HomeMy WebLinkAbout0166 OLDE HOMESTEAD DRIVE - Health 'i 66 Olde Homestead Drive
Marstons Mills P
043 001009
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Commonwealth of Massachusetts
. Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
166 Oide Homestead Drive
Property Address
Michael Walker
Owner Owner's Name r l
Information is required for every Marstons Mills MA 02648 9-27-4�
page. Cityrrown 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.
Impo`taint:When A. General Information
filling out farms
an the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not James D.Sears
key the return Name-of inspector
Y
Ca ewide Enterprises,LLC
VQ Company Name
153 Commercial Street
Company Address _
Masse —...
MA 02649
Cityrrown State Zip Code
508-477-8877 S 1623
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 16.340 of
/ p Title 5(310 CMR 15.000).The system:
❑ Passes Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
10-2-14
spectors Slgnature 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 completingthis inspection. If the system is a shared system or
P y y
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.
I
t5vts 3f13 Title 5 OfficialInson remr. ubeurtace Sewage Disposal System.Page 1 or 17
a-
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Oct 02 14 03:42p p.2
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
166 Olde Homestead Drive
Property Address
Michael Walker
Owner Owner's Name
information is required for every Marstons Mills MA 02648 9-27-48
page" Cityrrown 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:
Con pass-need to replace D Box.and con pass per ATT. Barn.B.O.H. Reg.. Pit is located under
paved drive way. Unkown if pit is H-10 or H-20 The system is a 1000 Gal. Tank, D Box and pit. Note:
Filter in outlet tee.
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):
t5ira-3113 Tide 5 Official Inspection Form:Subsurface Sewage Olspcsal System•Page 2 of 17
Oct 0214 03:43p p.3
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
166 Okie Homestead Drive
Property Address
Michael Walker
Owner Owner's Name
inquiredon a Marstons Mills MA 02648 9-27-18
required for every .
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(cunt_):
® 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):
El broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
® distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
Need to replace D Box and Barn Reg Pit under drive unknown if pit is H-10 or H-20.
�r
❑ 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
t5in3•31.3 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 3 of 17
Oct 02 14 03:43p p.4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
166 Olde Homestead Drive
Property Address
Michael Walker
Owner Owner's Name
information is required for every Marstons Mills MA 02648 9-27-48
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier,if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well*".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other.
D) Systems 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 ink is less than 6" below invert or available volume is less
than'/z day flow Ai I-
15ins•3113 Ttle 5 Orficial Inspection Fom1:Subsurface Sewage Disposal System•Page 4 of 17
Oct 0z-14 03:43p p,5
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
166 Olde Homestead Drive
Property Address
Michael Walker
Owner Owners Name
information is required for every Marstons Mills MA 02648 9-27-48
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ 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 I I 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.
t5ms.3113 Title 5 Oflidel Inspection Fam Subsurace Sewage Disposal System•Page 5 of 17
Oct 02 14 03:44p p.6
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
166 Olde Homestead Drive
Property Address
Michael Walker
Owner Owner's Name
information is required for every Marstons Mills MA 02648 9-27-48
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)1310 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
15ins•3rT3 InUe 5 Officiel h apaction Form:Subsurfeoe Sewage Disposal System•Page 6 of 17
Oct 02 14 03:44p p.7
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
166 Olde Homestead Drive
Property Address
Michael Walker
Owner Owner's Name
information is Marstons Mills MA 02648 9-27-48
pagerequired for every Cityrrown
page. State Zip Code Date of Inspection
D. System Information
Description:
The system is a 1000 Gal.Tank, D Box and Pit.
Number of current residents:
0
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
,000Ga1
02
Water meter readings, if available (last 2 years usage (gpd)): 20 2012-1 12-1 0 Gaps
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: NA
Date
Commerciallindustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(9Pd
I
Basis of design flow(seatstpersonslsq.fL,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:
ttina-3+'3 Title 5 Official Inspection corm Subsurface Sewage Dispasat Syslem-Page 7 or 17
Oct 02 14 03:44p p.8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
166 Olde Homestead Drive _
Property Address
Michael Walker
Owner Owners Name
information is required for every Marstons Mills MA 02648 9-27-48
page. citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: NA
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/Altemative 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):
t51ns•3113 Tntle 5 Official hspscfron Fomr.Subsurface Sewage Disposal System•Page 6 cr 17
�I
Oct 02 14 03:45p p,9
Commonwealth of Massachusetts
v Title 5 Official Inspection Form
1= Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
166 Olde Homestead Drive
Property Address
Michael Walker
Owner Owner's Name
information is required for every Marstons Mills MA 02648 9-27-46
page_ CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed(if known)and source of information:
1990 Permit#90-543
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
_
Depth below grade: 40"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.):
Pipeing is 4" PVC SCH 40.
Septic Tank(locate on site plan):
Depth below grade: 28"feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 Gal. Precast H-10
Sludge depth:
1"
t5ins•3113 Tile 5 Ofrrc)al Inspection For=Subsurface Sewage Disposal System-Page 9 of 17
Oct 0214 03:45p p.10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
System Form- Not for Voluntary Subsurface Sewage Disposal y TY Assessments
166 Olde Homestead Drive
Property Address
Michael Walker
Owner Owner's Name
information is Marstons Mills MA 02648 9-27-48
required for every
page. CityrTown 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 29
Scum thickness -
Distance from top of scum to top of outlet tee or baffle 8"
Distance from bottom of scum to bottom of outlet tee or baffle 17'
How were dimensions determined? Asbuilt-Plan -Tape
Sludge Judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc_):
Tank at working level.Tank and inlet cover at 28" below grade w/outlet cover at 8". Inlet tee,
outlet tee w/filter. No sign of leakage or over loading
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
(Sins•3113 Tide 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Oct 0214 03:45p p.11
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
166 Olde Homestead Drive
Property Address
Michael Walker
Owner Owner's Name
required for
�s Marstons Mills MA 02648 9-27-48
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
15ins•3113 Tipe 5 offldal Inspection Form;subsurrace sewage Disposal system•page 1:of 17
Oct 0214 03:46p p.12
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
166 Olde Homestead Drive
Property Address
Michael Walker _
Owner Owner's Name
information is required for every Marstons Mills MA 02648 9-27-48
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 0
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is 16"x16"-44"below grade Wone line out.Wall's are gone. Need to replace box.
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.):
it
* 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•Wa rille 5 Otidal Inspectlon Form.Subsurface Sewage Disposal System•Page 12 of 17
r
Oct 0214 03:46p p.13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
166 Olde Homestead Drive
Property Address
Michael Walker _
Owner Owner's Name -
requir required
is Marstons Mills MA 02648 9-27-48
required for every
Page_ Chyrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
1
® leaching pits number: --
❑ 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.):
Leaching is a 1000 Gal.Precast Pit per plan. Camera from D Box to pit. Pit is dry, past report
9-20-04 pit was half full. Pit under drive way.Unknown if pit is H-10 or H-20.
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
15ins-3713 7Elo 5 Offieiel Inspoaion Form:Subou(ato Sewego Disposal System-Page 136117
Oct 0214 03:46p p.14
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
166 Olde Homestead Drive
Property Address
Michael Walker
Owner Owner's Name
information is required for every Marstons Mills MA 02W 9-27-48
page. cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.).-
Privy (Iccate 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.):
f
15ins-3/13 Title 5 OTcial Inspection form:Subsurface Sewage Disposal System-Page 14 of 1T
Oct 0214 03:47p p.15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
166 Olde Homestead Drive y
Property Address
Michael Walker _
Owner Owner's Name
information is
required for every
Marstons Mills MA 02648 9-27-48
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
r,
A ,,�Z J 3 0.� -roar
k3 = 33 ' 2.
� ' T
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ISas•3113
Title 5 Official Inspection Form_Subsurface Sewage Dismal System•Pape 15 of 17
Oct 0214 03:47p p.16
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
166 Olde Homestead Drive
Property Address
Michael Walker
Owner Owner's Name
information is Marstons Mills MA 02648 9-27-48
required for every
page. City/rown State Zip Code Date of Inspection
D. System Information (cunt.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells N O 13'
Estimated depth to high ground water. feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
5-2-86
If checked, date of design plan reviewed: Date
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
T.H. on Design plan 5-2-86 no G.W.at 13'. Bottom of pit around 10' below grade. Bottom of pit at
around T above T.H.pit.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5im.3J13 Title 5 Vidal Inspection Form:Suburfaoe Sewage Oisposd System•Page 16 of 17
Oct 02 14 03:47p p.17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
166 Olde Homestead Drive
Property Address
Michael Walker
Owner Owner's Name
information is
required for every Marrsttons Mills MA 02648 9-2748
P 9e. T
Y 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-3113 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 17 of 17
Oct 02 14 03:48p p.18
���tHE Thy
Town of Barnstable Barnstable
A&Lens.�srnor.e.
��
,9$ M��. � Board of Health 1�
�679• ��
'°rfo ram" 200 Main Street, Hyannis MA 02601
2Ut17
Office: 508-5624644
FAX: 508-790•6304
October 9,2012
Revised November 20,2013
Public and Environmental Health Program
Policies,Procedures,and Guidelines
H-10 Components Discovered Beneath:Parking Areas and Driveways During Septic System
1.
Inspections Conducted Under 310 CMR 15.301,State Environmental Code,Title 5
No.2012-005
When a DEP certified inspector discovers an.1-1-10 septic system component located beneath a
parking area or driveway during a septic system inspection, conducted under 310 CMR 15.301
State Environmental Code Title 5,the system shall be deemed as a "conditional pass." The
system owner will then be ordered, by the Board of Health,to correct this problem within two(2)
years and will be provided several options to rectify the issue, including by:
a.) replacing the septic system component with a new component relocated into another area
of land which is not beneath any parking area or driveway, and properly abandoning the
discovered H-10 component; or by
b.) replacing the septic system component with an H-20 component beneath the parking area
or driveway, and properly abandoning the discovered H-10 component, (or in the case of
leaching pit, replacing the top of the leaching pit with an H-20 slab top); or by
c.) relocating the parking area or driveway in such a way that no vehicle will have access or
the ability to drive over the existing H-10 septic system component_
If it is unknown whether or not a particular system component which is located beneath a parking
area or driveway, is H-10 or H-20(for example: a leaching pit is located beneath a paved
driveway without an accessible steel cover to grade and there are no records on file indicating
whether the system component is H-10 or H-20),the system shall also be deemed as a
'`conditional pass". In this case, the seller must make the potential buyer(s)aware of the
"conditional pass" status, the unknown construction of the septic syste111 component(s),and it's
Wayne Miller,M.D, Paul Canniff, D.M.D. Juniehi Sawayanagi
4
QVOLICY.ES'HIKomponcrCc8MicathDriveivnys&Parkini;ArusRevised2013.doc
Oct 0214 03:47p p.15
Commonwealth of Massachusetts
CEIREMCM
Title 5 Official Inspection Form
Subsurface Sewage Disposal!System form-Not for Voluntary Assessments
166 Otde Homestead Drive
Property Address
Michael Walker
0W1W Owners Name
ftftrMan is
requiredquired(or every
Marstons Mills MA 02648 9-27-48
pa". cttyrrovm State Zip Code Dote of hispeefon
D. System Information (cons.)
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
13-1 16'
A •a' 3 O.�
A•,�= 33 , a
1
�,•3" Two Soft*ho b"Fam suowleos s.�aps o�sr�•vwo rs ar t?
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in co puter:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Application for Disposal 6pstem Construction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Owner's Name,Address,and Tel.No.
Location Address or Lot No./6(, + �¢�
AAdq
Assessor's Map/Parcel —f90J p AtM �li jjS ' �
Installer's Name,Address,and Tel.No. SO�f�»/' �,39 Designer's Name Address,and Tel.No.
8rlalot C'cv �l-r�c.�l-rart,�nc. Pt2 ��S� N��.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) tjQ4u
re o Q --
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 a of place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
ign "" Date ,
Application Approved by Date
Application Disapproved y Date
for the following reasons
Permit No. !' Date Issued 1
J
oo
No. _ _ - Fee
THE;COMMONWEALTH OF MASSACHUSETTS Entered in computer:
` 'Yes
RUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS '
Rpplication for Nsposal 6pstem Construction permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No./6G AL�6 re� &r(,W— Owner's Name,Address,and Tel.No. 2% 7qy' Y912(�¢J
Assessor's Map/Parcel p -OOI-
Installer's Name,Address,and Tel.No. SoFs-'»�- 9391 Designer's Name,Address,and Tel.No.
/,�rk�lv�".t C'�rz�c.�-/can,:�r-tc.._P•o•�K 7�5� ��/c�.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size.of Septic Tank Type of S.A.S.
Description of Soil
." Nature of Repairs or Alterations(Answer when applicable) NJQJ XJ 0 � S1 t;&J A/ n 4-
rL°'11�1cF(O('C� 1+ -fY, o d C46 {-
162,40-0- f
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 Cod d-not�lace•the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
ign �. M e a- Date 1 /J
Application Approved by /C'' l�/ ,. // `, Date
Application Disapproved y Date
for the following reasons
Permit No. Date Issued J
---------------------------------------------------------------------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
� �C U e_*S �� �`�`� Certificate of �Compriancr
THIS IS TO CERTIFY,that t'he On--site Sewage Disposals stem Constructed( ) Repaired(.�C) Upgraded( )
Abandoned( )by /J r' _o I G( t , 06 Ins�' bl'� :_Lnc-
at/66 "l n &We_-,k,4 Dr U^Q,, has been cons cted';Mated
ce
with the provisions of Title 5 and the for Disposal System Construction Permit No
Installer &r 4 I O Vt, Q:t r rro, =nC • Designer
i
#bedrooms N Approved design flow
�(J I� gpd
The issuance of this permit shall not be construed as a guarantee that the system will Q n f o as`ri designerd.
Date � ; Inspector rkt ^, A
1 �' 1(
---------;��----------------------------------------------------------------------------------------------------------- -------
To. �' Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal 6pstem Construction Vermit
Permission is hereby/granted to
Construct( ) Repaiirr,(k< jU grade( ) Abandon(System located at f V cs� CJG1�� /}')�5�f'Q [r`f'..
L...r
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 -upst��nconipl/e�d rr+ithin three years of the date of this permit. `
Date / !��// /, Approved by e' f
A
•. .. ............ Fizz.. 7,es.�.....
THE COMMONWEALTH OF MASSACHUSETTS
BO.3kRD OF HEALTH
-----.....---roe 41.0F..& ............................
Appliration for Disposal Works Tonstrurtivit Famit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at
...... ................................................
....................................................................
'T, Address
Installer Address
U Type of Building Size Lot..._ feet
Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder ( )
'_l
P4 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria ( )
PL4Other, res ...................................................................................................
Design Flow.......... ......... gallons per person per day. Total daily flow----
...............................gallons.
Wty-
Septic Tank—Liquid*capaci gallons , Length-1)'11-2...... Width................ Diameter................ Depth................
Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. f t.
Seepage Pit No......f------------- Diameter_....._.;2...... Depth below inlet...... ....... Total leaching area 7.*7 , .......4......r.sq. ft.
Z Other Distribution box Dosin tank ) - I i
Percolation Test Results Performed b _4 . .............. Date.45.:no.—ak.............
Test Pit No. 1...*0........minutesperinch Depth of Test Pit..... i.. Depth to ground water......._-.............
Test Pit No. 2................minutes per inch Depth of Test Pit.___._..........._.. Depth to ground water.___._...............__.
----------
------
----------------- ------------------
-------------
-----------
. ....................
0 Description of Soil.........4�n_ ............
-----------------------------------------------------------*-------------------------- -------------------------*-------*-------------------------------------------------------------------
.......................................................................................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
....................................................................................r...................................................................................................................
Agreement:
The undersigned M 'PT-agrees to 10 11 the aforedescribed Individual Sewage Disposal System in accordance with
-1 1
the provisions 5 of tate Sanitary Code— The undersigned further agrees not to place the system in
2ieratio nt Certificate mpliance has been issued by the board of health.
r
........ .. ...................................................................... .......
.............
Date
li
pplicat?h Approved By.................................... .................... .........1-6 —.71f
-----------------------
Date
Application Disapproved for the following reasons:..............................................................................................................
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Date
Permit No._.C�.. Issued.......................................................
Date
'
THE ooMMowvvsxcr* or mAssACxussrrs
���~��� ���� ���� HEALTH
� �����=" ~�~ �~" |
� �� � �r. | \
__------------.��F,I°���]�
��� ^�
������lir*otiou� ��� ��ws���«��ool Works Toustrurtioou Frrutot
Application ���
is hereby �oudefor u Permit to Construct ( . / or Repair ( ) an Individual Sewage Disposal
Owner Address
-----------------'--'------------'-----'--'---'--'- '--------------'----'----'------'------'--------'- |
Ins tall er Addres s
Type o6Building Size Lot-'/ -8g' feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. u6 persons............................ Showers ( ) -- Cafeteria ( )
~c --- '----'----'-'------------'-'- - '—'-'-'—'
DisposalTrench�b I�u --l_--_' Diameter 1��- D��b ��o~ b�ct__���__' Total �ucbb�|urea�� b.
_ _--,-"- �� -- -' -- ___,_',
Z Other Distribution box Dosing tankJ
~~ Percolation Test Result Performed bvo/AJ-/K� �iL/\i --- D�e-��' 7�'��'��----_'
Test Pit No. ]-~��.--o�uutcay�r�o6 Dr�t� c6 Iout'�d.-|��.-.-- Do�6to e�ouodvrut�r--................ �
Test Pit No. 2................minutes per inch Depth of Test I'iL.--.------. Depth to ground water.-----------
0 Description o6 Soil_ ......... '---'_-----
---''------'----------'---'------------'----------------'--'----'------'--'----'-----'------
----''r---------'---'-'--'----'----'---'-------'-------'--'---------'------'--'----
L) Nature of Repairs or Alterations--Answer when applicable.-----.----------..-_----.--'-------------.. |
'-----'------''--''--''--------------'----'-'-----'---'--'---------'-'----------------
� Agcccozcur:
The undersigned agrees to 11 the aforedescribed Individual Sewage Disposal System in accordance with
the provisionsATITLE 5 of ate Sanitary Code—The undersigned further agrees not to place the system in
'5eration ntil ertificate mpliance has been issued by the board of health.
Date
p PI ti3
Date
Application Disapproved
for the following reasons:.............................................................................................................. �
-------------------'--''--------------------'-----------'---''---'----------'-------
�1Z Date
PerozitN Issued'.......................................................
THE COMMONWEALTH orxxAssAcnussrTs
BOARD OF HEALTH
/x^�,m�/��7
----'�.�.�------.��F---���� ..............................................................
����
w�4���ufir��tr 4x Toutpliauurr
THLY IS TO CERTIFY That the Individual Sewage DisposalSystem constructed (/) or Repaired / )
bc--_--�-��'�--���'����'�'�'��-'............................................................................................................................................
..y\/___ ____ __________________
has been instilled- _ in accordance with -_ provisions-- of -
i�Tl o he te Sa;' Code as described in the
application for Disposal Works Construction Permit No.......
THE ISSUANCE OF THIS CERTIFICATE SH;�L��Of=EC �STRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.-----'-'----------'-_'-.'---'------'_--'-- I ---------'-------'----'----'---'__'__'-----
THsCowwomvxsAcr* ormAssAcHuscrrs
BOARD OF HEALTH |
�
a/ _""
� ----�i��'�------.��F---^�����^��-��1�Z�����--------'
------------- ------'-'-..........
amit
- Disposal '
Permission is hereby granted....[7.�� '�\/�
to Construct or Repair an Individual Sewage Disposal System
at Nu.�A ������1� �
- au shown oo the oppl�ut600�rDisposal Works Construction - ate
~------ '
......................-_-=�----'�����'���_�.�-----.--'-------
CATE' �9 ............. '
ponM /usm *oasowWARREN. INC.. puouaxEns
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' SITE PLAN SHEET I of 2
SCALE: I = 40"
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�o tiVILLIAM
o m;
WARWMCK Z
No. W71. o/
�F61STlik
.PydL LliiU� .
REGISTERED LAND SURVEYOR
26NE MA r',e-,i,:La 1 MAe�,2,
PLAN .REF. dcl'r 0 r- M A P 4$ DATE LEA (o
BENCH MARK DATUM 4) M/ ' UA�'Ut� WM. M. WARW'ICK 8 ASSOC., INC.
DOMESTIC WATER SOURCE-TOuJiJ w�r fi� 8oX 80I - NORTH FAL MOUTH
FLOOD ZONE.-N OL - HAZ-�SAID �G �� MASS. 02556 - (617) '563 -26 38
C QAS N SECTION NOT. . or TO SCALE sh�'c� Z f Z
24 C.L MH COVER
i EARTH F/L L BRICK AND MORTAR COURSES AS REO'D• TO BRING
COVER TO GRADE
8'FLOW LINE /
INLET L_ _ __ __:1 2' TO/" WASHED PEA 5TONE FREE OF IRONS,
FINES AND DUST /N PLACE
l I 3/4" TO /%2"WASHED CRUSHED STONE FREE OF
" OPENING WITH 4%B" IRONS, FINES AND OUST /N PLACE
% OUTER DIAMETER
AND l314" INS/DE "
DIAMETER "
�ovU cqA I. CONCRETE TO BE 4000 PSI 28 DAYS
t,r,A6-t-r. rl-` 2. REINFORCED WITH 6"x6" NO. 6 GA. W.W.M.
3. 2'AND 4' SECTIONS ARE AVAILABLE FOR
I " GREATER DEPTH REQUIREMENTS
40 r— 6'0" 2--� 4. NUMBER OF PITS REQUIRED 0OO
I
MIN' I NOTE: EXCAVATE TO ELEVATION GZ if OR EFFECTIVE DAME ER
(NOT TO EXCEED 3 TIMES EFFECTIVE DEPTH) LOWER AS REQUIRED TO REMOVE ALL
- WATER TABLE - LOAM AND CLAY BENEATH PIT. REPLACE .
EXCAVATED MATERIAL WITH CLEAN
TYPICAL PROF/LE GRAVEL TO DESIGNED GRADE.
SZ /B"STO. LT. WGT. C.I. MH COVER
8•I, .,• 1{',O ov �O
` 4"B/T.FIBER PIPE
/P/PE TIGHT JOINT OUTLET LEVEL
i DWELLING FLOW LINE, _ TO FIRST JOINT
'v /4 O 00 1 10 00 11
1 GV C./. TEEi ��I /,(.?� I I0 O0 1 1
if 0'O 00-1_I 1 1 ;
•N✓ S,jj PRECAST CONC. 1 0 0 0 0 0 0 1
tr j fJ �D/ST. BOX TO BE ' I I
��UGAL.SEPTIC TANK INSTALLED ON LEVEL, 1 1 1 0 00 0 0 0 1 1 1
STABLE BASE 1 1 1 100 ,00 0,1 I I
B •• .. ..:. �;: :.. III 100 00 0 1
SEPTIC TANK TO•BE I I 1 000 00 0 1 1
INSTALLED ON LEVEL I I I 100100 1
STABLE BASE. 1 1 1 0 0 0 0 0 0 1 1 1
11 000 O 0 1 1 , 1
LEACHING BASIN p
BASE TO BE LEVEL 1 1 1 18 0 0 0 pit
SOIL AND PERC. DATA P557o
:PERC. RATE MIN. /IN. 0�� TEST PIT N0. I 0., ST PIT N0. 2
TEST BY — ��1�/SvW�iot►� Gw�e �a ai_
o G�QY u� �i �(pa (
.WITNESSED. BY: T M 'M� LI;N 7..
TEST PIT GR. EL.
�v� o -� M b'L) I`h
DATE: 5-Z' t'v ,A 0 D el
NO
DE5I6N DATA GENERAL NO TES
BEDROOMS NO HEAVY EQUIPMENT TO RUN OVER SYSTEM.
DISPOSAL SEPTIC TANK, DIST. BOX AN LEACHING BASINS TO BE STANDARD
EST. TOTAL DAILY EFFL�2'-fGPD. PRECAST REINFORCED CONCRETE UNITS.
SEPTIC TANK GAL. ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN ACCORDANCE
SIDEWALL AREA z'SGAL./SQ.FT. TO REVISED TITLE 5 OF THE STATE ENVIRONMENTAL CODE,
MINIMUM REQUIREMENTS FOR THE SUBSURFACE DISPOSAL OF
BOTTOM AREA I -f GAL./SQ.FT. SANITARY SEWAGE EFFECTIVE ON JULY 1 , 1977.
:.LEACHING REQUIRED-172 SQ..FT.• ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD
ACTUAL LEACHING AREA
� OF HEALTH.
�SQ,FT. AT COMPLETION OF CONSTRUCTION, PRIOR TO BACKFILLING, THE
BOARD OF HEALTH SHALL BE NOTIFIED FOR INSPECTION.
PITCH ALL SEWER LINES I/4" / FT. UNLESS INDICATED OTHERWISE.
OF Af _4�,
>� �ss9 � SEWA GE DI SPOSA L SYS TEM
MARTIN yN
w MORANiA,,(7 �
•AE` rF23417�Q�� p�� �
o G/ST�c�\ate .--_
- S�°fQHAL O I(y�l`6
`a SCALE AS INDICATED OAT£-
WM. k WARWICK 8 ASSOC., INC.
80X 80/ - NORTH FAL MOUTH
MASS. OZ556 - (6/7) 5 63-2638
`PROFESSIONAL ENGINEER
........::
op 9�� � - T WN OF, N T BLE
Oka
LOCATION L q qow(-2 r04 .--e SEWAGE #
VILLAGE MA0,4i,,S (Mtt(S ASSESSOR'S MAP & LOTQ
INSTALLER'S NAME & PHONE NO. '�-1, D65C 1(
SEPTIC TANK CAPACITY 11000 god"�,.S
LEACHING FACILITY:(type) �emc(, 1);+ (size) I,Oro 2gi(-,(Ar
NO. OF BEDROOMS _PRIVATE WELL O PUBLIC WATER
BUILDER OR OWNER 1�4ys'4 P»'td:- �'
DATE PERMIT ISSUED: j ^ / 7
DATE COMPLIANCE ISSUED: Z,
VARIANCE GRANTED: Yes No Z/
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■ qx ID"7 ".
i
43
C p
a .IAL .E
Ln
rp Postage $
fLJ
Certified Fee ,r,' 0
O Postma Y
p ReturnReceipt Fee Here
O (Endorsement Required) NOV_c to a
Restricted Delivery Fee J 2014
O (Endorsement Required)
h.
rq
p Total Postage&Fees $ (j
Thomas and Katherine Ryan, Jr.
E
r c/o Lacy A. Walker Co-Trustees
166 Olde Homestead Drive
Marstons Mills 02648
Certified Mail Provides:
o A mailing g9ceipt "~
o A unique identifier for your mailpiece
o A record of delivery kept by the Postal Service for two years
Important Reminders:
o Certified Mail may ONLY be combined with First-Class Mails or Priority Mails.
o Certified Mail is not available for any class of international mail.
e NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For
valuables,please consider Insured or Registered Mail.
o For an additional fee,a Return Receipt may be requested to provide proof of
delivery.To obtain Return Receipt service,please complete and attach a Return
Receipt(PS Form 3811)to the article and add applicable postage to cover the
fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for
a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is
required.
o For an additional fee, delivery may be restricted to the addressee or
addressee's authorized agent.Advise the clerk or mark the mailpiece with the
endorsement"Restricted Delivery°.
o If a postmark on the Certified Mail receipt is desired,please present the arti-
cle at the post office for postmarking. If a postmark on the Certified Mail
receipt is not needed,detach and affix label with postage and mail.,. r t
IMPORTANT:Save.this receipt and present it when making an inquiry,
PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047
® Complete items 1,2,and 3.Also complete A. Sig ure.
item 4 if Restricted Delivery is desired. ❑Agent
® Print your name and address on the reverse X ❑Addressee.
so that we can return the card to you. B. Received b, f tinted Name) C.,Date of Delivery
o Attach this card to the back of the mailpiece,
or on the front if space permits.
D. Is delivery address different from item 1? ❑Yes.
1, Article Addressed to: If YES,enter delivery address below:. O No
t.
Thomas°nand-Katherine Ryan, Jr.
C/o Lacy.:A`Wa'fl er Co-Trustees
166 Olde-Hornestead Drive 3. Service Type
Marstons Mills:02648 ❑Certified Mail 13 Express Mail
❑Registered ❑Return Receipt for Merchandise
❑Insured Mail ❑C.O.D.
4, Restricted Delivery?(Extra Fee) ❑Yes
2._Article Number
(Transfer from seretce label j(j j i 1 j _ '`7 012 i 10110 i,0 0 0 0 i t 2 8 51, 3887 Fli j
PS February 2004` '.. Domestic Return Receipt 102595-02-M-1540
UNITES STATE Pr=Q:�T�f�rY� � r^. � �, '"", "" "Fi steM •MaT ,s...
_.
.�age" e ••Pahl. �
OS
encler: Please print your name, address, and ZIP+4 in this box •
Town of-Barnstable
Public Health Division
I 200 Main Street
I Hyannis, MA 02601
Ili ii , its i� ls=i't i� =a == l f,""ul1 li�iiiaiilf"i i
I l� � �� �I TI• i� , I�i� i' ��ri �t 1 is =
Town of Barnstable Barnstable
;; . .. ; Regulatory Services Department
�STABM 1 1
Public Health Division
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Richard V.Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL#7012 1010 0000 2851 3887
Thomas and Katherine Ryan, Jr. November 3, 2014
.c/o Lacy A. Walker Co-Trs
166 Olde Homestead Drive
Marstons Mills, MA 02648
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 166 Olde Homestead Drive, Marstons Mills, MA,was last
inspected on 9/27/14, by James D. Sears, a certified septic inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Conditionally Passes"
under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• • A system component (leach pit) is located beneath the driveway. It is
unknown whether it is constructed of heavy duty loading (1120)which is
designed for vehicular traffic.
When it is unknown whether or not a particular system component which is located
beneath a parking area or driveway, is H-10 or H-20 (for example: a leaching pit is
located beneath a paved driveway without an accessible steel cover to grade and there are
no records on file indicating whether the system component is H-10 or H-20), the system
shall also be deemed as a"conditional pass".
In this case, the seller must make potential buyer(s) aware of the "conditional pass"
status, the unknown construction of the septic system component(s), and its safety
concerns.
Also in this case, the distribution box needs to be replaced. You are ordered to replace
the distribution box within sixty (60) days from the date you receive this notification..
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
omas McKean, R.S., CHO
Agent of the Board of Health
Enclosure: Copy of Town of Barnstable Policy: H10 Components...No.2012-005
Q:\SEPTIC\Conditionally Passes Ltr\166 Olde Homestead Drive-2-Unknown H10 H2O drivewal0-22-14.doc
f
pn
COMMONWEALTH OF
MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
f DEPARTMENT OF ENVIRONMENTAL PROTECTION
1+ Y
i-4AP F
i
W
e 0cE>, OCT 0 5 2004
fi
OT
TOWN OF BARNSTABLE
TITLE 5 HEALTH DEPT.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 166 OLDE HOMESTEAD DRIVE MARSTONS MILLS,MA 02648
Owner's Name: LYON
Owner's Address: 166 OLDE HOMESTEAD DRIVE MARSTONS MILLS,MA 02648
Date of Inspection: 9/20/04 LOrY
Name of inspector: (please print) JOHN GRACI,INC.
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536
,
Telephone Number: 508-564-6813 FAX 508-564-7270 =
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below 3s
true,accurate and complete as of the time of the inspection. The inspection was performed based on my.--j 1,g ands `1'
experience in the proper fimction and mainte rice of on,site sewage disposal systems. I am a DEP approved system
inspector pursuant to Section 15.340 of ' e 5(310 CMR 15.000). The system: ''
X Passes cri M
_ Conditional sses
_ Needs Furt valuation by the Local Approving Authority
Fails
Inspector's Signature: , Date: 9/20/04
The system inspector shall submit.a c py of this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this inspecti If the system is a shared system or has a design flow of 10,000 gpd or greater,the
inspector and the system owner shal submit the report to the appropriate regional office of the DEP. The original should be
sent to the system owner and copies ent to the buyer, if applicable, and the approving authority.
Notes and Comments
SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
****This report only describes cond
itions 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.
Titles S (ncnertinn Form 6/1 S/?nOO 1
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PA
RT A
CERTIFICATION (continued)
Property Address: 166 OLDE HOMESTEAD DRIVE MARSTONS MILLS,MA 02648
Owner: LYON
Date of Inspection: 9/20/04
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X 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:
SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
B. System Conditionally Passes:
_ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,
upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain.
n/a The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits
substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced
with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally.sound,not leaking and if a Certificate of Compliance indicating
that the tank is less than 20 years old is available.
ND explain: n/a
n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed
pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of
Health):
_ broken pipe(s)are replaced
_ obstruction is removed
_ distribution box is leveled or replaced
ND explain: n/a
n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
_broken pipe(s)are replaced
_obstruction is removed
ND explain: n/a
h
Page 3 of 1 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 166 OLDE HOMESTEAD DRIVE MARSTONS MILLS,MA 02648
Owner: LYON
Date of Inspection: 9/20/04
C. Further Evaluation is Required by the Board of Health:
Conditions exist which rewire further evaluation by the Board of Health in order to determine if the system is failing to
protect public health, safety or the environment.
I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is
not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water
supply or tributary to a surface water supply.
_ The system has a sep,.ic 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-ised to determine distance n/a
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and
volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A co
of the analysis must be attached to this form. py
3. Other:
n/a
Page 4 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 166 OLDE HOMESTEAD DRIVE MARSTONS MILLS,MA 02648
Owner: LYON
Date of Inspection: 9/20/04
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all-inspections:
Yes No
- X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
- X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
- X Liquid depth in cesspool is less than 6"below invert or available volume is less than'h day flow
- X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped SYSTEM PUMPED 2003 PER OWNER.
- X Any portion of the SAS, cesspool or privy is below high ground water elevation.
- X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone I of a public well.
- X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
- X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP
certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.]
NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in
310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
- X the system is within 400 feet of a surface drinking water supply
- X the system is within 200 feet of a tributary to a surface drinking water supply
- X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat
under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner
should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 166 OLDE HOMESTEAD DRIVE MARSTONS MILLS, MA 02648
Owner: LYON
Date of Inspection: 9/20/04
Check if the following have been done.You must indicate"yes" or"no"as to each,of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period`?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out?
X _ Were all system components,excluding the SAS, located on site?
X _ 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 ?
X _ Was the facility owner(and occupants if different from owner)provided with information om the proper maintenance
of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
X _ Existing information. For example,a plan at the Board of Health.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable) [310 CMR 15.302(3)(b)]
5
Page 6 of 11
OFFICIAL INS
PECTION FOR
M—NOT FOR VOLUNTARY ASSE
SSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 166 OLDE HOMESTEAD DRIVE MARSTONS MILLS,MA 02648
Owner: LYON
.Date of Inspection: 9/20/04
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
Number of current residents: I
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): NO
Seasonal use: (yes or no): NO
Water meter readings, if available(last 2 years usage(gpd)): nfa 0 � _ l C6
Sump pump(yes or no): NO
Last date of occupancy: n/a U 3 - (p(�(7 oo
COMMERCIAL/INDUSTRIAL U Z - 160; 6�
Type of establishment: n/a
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sqft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information: SYSTEM PUMPED 2003 PER OWNER
Was system pumped as part of the inspection(yes or no):NO
If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X Sep=ic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records, if any)
_lrmovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from
system owner)
_Tight tank Attach a copy of the DEP approval
Other(describe): n/a
Approximate age of all components,date installed(if known)and source of information:
1992 PER OWNER
Were sewage odors detected when arriving at the site(yes or no): NO
Page 7 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 166 OLDE HOMESTEAD DRIVE MARSTONS MILLS,MA 02648
Owner: LYON
Date of Inspection: 9/20/04
BUILDING SEWER(locate on site plan)
Depth below grade: 0"
Materials of construction:_cast iron —40 PVC Xother(explain): 20 PVC
Distance from private water supply well or suction line: n/a
Comments(on condition of joints, venting, evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade: 0"
Material of construction:Xconcrete_metal .fiberglass—polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: L 8' 6" H 5' 7" W 4' 101111'
Sludge depth: I"
Distance from top of sludge to bottom of outlet tee or baffle: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 18"
How were dimensions determined: MEASURED
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage, etc.):
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.
GREASE TRAP:_(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related
to outlet invert,evidence of leakage, etc.):
n/a
Fage 8 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Prop
erty Address: 166 OLDE HOMESTEAD DRIV
E MARSTONS MILLS,MA 02648
Owner: LYON
Date of Inspection: 9/20/04
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass—polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level:N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches, etc.):
n/a
DISTRIBUTION BOX:X(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into
or out of box,etc.):
D-BOX IS STRUCTURALLY SOUND.
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
R
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 166 OLDE HOMESTEAD DRIVE MARSTONS MILLS,MA 02648
Owner: LYON
Date of Inspection: 9/20/04
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
1000 GAL 6' X 6' leaching pits, number:
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.):
DID NOT EXPOSE,LEACH PIT UNDER DRIVEWAY.PIT WAS VIDEO INSPECTED AND APPEARS TO BE
STRUCTURALLY SOUND.PIT WAS HALF FULL AT TIME OF INSPECTION.RECOMMEND EXPOSING AND
RAISING COVER.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 166 OLDE HOMESTEAD DRIVE MARSTONS MILLS,MA 02648
Owner: LYON
Date of Inspection: 9/20/04
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.
Lccate all wells within 100 feet. Locate where public water supply enters the building.
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Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 166 OLDE HOMESTEAD DRIVE MARSTONS MILLS,MA 02648
Owner: LYON
Date of Inspection: 9/20/04
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 12+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans.on record-If checked,date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators,installers-(attach documentation)
NO Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
HAND AUGER- 12+FT.
L