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HomeMy WebLinkAbout0071 PRINCE AVENUE - Health 7J'PRINCE R►/'� _ b, I� = 077 043' mQ Sdn :.J Commonwealth of Massachusetts o q3 F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . 71 Prince Ave Property Address Richard Webber Ida Owner Owner's Name ;Y information is Marston Mills MA 02648 5-11-18 X required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information ,57, 130on the computer, a,a., waq►wrnuq����� use only he tab ��� �t���N OF MA`SS9'4,,� 1. Inspector: key to move your O� �G cursor-do not JAMES James D.Sears =�; m kee the return Name of Inspector ? YCn Capewide Enterprises CI o Company Name �s�, ..,ITT c�--j��y` 153 Commercial Street pF 5 INSP�G� Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S 1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 5-12-18 ;spie"ctors 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 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. /1 r- p-go.,t5ins.doc•rev. 6 6 Title 5 Official Inspection Form:Subsurface Sewage Disposal of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 Prince Ave Property Address Richard Webber Owner Owner's Name information is required for every Marston Mills MA 02648 5-11-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 1500 Gal. Tank D Box and six chamber's. 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): I t5ins.doc•rev.6/16 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 71 Prince Ave �tJ Property Address Richard Webber Owner Owner's Name information is required for every Marston Mills MA 02648 5-11-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Prince Ave Property Address Richard Webber Owner Owner's Name information is required for every Marston Mills MA 02648 5-11-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 99 p ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in OEM is less than 6" below invert or available volume is less than %day flow , EX-MN; t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Mli Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 Prince Ave Property Address Richard Webber Owner Owner's Name information is required for every Marston Mills MA 02648 5-11-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow.of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304, The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6/16 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 71 Prince Ave Property Address Richard Webber Owner Owner's Name information is required for every Marston Mills MA 02648 5-11-18 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health, ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form F Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 Prince Ave u Property Address Richard Webber Owner Owner's Name information is required for every Marston Mills MA 02648 5-11-18 page. City/Town State Zip Code Date of Inspection D. System Information Description: 1500 Gal. Tank D Box and six chamber's. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 2016-9,000 Gals g ( y g (gpd))' 2017-9,000 Gal s Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts z Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 Prince Ave Property Address Richard Webber Owner Owner's Name information is Marston Mills MA 02648 5-11-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 I c Commonwealth of Massachusetts _ r� Title 5 Official Ins ection Form p Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Prince Ave Property Address Richard Webber Owner Owner's Name information is required for every Marston Mills MA 02648 5-11-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1999 Permit # 99-303. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 27" feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH -40. Septic Tank(locate on site Ian): Depth below grade: 17" feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gal. Precast H-10 Sludge depth: 2" t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form -�� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 Prince Ave Property Address Richard Webber Owner Owner's Name information is required for every Marston Mills MA 02648 5-11-18 page. CityfTown 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 28" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 8,1 Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbuilt-Tape Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank and inlet cover at 17"w/outlet cover at 7". In and outlet tee's. No sign of leakage or over loading. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 Prince Ave Property Address Richard Webber Owner Owner's Name information is required for every Marston Mills MA 02648 5-11-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Title 5 Official Ins ection Form:Subsurface Sewa a Dis osal S stem•Pa a 11 of 17 t5ins.doc rev.6/16 p 9 P Y 9 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 71 Prince Ave Property Address Richard Webber Owner Owner's Name information is required for every Marston Mills MA 02648 5-11-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x16"-14" below grade w/two line's out. Box is clean and solid w/no sign of over loading or solid carry over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form �! Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 Prince Ave Property Address Richard Webber Owner Owner's Name information is required for every Marston Mills MA 02648 5-11-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 6 ❑ leaching galleries number: ❑ leaching trenches number,length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is six infiltrators(10'x45'x2') ck D Box and camera out lines. T.H. above chamber's. No sign of over loading or solid carry over. No sign of holding water. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 r c Commonwealth of Massachusetts Title 5 Official Inspection Form Fia Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 Prince Ave u Property Address Richard Webber Owner Owner's Name information is required for every Marston Mills MA 02648 5-11-18 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.doc-rev.6/16 .Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 l_ i Commonwealth of Massachusetts Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments L 71 Prince Ave V Property Address Richard Webber Owner Owner's Name information is required for every Marston Mills MA 02648 5-11-18 page. CitylTown 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 � a C 3- 09 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Prince Ave Property Address Richard Webber Owner Owner's Name information is required for every Marston Mills MA 02648 5-11-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Na 10, Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record 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: Auger T.H. 10' no G.W.. Bottom of leaching at 4' below grade. Bottom of leaching at 6' above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 r - c Commonwealth of Massachusetts Title 5 Official Inspection Form Fi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ./ 71 Prince Ave Property Address Richard Webber Owner Owner's Name information is Marston Mills MA 02648 5-11-18 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 4 * , Massachusetts Department of Environmental Protection 100285992 BWP AQ 04 (ANF-001) Asbestos Project# f Asbestos Notification Form y r-J Project Revision IL Project Cancellation Mll A. Asbestos Abatement Description bay IX 1.Facility Location: { WEBBER 71 PRINCE AVE w%� Instructions 1.All a.Name of Facility b.Street Address !Rw sections of this form BARNSTABLE MA 02648 0000000000 must be completed in order to comply with c.City/Town d.State e.Zip Code f.Telephone MassDEP notification x x requirements of 310 CMR 7.15 and g.Facility Contact Person Name h.Facility Contact Person Title Department of Labor Worksite Location: BASEMENT Standards(DLS) notification i.Building Name,Wing,Floor,Room,etc. requirements of 453 2. Is the facility occupied? Re a.Yes rb.No CMR 6.12 3. Is this a fee exempt notification (city,town, district, municipal housing authority, state facility, or owner-occupied residential property of four units or less)? F, a.Yes ' b.No MassDEP Use Only 4.Blanket Permit Project Approval,if applicable: Date Received Approval ID# 5.Non-Traditional Asbestos Abatement Work Practice Approval, 2.Submit Original if applicable: Approval ID# Form To: Commonwealth of Massachusetts 6.Asbestos Contractor: P.O.Box 4062 Boston,MA 02211 NEW ENGLAND SURFACE MAINTENANCE LLP 850 WASHINGTON ST a.Name b.Address WEYMOUTH MA 02189 7813372117 a City/Town d.State e.Zip Code f.Telephone A0000196 h.Contract Type: rJ 1.Written r-`2.Verbal g.DLS License# 7. JOHN P.VAWQUETTE AS060773 a.Name of Contractor's On-Site Supervisor/Foreman b.DLS Certification# 8 RICHARD K BOWEN AM061044 a.Name of Project Monitor b.DLS Certification# 9 FU ENVIRONMENTAL INC AA000144 a.Name of Asbestos Analytical Lab b.DLS Certification# 10. 6/15/2018 6/15/2018 a.Project Start Date(MM/DD/YYYY) b.End Date(MM/DD/YYYY) 8-4 N/A c.Work Hours-Monday Through Friday d.Work Hours-Saturday&Sunday 11.What type of project is this? r a.Demolition F b.Renovation r c.Repair rj d.Other-Please Specify: Revised: 11/13/2013 Page 1 of 4 Massachusetts Department of Environmental Protection 100285992 BWP AQ 04 (ANF-001) r Asbestos Project# Asbestos Notification Form Project Revision r' Project Cancellation A.Asbestos Abatement Description: (cont.) 12.Abatement procedures(check all that apply): r a.Glove Bag r b.Encapsulation ' c.Enclosure I-! d.Disposal Only r e.Cleanup r f.Full Containment r g.Other-Please Specify: 13.Job is being conducted: r; a.Indoors r1 b.Outdoors 14 a.Total amount of each type of asbestos Containing materials(ACM)to be removed,enclosed,or encapsulated: 300 1.Linear Feet(Lin.Ft.) 2.Square Feet(Sq.Ft.) 'b.Boiler,Breaching,Duct, c.Transite Pipe Tank Surface Coatings 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. d.Pipe Insulation 300 e.Transite Shingles 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. f. Spray-On Fireproofing g.Transite Panels 1.Lin.Ft 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. h.Cloths,Woven Fabrics i.Other-Please Specify: 1.Lin.Ft. 2.Sq.Ft. j.Insulating Cement 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. 15.Describe the decontamination system(s)to be used: AS REQUIRED 16.Describe the containerization/disposal'methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2) (g): AS REQUIRED 17.For Emergency Asbestos Operations,the MassDEP and DLS officials who evaluated the emergency: a.Name of MassDEP Official b.Title of MassDEP Official c.Date of Authorization(MM/DD/YYYY) d.Waiver# e.Name of DLS Official f.Title of DLS Official g.Date of Authorization(MM/DD/YYYY) h.Waiver# 18.Do prevailing wage rates as per M.G.L.c. 149, §26,27 or 27A—F apply to this r a.Yes Wo, b.No project? Revised: 11/13/2013 Page 2 of 4 Massachusetts Department of Environmental Protection 100285992 7LIBWP AQ 04 (ANF-001) - Asbestos Project# Asbestos Notification Form Project Revision Project Cancellation B. Facility Description 1.Current or prior use of facility: RESIDENCE 2.Is the facility owner-occupied residential with 4,units or less? W a.Yes r- b.No 3 WEBBER 71 PRINCE AVE a.Facility Owner Name b.Address BARNSTABLE MA 02648 0000000000 c.City/Town d.State e.Zip Code f.Telephone 4.X X a.Name of Facility Owner's On-Site Manager b.Address X MA 00000 0000000000 c.City/Town d.State e.Zip Code f.Telephone 5 X X a.Name of General Contractor b.Address X MA 00000 0000000000 c.City/rown d.State e.Zip Code f.Telephone X g.Contractor's Worker's Compensation Insurer X 1/1/2019 h.Policy# i.Expiration Date(MM/DD/YYYY) 6.What is the size of this facility? 1500 2 a.Square Feet b.#of Floors C. Asbestos Transportation & Disposal 1.Transporter of asbestos-containing waste material from site of generation: r a.Directly to Landfill or r b.To Temporary Storage Location/Transfer Station NEW ENGLAND SURFACE MAINTENANCE,LLP 850 WASHINGTON STREET c.Name of Transporter d.Address Note:Temporary storage of Asbestos WEYMOUTH MA 02189 7813372117 containing waste e.City/Town f.State g.Zip Code h.Telephone material is only allowed at the place of business of a DLS 2.If a temporary storage location/transfer station is used,list name of transporter of asbestos containing licensed Asbestos t l f waste material temporary storage location/transfer station to final disposal site: contractor or a transfer p �' g p station that is permitted by REDTECHNOLOGIES 10 NORTHWOOD DRIVE MassDEP and a.Name of Transporter b.Address operated in compliance with Solid BLOOMFIELD CT 06002 8602182428 Waste Regulations c.City/Town d.State e.Zip Code f.Telephone 310 CMR 19.000 Revised: 11/13/2013 Page 3 of 4 Massachusetts Department of Environmental Protection 100285992 L7IBWP AQ 04 (ANF-001) Asbestos Project# Asbestos Notification Form r Project Revision r Project Cancellation C.Asbestos Transportation&Disposal: (cont.) 3.Name and address of temporary storage location/transfer station for the asbestos containing waste material: RED TECHOLOGIES 203 PICKERING STREET a.Temporary Storage Location Name b.Address PORTLAND CT 06480 8603421022 c.City/Town d.State e.Zip Code f.Telephone 4.Name and location of final disposal site(asbestos landfill): MINERVA ENTERPRISES MINERVA a.Final Disposal Site Name b.Final Disposal Site Owner Name 9000 MINERVA ROAD c.Address WAYNESBURG OH 44688 3308663435 d.City/Town e.State f.Zip Code g.Telephone A Certification KEN FURTNEY KEN FURTNEY "I certify that I have personally 1.Name 2.Authorized Signature examined the foregoing and am PARTNER 5n12018 familiar with the information contained in this document and 3.Position/Title 4.Date(MM/DD/YYYY) Note:Contractor must 7813372117 NESM,LLP sign this form for DLS all attachments and that, based notification purposes on my inquiry of those 5.Telephone 6.Representing individuals immediately 850 WASHINGTON STREET WEYMOUTH responsible for obtaining the 7.Address 8.City/Town information,I believe that the MA 02189 information is true,accurate, and complete. I am aware that there 9•State 10.Zip Code are significant penalties for submitting false information, including possible fines and imprisonment.The undersigned hereby states that I have read the Commonwealth of Massachusetts regulations governing asbestos abatement (453 CMR 6.00 promulgated by the Department of Labor Standards and 310 CMR 7.15 promulgated by the Department of Environmental Protection), and that I am aware that this permit application or notification shall not be deemed valid unless payment of the applicable fee is made." Revised: 11/13/2013 Page 4 of 4 e Massachusetts Department of Environmental ProtectionLl 100286948 BWP AQ 04 (ANF-001) Asbestos Project# Asbestos Notification Form rl Project Revision r;; Project Cancellationr..3 ram... —IN A. Asbestos Abatement Description 1y 1.Facility Location: X. WEBBER 71 PRINCE AVE 1X0 Instructions 1.All a.Name of Facility b.Street Address tCD sections of this form BARNSTABLE ew,x must be completed in MA 02648 0000000000 order to comply with c.City/Town d.State e.Zip Code f.Telephone MassDEP notification X X requirements of 310 CMR 7.15 and 9.Facility Contact Person Name h.Facility Contact Person Title Department of Labor Worksite Location: BASEMENT Standards(DLS) notification i.Building Name,Wing,Floor,Room,etc. requirements of 453 2. Is the facility occupied? r,7 a.Yes r-b.No CMR 6.12 3. Is this a fee exempt notification (city,town, district, municipal housing authority, state facility, or owner-occupied residential property of four units or less)? 1v a.Yes r b.No' MassDEP Use Only 4.Blanket Permit Project Approval,if applicable: Date Received Approval ID# 5.Non-Traditional Asbestos Abatement Work Practice Approval, 2.Submit Original if applicable: Approval ID# Form To: Commonwealth of Massachusetts 6.Asbestos Contractor: P.O.Box 4062 ' Boston,MA 02211 NEW ENGLAND SURFACE MAINTENANCE LLP 850 WASHINGTON ST a.Name b.Address WE YMOUTH MA 02189 7813372117 c.City/Town d.State e.Zip Code f.Telephone A0000196 h.Contract Type: r 1.Written r_j 2.Verbal g.DLS License# 7. JOHN P.VALLIQUEfTE AS060773 a.Name of Contractor's On-Site Supervisor/Foreman b.DLS Certification# 8 RICHARD K BOWEN AM061044 •a.Name of Project Monitor b.DLS Certification# 9 FU ENVIRONMENTAL INC AA000144 a.Name of Asbestos Analytical Lab b.DLS Certification# 10. 6/15/2018 6/15/2018 a.Project Start Date(MM/DD/YYYY) b.End Date(MM/DD/YYYY) 8-8 N/A c.Work Hours-Monday Through Friday d.Work Hours-Saturday&Sunday 11. What type of project is this? r a.Demolition r b.Renovation r c.Repair r d.Other-Please Specify: Revised: 11/13/2013 Page 1 of 4 a � Massachusetts Department of Environmental Protection 100286948 BWP AQ 04 (ANF-001) Asbestos Project# Asbestos Notification Form r, Project Revision I- Project Cancellation A.Asbestos Abatement Description: (cont.) 12.Abatement procedures(check all that apply): r a.Glove Bag r b.Encapsulation r i c.Enclosure r d.Disposal Only r e.Cleanup r f.Full Containment r g.Other-Please Specify: 13.Job is being conducted: r, a.Indoors r b.Outdoors 14 a.Total amount of each type of asbestos Containing materials(ACM)to be removed,enclosed,or encapsulated: 1120 1.Linear Feet(Lin.Ft.) 2.Square Feet(Sq.Ft.) b.Boiler,Breaching,Duct, c.Transite Pipe Tank Surface Coatings 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. d.Pipe Insulation e.Transite Shingles 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. f. Spray-On Fireproofing g.Transite Panels 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. h.Cloths,Woven Fabrics i.Other-Please Specify: 1.Lin.Ft. 2.Sq.Ft. j.Insulating Cement VAT 1120 1.Lin.Ft. 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft. 15.Describe the decontamination system(s)to be used: AS REQUIRED 16.Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2) (g): AS REQUIRED 17.For Emergency Asbestos Operations,the MassDEP and DLS officials who evaluated the emergency: a.Name of MassDEP Official b.Title of MassDEP Official c.Date of Authorization(MM/DD/YYYY) d.Waiver# e.Name of DLS Official f.Title of DLS Official g.Date of Authorization(MM/DD/YYYY) h.Waiver# 18.Do.prevailing wage rates as per M.G.L.c. 149, § 26,27 or 27A—F apply to this r a.Yes rk-0 b.No project? Revised: 11/13/2013 Page 2 of 4 7LIMassachusetts Department of Environmental Protection 100286948 BWP AQ 04 (ANF-001) Asbestos Project# Asbestos Notification Form r—, Project Revision r7 Project Cancellation B. Facility Description 1.Current or prior use of facility: RESIDENCE 2.Is the facility owner-occupied residential with 4 units or less? r7o a.Yes r- b.No 3 WEBBER 71 PRINCE AVE a.Facility Owner Name b.Address BARNSTABLE MA 02648 0000000000 c.City/Town d.State e.Zip Code f.Telephone 4 X X a.Name of Facility Owner's On-Site Manager b.Address X MA 00000 0000000000 c.City/Town c'.State e.Zip Code f.Telephone 5.X X a.Name of General Contractor b.Address X PIA 00000 0000000000 c.Citylfown d.State e.Zip Code f.Telephone X g.Contractor's Worker's Compensation Insurer X 1/1/2019 h.Policy# i.Expiration Date(MM/DD/YYYY) 6.What is the size of this facility? 1500 2 a.Square Feet b.#of Floors C. Asbestos Transportation & Disposal 1.Transporter of asbestos-containing waste material from site of generation: r a.Directly,to Landfill or 1✓ b.To Temporary Storage Location/Transfer Station NEW ENGLAND SURFACE MAINTENANCE,LLP 850 WASHINGTON STREET c.Name of Transporter d.Address Note:Temporary storage of Asbestos WEYMOUTH MA 02189 7813372117 containing waste e.City/Town f.State g.Zip Code h.Telephone material is only allowed at the place of business of a DLS 2.If a temporary storage location/transfer station is used,list name of transporter of asbestos containing licensed Asbestos waste material from temporary storage locationitransfer station to final disposal site: contractor or a transfer p � g p station that is permitted by RED TECHNOLOGIES 10 NORTHWOOD DRIVE MassDEP and a.Name of Transporter b.Address operated in compliance with Solid BLOOMFIELD CT 06002 8602182428 Waste Regulations 310 CMR 19.000 c.City/Town d.State e.Zip Code f.Telephone Revised: 11/13/2013 Page 3 of 4 f Massachusetts Department of Environmental Protection 100286948L771 —� BWP AQ 04 (ANF-001) Asbestos Project# Asbestos Notification Form r Project Revision r Project Cancellation C.Asbestos Transportation& Disposal: (cont.) 3.Name and address of temporary storage location/transfer station for the asbestos containing waste material: RED TECHOLOGIES 203 PICKERING STREET a.Temporary Storage Location Name b.Address PORTLAND CT 06480 8603421022 c.City/Town d.State e.Zip Code f.Telephone 4.Name and location of final disposal site(asbestos landfill): MINERVA ENTERPRISES MINERVA a.Final Disposal Site Name b.Final Disposal Site Owner Name 9000 MINERVA ROAD c.Address WAYNESBURG OH 44688 3308663435 d.City/Town e.State f.Zip Code g.Telephone. D. Certification KEN FURTNEY KEN FURTNEY "I certify that I have personally 1.Name 2.Authorized Signature examined the foregoing and am PARTNER 5/21/2018 familiar with the information contained in this document and 3.Position/Title 4.Date(MM/DD/YYYY) Note:Contractor must 7813372117 NESM,LLP sign this form for DLS all attachments and that,based notification purposes on my inquiry of those 5.Telephone 6.Representing individuals immediately 850 WASHINGTON STREET WEYMOUTH responsible for obtaining the 7.Address 8.City/Town information, I believe that the MA 02189 information is true, accurate,and complete.I am aware that there 9.State 10.Zip Code are significant penalties for submitting false information, including possible fines and imprisonment.The undersigned hereby states that I have read the Commonwealth of Massachusetts regulations governing asbestos abatement (453 CMR 6.00 promulgated by the Department of Labor Standards and 310 CMR 7.15 promulgated by the Department of Environmental Protection), and that I am aware that this permit application or notification shall not be deemed valid unless payment of the applicable fee is made." Revised: 11/13/2013 Page 4 of 4 -7 TOWN'O/F BARNSTABLE ✓� LOCATION ` / l-MI e i7'!/ SEWAGE # VILLAGE AafVOIV5 fSj & ASSESSOR'S MAP&LOT D���V� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY �31x' r�C r LEACHING FACILITY: (type).T, t by (size) /O')1 ya'� ' NO.OF BEDROO 7 BUILDER O OWNER . PERMTTDATE: 4V—RE COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist I, on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist J within 300 feet of leaching facility) ��/ Feet Furnished by Rttip �b O r VV b, No. ?"03 { Fee Y THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppricaction for Oi-4pogal *pgtem Con!truction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) 11 Complete System El Individual Components Location Address or Lot No. 71 Owner's N"e,Address and Tel.No Assessor's Map/Parcel Installer's Name,Address,and Tel.No. �f✓ / Designer's Name,Address and Tel.No. 27� Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( !� Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow �� gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 5'Em,9,0,/ Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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 Certifi- cate of Compliance has been issued b this d of alth. Signed Date 3;Ilel Application Approved by Date V - Application Disapproved for the ollowtng reasons Permit No. Date Issued �Rw . -+ r r ' ,.._C A- 't..rr�lJ. .J. r J .. •J.. t;.a.:..� .:.-r�-e•-�^~e O' J., , A .. . .-� .. 97 No. 9A 3 Fee v" I~ :� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 20pfic4tion for �Digaal *p5tem (tomaruction Vermit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. -71 ��j�� v �i i© Owner's Name,Address and Tel.No Assessor's Map/Parcel ( C�C�- !/� 14-,1&1 jam'fl31l,S Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 7 Lot Size sq. ft:�;- Garbage Grinder p Other Type of Building zif 5 No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow �7 gallons. Plan Date. Number of sheets Revision Date Title Size of Septic Tank Z_�E©D Type of S.A.S. Description of Soil. i Nature of Repairs or Alterations(Answer when applicable) ' I 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 Certifi- cate of Compliance has been issued by this o d of Health. Signed ' . Date Application Approved by Date -IV Application Disapproved for the ollowing reasons t Permit No. Cb Date Issued - THE COMMONWEALTH OF MASSACHUSETTS )7 7`% q3 , BARNSTABLE, MASSACHUSETTS # Certificate of (Compliance THIS IS TO CE TIFY,that the On-site Sewage Disposal System Constructed( )Repaired (Upgraded( ) Abandoned( )by G)f IVZO jf`/ 1,"410�571 at 7/ �i'1ece atilt has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 791-30 3 dated Installer Designer - r`, d "10 The issuance of this permits all n be;construed as a guarantee that the system vvll:,unstpn a d ..esigned ,+ / �1 Date 1 -f Inspector_% 0 I, .fa -r f, , 6� ^ f r No. �� �o� ------------------�f77 CJ- 3 Fee V` 0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS lwigpogai *potent Construction Vermit \ Permission is hereby granted to Construct( )Repair(1/ )Upgrade( )Abandon( ) System located at 7 f 1-)I1Ce 47l/e 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 cp�ermit. .Date: �! - Approved by R .�� ` 5 TOWN OF BARNSTABLE G LOCATION �� f/�C �� SEWAGE # �! VILLAGE—/ QI��TDi1s / j��/� ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /yX 6-1 LEACHING FACILITY: (type) NO.OF BEDROO BUILDER O OWNER PERMITDATE: 7'V— COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility S t Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) I?0 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) ��� Feet Furnished by -7, Rfy-� _. 6T rJ 5 3b 0 n� I' 1 1000 I� 71 l 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, Zr"0- id/`A`eP// ,hereby certify that the application for disposal works construction permit signed by me dated /���� , concerning the property located at 7/ /"/'1?Ge all of the following criteria: 7✓ The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. /Thesoil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. ✓ There are no wetlands within 100 feet of the proposed septic system Y There are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed There are no variances requested or needed. /The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] If the S.A.S.will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: / G' A) Top of Ground Surface Elevation(using GIS information) B) G.W. Elevation +the MAX.High G.W. Adjustment. Zr DIFFERENCE BETWEEN A and B-4fv l ` SIGNED : ` DATE: ,jam! Ile [Sketch proposed plan of system on back]. q:health folder:cert