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HomeMy WebLinkAbout1652 OST.-W.BARN. RD - Health FA 52 0- tt, W a ►ten - stons Mills P ---- — - --- = 127 006 y, • �a� � a� Commonwealth of Massachusetts f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 1652 Ostetville-West Barnstable Road Property Address Richard &Maureen Mahoney Owner Owner's Name / information is Marstons Mills �/ Ma 02648 5/11/2021 required for every page. Citylrown State Zip Code Date of Inspection E Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information 510 16 31aq on the computer, use only the tab Sean M. Jones key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. 74 Beldan Lane 00 Company Address Centerville Ma 02632 City/Town State Zip Code 774-2484850 smjonestitle5@gmaii.com, SI4522 sean@smjonestibe5.com License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 16.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 5/11/2021 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.MAW Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 q Commonwealth of Massachusetts Title 5 Official Inspection Form lowSubsurface Sewage Disposal System Form-Not for Voluntary Assessments 1652 Osterville-West Barnstable Road Property Address Richard &Maureen Mahoney Owner Owner's Name information is required for every Marstons Mills Ma 02648 .0 5/11/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1)-System'Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The property located at 1652 Osterville-West Barnstable Rd. Marstons Mills is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and 9 ARC 36 leaching chambers.Although the system was found to be in proper working condition at the time of inspection this report does not guarantee future performance under similar or increased usage. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5insp.doc•rev.7/2612018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts -� Title .5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1652 Osterville-West Barnstable Road Property Address Richard &Maureen Mahoney Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/11/2021 page. cityrrown - State Zip Code Date of Inspection C. Inspection Summary (coot.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Cow'd of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5kisp,doc.,v;7fAM18 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Pape 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1652 Osterville-West Barnstable Road Property Address Richard&Maureen Mahoney Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/11/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: 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 t5nsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subswilaos Sewage Disposal System•Pape 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1652 Osterville-West Barnstable Road Property Address Richard&Maureen Mahoney -- Owner Owner's Name information is Marstons Mills Ma 02648 5/11/2021 required for every page. Cityrrown State Zip Code Date of Inspection C., Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® ; Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy ofe thic-i anialysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 110,000 gpd. ❑ ® The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be cous£' itc- a ryv:ea'.ti a a fac-111y"s': i a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the syst m is mliihin 400 foot of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5msp.dae-rev.,7/26/2018 Tide 5 official Inspection Form:"swfsce Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1652 Osterville-West Barnstable Road Property Address Richard&Maureen Mahoney Owner Owner's Name information is Marstons Mills Ma 2 required for every 0 648 5/11/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for-the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (f any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)1310 CMR 15.302(5)] tSlnWdoc•rev.7lAMI8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1652 Osterville-West Barnstable Road Pr3perty Address Richard&Maureen Mahon Owner Owner's Name information is Marstons Mills Ma 02648 5/1.1/2021 required for every page. City/rown State Zip Code Date of Inspection D. System Information 1. 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 gpd Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): - Detail: Sump pump? ❑ Yes ® No current Last date of occupancy: Date t8insp.doo-rev,7/2612018 rdle 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 or 18 Commonwealth of Massachusetts Title 5 Official Inspection Form k't 9W I - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1652 Osterville-West Barnstable Road Property Address Richard&Maureen Mahoney Owner Owner's Name information Is Marstons Mills Ma 02648 5/11/2021 required for every Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/lndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: °. Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.71AWI8 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 16 Commonwealth of Massachusetts -� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1652 Osterville-West Barnstable Road Property Address Richard&Maureen Mahoney Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/11/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box,soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components,date installed(if known)and source of information: system repaired 3/2012 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 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.): Inlet of tank under patio and is not accessible. t5insp.doe•rev.71282018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts uv. Title 5 Official Inspection Form Subsurface Sewage Disposal System Foam-Not for Voluntary Assessments 1652 Osterville-West Barnstable Road Property Address Richard&Maureen Mahoney Owner Owners Name information is required for every Marstons Mills Ma 02648 5/11/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain) ._..._..... If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes No Dimensions: 1000 gallons Sludge depth: 5„ T Distance from top of sludge to bottom of outlet tee or baffle - Scum thickness 2° Distance from top of scum to top of outlet tee or baffle !n Distance from bottom of scum to bottom of outlet tee or baffle -1Olt How were dimensions determined? Opened covers and took measurements_ 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 does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance.water level was even with outlet,tank was not leaking and was structurally sound. ...................... t5insp.daa-rev.'712SM18 Title 5 Official inspection Farm:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-'Not for Voluntary Assessments 1652 Osterville-West Barnstable Road Property Address Richard&Maureen Mahoney Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/11/2021 C frown page ity State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet — Material of construction: ❑concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle -- - Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day tS .doc-re.M26 018 TItIe 5 Official Inspection Form:subsurface sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form,-Not for Voluntary Assessments a. r 1652 Osterville-West Barnstable Road Property Address Richard &Maureen Mahoney Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/11/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9.. Distribution Box(if present must be opened)(locate on site plan): oil Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box was video inspected and found in good condition with no rot. Water level was even with outlet invert. t5vrspAoc-rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form k'�'Wj Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1652 Osterville-West Barnstable Road Property Address Richard&Maureen Mahoney Owner Owner's Name information isMarstons Mills _Ma 02648 5/11/2021 required for every ___ page. Ctyrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System(SAS)(cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): s.a.s.consists of 3 rows of 3 ARC leaching chambers in a 32.4x8.5 field. Leaching facility was inspected from obs port and found dry with a clean sand bottom. 12.. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration -- — ----- Depth-top of liquid to inlet invert Depth of solids layer - Depthof scum layer ---............._._......_.._._..............._.._.__........_........_____.____ Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,, etc.): fS l5insp.doc-rev.MM01 B Title 5 Ofrr4al Inspection Form:Subsurface Sewage Disposal System•Page 14'of 18 i 3 i Commonwealth of Massachusetts ;' action Form Official inspection Assessments Title 5 Of f Subsurface Sewage Disposal System Form- Not for Voluntary 1652 osterville-West Barnstable Road Property Address N Richard&Maureen Mahone Ma 0264�_ 5f 1112021 owner Owner's Name _ Date of Inspection information is State Zip Code required for every Marstons Mills CttylTown page. D. System Information (cont.) 10. Pump Chamber(locate on site plan): ❑ Yes ❑ No* Pumps in working order: ❑ Yes ❑ No* Alarms in working order: appurtenances,etc.): Comments(note condition of pump chamber,condition of pumps and orlon order, system is a conditional pass. « s or alarms are not in working� m If pumps ul 11. Soil Absorption System(SAS)(locate on site plan,exc avation not required) If SAS not located, explain why: j Type: number: leaching pits 9 ARC 36 I ❑ number: Chambers leaching chambers number leaching galleries - " ❑ number, length: ti g, ❑ leaching trenches `� ❑ number,dimensions: leaching fields ❑ overflow cesspool number. ,y . ❑ innovativelaltemative system P Typeiname of technology' Inspedion form:sub-face Sewage piaposal System•Page 13 of 18 y pir�cial :> �¢�p.doc•rev.712812018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1652 Osterville-West Barnstable Road Property Address Richard&Maureen Mahoney Owner Owner's Name information is required-for every Marstons Mills Ma 02648 5/11/2021 page. City/rown state Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1652 Osterville-West Barnstable Road Property Address Richard &Maureen Mahoney Owner Owner's Name --- — -- -- information is required for every Marston Mills Ma 02648 5/11/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately wu, A•asc-i6.S DWc-St,S BACK -k5•A5-5'` 5 -k mzs.�--p65 t ue,*c;b foS 'PATiO $ouT-26.1- DDcK-0,4 t'�s A•5--�t Vt.%*60tt--Tj�,:� J Frwcr- Ht I H2O ta�glc�s tJ�rvt�obs�t. ' t5insp doc-rev.7/2M18 Title 5 Official inspection Form:Subsurface Sevmge Disposal System•Page 16 of is Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1652 Osterville-West Barnstable Road Property Address Richard&Maureen Mahoney Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/11/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 115. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12r+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date - ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater was established by accessing town of Barnstable groundwater contour maps. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5insp.dw•rev.U26=18 Idle 5 official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1652 Ostervilie-West Barnstable Road Property Address Richard&Maureen Mahoney Owner Owners Nam —� information is required for every. Marstons Mills Ma 02648 5/11/2021 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed &Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3,or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8:Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5lnsp.doc•rev.7126f2018 Idle 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 18 of 18 ENVIROTECH LABORATORIES,INC. HA CERT.NO.:M MA 063 8 Jan Sebastian Drive Unit 12 Sandwich,MA 02563 (508)888-6460 1-800-339-6460 FAX(S08)888-6446 Client Name: Mahoney,Richard&Maureen Location Address; PO Box 242 1652 Osterville West Barnstable Rd, W Barnstable,MA Marston Mills,MA 02668 Lab Number: DW-210896 Collected By: Richard Mahoney Date Received: 03/1821 Sample Type: Kitchen Faucet Well Specs: Existing Well Location Source' Date CoAected T7itie Collected - Comments A 03/18/21 11:30 Analysis Requested Units Recommended Limits Analysis Result Method Date Analyzed Analyzed By Total Coliforrn CFU/100mL 0 0 SM9222B 03/182021 NB @ 13:00 pH pH units 6.5-8.5 T 6.52 SM 4500-H-8 03/18/2021 _ SD Specific Conductances umhos/cm 500 121 EPA 120.1 03/182021 SD Nitrite-N mg/L 1.00 <0.006 EPA 300.0 03/182021 _ SD Nitrate-N mg/L 10.0 0.61 EPA 300.0 03/182021 _SD Sodium mg/L 20.0 11 EPA 200.7 03/232021 KB Total Iron mg/L 0.3 0.01 EPA 200.7 031232021 KS Manganese mg/L 0.05 0.006 EPA 200.7 03/232021 KB Comments: All samples were analyzed within the established guidelines of US EPA approved methods with all requirements met, unless otherwise noted at the end of a given sample's analytical results. We certify that the following results are true and accurate to the best of our knowledge. Water meets EPA standards and is suitable for drinking for parameters tested. Date 3/24/2021 Ronald J.Saari Laboratory Director BRL=Below Reportable Limits `See Attached Page 1 of 1 cCert1fication is not available for this analyte for potable water samples.. SNF Town of Barnstable Barnstable T�ti Regulatory Services Department j ealcaC 6ARNSTABLE, � � I.F ^ r a67q Public Health Division QjA �0 'ED'"A'`a 200 Main Street, Hyannis MA 02601 2e07 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 '\ Thomas A.McKean,CHO i CERTIFIED MAIL # 7006 0810 0000 3524 5638 January 12, 2012 Bank of America,NA PO Box 5170 Simi Valley, CA 93065 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 1652 Ost.-W. Barnstable Road, Marstons Mills,MA, was last inspected on 11/22/2011, by Michael T. Bisienere, a certified septic inspector for the State of Massachusetts: t The inspection of the septic system showed that the system "Fails"under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: • Hydraulically Overloaded. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the`septic system with the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S. CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Eval\1652 Ost.-W.Barn.MM.doc No. a -0,57/ - Fee �'U THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZIPpYication for Dtgpoar *pgtem Couoructiou Vermit Application for a Permit to Construct( ) Repair(Upgrade Abandon O Complete System ❑Individual Components Location Address or Lot No. r�S� i-�id p-u&r-�, CoOwner's�N/ame,Address,and Tel.No. Assessor's Map/Parcel ��7 � �i M i`��S O � iC Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Vcw.'S/c 4 43� Fs i � N y,�•� e r�� U•l¢�:�; dill `` �%' Type of Building: 315-1> �1 h Dwelling No.of Bedroomss`I�ot Size �%,(, 7O sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 330 gpd Design flow provided �`f� `�, gpd Plan Date 1 y�- Number of sheets Revision Date Title Size of Septic Tank x� � Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) iStt ,� 1►1C'4il a,S 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 th' o d f Health. Signe " Date 3 i, Application Approved by Date 2 Application Disapproved by: Date for the following reasons Permit No. Date Issued 3 ! Z 1 1 No. f d —(JS/ • � Fee lUr✓ t Entered in computer: THE COMMONWEALTH OF=,;MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for ai�poal 60tem Congtrucfion Permit' +" Application for a Permit to Construct( ) Repair(Upgrade Abandon(`) ,Complete System ❑Individual Components Location Address or Lot No. �Cs�� f0���e_� Owner's Name,Address,and Tel.No. Assessor's Map/Parcel /A7 ^OOG � M;II S Mrr C i Installer's Name.Address,and Tel.No. Designer's Name,Address and Tel.No. 12 /c z 13r0,,oa Z^'C. ­V51ar_ r►r r�,s GJa/�$ S y77—S3/� '508-WCU-7/5 � Type of Building: 310 1 , ti Dwelling No.of Bedrooms �2xts�lr , 3 fat Size 54670 sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 C gPd Design flow provided gp 3�S d � Plan Date 2 I-)7 /'t-- Number of sheets Z Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) i'\)S t&(1 w)p.) C1. . 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 andnot to place the system in operation until a Certificate of Compliance has been issued by this-�Pd` f Health. Pt Signed_ , Date Application Approved by LPV w, '1 Date 3A_ / _1L IJ Application Disapproved by: Date for the following reasons Permit No. ° 1 a 0 S ( Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( 1.,I)/Upgraded ( ) Abandoned( )by at 16 S2 CUSP rN ?ram has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. �? 00 �� �/ dated A f A Installer �x�f: jkwr,t tx Designer J5-7rys►ivr t r l n,r �G//C�S #bedrooms Approved design flow gpd I' The issuance of this permit shall nho be construed as a guarantee that the system will fun iion as designed. Date � Inspector �/� No. (J�_• Fee r 6 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS &5po5al *pgtem Construction Verrnit Permission is hereby granted to Construct (/ ) ��/Repair ( ✓�Up rade ( ) Abandon ( ) System located at /G �¢ �S t<GI/i 1�� l/" /7G/ry ) and as described in the above Application for Disposal System Construction Permit.The applicant recognizes 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 P it Date ' �i Z Approved b .j� PP Y C/ 7 • r, Town of Barnstable Regulatory Services Thomas F. Geiler,Director BAWWABM Public Health Division �'►` Thomas McKean,Director Me+- 200 Main Street, Hyannis;MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Date: G I Sewage Permit# (7 Si Assessor's Map/Parcel Z? —a'o fO Installer&Designer Certification Form Designer: E,.,�; n¢,e,r•', W a n t s� 1 n c . Installer: Address: iz W. Cro s s e 1cl K Address: a z�y y C-e v► �e,�✓.11�e �1�A 8 2�3'� On '3 S 2 ���` � nL was issued a permit to install a ( te) (installer) �u 1i3VA sFf.�� septic system at 1 b..�Z, C�_— bashed on a design drawn by (address) j�e a-el C dated 7— (designer) UL I 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. Stripout (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. Stripout (if required) was cted and the soils were found satisfactory. CA,IH OFMgsd' e� 9cy PETER T. r McENTEE -1 ( staller s Signature) CIVIL A ,� No.35109 e ST6�� (Designer's Signature) (Affix Design re) 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. q:\office forms\designercertification form.doc { .. t TOWN OF BARNSTABLE tLOCATION 5�� RA 2� SEWAGE# 00 —QS— VILLAGE��efSS �ai1«� ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. A Zrow)ry T-n)L SEPTIC TANK CAPACITY LEACHING FACILITY (type) 11­. J (size) q NO.OF BEDROOMS .. OWNER r...y�[ ( � rAe(%C fib PERMIT DATE:_ I �' ' 1 2 COMPLIANCE DATE: G ed Separation Distance Between the: -")cr��►}�' Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 14 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 r�Ck�T►�(C '�.Qi we i I A't BAC1< -65 OUT -.za,.r ao f O,;z 3 i.ou---C:. of 3 A(C 3C He H2® cooplm Uemn/obsp+ oar Town of Barnstable P# IL3 5�5_-,5 Department of Regulatory Services f : MARNUMBr& s Public Health Division Date 1�-- >uuM. ia3y ,b� 206 Main Street,Hyannis MA 02601 Date Scheduled ,Time Fee Pd. Soil Suitability Assessment for Sewage Disposal Performed By: �e1�4/'/t'tC����e Witnessed LOCATION& GENERAL INFORMATION [Assessor's cation Address 16.5 Z taS�r-Ji IL.Q Lj= ijcv(nS'f e ' er's Name �,.1K P/� me,-t Cq tm]� Address Map/Parcel: /Z-7 —6 0 6 '. 1 Engineer's Name f e - r VLC-EvL�ee ec- NEW CONSTRUCTIO N REPAIR X Telephone# J 0 3 -LI 7 6 F Land Use 1 ` ofA- es(%) Surface Stones Distances from: Open Water Body ?3 ft Possible Wet Area ft Drinking Water Well Drainage Way N/A- ft Property Line 'ICJ ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands fn proximity to holes) ,&I m to Parent material(geologic) ®� } L� Depth to Bedrock Depth to Groundwater. Standing Water in Hole: �1 Weeping from Pit FpCe L11/A -> 3 �r Estimated Seasonal High Groundwater z J DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: in. Depth to Soil mottles: in. Depth to weeping from side of obs.hole: in, Groundwater Adjustment ft. _ Index Well#_ Reading Date: , Index Well level, -,.� Ad!,factor—_ Adj.Crtwndwnter level PERCOLATION TEST Date�..�. Thne.__�._ Observation Hole# �R�C C7✓� Time at h" Depth of Perc Time at 6" Mt n/i R C i-r Start Pre-soak Time® Time(9"-6") End Pre-soak / Mee-h Rate Min./Inch. � • Site Suitability Assessment: Site Passed-- Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one (1) week prior to beginning. Q:VS EPPIMERCFORM.DOC DEEROBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture .Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistency, Gravel) 6 6 sGAd z�s'Y 713 DEEP OBSERVATION HOLE LOG Hole# 2_ Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. _ Consistency.% ray DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. Gravel) tr.. �. -''DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. orisi t n r - w Flood Insurance Rate Map: Above 500 year flood boundary No— Yes Within 500 year boundary ! No Yes Within 100 year flood boundary No Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervt us material exist in all areas observed throughout the area proposed for the soil absorption system.. s If not,what is the depth of naturally occurring pervious material? Certification I certify that on �� (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the required tra' ' expertise and experience described in 310 CMR'15.017. Signature Date Q;\S,EpTIC\PBRCFORM.DOC r '{ U.S.POSTAGE>>PITNEYBOWES Town of Barnstable ► - `�-�, _m y Public Health Division 11 � - _ .---�'ABLE.e! 200 Main Street ZIP 0260 $ 005.590 � fA&5 0 ""�Eo;or•0 Hyannis,MA 02601 h 1 0001361475 DEC. 1.3. 2011. 7011 0470 0001 4525 5471 - ----- - - -_ thel F. Delouche �,6 st.-W. Barnstable Road 10 ' ons Mills, MA 02648 M RETURN 70 SENDER It NO SUCH tclmMBER I UNAMLE To FORWARD i G16ei ♦.AbG��F6d M1.Ri®1W ''�i ..l Gl o}-4d^#cVd.�S+3—aF.� - s sii -- - Sri -rrii ti I it ►4 t [tit iiii tt#iii fiti i# i ti. COMPLETE�THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Signature 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 by(Printed Name) C. Date of Delivery ■ Attach this card to the back of the mailpiece, or on the front if space permits. D. Is delivery address different from item 1? Oyes 1.Article Addressed to: If YES,enter delivery address below: ❑ No Mrs: Ethel,E.-Delouche 1652 OsterviHe-West Barnstable Road Marstons'°MAls, MA 02648 h 3. Service Type I ❑certified Mail ❑Express Mail i ❑Registered ❑Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes I _ 2. Article Number 7 011 0l4 r'0 0001 4525 5471 I (rransfer from service label) PS Form 3811,February 2004 Domestic Return Receipt s 102595-02-M-1540 UNITED STATES POSTAL SERVICE First Qlass Mail USP89e&Fees Paid Perm t:;No.G-10 • Sender. Please print your name,address, and ZIP+4 inM is boxy• Town of Barnstable 's i Public Health Division 200 Main Street Hyannis, MA 02601 i i r I i i oFt� Town of Barnstable Barnstable Regulatory Services Department j e`sa j t BARNs-rABLE,�• O Dm 9� ^S S. r�6gq. Public Health Division �6 A'f0 Mpg a. 200 Main Street, Hyannis MA 02601 2°07 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL # 7006 0810 0000 3524 5471 December 14, 2011 Mrs. Ethel F. Delouche 1652 Ost.-W. Barnstable Road Marstons Mills, MA 02648 • ORDER TO COMPLY WITH-STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 1652 Ost.-W. Barnastable Road, Marstons Mills,MA, was last inspected on 11/22/2011, by Michael T. Bisienere, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: • Hydraulically Overloaded. You a_-e ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system with the deadline period will result in future enforcement action. PER ORDER OF T BOARD OF HEALTH Thomas McKean, R.S. CHO -Agent of the Board of Health kf Q:\SEPTIC\Letters Septic Inspection Failures\Town of Bamstable.doc Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1652 Osterville-West Barnstable Road - Property Address Bank of America/Ethel DeLouche owner Owner's Name information is required for Marston Mills MA 02648 11/22/2011 every page. Cityrrown State Zip Code Daenspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. important: A. General Information forms filling out frm I orms on the computer,use only the tab key 1. Inspector: to move your Michael T. Bisienere cursor-do not Name of Inspector use the return --, key. A&K Septic Systems Plus Company Name � _ ,' ,Z) lil�Q 1. 565 Carriage Shop Rd. Company Address East Falmouth MA 02536 Cityrrown State Zip Code 508 540-6706 S13938 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: . . �i. ❑ Passes ❑ Conditionally Passes ® Falls ❑ Needs Further Evaluation by,the Local Approving Authority 11I22/2011 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the --- report to the-appropriate-regional-offce-of-the-DEP_Jh�otginal 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Town of Barnstable Barnstable P °�\ Regulatory Services Department A""'eficac ftv BARNSCABLE, / m NAss s Public Health Division �A i639' 2Q07 TED h1A`a 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6 304 Thomas A.McKean,CHO CERTIFIED MAIL # 7006 0810 0000 3524 5471 December 14, 2011 Mrs. Ethel F. Delouche 1652 Ost.-W. Barnstable Road Marstons Mills, MA 02648 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 1652 Ost.-W. Barnastable Road, Marstons Mills,NIA, was last inspected on 11/22/2011, by Michael T. Bisienere, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: • Hydraulically Overloaded. You are ordered to repair or replace the septic-system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system with the deadline period will result in future 'w enforcement action. pJ PER ORDER OFT BOARD OF HEALTH Thomas McKean, R.S. CHO Agent of the Board of Health I Q:\SEPTIC'd.etters Septic Inspection Failures\Town of Bamstable:doc ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 1652 Osterville-West Barnstable Road Property Address Bank of America/Ethel DeLouche Owner owner's Name information is Marston Mills MA 02648 11/22/2011 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w� 1652 Osterville-West Barnstable Road Property Address Bank of America/Ethel DeLouche Owner Owner's Name information is required for Marston Mills MA 02648 11/22/2011 every page. City/town State Zip Code Date of Inspection .B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipes)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•09l08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1652 Osterville-West Barnstable Road Property Address Bank of America/Ethel DeLouche Owner Owner's Name information is required for Marston Mills MA 02648 11/22/2011 every page. Cityrrown 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 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 ® 0 —Backup-of-sewage-into-facility-or--system-component due-to-overleaded-or----- clogged SAS or cesspool El- - Discharge orponding 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 EJ or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•09/08 Title 5 official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 1652 Osterville-West Barnstable Road Property Address Bank of America/Ethel DeLouche Owner Owners Name information is required for Marston Mills MA 02648 11/22/2011 every 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 - El ❑ the-system-is located-in-a-nitrogen-sensitive-area-(Inter-immellhead-Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. l5ins•09/08 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 1652 Osterville-West Barnstable Road Property Address Bank of America/Ethel DeLouche Owner owner's Name information is required for Marston Mills MA 02648 11/22/2011 every page. Cityrrown 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? ❑ ® been Y or as P Have large volumes of water b introduced to the system recent) art 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): Number of bedrooms (actual): 2 i DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): E I t5ins•09/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1652 Osterville-West Barnstable Road Property Address Bank of America/Ethel DeLouche Owner O+vner's Name information is required for Marston Mills 2011 every page. Ci ,mown MA Zip 11/22 inspection State Zip Code Date of Inspection D. System Information Description: System consists of 1000 Gallon Septic Tank D-box and SAS Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail Well Water I i I , i i Sump pump? ❑ Yes ® No j Last date of occupancy: Sept.-2009 Date i 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 -f Water meter readings, if available: t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 f - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1652 Osterville-West Barnstable Road Property Address Bank of America/Ethel DeLouche Owner owner's Name information is required for Marston Mills MA 02648 11/22/2011 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract to be obtained from system owner)and a copy_off latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-09/08 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 1652 Osterville-West Barnstable Road Property Address Bank of America/Ethel DeLouche Owner Owner's Name information is required for Marston Mills MA 02648 11/22/2011. every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 6" Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feetet Plus Feet Comments(on condition of joints, venting, evidence of leakage, etc.): I Septic Tank(locate on site plan): 411 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gallon ST Sludge depth: t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 1652 Osterville-West Ba rnstable Road Property Address Bank of America/Ethel DeLouche Owner information is Owner's Name required for Marston Mills MA 02648 every page. Ci mown 11/22/2011 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 23' Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 101, Distance from bottom of scum to bottom of outlet tee or baffle 20' 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.): System shows evidence of Hydraulic Failure I Grease Trap(locate on site plan): I Depth below grade: feet i Material of construction: I ❑ concrete ❑ metal ❑ fiberglass 9 El polyethylene ❑ other(explain): i I Dimensions: Scum thickness i Distance from top of scum to top of outlet tee or baffle i Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 i i I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 1652 Osterville-West Barnstable Road Property Address Bank of America/Ethel DeLouche Owner Owners Name information is required for Marston Mills MA 02648 every page. City/Town 11/22/2011 State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass 9 ❑ polyethylene El other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day i i Alarm present: El Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No i Date of last pumping: Date Comments(condition of alarm and float switches, etc.): t i I i Attach copy of current pumping contract(required). Is copy attached? Yes ❑ No t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 or 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 1652 Os terville- W est Barnstable Road Property Address Bank.of America/Ethel DeLouche Owner Owners Name information is required for Marston Mills MA 02648 every page. Citylrown 11/22/2011 State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-Box shows evidence of Hydraulic failure 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.): i i i I i i Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: - i t5ins•ogioe 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 M 1652 Osterville-West Barnstable Road Property Address Bank of America/Ethel DeLouche Owner Owners Name information fo is Marston Mills MA 02648 11/22/2011 required for every page. " Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits -. number: One ❑ leaching chambers number: ❑ Igaching 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.):. System shows evidence Hydraulic 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 t5ios-09/08-" Title 5 Otfidarinspection Form:-Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 1652 Osterville-West Barnstable Road Property Address Bank of America/Ethel DeLouche Owner Owner's Name information is required for Marston Mills MA 02648 11/22/2011 every 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(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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not.for Voluntary Assessments M 1652 Osterville-West Barnstable Road Property Address Bank of America/Ethel DeLouche Owner Owner,s Name information is required for Marston Mills MA 02648 . 11/22/2011 every page. Cityrrown 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 w Loaf v - 3 3: , � � t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page'15 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,• 1652 Osterville-West Barnstable Road Property Address Bank of America/Ethel DeLouche Owner Owner's Name information is required for Marston Mills MA 02648 11/22/2011 every page. City/rcwn 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. Undetermined failed system feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers (attach documentation)- Accessed USGS database-explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09/08 Title 5 Official Inspection Form;Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 1652 Osterville-West Barnstable Road Property Address Bank of America/Ethel DeLouche Owner Owner's Name information is required for Marston Mills MA 02648 11/22/2011 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 4 COMMONWEALTH OF MASSACHUSETTS x EXECUTIVE .OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED I V 7 SJ• AUG 0 3 2001 TOWN OF BARNSTABLE TITLE 5 HEALTH DEPT. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSM SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:. Owner's Name• /��� Owner's Address - � 2au . l Date of Inspection: _-- Name of Inspector: please print) t"�' �' �r 7 .Company Name: CU�%�4sG Mailing Address: •U< x _ T Telephone Number: �7 —9aL92 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true., accurate and.complete as of the time of the inspection.,The inspection.was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems:1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: d Passes Conditionally Passes Neyds.F her Evaluation.by the Local Approving Authority F,dils . Inspector's Signature: C Date: A 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]0,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. di This inspection does not address how the system will.perform in the future under the same orfferent conditions of use. Title 5 Inspection Form 6/15/2000 page I f Page 2 of 1 I OFFICIAL INSPECTION FORM—N T FOR VOLUNTARY_ASSESSMENTS SUBSURFACE SEWAGE-DISM AL SYSTEM INSPECTION FORM. PA; TA r CERTIFICA .ION (continued) Property Address;. Owner:. Date of Inspe tion: Inspection Summary: Check A,B,C,D or E ALWAV S complete all of Seetion D A. System Passes: t! I have not found any information which:indicates hat any of the.failure.,criteria described..in 310 CMR 15.363 or in 310 CMR_15.304 exist.Any failure criteria n jt 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 replacemeni or repair, as approved by the Board*of Health,iyill pass. Answer yes,no or not determined(Y,N,ND)in the or 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 ex,filtration or.tank failure>is imminent. System will pass inspection if the existing tank is replaced with a complying septic tanl,as'approved by the Board of-Realth. *A metal septic tank will pass inspectionif it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is avail.42. ND explain: Observation of sewage backup or break out or high-static water level in the distribution box due to broken or obstructed.pipe(s)or due to a broken,settled or uneven di§'..bution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are re laced obstruction is remov d distribution box is le v eled or.replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health):. broken pipe(s)are rep aced obstruction.is removed ND explain: . i 'age 3 of I'l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued). Property Address: Owner: Date of nsp ction:. 1 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. I. System will.pass uiiiess'Boaril ofHealtlide.terinines In accordance with-310 CMR_15.303(1)(b).that the system,is not functioning in a.nianner 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: a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a _ The system has � Y P 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 I of a public water supply. _ The system has a septic tank and SAS and the SAS is:within 50 feet of a private.water supply well. _ The system,.has a septic tank and.SAS and the SAS is less than.100,feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free fronn 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 failu-e criteria are triggered. A•copy of the analysis must.be attached to this form. 3. Other: 3. Page 4 of 11 OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARYASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM''INSPECTION FORM T PAR A II °CERTIFICATION(continued] Property Address: 14A Owner: I te Pfl Mo_11. Date of Inspe ion: l A/ D. System Failure Criteria applicable to all systems:- You must indicate"yes"or"no to each of thefollowing for all inspections: Yes N Backup of sewage into facility or system component due to overloaded or clogged SAS or.cesspool ischarge or ponding of effluent to the surface of the ground or surface waters due to an overloade&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 %day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed i e s�� p p O.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 l water.supply. V 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 P rivate water sup ply y 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: Ye( s/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 y system owner.should contact-the Board-of Health to determine what will be necessary to correct the failure. -s E.: Large Systems: To be considered a large'systemahe system must serve a facility with a-design flow of 10,000 gpd to:15,000 gPd• . You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is.within 400 feet of a surface drinking water supply _ — the system is within 200 feet of a tributary to a surface drinking water supply t . _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered . "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. '4 zge 5 of 1.1 OFFICIAL INSPECTION h,ORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE`DI8POSAL S.YSM INSPECTION-FORM PART B CI1ECKLIST Property Address: Owner: d Date of Inspe ion: Check if the followinghave been done. You must indicate"yes"or,"no"as to each of the following; Yes -o I 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, s 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 1/ 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_o►i: Y no _ Existing.information.For example,a plan.at the 13oard,of Health. Determined in the field(if any of the failure criteria related to Part C.is at issue.approximation of distance is unacceptable)[310 CMR 15..302(3)(b)] 5 Page 6 of 1 l OFFICIAL INSPECTION FORM .—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SE WAGE=DISPOSAL SYSTEM INSPECTI.ON FORM PART C SYSTI+�M INFORMATION Property Address: Owner: � �A Date of Inspection: To FLOW CONDITIONS RESIDENTIAL , Number of bedrooms(design): Number of bedrooms(actual):. CP DESIGN flow based on 310 CMR 15.203 (for example: I Mg d x#of bedrooms): Number of current residents: aqt&V Does'residence,have.a garbage grinder(yes or no): �"" Is laundry on-a separate sewage system (yes or no): '[if yes separate inspection required] Laundry system inspected(yes or noL. Seasonal use:(yes or no): . Water meter readings, if available.(last 2 years usage(gpd)): Sump pump(yes or no : ti Last date of occupancy: ._ COMMERCIALIINDUSTRIAL � Type of establishment:. Design flow.(based on 310 CMR.15.203):. gpd Basis of design flow(§eats%persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no):— Non-Sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of informafiow. '02 0 Was system pumped as4jpmofhe i spection(yes or no): If yes,-volume pumped:. gallons. How was quantity pumped determined? Reason Torpumping: . TYP OF SYSTEM _Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool _:Privy —Shared system.(yes or no)(if yes,attach previous inspection records, if any) Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained'from system owner) —Tight tank _Attach a copyof the DEP:approval —Other'(describe): A-nroximate age of Il components,onents, date Itista Iled(if known)and sourc of i inflormayon Were sewage odors-detected when arriving.at the site(yes or no): �— F `age 7 of I l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:. ' /A-/ Owner: Date oflnspe BUILDING SEWER(locate on site plan) � Depth below grade: _ Materials of construction:_cast iron _40 PVC_other(explain): Distance from private water supply well.or suction lire: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC.TANK:' (locate on site plan) Depth below grade: Material of construction: 21concrete metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no (attach a copy of certificate) Dimensions:,,5r X CD' x / Sludge depth: JF" k211 Distance from top f sludge to bottom of outlet tee or baffle: Scum thickness: r� ^�0.61 >/ Distance from top of scum to top of outlet tee or baffle: Z �/ Distance from bottom of scum to bottom of outlet tee or baffle:_!L How were dimensions determined: . Comments(on pumping recommen- ations, �Ietand outlet tee or baffle condition,structural integrity, liquid levels s related to outlet invert,evidence of leakage,etc:)' 4 1/a lljol GREASE TRA`�locate on.site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass__polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 7] 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SVSTEM INSPECTION FORM PART C SYSTEM`INFORMATION(continued) Property Address: Owne Date of+nection: To 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/day Alarm present(yes or no): Alarm level: Alarm in,working orden(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: i" resent if must be( p opened)(locate on site plan) Depth of liquid level above outlet invert: .4eAe� Comments(note if box is level and distribution to outle equal,any evidence of solids carryover,any evidence of kage into or out of box,etc. : -" /.Jpl 0-",-,* &W'd' 6LA t1lP64.1"Y' W. PUMP CHAMBER: A --locafe on�site'plan) Pumps in working order(yes or no) Alarms.in•working order(Yes'or.no):. ' Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspe tion: SOIL ABSORPTION SYSTEM (SAS):.Zlocate on site plan,excavation not required) If SAS not located explain why: Type 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, c.); /000) 9 0 IVA /I CESSPOOL cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater'inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition ofwegetatia�,.etc.): PRIV (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 i i Page 10 of I 1 OFFICIAL INSPECTION FORM NOT FOR.YOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM P LL�R� T_ C SYSTEM INFO1t ATION'(continued) Property Address: A Owner: Date of dnsp#Ctio2w. . SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage,disposal system includir g ties to at least two permanent'reference landmarks or benchmarks. Locate all wells within.100 feet. Locate where public water supply enters the building. log I ° �. 69u, 1 �a 3 . 0 26 . 10 Page 11 of I 1 OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address: • `L4 Owner: Date of IPsppechon: /6? /O/ SITE EXAM Slope Surface water Check cellar. Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: hecked with local excavators, installers-(attach documentation) V Accessed USGS database=explain: You must describe how you established-the high ground water elevation.. 11 LOCATIOR SEWAGE PERMIT NO. /sr RZI VILLAGE INSTALLER'S NAME a ADDRESS l UILDE It OR OWN EA DATE PERMIT ISSUED DATE C 0 M P L I A N C E ISSUED r 2- 3 1 o, �_�.,� a � �i � � �� � /`�� Sic j�3 Ion 1, �.sr.�.�lJa��� � �trrs�" �i3/te/sT/�il/� /��Q` z. i a_ ! Fmc............._............... 0o THE COMMONWEALTH OF MASSACHUSETTS ' BOAR® OF HEALTH W z(t?6 �� �� ®. /✓..............OF..... f�. .L.... c� _4.��................. Appliratiuu for 14"viial Marks Tami rurtiurt Vamit Application is hereby made for a Permit to Construct ( �Jor Repair ( ) an Individual Sewage Disposal System at: ................_........_...................................................................... ... ""-5-----. }- Lo ation•Address or Lot No. ......................G� .. -.. ............... O Ellera� Address ........................•------- Address Q Type of Building Size Lot_�.t,,_7z-_t.....Sq. feet Dwelling—No. of Bedrooms..................z _____.__.__...Expansion Attic.,�' Garbage Grinder 'w Other—Type T e of Building I—p, yp g __.._._._. �___ No. of persons__________ _ _____________ Showers ( ) — Cafeteria ( ) a' Other fixtures -------------------- • o WDesign Flow................... ............gallons per person per dad. Total daily flow....----_---.----�.Z ___.______._gallons. WSeptic Tank—Liquid capacity M 70'gallons Length-!?... ... Width...-C.A ."biameter................ Depth..a. x Disposal Trench—No.............................. Width................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No._-_---.1.__.._._.... iameter.....�. __.__ Depth be ow inlet...•-.._�____-_-_� pag p � � � ___ Total leaching area_,;.3._®�.sq. ft. Z Other Distribution box ( Dosing to _ �� 3 g Z Percolation Test Results Performed by...............� .......�.�..... __............. Date.........!/.-�-----.-.--.--_-- aTest Pit No. 1-_-__¢minutes per inch Depth of Test Pit.................... Depth to ground water-------................. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ R+' ............................................... .... ......... --......................................................... ----------------------------------.-- - O Description of Soil--------�-�'--�=�`-s--Q------�-w � �� ���-------................................................... W V__ --------------------•--------------------•--••----------•-------------------.---....-------------..---------------------------------------_---------------------------------•-------------------- W VNature 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 TITI:' 5 of the State Sanitary Code e undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issue oard of health. Sied ��. .............• -- ......................................................... VApplication Approved By--•- -••--• -------------------------------------••••-------------------.......... 2_ Application Disapproved for t e f ollowing reasons: --•----------------------------------•--------•----------•---•--•-•------------......_..--------••••-••-.............................................................................................. Date PermitNo......................................................... Issued....................................................... Date No.. Fuic.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ,Y / 0 W,n✓ 0 F.....�f'�M/ Sk A.0....... . ........... Appliratilan for UwposFal Works Toustrnrtiun amit Application is hereby made for a Permit to Construct ( 10<or Repair ( ) an Individual Sewage Disposal System at: ................ ,........................................ ........ - o ation-Address or Lot No. ..................... ..si .s---------------•-------........... ..........--............................... ---............................. .................. Owner Address W .................... ...................----•---------------•- .......-----------...•--••- ----....-------------------•---------•--•-..... a nstaller Address Type of Building Size LotX.t,..7 I.....Sq. feet Dwelling—No. of Bedrooms................. ...Expansion ttick--- Garbage Grinder, k- l''' Other—Type of Building 7 r No. of ersons....._... ....... .__.. Showers — Cafeteria Pa yP g P ( ) ( ) Other fixtures ._ Design Flow - ... gallons per person per day. Total daily flow................z- ....gallons. W ' Septic Tank—Liquid'capacity 4�:'�:`gallons Length g... ... Width__" ._ G'*Diameter................ Deptr�-'� _�'�__'.. x Disposal Trench—No..................... Width... ._............. Total Length............�....Total leaching area....................sq. ft. Seepage Pit No........:........... iameter.._..1.�"`...... Depth below inlet.tn. .... Total leaching area.. a sq. ft. Other Distribution box ( Dosing to Z Percolation Test Results Performed by------------- -+ .'---.�! �'� - --.-.----•. Date..... I ,3 �.. - --- aTest Pit No. I...._�'A..minutes per inch Depth of Test Pit.................... Depth to ground water......................... f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P� •-••--•--•• ---•••......••----•.....-----•• •-•--#.....•...y -- ------• ---------------•-------------------------------------------------- ODescription of Soil..... a• .................................................` ' j '�'"�---e...'......----•----------------------------------------•------ 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 TITIS 5 of the State Sanitary Code -,The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued�bytth oard of health. Signed .l ------------------•...................................... .... --Date ............. Application Approved By----....... -- .... �._.... -- •-- X��� i 7Date L Application Disapproved for tit e following reasons---------------------------------------------------............................................................. _....•---•--------•••-••...............................•.----------•-.........._.._................_...._.......---------•--•••-•--•-•-••---•----•-----.-----.-•-•-•-••-•--•----•---_ •---•........_ Date PermitNo......................................................... Issued......................................................... Date THE COMMONWEALTH OF MASSACHUSETTS .» - BOARD OF HEALTH ..........................................v7OF.....��...... ....�^...5.�e ..a.......................................... Trrtifiratr of TompliFanrr THIS IS TO CE IFY, That the Individual Sewage Disposal System constructed (P-11"or Repaired ( ) by-------_----------_----- .... ..... Insta ,r G "S r" er' /�� tom' u J--44 --- at----- ` ------..- • -•---------------------------•-• -------- . ....... • ------------------------...........--•------•- has been installed in accordance with the provisions of TITI - "5 The. State Sanitary Code as described in the application for Disposal Works Construction Permit No..:,.._.....____ �....:.............. dated__..____/_ ...... � , .......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE C�NSTRUE® AS "/UUARA'�NTQ THAT THE SYSTEM WILL FUNCTION SATISFACTORY. �7 DATE.-•.................................••-.........�-�'_.....:°.$3........._._. Inspector..................................................�.�..._-------------••-•--------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH }� J '.<r4f> '?.............OF..-- .si. .�: ?'.. '" '.............................. No......................... FEE........................ �t r tt rk� �nns#rudinn r =. -.a ,/ Permission is hereby granted ""'�c -------- - /�! to Construct (e^T,or Repair ( ) an Individual Se;;,age Disposal System atNo.. J....... ..............��tJvt..................................... Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... ---------------•--------------•-------------------------------------•------.......••-••••------•-------- Board of Health DATE......... -----------•................................... FORM 1255 A. M. SULKIN, INC.. BOSTON ti No. 'w 'a© b G Fee------ -- ------ BOARD OF HEALTH TOWN OF BARNSTABLE Zippiication-*rVell Cootruction Permit L A1;to /AcGc �G�fwr Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair ( )an individual Well at: Location — Address Assessors Map and Parcel 3 °t— L�— _ — � _—__ Owner Address ___-- --------_. _-- Installer — Driller Address Type of Building Dwelling----- -- - - --- — Other - Type of Building--=--------_______ No. of Persons.------------------- — --- Type of Well -- ---------- Capacity---- — - --— -—-- — Purpose of Well--- '—^—' -------------- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate .of Compliance has been issued by the Board of Health. Signed r � _—_--_ _ �1' D�_—. date Application Approved By _--- ----_-- ___-- date Application Disapproved for the following reasons: -------------------------------- --------- date PermitNo. --- -- Issued----------------------------------___.__._.__. date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( ) f A Installer ell at— 621 has been instated in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. -------------------Dated------ ------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE-- —- - — Inspector-- - —-------------- — ---------—- Lv -�C, b S�-- �/s------------ ---- No.------- Fee------BOARD OF HEALTH TOWN OF BARNSTABLE 0(ppYicat ion iforlVell Con5truct ion Permit Application is hereby made for(a permit to Construct ( ), Alter ( ), or Repair ( )an individual Well at: q Location — Address —— — A;;;Ls/,,—Map and Parcel ---Z� '# ------� T F (�i — n s- - s` - "`4.,,,,F Owner Address ' Installer Driller Address Type of Building Dwelling--------------------------------------------------- Other - Type of Building--=-------- -------- No. of Persons------------ ------------------.---- Type of Well--- ---------— ---- Capacity-- — - - --— -- -- ---— Purpose of Well — r'�-^' ---------__ M Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to g g g �,.. place the well in operation until a Certificate .of Compliance has been issued by the Board of Health. Signed w � _.... { 4 date Application Approved.By — --_—___—_____ ___— _________:____ date ., ' t Application Disappro�ed for the following reasons:— —------ --_—— ---------------------------- date Permit No. —— '. — --— Issued------- -— - - -- — —— ------------- date ._______________________________ -------___-----_.____—_---__—_____—_____—___, BOARD OF HEALTH TOWN OF BARNSTABLE Certificate ®f Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired--------------------- ( ) installer"`. ---------_---- at6 Ig V '12t —�%�— 461---------------------------------------------------- has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. ----------------------Dated-------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. ` DATE----- --- — - --- Inspector----------------------------------------- — BOARD OF HEALTH TOWN OF BARNSTABLE 1perr Con5truct ion Permit NO. — Fee—� -- Permission is hereby granted— `D �`Q""'� ----------------------------------------- to Construct ( ), Alter ( ), or Repair ( an Individ al Well at: Street ----- --�--�-------�------- as shown on the application for a Well Construction Permit I No.-- _ — _------- Da d-- ^---- —---------------- ------------------- -- ------------------ / -- — -- Board of Health DATE S-1 zoo w� to COMMONWEALTH OF MASSACHUSETTS T ,e ;E-LE EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF E.NjVIRONMENTAL PROTECTION p TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR,VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 96 Owner's Name: '00W/77 Owner's Address: r / �✓E7t�9?vsr�;�Jce-�°e� Date of Inspection: Name of Inspector: (please print) t Company Name: FqS S'do? Fy Mailing Address: 90 /72� o3 6p•V1 2F-- dzs 6 3 = Tf Telephone Number: -6 z>6 — 43f5- -56. 19 FPS— P.+9fi—Z49� C_nr CERTIFICATION STATEMENT M I certify that I have personally inspected the sewage disposal system at this address and that the in rmation 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: V-P-asses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails I Inspector's Signatu 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. (� Notes and Comments c�l��Tt/I�'GL �r✓/f / O�r/�/cgGt ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. � Title 5 Inspection Form 6/15/2000 page I Page 2 of I I OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATI/O7N (continued) Property Address: S?vvS iccs Owner: W, rAf, Y Date of Inspection: /O- 5-d 4 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D Ae:�►Passes: 7I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. tem Conditionally Passes: A//_4 One ore system components as described in the"Conditional Pass"section need to be replaced or repaired.The sy ,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not dete ed(Y,N,ND)in the for the following statements. If"not determined"please explain. Th.e septic.tank is metal and ov 20 years old*or the septic tank(whether.metal or not)is structurally unsound,exhibits substantial infiltration xfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying se 'c tank as approved by the Board of Health. •A metal]septic tank will pass inspection if it is cturally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is a ilable. ND explain: Observation of sewage backup or break out or high stati ater level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution ox. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed p (s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 i i' t Page 3 of 1 l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Sz Irrl-41. e.*ys Owner: �9i1YJxGt/ Date of Inspection: C. Farther Evaluation is Required by the Board of Health: A'14- Co ditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to otect public health, safety or the environment. 1. System wi pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b)that the Ys system is no unctioning in a manner which will protect public health; ��d the environment: _ Cesspool or p 'vy is within 50 feet of a surface water _ Cesspool or pri is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board o ealth(and Public Water Supplier,if any)determines that the system is functioning in a manner that p tects the public health,safety and environment: _ The system has a septic tank and soil a orption system(SAS)and the SAS is within 100 feet of a :surface water supply or tributary to a surface ter supply. _ The system has a septic tank and SAS and the AS is within a Zone I of a public water supply. _ The system has a septic tank and SAS and the SA is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is 1 s than 100 feet but 50 feet or more front a private water supply well".Method used to determine distan "This system passes if the well water analysis,performed at a D certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is fre om pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or les han 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to th form. 3. Other: 3 t Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 5-2- Owner: wib' Date of Inspection: /O-Q- 0 4 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ 3 ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or pond ag,b� luent to the surface of the ground or surface waters due to an overloaded or logged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool 4//# Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number f times pumped Any portion of the SAS,cesspool or privy is below high ground water,elevation. �i ,a,_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface . ater supply. V Any portion of a cesspool or privy is within a Zone 1 of a public well. t/Any portion of a cesspool or privy is within 50 feet of a private water supply well. " :Z 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.] Alf (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. arge Systems: 9" To be sidered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate ' er"yes"or"no"to each of the following: (The following criteria 1 to large systems in addition to the criteria above) yes no the system is within 400 feet o face drinking water supply _ the system is within 200 feet of a tributary surface drinking water supply the system is located in a nitrogen sensitive area(I,nte ' Wellhead Protection Area-1WPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is consider significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any system considered a significant threat under Section E or failed under Section D shall upgrade the system in acc ance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 I Page 5 of I:. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: ��SZ �� ,kj. &' .4?'Gc Owner: Date of Inspection: !o-g •D 9 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No — — Pumping information was provides;? th owne 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? Ir 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? lac v.rl1- Were all system components gthe SAS, located on site? _�_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no Existing information. For example, a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 r Page 6 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: rG,r2 e2se lv .c13 /e, Owner: Date of Inspection: /O-B -o�— FLOW CONDITIONS RESIDENTIAL 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): 33 d Number of current residents: 6r9- Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):Ab [if yes separate inspection required] Laundry system ,ected(yes or no):� Seasonal use:(yes or no): 4/o // Water meter readings,if available(last 2 years usage(gpd)): ���� �r4 Sump pump(yes or no):�a Last date of occupancy:� E NI COM CIAIANDUSTRIAL Type of esta • ent:. Design flow(base 310 CMR 15.203): gpd Basis of design flow(sea rsons/sgft,etc.):_ Grease trap present(yes or no):_ Industrial waste holding tank present r no):_ Non-sanitary waste discharged to the Title 5 s (yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records �� 1 Source o OGf information: k ex- — Agml-oTT/ ?Ylz r 4 o Was system pumped as part of the inspection(yes or no):_'41b If yes,volume pumped:gallons--How was quantity pumped determined? A114 Reason for pumping: 6 4-e- / /lsc! j -- 4 :, 5*2-";kr-d-4XFf r4vT TYP F 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) _Iflnovative/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): Ap ximate a of all compone ts,date installed if known)an source of information: S � Were sewage odors detected when arriving at the site(yes or no): 6 F Page 7 of 8 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: SZ &1 GCS' Owner: Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: cast iron L40 PVC_other(explain):tee Distance from private water supply well or suction line: Comments condition of joints,venting,evidence of leakgcc.): "/!ll�T�J•f/�� fG� �yT--tr/�i✓r-ic,�, VP eeV k*'a'e-- 4r<a.J m74'Utc SEPTIC TANK:V(locate on site pl , Depth below grade: Material of construction:✓ncrete_metal_fiberglass polyethylene —other(explain) ,J If tank is metal list age. -Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: . ;i!4'a4*— Sludge depth: A/utiv1- 1Z6S d ur— Distance from top o sludge to bottom of outlet tee or baffle: A/Q 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: Ze" How were dimensions determined: )--/0OAVe$JZ4W Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related t Ltlet invert,evidenceS of eakage,etc.): N�GR TRAP:_(locate on site plan) Depth below grade:— Material of construction:— ete_metal_fiberglass polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle. Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle con , structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): 7 I Page 8 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFO/RIMATION(continued) Property Address: li s2 �57` �'AY/IS'�J c� Owner: •tom y Date of Inspection: T GHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth belo ade; Material of cons n: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gal Design Flow: gallons/da Alarm present(yes or no): Alarm level: Alarm in working order(yes or no Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: V (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distri/ut—io—nto outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box,etc.): /UvV 3,9" -r,:7 ;/L `t�c� �5�2� L J"vrry 2'?rJi,�F �.✓ cr�� �4 PU MBER: (locate on site plan) Pumps in working order ye Alarms:in working order(yes or no): Comments(note condition of pump chamber,condition o d appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1652 �T �• 4W �O ,Q /Yficcs Owner: yo � Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): ✓ (locate on site plan,excavation not required) If SAS,aert't6cated explain why: Typeleaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number:_ innovative/alternative syste Type/name of technolo�Y o e.n ( ot condition of soilgns of hydraulic failure level of ponding amp soit ondition of vegetation) et �5 N��t/r� l �t2,var aatr N� q-� s � -'4',0,4L Tr:y d�'piT' 82''�P,�✓Cv /PL�.S'7trrcT ,=2t��ooc�t<E9 ' loF'i 9--3(y = le v�i�cia •�uva� CE POOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number an uration: Depth—top of liqui let invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level o�po�condition of vegetation,etc.): wh PR (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, ]eve ding, condition of vegetation,etc.): 9 Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: f2 �6f /lS Owner: Date of Inspection: /!/—B—O¢ SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 93 $` i p•l-1• ro µ , �\ I i 8 1 �1 I 9.a'1c. t1lot G—S lots 3 l ,$9/ln/lWa- a-'✓!t-7t!/ATta'cJ"Th-v 10 I I Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INNFORMATION(continued) Property Address: area c c Owner: Date of Inspection: �— SITE EXAM Slope 77. 7- Surface water Alv&,v- Check cellar D P*(>n*"rFwJheav �-- Shallow wells 4 ,� Estimated depth to groiind water 94 feet (�;a oai'�r•� -� �}s ^f:co q Please indicate(check)all methods used to determine the high ground water elevation: -Obtained from system design plans onEcoord checked,date of design plan reviewed: Observed site( property/ within 150 feet of SAS) a#M00410 W&c 4 Po ia/T "4,/ Checked with local Board of Health-explain: 1199S771CIZ 1A,4 _ 1"eij�t2 e72 /0 Checked with local excavators,installers-(attach documentation) ozoO 4 Accessed USGS database-explain: �-�Q4W Lr�� 4� �L� got Y9 mustAq Js scrisboelh h'o wnycou�e�s,vtzabl}",The�ds.the sJ d water elevation: L •9 ¢ , —g 8.0 z 9.¢ �o�✓ �►�►`C Gl S�� L .�s 1-741 r iob.vv LS (� G�cc..a✓,�r,�n �ri��c 8.�z 9i. �f� T,� o� S'I!r✓dc.�i✓?��I� �Lf�K�F/"`�'ld✓t/Z_ �3 .G' S' � , 3 . 1" SS E��a�r4ri.cc. �Sr,0 /25-? 6�wTO¢ <NOh;>e •���`vt���crne 8 =3%7�f�- >3 2. 3 0 �- g 8.D 0 Certified Mail#7008 3230 0002 5177 8209 Town of Barnstable- ' Inspectional Services Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 November 6, 2019 i Maureen& Richard Mahoney PO Box 242 West Barnstable, MA 02668 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY CODE II — MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE CODE CHAPTER 170. The property owned by you located at 1652 Osterville-West Barnstable Road, Marstons Mills MA was inspected on November,6, 2019 by Timothy B. O'Connell, R.S., Health Inspector for the Town of Barnstable. This inspection was conducted on the basis of Chapter 170 of The Town of Barnstable Rental Ordinance. The following violation(s) of the State Sanitary Code were observed: 105 CMR 410.450—Means of Egress: Room was observed in the basement being used for sleeping purposes and lacks adequate secondary egress. -� .You are directed to correct State Sanitary Code violations listed above within twenty four(24) hours of your receipt of this notice. You are directed to cease and desist using above mentioned room for sleeping purposes. You may request a hearing before the Board of Health if written petition requesting same is received within ten(10) days after the date the order is served. Non-compliance will result in a fine of $100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. PER ORDER OF THE BO RD OF HEALTH in cKean, R.S., CHO *Director of Public Health ' Town of Barnstable Cc: Corey Egan, Occupant \\toa\depts\1iEALTH\0rder letters\Housing-Motel Violations\1652 ost-w barn rd 11-6-19;docx Postal tServiceTM CERTIFIED MAILTM RECEIPT 1 � � Domestic Mail On! •No Insurance Covera a Provided � 1 =W 1 [F•or,deIiv—e ,information visit our website at wwmusps.com® ' FICIAL USE S J Wo1 �.kl! f° W 0¢1� "M J O I� 1 owl Owl - _ O ,. OF CI o11■ . ■- _ Qml`_ r ¢1�y W 1 iv IPI� 5o1\iSent To or 1 1 ■Box 1 1 1 1 PS Form 38007August 2006 See Reverse Frjnstructions Certified Mail Provides: ; a A mailing receipt 12 A unique identifier for your mailpiece n A record of delivery kept by the Postal Service for two years _ t Important Reminders: " LL e Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail®. a Certified Mail is not available for any class of international mail. a NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. a For an additional fee,a Return Receipt may be requested to provide proof of f 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"Retum Receipt Requested".To receive a fee waiver for adpl to return receipt,a LISPS®postmark on your Certified Mail receipt is required. I 1. a 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 Deflvery". 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. l IMPORTANT:Save this receipt and present it when making an inquiry. PS.Form 3800,August 2006(Reverse)PSN 7530-02-000.9047 Complete and return corenstewart@ya...Anbox -� Caren Stewart<corenstewart@yahoo.com> Oct 29 at 133 PM To:Coren Stewart<corenstewart@yahoo.com> A�yi � 7F: tfi?.' ";+. P •��.,�-RrTfa cp:IiAiI°�4I,INSPECTION PERMISSION T_�R�+ -L`I ii+l*J t V�ublir--Acalth Division Town of -�..��F ��J =.�..:��:.= ��,.-�;-"�08-862'-4644a•,. .� �. � �� ��-�� -`.� a To wh-Mjf May Concern P f = vatuntarllygtantper�itsstrinto - Hof Barnstable hoard a£Heaidi(Agentor Heaithinspeetotolttst ffiY tlwe3l�ur$ _ 4- `�ocatcd at � tt t ,Muni# ie+ 0 — — _ WM tilt T m of Bamsmble Coda_( ttsa Slate S utatY u (1fl5 CMR 410;000)on IWe_b authorize . . (Date of mspeenn q mot,_ to hem'tenatit`izpiescntadV fo the r utpttse t ili3s insgtctton is an adalt Pet = desiguaW and dulyaudtortzcd to op m ybehalfand will be co}npaitying thtTown �. �. _ �- - -o access to oWwd A l©cattons. 9 flfamstable Board of Hesith fc�rthenspa�on,granittg finwl ding'bedioa �.tea OmS,closets,elo.,}aHov�+ingihc use ofphothgra bs and answering gaeshonsAhis authonza6oa is Oilly:valid for the mspectton data spcc's Q above,and must bc�eiieevedfor yfiittlre mspectio»fs,) - . _._ w . - - �-27 � - eitts I �1-Date Occupants irsenntatn+e 53gnf+►te e cn Deel,*,AO jM.P'emual for feipm 2dM' C ,jr, aruf Se+rOl1^ - - 4 Sent from yahoo Mail on Android •i'tr:�!11. ,'�f,fy.a+tff'ri"] n-s•?�+.� 1 r9' � ��'{';'.} T.t'�E.t:�,'.t.•yr;,,ry 'r:'•,:c,:tri.:� 'tGV'�4ii*t�.t,.yt>*y-: fG.•itr.t 1f1A.f.;ri°'•t{+af'.rgeci:W.' et.SY _.. pT >I. �•i ! s , ,L n tl, et �F.fir . S ,1:. , .u !' •S ! f - , •- 'i,'>3 1 ... ~• p..�+""'�^'.'—`.� _. � •its- Ei �. t , t.'M� �..t r.f �tr -t� ,.•C. a E � .:� •i t •d.. .. �M1! '�.. �rt fit' '+7.to 1L'}, ,✓. •t.. ^r '•� .s.� �:. .s t ..7 +� � . f.f -^. - ."Y wt h�1 �.Y"�.. 71 r.;, `{ u_� .l-�€ I:k �} � •w �t ,. A g: •`t(tr fI .. : ✓ . !•tAii M:, � ..,.. . t a. . y. r n ei .ar vf.•... 'sy ,{t. .'c„j. r.' f f" . Ir c �''. :�'waYasp�g,,SKYeil�dw�,.n ra`".`•'rw'r..i��*�-'�t4f1,k�.�s�•&:a «.aw,ra.,.mw.,.....,,.,.,.,.,..........._ t E. • TOWN OF BARNSTABLE BOARD OF HEALTH yy ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date 6 �— Time: In Out Owner Tenant Address Address S ��`�� 6' r, Z . Compliance Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities 6. Heating Facilities 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 A^ BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date "" V~ 1 ,� Time: In Out Owner +� Tenant Address © ^� \ Address j r7 1AW Compliance Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply tea, 5. Hot Water Facilities - 6. Heating Facilities 7. Lighting and Electrical Facilities 8-Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits f .... , 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal f 17. Temporary Housing ' 18. Driveway Width 19. Number of Tenants Observed Fs •' f PART-11 37. Placard ing of•Condemned Dwelling,.,"17rM'"" . 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 t � 'I Norte=— Z2�AI7'7o.u5 6s}.xE+"D ati �1•`��uhNZ3 -D�L''7 G tz 73,8 � r S�BSo>L ` ZZ.70. 3v .,�. \ sal 4te Wirfl \ FlNG" P4 G h` #N Nov. 3 /fez- t � fi l 4' Ai I~. rf9G. 7' R�AI?- _ O _QF V9UNVATIOW MAN O L. To P,X , D o f►N►sµ CRAM AUW. 2% ti� �• — -&_do _ WITNIN ONE. FOOT' of F►N R L A tSH GRAPE ov LEACH AREA /01 �4E C 'MW zo, 2`�OF PGA STONS Foe B 1 GN ZZ4''vIA. COVf�t �5SoBVt�ori , 1MF"EAvIou 5 GaV142. Tb q.m , _ _ _ j2 lrEYt�i. PR E ►.I T F I�>G5 F#zoM i r►iw. �c ItiIF1l,T1�ZAtil•Ira t�tF.. 4,CA , IRoI.1 Mtn1. - Oft �.40 r ��01� �(� � J_. T /�/ - Id N. I44,� !ti► �+'' _ z t �;� ` try it f -� — NVN. -f �r 14 FcbT // « olio '�4A—tYZv ^►. .3.47 IM/I,Rr I INVERT 7Z_3.o j/ F'Vr STONE GAL_ 4` 73.G� CA CITY nAor1 �� 1 T � ' ALt- a p� 7Z.47 4 OIA. PVC., c.: r�v�- jA90Ur v SEPTI G YANK m « r _ WAT1r�tSi ) 1 NV>GRT PI q. 7/,30 o ( 'trz- 3 0 �v 10 n,q GARBA-E G9?iMPER 0 � 'I -S�ST�N1 T` •- - -- - IrPTI 5Y5T EM CoN 5YR Uc.1)QN 51ALL CONFORM 'Tb THE MAS6. NUMP F.ft of g�sOROC�/1A5; 2 x vi izot4meN AL cops R v I SE0 7- t-77 ThtF- 1'bNlIN / �fi.. �. iAR>7 OF N ►1.'f�-t REcaUI.ATIOnt5r D -�llat�l �"1..OW . — — -- -- p SEPTSc.TA^!k 4� 9.A e> ois-r i w-ioN COo)I `. sr LEAGNI�ICa i'ZAT� 7 ;�•�Q a c v ti I'A�(MA . AN C� LEAGN Ititla P't T To t31i✓ of �....� ,r.-` R�Q fl. LF.AOI-F. CA PS'PjFoRcav cot-1GRcT'E. : 3G G P , , M/1N%oNe-a . S SOmmw1 3o=ml PRoPoSaV LEAG14 CAPAC1V 4 '._ —� ' _ N 10 I,0A41t4cq PRt,JV.VJ >1 Nor To DF. LOCbrMo �4%,A OF OV 1Eit /5 -EM U'Q LF,As 4- 2O /,y �t cep.rc . t 9ES1 CaN LoAi'f1W4 LIyED Ass," 'j+° LA_N 1 -I! t;o 17:8s 1 (XA110tsl� k1�sT PNST BG�' /cjgs F ALL Pr P�-ro oe WATgg'fi�HT .�� Y. Sy�T TO f�s om F,gm 5Aoss ��.. ►Rnlc.7, aroma, of vEEvs G t Q SC:s�' ,S7-&4 1/� �T ,120 ENGINEERING o ° o DESIGNING BUILDING (027 INC. H EA l�T�-1 A� ' APPfRo�h� DENNIS, MASS. 3 0 5 0 2 31 A. ;..�sF ;... '-7u.' a- �.,� > s .� _ ..�f<..vf..:��, ..._ �,;,�{_�.. a.� -�'�.,... '+ ,-".3 - — A�te:�.`� a."-s- - ,3a...�.�•— _�s..e— ----`^ffi...>r..� s.�.. _. , _ ..>..�_f= -� _ >..�,. �,_ e ...,. .° -'.�.�. _..,,... ... .--�; x._..�x ., ?✓,e..,.x aeS,Ftc ��...at .. .u„"=:2 ,a ... -. ,.�. 1 y 4 --100-- EXISTING CONTOUR _ N - x 100.98 EXISTING SPOT GRADE EXIST. p'QOp TEST PIT °Jtie �a #���� D+ �RTY G EXISTING GAS SERVICE r T..O.F= O j _ F O:H.K-- -OVERHEAD WIRES °sc \e0�c 124.St 32_4 ?� °�IN to A) Benchmark Set �� s p,.S. EXISTING WELL (IAT OUTSIDE COR./BOTT. STEP ,�5 `PROP___:__ BENCHMARK 3° Path 37�5�8 EL.=46.75 (assumed) LEGEND z o Ra p CB 35.57 SAS LAYOUT a ae LOCUS °ay EXISTING SEPTIC TANK LOCUS MAP Z0 (To remain) NOT TO SCALE �3 13-----------134 TOP OF TANK, EL.=118.67 p INV.(OUT), EL.=117.34f GENERAL NOTES: 133.40 13� x EXISTING LEACH PIT 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL BOARD OF HEALTH AND THE DESIGN ENGINEER. ----1-321------ 4,2 128.20 9'. -_13, 30 CONTRACTOR SHALL PUMP, 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS 127.95 --------- FILL WITH SAND & ABANDON. OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE "- LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW: -�C' -310 CMR 15.405(1)(b): s7 . _ _:f�4-- 1) A 2' variance to the 3' maximum cover requirement, for 5' jg4 EXIST Ivy of max. cover. S.A.S. shall be H-20 and vented. + 16 2� 0 112 ° 6.96 .. .23 ;�,, -120 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR \ `7� ' x `` h1.5 7-�4�� TP-1,'' TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE _ O.F= 04 4�i ^' DESIGN ENGINEER. 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING w' - e... :. ;; 1 119.85 54 - ---f1$----- -'y s2.� REPORTED TO THE DESIGN "�� � FROM THOSE SHOWN HEREON SHALL BE ENGINEER BEFORE CONSTRUCTION CONTINUES. x 116 .. ,".•'... .2z-----� iVcc).;..;.•.:..,..: ....'' �-----------91 x 9 TP-2 5 ALL ELEVATIONS BASED ON AN ASSUMED DATUM (APPROX. MASHPEE S . 96 7- 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF 114A0'•:.. x 117.08 __ ,.N V .,� - x 114.99 HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. :x,... -SAS S C. Y 114.35 :,..:..•.;•. r STREET(appro):�., ---------11-4----------- --- __ _ 7 WATER SUPPLY PROVIDED BY PRIVATE WELL � x 1�'6'• -----' % 8. THERE ARE NO POTABLE WELLS WITHIN 150' OF THE PROPOSED S.A.S. 113.13 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS ___ / �- __ AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE `- --------1-1-4 a� _� ; DIRECTED BY THE APPROVING AUTHORITIES. D::.; `x 113.77 113.55 x113.4 ; 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING 146 CONSTRUCTION. ____--� ; ;' 9v 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS "" I v IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND Lot 4 �� /� REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). s i\ 115,1211, ; I % 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE i *WELL l "' MBLU 127-006 2 �, o.00 x INSPECTED BY DESIGN ENGINEER PRIOR TO BACKFILL. i ■=lsJ. �' $ 1"D`'. j x 110.33 -I• ' ; 13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND -<: 51 670f S.F. ` 113.39 < 4 ' IS NOT CONSIDERED TO BE A PROPERTY LINE SURVEY. I 1 x5.61 454.38 T' --- C --- -6�•.116.01 I 10.66 S 1'59" W _;' ; 24'5 , , �_ ------------ 1-08----------------- 119.6 M7.50 116.37 6+ --------__ 113.75 edge of pavement 111.73 110.60 109.65 PROPOSED SEPTIC SYSTEM UPGRADE PLAN PETER T. s OS TER VILLE - WEST BARNSTABLE ROAD C) Mc TEE 1652 OSTERVILLE-W. BARNSTABLE ROAD, MARSTONS MILLS, MA CIVIL Prepared for: D.A. Brown, Inc. P.O. Box 145, Centerville, MA 02632 No, 35109 Q OWNER OF RECORD SCALE DRAWN JOB. NO. O Engineering by: 1'=20' P.T.M. 116-12 S£�ISZF��G� BANK OF AMERICA NA Engineering Works, Inc. P.O. BOX 5170 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO. ZjZ'7�(-L SIMI VALLEY, CA 93065 (508) 477-5313 2/27/12 P.T.M. 1 Of 2 NOTE: TO PREVENT BREAKOUT, THE PROPOSED FINISH GRADE SHALL NOT BE < EL.115.33 FOR A DISTANCE OF 15' AROUND THE PERIMETER OF THE S.A.S. SEPTIC TANK PROPOSED D—BOX PROPOSED S.A.S. INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & WATERTIGHT I INSTALL 1 INSPECTION PORT AT OUTLET AND SET TO 6" OF FINISH GRADE COVER SET TO 6" OF GRADE EACH END OF S.A.S. CHARCOAL VENT T.O.F. (CONNECT ALL LINES) EXISITNG F.G. EL: 120.33(MAX.) F.G. EL.=121.0f � F.G. EL: 119.0t MAINTAIN 2% GRADE (MIN.) OVER S.A.S. L 34' L = 6'(MAX) INSPECTION PORT ® S=1% (MIN.) ® S=1% (MIN.) (1 MINIMUM) 4'SCH40 PVC 4'SCH40 PVC 17.46" 6" 10"I 8 —+{INSTALLED 14" 10.75' TO I LENGTH 48" LIQUID INVERT I I 945" LEVEL G AAS BAFF� INV.=115.17 PROPOSED INV.=115.00 (3 ROWS OF 6 UNITS AT 5.0'/UNIT) + 2.4' (2 COUPLERS) = 32.4' 16Mtl37" INV.=117.34t D—BOX SOIL ABSORPTION SYSTEM (PROFILE) EXISTING INV.=1 14.90 10.38" EXISTING SEPTIC TANK INVERT DOME END ESTABLISH VEGETATIVE COVER HEIGHT BACKFILL WITH CLEAN NATIVE OR POST END PERC SAND TO TOP OF CHAMBERS 33.75" BREAKOUT=TOP TOP ELEV.=115.33 INV. ELEV.=114.90 NOTES: BOTTOM ELEV.=114.00—� 1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE 2,83' NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT INVERTS, PRIOR TO INSTALLATION. 4' OF NATURALLY OCCURRING TO CHANGE WITHOUT NOTICE. PRODUCT DETAIL MAY 2) D—BOX SHALL BE SET LEVEL AND TRUE TO PERVIOUS MATERIAL EFFECTIVE WIDTH=8.5 DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE. GRADE ON A MECHANICALLY COMPACTED SIX 5' MIN. SEPARATION TO G.W. EXISTING SUITABLE 4640 TRUEMAN BLVD INCH CRUSHED STONE SASE, AS SPECIFIED NO GROUNDWATER, EL.=106.3 — MATERIAL ® HILLIARD, OHIO 43026 Are 36HC SIDE PORT COUPLER IN 310 CMR 15.221(2). 3) INSTALL INLET & OUTLET TEES AS REQUIRED. ADVANCED DRAINAGE SYSTEMS. INC. UNITS MUST BE STAMPED H-20 4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE USE 3 ROWS OF 6—ADS Arc36HC UNITS + 2 COUPLERS PER 63.25"- AS MANUFACTURED BY TUF—TITE, ZABEL OR EQUAL. ROW WITH NO SEPARATION BETWEEN SECTION EACH ROW & NO STONE �. SEPTIC SYSTEM PROFILE TYPICAL N.T.S. 34.5" DESIGN CRITERIA SOIL LOG DATE: FEBRUARY 23, 2012 (REF#13,555) TOP VIEW NUMBER OF BEDROOMS: 2 BEDROOMS SOIL EVALUATOR: PETER McENTEE (SE#1542) 60" SOIL TEXTURAL CLASS: CLASS I WITNESS: DON DESMARAIS—HEALTH AGENT END CAP END CAP DESIGN PERCOLATION RATE: <2MIN/IN Elev. TP— 1 Depth Elev. TP-2 Depth FRONT VIEW SIDE VIEW 118.4 0" 117.3. 0" END CAP DAILY FLOW: 220 GPD A A REAR/TOP VIEW DESIGN FLOW: 330 GOD SANDY LOAM SANDY LOAM NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT SIDE VIEW 1OYR 4/2 10YR 4/2 TO CHANGE WITHOUT NOTICE. PRODUCT DETAIL MAY GARBAGE GRINDER: NO 117.9 6' 116.8 6 DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE. LEACHING AREA REQUIRED: (330) = 445.9 SF BLOMY SAND BLOMY SAND 4640 TRUEMAN BLVD 74 10YR 5/8 10YR 5/8 HILLIARD, OHIO 43026 Arc 36HC DETAIL 114.9 30" 114.8 30" LLLLLLPAN, EXISTING SEPTIC TANK: 1000 GALLON CAPACITY C C ADVANCED DRAINAGE SYSTEMS, INC. UNITS MUST BE STAMPED H-20 PROPOSED D—BOX: 1 INLET, 3 OUTLET (MINIMUM), H-10 RATED PROPOSED SEPTIC SYSTEM UPGRADE PLAN USE 3 ROWS OF 6-ADS Arc36HC UNITS + 2 COUPLERS PER F s SAND 2.5Y 7//33 2.5.5Y 7/3 ROW WITH NO SEPARATION BETWEEN EACH ROW & NO STONE 1652 OSTERVILLE—W. BARNSTABLE ROAD, MARSTONS MILLS, MA BOTTOM AREA: (GENERAL USE APPROVAL FOR 4.80 SF/LF OF UNIT) Prepared for: D.A. Brown, Inc. P.O. Box 145, Centerville, MA 02632 (Arc36HC Units) 18 UNITS x 5.0 LF x 4.80 SF/LF = 432.0 SF Engineering by: SCALE DRAWN JOB. NO. (COUPLERS) 6 COUPLERS x 1.2' x 4.80 SF/LF = 34.6 SF 107.4 132" 106.3 132" En ineerin Works, Inc. N.T.S. P.T.M. 116-12 TOTAL AREA = 466.6 SF PERC RATE: <5 MIN/IN. (ON FILE) 9 DESIGN FLOW PROVIDED: 0.74(466.6 S.F.) = 345.3 G.P.D. SOILS ARE CONSISTENT WITH PERC RATE ON FILE 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO. NOkGROUNDWATER OBSERVED (508) 477-5313 2/27/12 P.T.M. 2 Of 2 t