MM) - Health 1471 OLD POST ROAD Marstons Mills. A = 057 — 066 — -- --_--- - -- — - { I i L f 3 TOWN OF BARNSTA4EWAGE BLE LOCATION ' (} (j a 20 # 9-1 3� VILLAGE M_,A r6 AYY\5 �'I{I LSASSESSOR'S MAP&PARCEL 7 INSTALLER'S NAME&PHONE NO. arl� analS 66 ,, s�� �447 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) —r)W �4 (size) f .L NO.OF BEDROOMS F OWNER PERMIT DATE: letUAGa 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 leaching'facility) II tr Feet Z—FURNISHED BY k� e Pd e 43-33 IC ka�. O F BARN TABLE LOCATIO 7/ SEWAGE # VILLAGE,` � ;� ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERM TDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and,Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by_ a . SUBSURFACE SEWAGE DISPOSAL SYSTEM OISPEcnoN FORM. .. PART C SYSTEM BIFORMATION(amalnn01 oR •. WA 1WIEIN0.Po5r R0, Data Of kamptar !g-O-I p 111q ' SKETCH OF SEWAGE DISPOSAL SYSTEM: Inalede dda b at bast two permanent rabrenae landmarks at banehmarka lecata an walls within 100'(Loeeb where puhfie water wpply somas into house) I ; 41 f I I GPRP�� t i 3�a 1� ) I ,yo i i 1 �I i $4,2" 5�1 TOWN OF BARNSTABLE- LOCA `IJN SEWAGE # ✓B,LAGE- t;} 3 AA CIS ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS - BUILDER O OWNE (�ol�a�eft / � PERMITDATE`. COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by le, Re,r .off 4c)L)��� 1 c , No._� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: _ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS YeS 9ppliCation,for Vspo8al *pstrm Construction Permit Application for a Permit to Construct( ) Repair o4pgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Addres Mot No. !47) 0/'0 p05 M� Owner's Name Address,and Tel.No. SSp�- Assessor's Map ,/ 7 — 3 `f' Installer's Name,Address,and Tel.No. SO$'3&Z r.o2/,?) Designer's Name Address,and Tel.No. N'Of- Type of Building: Dwelling No.of Bedrooms O C1-&^)S,ot Size -:Q/0i sq.ft. Garbage Grinder )� Other Type of Building /�t9� 2i.✓rizr9 Is No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) ..d gpd Design flow provided ��_ gpd Plan Date Q t p % �B a''� Number of sheets Revision Date Title Size of Septic Tank / Type of S.A.S. +� � Description of Soil aSu sD py= Nature of Repairs or Alterations(Answer when applicable) sly( ge o7ok 4: JQ?�Z4,Ltf Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board,of Healt gned Date " e I Application Approved by Date Application Disapproved by Date for the following reasons Permit No. ;?4'2 2- o Date Issued I 9 eAlf No. /t�� 7 {' Fee /tit/ Entered in com uter r }. THE COMMONWEALTH OF MASSACHUSETTS p'` Yes- PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE MASSACHUSETTS 2ppYicat on for -D sposal 6pstem xCons truttioi,,Vermit Application for a Permit to.Construct( ) Repair(loo�Upgrade( ) Abandon( ") ❑,Complete System El Individual Compon nts Location Address'or Lot No �1 —7) Q l0 t�G 54 � Owner's Name,Address,and Tel.No. S 1 j I� `tv�-yr I�,• �s ASes or's Map1/P9 b !M 4 r�}r h S J'h J 11 S -Sii t L dde* Installer's Name,Address,and Tel.No. S08' 36,2 (a Designer's Name,Address,and Tel.No. /3ro Ti-,-r$ C c 5 %0`13/`h k r`r7 s,lk 2 ' �'" J� e r l z s a ri 7 f a; i r3rX 7 / 3 , Type of Building: ( K J G✓V '' Dwelling No.of Bedrooms G d"7f of Size 4Q'0! � sq.ft. Garbage Grinder )4 Other Type of Building �.E-5� A�i,,.cw G- No.of Persons YShowers( ) Cafeteria Other Fixtures J ...r Design Flow(min.required) Co+' gpd Design flow provided gpd i ,h Plan Date l a,r ��} Number of sheets Revision Date Title -Size of Septic Tank �.$� Type of S.A.S. .� dp� iC. -�✓t►lr /3 'g~ ,,,e; ,` Description of Soil e �v.,* C e ! G L * 'A _ V 7­41, 1 4 .5 ff- " Nature of Repairs or Alterations(Answer when applicable) J Y'y' (`j) J w Date last inspected: Agreement: µ The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in „ f, Environmental Code and not to place the system in operation until a Certificate of accordar ce with the provisions of Title 5 of the Compliaice has been issued by this Board of Health. Signed ' / �' ���^ --� DateOf Application Approved by i Date !Q 7;71 / Application Disapproved by Date for the following reasons ti Permit No. T�?_ j 3 2_ U Date Issued y r ! - THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance j THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(V) Upgraded( ) Abandoned( )by J-i- ' t n at IL01 has teed tghstru/ ted'i"n accordance / with the provisions of Tifle 5 and the for Disposal System Construction Permit No.e071 3 Zo dated a/2I/�]!� Installer ar f 1 �%°5�'('i L.Pt S �G rf Designer_Cf,_:� ! �. ,p ' /. Pam✓ f #bedrooms r+' Approved design flow , gpd i The issuance of this permit shall not be construed as a guarantee that the systemwiiiuncti n designed. Date ,r Inspector - _fi No. t-0 K ' ?7 Fee THE COMMONWEALTH OF MASSACHUSETTS ` PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS \ +a» Misposal 6pstem Construction permit Permission is hereby granted to Construct( ) Repair( Upgrade( ,) Abandon( ) System located at ( "� E (.� f M� i�G S}" 12,y Pd j r S G �i C , a � and as described in the above Application for Disposal System,Construction'Permit. The applicant recognized his/her duty to comply with t1e 5•aiid ttie following local provisions or special conditions:_ L Provided:Construction must be completed within three years of the date of this permit. . �,. .�:. W Date Approved by Town of Barnstable �`"E'�'% Inspectional Services s Public Health Division °fA p Thomas McKean,Director s6gq. Qb 200 Main Street,Hyannis,MA 02601 Office: 508-8624644 Fax: 508-790-6304 Installer&Designer Certification Form Date: ` Z! Sewage Permit# 0-�r 3JACssessor's Ma \Parcel g P Designer: . ��� �°'L �/J��'J �n`Installer: ����a`S �d 7 CC. iP4 Address: �o' �X 71/ Address: 93 0 n ki— � ons v 06 7GO On �dTkG rs C was issued a permit to install a (date) (installer) _ J septic system at based on a design drawn by (address) dated: (designer) t1l, certify that the septic system referenced above was installed substantially according to the design, which'may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. -Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component. of the septic system)but in accordance with State&Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required)was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed in compliance with the terms of the IAA approval letters(if applicable) �No�aaq' TERE-NCE cy HAYES No. 979 C T E� (Designer's Signature) (AffiDps s;-S p Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. �\toa\depts\HEALTIASEWER connect�SEPTIC\Designer Certification Form Rev&14-13.DOC Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w., •'. 1471 Old Post Road Property Address , Peggy Bretz Owner Owner's Name information is required for every _Marstons Mills _ MA _02648 3/23/15 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 A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your 'cursor-do not Michael DiBuono ' use the return key. Name of Inspector DiBuono Sewer and Drain Q Company Name 8 Johns path Company Address S Yarmouth MA 02664 City/Town State Zip Code 508-364-9587 S113522 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 b thre Local pproving Authority 3 26, 3/23/15 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. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts W Title 5 Officia-I Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1471 Old Post Road Property Address — Peggy Bretz Owner Owners Name information is Marstons Mills required for every MA 02648 3/23/15 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: The system contains a 1,500 gallon tank as well as a concrete Distribution box. Distribution box is rotted and in need of replacement. The leaching consists of a single leach pit. I was able to use a sewer camera to identify level in pit. Pit seems to be functioning properly and level at time of inspection was aproximately 22"'s below invert. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 1471 Old Post Road Property Address Peggy Bretz Owner Owner's Name information is required for ever) Marstons Mill! MA Q2648 3/23/15 page. City/Town 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): El obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): System is functioning properly however Dbox is rotted and decayed. ❑ 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 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,•'" 1471 Old Post Road Property Address Peggy Bretz Owner Owners Name information is required for every Marstons Mitls MA 02648 3/23/15 page. CitylTown 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 '/2 day flow t5ins•3/13 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 1471 Old Post Road Property Address Peggy Bretz Owner Owners Name information is required for every Marstons Mill!5 MA 02648 3/23/15 page. City/Town 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 E] ® 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 ❑ ❑ 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—)WPA) 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. 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 �M ,•'' 1471 Old Post Road Property Address Peggy Bretz Owner Owner's Name information is required for every Marstons Mills MA 02648 3/23/15 page. Citylrown 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): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 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 M 1471 Old Post Road Property Address Peggy Bretz Owner Owner's Name information is required for every Marstons MillsMillsMA 02648 3/23/15 page. City/Town State Zip Code Date of Inspection D. System Information Description: The system contains a 1,500 gallon tank as well as a concrete Distribution box. Distribution box is rotted and in need of replacement. The leaching consists of a single leach pit. I was able to use a sewer camera to identify level in pit. Pit seems to be functioning properly and level at time of inspection was aproximately 22"'s below invert. Number of current residents: 2 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)): 2013 69,000 Detail: 2014 61,000 for a total of 178.6 GPD Sump pump? ❑ Yes ® No Last date of occupancy: Occupied 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•3/13 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 wM 1471 Old Post Road Property Address Peggy Bretz - Owner Owners Name information is required for every Marstons Mills' MA 02648 3/23/15 page. Cityrrown 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 M ,•'' 1471 Old Post Road Property Address Peggy Bretz Owner Owner's Name information is required for ever, Marstons Milfs MA 02648 3/23/15 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) Approximate age of all components, date installed (if known) and source of information: 30+ years Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: 18 "s feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): System is vented throu ht the roof Septic Tank (locate on site plan): Depth below grade: 1 ft feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1,500 gallon 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: 3" t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1471 Old Post Road Property Address Peggy Bretz Owner Owners Name information is Marstons Mills MA 02648 3/23/15 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 24"s Scum thickness 3"s Distance from top of scum to top of outlet tee or baffle 42"s Distance from bottom of scum to bottom of outlet tee or baffle "Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to'outlet invert, evidence of leakage, etc.): Tank was at normal operating level. Grease Trap (locate on site plan): Depth below grade: NA 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 N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1471 Old Post Road Property Address Peggy Bretz Owner Owner's Name information is required for every Marstons Mills'" MA 02648 3/23/15 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.): Tees are in place and levels are normal. 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 1471 Old Post Road Property Address Peggy Bretz Owner Owners Name information is required for every Marstons Milfs MA 02648 3/23/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth-of•fiquid level above outlet invert Dbox is decayed and needs.replacement. 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.): Dbox is decayed and in need of replacement. 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: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1471 Old Post Road Property Address Peggy Bretz Owner Owners Name ------------ - information is required for every Marstons'Mills MA ' 02648 3/23/15 page. Cltyrrown 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.): No signs of carry over. no signs of hydrualic failure 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 N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1471 Old Post Road Property Address Peggy Bretz Owner Owner's Name information is required for every Marstons Mills MA 02648 3/23/15 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.): No signs of ponding or h drualic failure. 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntar y Assessments °M 1471 Old Post Road Property Address Owner Peggy Bretz Owners Name information is required for every Marstons Mills MA 02648 31 1./23/15 page. City/Town 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 I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 II r i SU3SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION(cordimied) Property Address: j q71 OLE) owner: W I Ifu 1 P1lU EN Dante of Inspection:�j�! SKETCH OF SEKAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 3 ,ctt 3� revised 9/2/98 Page 10of11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1471 Old Post Road Property Address —- - Peggy Bretz Owner Owners Name information is required for every Marstons Mills MA 02648 '3/23/15 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: 12 + ft 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: 5/17/79 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with loc al excavators, Installers -(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Plan shows NGE at 12 ft Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1471 Old Post Road' Property Address Peggy Bretz Owner Owners Name information equir for is Marstons Mills required for every MA 02648 3/23/1'5 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 aC) No. � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Zipplitation for Disposal *pstem Construction permit Application for a Permit to Construct( ) Repair/Upgrade( ) Abandon( ) ❑Complete System ndividual Components Location Address or Lot No. /S/7/ Ql 05�- Owner's N� e,Address,and Tel.No. �� -lc Sg-4 Vi Assessor's Map/Parcel%Z� /(p(p 461 Installer's Name,Address,and Telf N o.;f 1) ')/-937�9 Designer's Name,Address,and Tel.No. is M� Type of Building: Dwelling No.of Bedrooms AA Lot Size sq.8. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided p'f gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil r Nature of Re airs or Alterations(Answer when applicable) Date last inspected: Agreement: -he undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code n o place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Si d Date Application Approved by Date 3 c, Z,/7 Application Disapproved b Date for the following reasons Permit No. 2©�h 0 5 3 Date Issued Z 5 12,t i Jr No.// 3 Fee /M' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Rpplication for Misposal 6pstetn Construction Vertnit Application for a Permit to Construct( ) Repair/upgrade( ) Abandon( ) ❑Complete System W3 ndividual Components Location Address or Lot No. 0/ Owner's Name,Address,and Tel.No. -'Z A46,es Assessor's Map/Parcel6S7/04<- Installer's Name,Address,and Tel/No. SoS 1) �/-g�`J/ Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures /.n Design Flow(min.required) 6� gpd Design flow provided AM gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank AA Type of S.A.S. Description of Soil Nature of Rairs or Alterations(Answer when applicable)?A-4 Y Date last inspected: t /� Agreement: A,r The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code tl2to placelthe system in operation until a Certificate of Compliance has been issued by this Board of Health. �7 Si sd Date Application Approved by Date /7 Application Disapproved b Date for the following reasons V Permit No. 70 J 0 5 Date Issued Z i --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,/that the On-site Sewage Disposal system Constructed( ) Repaired( � Upgraded( ) Abandoned( )by )36►--6 ( C- at /V7 1 Old jobS 66 �1,/6 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit NoZc))5 -v 53 dated ii 5 Installer Jf t O ,L Designer #bedrooms Approved design how sff, J _gpd W The issuance of this pe itt - 11 not be-construed as a guarantee that the system will ctib �desig fnedr y,+ it ) -- Date �J .�ll lJ / Inspector i. ------------ - - - l v No� 157 _/ � - --- --- --- --- --- - ----------------------------------------------Fee ®-�J-----,- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Disposal fppstet _Cot6truction permit Permission is hereby granted to Construct ) Repair( ) Upgrade( ) Abandon( ) System located at Old PS� &AX 11-4 64- . �_e,,A and as described in the above Application for Disposal System Construction Permit. The applicant.recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permi . Date �j Z� A�� Approved by Y� f N&af.. THE COMMONWEALTH OF MASSACHUSETTS ® U BOAR® OF HEALTH 1 ✓ �Q. /v............OF.... N.sS', /4. �. ' Appliratiou for Uhipaii al Works C ontitrurtion Famit Application is hereby made for a Permit to Construct (s�or Repair ( ) an Individual Sewa Disposal System att ....._......4 ...�'o.l...0 t.l os�� O �L C?. - - •?ass 05% i................4 ocation- ddress or Lot0. Owe Address ►-a !!l..__�_l..C.��.-- •-•----..l.QlYJ. ..1.......................................... ...................................... Installer Address 1�-------^-•----- 5 20 - Type of Building Size Lot____.._ y. _$.....Sq. feet U Dwelling—No. of Bedrooms._.---------------------------------Expansion Attic ( ) Garbage Grinder (DSl Other—T e of Building .... No. of persons............................ Showers — Cafeteria . a+ Other fixtures --------------------- - -- `W Design Flow.................j"'.5 ____....._ gallons per person per day. Total daily flow____-_--� - _....................gallons. WSeptic Tank L-Liquid capacity/$ gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length..__...____.. Total leaching area_.____.. ........sq. ft. Seepage-Pit No----------/....... Diameter.-_-1-2--------- Depth below inlet--------/-------- Total leaching areL� .r....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-____-____-------_---- (i, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P' ------------------------------------------- •--------------- -.--------------------- •......... .------- ------------------------------•---•-........ .------------ 0 Description of Soil................................................................................................._---...-------------------------------------------------•------------- V ----•-•---------------------------------------------••-------------.....--•-------------•-••-------------------------------•-----------------'-------------............................................................ W ---------------------------------------------------------------------------------------------------------------------------------------------------------------------•------------------------•-_..... UNature of Repairs or Alterations—Answer when applicable._...........:.................................................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee sued by the boar of health. Sign ... - ----------------------------------------- - Die ?7 Application Approved By....... �- - ----� .. .. � �' -------------- ....o = Date F--- Application Disapproved for the following reasons---------------------------------------------------------------------------------------------------------------- •-----...-•------------------•----•-----.....---------------•-----------------------•--......----------------------------------------------------------------------------------------------------•------ Date. PermitNo................ - ........ Issued_................................. ._..... 7. Date � Y?E S l•�.-.l �.�.�.��"to � _..___- ---�`_..-- t7A�L�f F'Ww z 1to t 3 aia.P.D" _ u 4;E 1500 t.>t5PO5AL PVT V;E (000 SAL SIVEWALL Ae6A = l89 SC' BoTroAn AQeA- '76 51c F ✓ '� � gSF a I'v - 1?' G P� r l ToTA�. L7E5�6 e.! �JdB G- D v T t4W oeLFf,S. D PICHAM) ',I > H .� -�- 'f125T ( �r^ q �G,= qq + i -roP Fum - Go- c.=R8 77XW7 "" �' 4 P/vA wK• q1.o Svc ¢"lac vt5t cac.. r�•g Blot. �jG-� S6PPiG . Tp�.ltL i' 1' wv GAL. LFAC." 4 Pt '54 b -8/4 0 VIMuw cTuy�. 90 n CE2 T t F i Er-> vl- -r Pl-A t�1 `� i A�Z�yTc?txj !V 't.' Wo S-ALr-- 5G/�t_6 ►'_ Oo VJATVL P oP pLt� �,.t ¢.WreXE.►.tc.E t CmC%i F`f T"AT TKE. �GV L�.C..0 hl(..s SNouv�.► ► se a o%,4 GOMPt-`f S wtr" 'r"F- LT" AwV SETBACw TJS of TWE t"pTv �a � Tb K i�•l (O F /Z i�'e7 A C.C�S 9j�-V 1 n& PAYE t (1 . tJ�� aA) Tel i u`(E. t�.►C.. Qlt—tS'TE 7-em> LAd.in Si}QVE`(Oe� T414P PL&W 1Ii LJOT $o5ED OU AU lQ4TWMEuT OerTe-Z Vt• • AAA.SS• 5uev rf TN4 0FF$Q.T9 SuouLv LAOT ISE USEJ> APPI.tGAatT To -pETr-ZMt uts twoT L(WE;. H�S1�EL.L �.�7 iTt2J ia�.1 w a CO111I0IvtiVEALTH OF IVWSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617)292-5500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address:P y 7` OL A PST Q8 Name of Owner (Ah/1V j KA(/y6A Date of Inspection:2.40_N C/9 Address of Owner: CO TOV iT Name of Inspecton(Please Print)6-,/>W',4A0 C,S4cisl'In o 1 am a DEP approved system inspector pursuant to Section 15.340 of Tide 5(310 CMR 15.000) Company Name: E06',9QO C, 6)04S11EZj0 Mailing Address: T Woe.0 14l:F'.SFIwok-j Cw m4 Od SE3 Telephone Number: 30 99Y E3.23 CERTIFICATION STATEMENT 1 certify that 1 have personally inspected'thd Is disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails cCa Inspector's Signature:� C. �� Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS E00 6.4U0,V S61>7`IG 7` IUK , /Uc1 -SoC 40 S VCR GOOD CONE/7`ION 000 604colry LEACH ,P/r 7_ ,(U0 e_/avl0 — e+ 1 /P.4 1p �® revised 9/2/98 Pagel of11 i�Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: /y7/ 01-0 POST 10 Owner: il.'l1A;1 1<140/VEAJ Date of Inspection: 4—,.� ' INSPECTION SUMMARY: Checia B, C, or A A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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. Indicate yes, no, or not determined(Y,N,or NO). Describe basis of determination in all instances. If"not determined",explain why not. _ The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(30)years prior to the date of the inspection:or the septic tank,whether.or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four 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 II i revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: (y 71 OC4 PoS%AO Owner: W 11AJ11Q111U N Date of Inspection: _ _Iclq I 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 the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT 7HE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis 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. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3orii SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:/4/71 owner: UV I NV I r41WON Date of Inspection: 4_IC yq D. SYSTEM FAILS: You must indicate either"Yes"or"No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No 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 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 112 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 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 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. 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. E. LARGE-SYSTEM FAILS: 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: 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 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 If of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: !q 7I 01-0 POST- Owner-. I,ll 11 N(KR1NE/V Date of Inspection:8-Ip_19 C11 Check;if the following have been done:You must indicate either"Yes" or"No" as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health. _ • None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. NOVS E .AIRS BEEN C111,07Y As built plans have been obtained and examined. Note if they are not available with . _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. The site was inspected for.signs of breakout. _ All system components, , have been located on the site. _ The septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. The size and locaticn of the Soil Absorption System on the site has.been determined based on: Existing information. For example, Plan at B.O.H. _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [15.302(3)(b)) The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: / -/7/ OLO 2®, Owner: ICJ-!IIVif 014147N Date of Inspection:g 4-19 Cl I FLOW CONDITIONS RESIDENTIAL: Design flow: /1,0 g.p.d./bedro m. , Number of bedrooms(design): 7 Number of bedrooms(actual): Total DESIGN flow Number of current residents:D Garbage grinder(&or no):_as Laundry(separate system) (yes or�gf .ALO, If yes,separate inspection required Laundry system inspected (yes or no) Seasonal use(yes or&:/V0 Water meter readings,if available(last two year's usage(gpd): Sump Pump(yes or 4D. 00 Last date of occupancy: L YE/K COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: qpd ( Based on 15.203) Basis of design flow Grease trap present:(yes or no)_ Industrial Waste Holding Tank present: (yeslor nol_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes orb} V If yes,volume pumped: gallons Reason for pumping: TYPE OF SYSTEM _ Septic tank/dis�-Jaax/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components,date installed(if known)and source of information: 1/(S / d&JN67/q Sewage odors detected when arriving at the site:(yes ore revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: q'71 (LLD PLZST RO Owner: t01"Ol rOV Date of Inspection:8—b 1—tiggq BUILDING SEWER: (Locate on site plan) Depth below grade:_ Material of construction:_cast iron_40 PVC_other(explain) Distance frcm private water supply well or suction line Diameter Comments:(condition of joints,venting, evidence of leakage,etc.) SEPTIC TANK: (locate on site plan) Depth below grade: IS(NG-(S Material of construction: iconcrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ Is age confir/ 7'med by Certificate of Compliance_(Yes/No) Dimensions: ��� ���- Ysgr/L+x-5-b�" � Sludge depth: a //iiCMS Distance from top of sludge to bottom of outlet tee or baffle:.31 micks Scum thickness: Say r DS 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 dimensions were determined:T48EIW695(>�2E Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) PL IDUC 7`-ES i 06WID 47-gUM114 OF D07"L6:7-, T4AJK /S /I•' V 67i2Y GOAD Co tub(V GREASE TRAP: (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: r Date of last pumping: Comments: (recommendation for pumping,condition of inlet and outlet tees'or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C J t� SYSTEM INFORMATION(continued) Property Address:! 171 ZJLO PO,SOr ,2D Owner: tAYI9 AJI K41jue-V Date of Inspections- ,yyy TIGHT OR.HOLDING TANK: (Tank must be pumped prior to, or 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 Alarm level: Alarm in working order:Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal,evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER:_ (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.) revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /y7/ oc.o AST RA Owner: (, 1W 114ijUCN Date of Inspection: S-b/1yq SOIL ABSORPTION SYSTEM(SAS)Xr (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: Type: leaching pits,number.,C'F 51,k Four (000 64 UM) L09Cr1 PST' leaching chambers,number:_ leaching galleries,number:_ leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.) PIT, is Finlml— /Uo Uau+n Ar0 ,ponloi/V6 soic 6 DRy CESSPOOLS-_ (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 (cesspool must be pumped as part of inspection) 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.) revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION(continued) Property address: �71 OLD P05T PRO, Owner: ( (1 MICAlly€N Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) S I� revised 9/2/98 Page loorn SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: OLD Ptas7 PP Owner. Date of Inspection: r17 l i NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAMI Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater 6 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Pq fil ' 6PovN-0 W069 /71/9P� 76PO nr�9t' revised 9/2/98 Page 11of11 TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date ' 1 Time: In Out Owner Tenant Lf Address Address f Compli nce Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities Amroved: 12-(rr 6. Heating Facilities ID cvt 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use - 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage,Disposal 17. Temporary Housing 18. Driveway Width 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms Number of Vehicles Allowed (max) Number of Persons Allowed (max) Person(s) Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date 1zhqj10Time: In Out Owner Tenant j II L �1 P Address 1 yy �t? 1"f l LC R ,N�I� 1�.� Address Lf' �L� 1''n0� M 1 Compliance Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities . •�Fiiwirrw_«� 3. Bathroom Facilities , _.#V MD -- 4. Water Supply 5. Hot Water Facilities V ® � �q S 6. Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities r 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 9 17.Temporary Housing 18. Driveway Width to 7,on7C � 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms 3 Number of Vehicles a (m Number of Persons Allowed (max) 5 �Person(s) lnterviewed It. Ql� �v . Inspector If Public Building such as Store or Hotel/Motel specify here FORM30 C&W HOBBSB WARREN TM THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL C TY/TOWN w RTMENT ADDRESS G7N SVByo TELEPHONE Address I Occupants_ Floor Apartment No. No. of Occupants No. of Habitable Rooms No.Sleeping Rooms No.dwelling or rooming units_ No. tories Name and address of owner L Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish /l Containers: need: �. Drainage RI f1 i.A(�. - Infestation Rats or other: tvw6ww STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑I F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room 67 Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: St cks, Flues,Ve afeties: Kitchen Facilities n e Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR. (See Over) "THIS INSPECTION REP IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES R I J -5 INSPECTOR TITLE DATE f TIME lV �" M. A.M. THE NEXT SCHEDULED REINSPECTION / P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises.This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter II, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply'of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for period of 24 hours or longer. (B) Failure to provide heat as required-b'y=105zCM.R 410 201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(Bdr4-1;0:-2_. 0_ 2 (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of Ieadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. � HoBBs&WARREN THE COMMONWEALTH OF MASSACHUSETTS FORM 30Ca BOARD OF H A H CITY/TOWN W D ARTMENT \ n lY/y SV 9 yw ADDRESS ONE _ LEPH Address / I Occupant Floor Apartment No. No.of Occupant No.of Habitable Rooms No.Sleeping Rooms No.dwelling or rooming units_ No.Stories Name and address of owner 14 Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: " rove Drainage -- Infestation Rats or other: mLD Cert. -.•_ STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: Half, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.: s, Flues,Vents,Safeties: Kitchen Facilities Sink Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin, Shower or Tub: Infestation Rats, Mice, Roaches or Other.- Egress Dual and Obst'n: - General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REP, IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PERJU,Y INSPECTOR TITLE 4 ° O� A.M. DATE—a TIME P.M. A.M. THE NEXT SCHEDULED REINSPECTION P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply°of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B)4and.L410 202.;b:;Y" (C) Shutoff and/or failure to restore electriicci y or gaWs. �^" (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of-105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. I FORM 30 CL HOBBS&WARREN TM THE COMMONWEALTH OF MASSACHUSETTS • BOARD OF LX H CITY/TOW W D TMENT �G,M SVey`o /L•l-/A`�l ADDRE �-7 f TELEPHONE l I - Address — Occupant_- Floor Apartmento. No.of Occupants_ No. of Habitable Rooms ' * N Sleeping ping Rooms No.dwelling or rooming units_ No.Stories Name and address of owner Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls.- Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: \ Stairs: -------- Lighting: STRUCTURE INT. Hall,Stairway: r - r Obst'n.: Hall, Floor,Wall,Ceilin : Hall Lighting: Hall Windows: HEATING Chimneys: — Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom 1 3 Bedroom 2 17 3 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.: Sla,Qks, Flues,Vents,Safeties: Kitchen Facilities ink ove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: ' ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION R 0 T IS SIGNED AND CERTIFIED UNDER HE PAINS AND PENALTIES OF PER Y. ' INSPECTOR TITLE -6 DATE TIME U P.M. /�— A.M. THE NEXT SCHEDULED REINSPECTION / P.M. .�` ��� .. ..: _.,_ �' .;ry. t -r. 1 ...1'N`-'�r�" .. i. •ar ^ � ram,}' r .. .. ...... .� ,. '+r{t :•1 I f 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions,when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises.This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter II, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a_supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B)and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish,filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, and.electrical wiring standards or failure to maintain such facilties as are required b 105 CMR 410.351 and 410.352 g q y , gas-fitting so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410,550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. FORM30 C&W HOBBSBWARRENTM THE COMMONWEALTH OF MASSACHUSETTS B D OF H, ALTH CI Y EPAROWN W DT ENT a 1 ADDRESS M S e y`o c I TELEP N Y Address� ! Icy i��' M. — OccupanP/YIrJ �1� V ��� 4 Floor Apartme No. No. of Occi nts '}� U 'P Y C2_ No. of Habitable Rooms No.Sleeping Room No.dwelling or rooming units No.Stories �+_ `_' Name and address of owner�.a�'Y_�Iiu s�l'�� � a , 1 f!�.�I �(v�111�/*Q:2673s— Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: / Drainage r Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches.- Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N E ui . Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den —Living Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.: Stacks, Flues,Vents,Safeties.- Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin, Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Buildin Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS IN ECTIO ORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTI JU " INSPECTO TITLE I A.M. DATE TIME P.M. A.M. THE NEXT SCHEDULED REINSPECTION P.M. 410.750: Conditions Deemed to Endanger..or Impair Health or Safety The following conditions,when found to exist in residential premises,"shall be deemed conditions which may endanger or impair the health, or safety and well=being of a person or persons occupying the premises.This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter II, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included iri this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.880 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180,and 410.190 for a period of 24 hours or longer. (B) , Failure to provide heat as required:by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR-410.200(B)and 410.202.- (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. -- (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway,porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). + (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. I TOP OF FOUNDATION —_--- 20 FT. MINIMUM FROM CELLAR OR CRAWL SPACE ELEV. s — 100.00 10 FT MINIMUM 10 FT. MINIMUM FROM SLAB CLEAN SAND —_—_ (ASSUMED) COTE INSPECTION PORT 4" SCHEDULE 40 PVC PIPE LOAM AND SEED MIN PITCH 1/5- PER FT 2" LAYER 2 1/8' TO 1/2" WASHED STONE OR FILTER FABRIC �� 4" CAST IRON PIPE �"� MAX 97JO UK OTTREQUIRED (OR EQUAL) MINIMUM PITCH 1/4" PER FT. T� Z LE � FLOW LINE ° ELEV = 97.00_ 10" 00000000000 MIN W46 ( ,�•^• • • • o ELEV. BAFFGLAES ELEV. _ -� �6" SUMP V Q0000000000 01' o DISTRIBUTION ELEy • . 0 ❑ O ❑ 0 0 0 0 0 ❑ 0 ° oLE � LIQUID OUTLET BOX _� •o o ° ° ° E7 VDEPTH TEE .• 4 FEET 14 INCHES (EXISTING) TO w•'I<R TESTED 2 500 GALLON GALLEYS WITH 5 FEET 19 INCHES CM /� IF MORE THAN ONE OUTLET STONE !N AN 7 FFEEEET 24 INCHES 1500 GALLON (TO BE PLACED ON FVtM BASE) 13 X 2� X r TRENCH FORMATION is WELL N/A 8 FEET 34 INCHES SEPTIC TANK _ �p���p 3 °0 ZONE 3/4 TO 1 1/'Y CLEM � ABS0RP nON ;� INDEX FREE OF SET SYSTEM SAS H-20 ADJUST SEWAGE DISPOSAL SYSTEM �� uSGs PROBABLE WATER TABLE ELEV. = J J WATER TABLE ( / / ) ELEV. _ NOT TO SCALE BOTTOM OF TEST HOLE ELEV. _ SOIL TEST P#21 --223 DATE OF SOIL TEST AUGUST 9. 2021_ SOIL TEST DONE BY S,WEETFR ENGINEERING WITNESSED BY _-Q, STANTON` - OBSERVATION HOLE 1 ELEV.= "-0 PERCOLATION RATE < 2 _ MIN./INCH AT 44 INCHES WTH HORIZ TEXTURE COLOR MOTT. OTHER 0-5' Ap LOAMY SAND 10YR5/1 NO ROOTS 5-21' le LOAMY SAID IOM/4 - ROOTS _- 21-132' C MEDIUM/COAR. SANC 2.5Y7/4 NO WATER ENCOUNTERED AT --?32_ ELEv. 87.0 OBSERVATION HOLE 2 ELEV.- 98.0 DEPTH HORIZ TEXTURE COLOR MOTT. OTHER 0-5' Ap LO_AMY_SANO 1_0YR5/1 NO ROOTS 5-21'- 8 -- LOAMY SAND 10YR6/4 ROOTS 21-132" C MEDIUM/COAR. S 2.5Y7/4 NO WATER ENCOUNTERED AT _1327 ELEV. 87.0 185- 1g (o� LOT 4 20,498 SQ. FT. Jy 15W GALLON oSEPTIC TANK PIT _ �m W M1 m r 130, l " SOIL TEST TEST 1y ROBIN _ WiLLIAM D 97.8 BOX \ WILCOX N i �.$s N©. 31341 � '4. �G/STEEL J�J .� by 0- I ��v.A L L k DESIGN CALCULATIONS NUMBER Of BEDROOMS 3 N� 2 3 19 1>`� Sin GARBAGE DISPOSAL UNI` °� TERENCE ` ` TOTAL ESTIMATED FLOW 110 OAL./ L/bAY X --I-- BR.) GAL 'DAY HAYES REQUIRED SEPTIC TANK CAE-` - Q_ GAL. u ' ACTUAL SIZE OF SEPTIC TANK (EXISTING) 1000 GAL �IO. 979 SOIL CLASSIFICATION \'STI DESIGN PERCOLATION RATE !!I MIN./IN. EFFLUENT LOADING RATE 034 GAL./DAY/S_F. LEACHING AREA 4 SO. FT. LEACHING CAPACITY (AREA X RATE) 332.9151 GAL./DAY 477.00 X 0.74 NOTES; RESERVE LEACHING CAPACITY III -,AL./DAY I. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P TITLE 5 AND THE TOWN'S RULES AND REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE 2. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO WITHIN OF FINISHED GRADE. APPROVED: BOARD OF HEALTH 3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS. H-20 LOADING SHALL BE USED UNDER OR WITHIN 10 FT OF DRIVES OR PARKING AREAS 4. ANY MASONARY UNITS USED TO BRING COVERS TO GRADE SHALL BE MORTARED IN PLACE. DATE AGENT 5. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR ZONING REGULATIONS OWNER / APPLICANT IS TO -- - OBTAIN R SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. MA TIO I�I �V• PROPOSED SEPTIC DESIGN 6. UTILITIES SHOWN ARE APPROXIMATE ONLY, EXCAVATION CONTRACTOR � y IS TO CALL "DIG-SAFE" AT 1-888-344-7233 AT LEAST 72 HOURS FOR PRIOR SALLY BERQUIST j 7. CONTRACTOR COMMENCING WORK ON SITE.TOR IS TO VERIFY GRADES AND ELEVATIONS AS WELL AS SITE CONDITIONS PRIOR TO COMMENCING WORK ON SITE. ANY VARIATION 26e�,�� -- IS TO BE BROUGHT TO THE ATTENTION OF THE DESIGN ENGINEER IMMEDIATELY. L°� 1471 OLD POST ROAD 8. PARCEL IS IN FLOOD ZONE X 9. LOT IS SHOWN ON ASSESSORS MAP _37__ AS PARCEL _ 65 T111T� �' �Q. 10. EXISTING LEACH PIT IS TO BE PUMPED AND BACKFlLLED WITH SAND. Q� '7 11-�O/.l, �J 11. THE INSTALLER IS TO GIVE THE ENGINEER A MINIMUM OF 48 HOURS .`�' (2 WORKING DAYS) NOTICE FOR THE FINAL INSPECTION (NUMBER BELOW). QJ V) S3� AM� N ZRMG 0 203 SETUCKET ROAD a P. 0. BOX 713 0 508 SOUTH DENNIS. MASS. 385-6900 02660 LEGEND- o __—] IEXISTING SPOT ELEVATION 00,0 DATE AUG. 9, 2021 SCALE 1 " = 20' EXISTING CONTOUR ----00---- ® ------ FINAL SPOT ELEVATION Ell? FINAL CONTOUR SOIL TEST LOCATION V. JOB NC• a C9Br 00 UTILITY POLE _0__ _ ... TOWN WATER —W--m--W— CATGASCLINEA�N �8` LOCATION MAP " SHEET ' OF 1 CLEAN OUT C CESSPOOL C.P. 0 C: �S8�PROlk8598-00\dwg�8598-SAS.DNG 0 2021 SWEETSER ENGINEERING