HomeMy WebLinkAbout0023 REGENCY DRIVE - Health 23 REGENCY DRIVE, MARSTONS MILLS
064 049 9
1
TOWN OF BARNSTABLE
LOCA�O0— 3 0` 4 t Lz Dig-. SEWAGE#
VILLAGE A. AI. ASSESSOR'S MAP&LOT D
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACR rrY: (type)o2 (size) X 6
NO.OF BEDROOMS '3
BUII_DER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) 1 Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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TROY WILLIAMS NOV 2 1 1995
SEPTIC INSPECTIONS
w.
Certified by MA Department of Environmental Protection 508) 760-1819
40 Old Bass River Road S
South Dennis,MA 02660
00
Q I
I conynonweatth of Massachusetts
ExecutMe Office of Ertivlformerttd Affairs Department of COPY
Environmental Protection
WMAM F.W*W
tae..n„r
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: f ^ c 4 i. o� S �'(r5
�: /y�9S / M Sf'^ Address of Owner. Fn)
Date of Inspection: / �.
Name of 1 0(different)
Inspector:�oy G.J. /�;u-'h S -2
Company Name, Address and Telephone Number:
S« ASw&. Ors, alp ll� AI-T 076 Z/
7TIFI,CATI,ON STATEMENT
tifytIhave personallyinspected the sewage disposal system at this address and that the informationcot as of the time of inspection. The in below is true,atxtrrate
sped inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
—ZPasses
_ Conditionally Passes
_ Needs Further Evaluation By the local Approving Authority
Fails
Inspector's Signature: Dater
//C /y S—
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of eornpleting this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B. C, orD
Al SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defused in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
81 SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the mplacemerrt or repair,
passes inspection.
II Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If'not determined', explain why not)
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfihration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health
Ire���<d 1/1S/9S�
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: a 3
Owner: C v �e
Date of Inspection: /(
B) SYSTEM CONDITIONALLY PASSES (continued)
— Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipes) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of 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 APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
EN VIR0NhiENT:
the sk-stem has a septic tank ano so" adsorption system and is within 100 feet to a surface water supply or tributary %,a
surface water supply
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The s�-stem has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The systen, has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a well Kater analysis for coliform bacteria and volatile organic compounds indicates that the well is
free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm.
tI SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or pondrng of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool
c—ised 6/15/95,
2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: v?
Owner.
Date of Inspection:
D] SYSTEM FAILS (continued):
Static liquid level in the distribution box above outlet invert due to an overloaded or dogged SAS or cesspool.
Liquid depth in cesspool is less than 6' below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to dogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of.a public well.
Any portion of a cesspool or privy is within 50 feet of a.private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
11 LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety
and the environment because one or more of the following conditions exist:
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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
revised 8/15/95) 3
i I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART 6
CHECKLIST
Property Address: a3 i, C y
Owner: v I I
Date of Inspection:
Check'if the following have been done:
Zumping information was requested of the owner, occupant, and Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. large volumes of water have not been introduced into the system recently or as part of this inspection.
V/As built plans have been obtained and examined. Note if they are not available with WA.
JL/The facility or dwelling was inspected for signs of sewage back-up.
_L/The system does not receive non-sanitary or industrial waste flow
ZThe site was inspected for signs of breakout.
_1//All system components, excluding the Soil Absorption System, have been located on the site.
V The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
V The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
V"The facility own,- tamed ocCuranis, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
)revised S/]5/95) 4
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 0?3
Owner:
Date of Inspection:
RESIDENTIAL: FLOW CONDITIONS
Design flow: 330 gallons
Number of bedrooms: I
Number of current residents:
Garbage grinder (yes or no): ND
Laundry connected to system (yes or no): ivC S
Seasonal use (yes or no): A/0
Water meter readings, if available:__
_ast date of occupancy: V1.c'4. ,,I-
COMMERCIAUINDUSTRIAL•
type of establishment:
Design flow:------gal Ions/day
,Srease trap present: (yes or no)_
industrial Waste Holding Tank present: (yes or no)_
ion-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
_ast date of occupancy:
OTHER: (Describe)
..ast date of occupancy:
GENERAL INFORMATION
PUMPING
�R�E�CORD�S and source of information: / p / T
t1 rh .o. _ 4 / r-. 16 Q y,c�r ( A L �-c 61 f O✓H s
System 6umped as pan of inspection: (yes or no) A/A
If yes, volume pumped gallons
Reason for pumping:
TYPE O SYSTEM
Septic tank/d+uulwsiea.boodsoil absorption system p: 5ys
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Other (explain)
NPPROXIMAT� AGE of all components, dilate installed (if known) and source of information:�n S
T
u S — �✓ Cn C7orh f TF �I< 9Q.�
sewage odors detected when arriving at the site: (yes or no) A/U
revised 8/15/951 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: v22 kc y u.,
Owner:
Date of Inspection:
SEPTIC TANK:
(locate on site plan)
Depth below grade: �
Material of construction: LEoncrete _metal _FRP —other(explain)
Dimensions:_ ,S Y X 6 /000 a titi S .
Sludge depth: " :, k; * /-7- yI" ; h �o,��J�y �k
Distance from top of sludge to bottom of outlet tee or baffle: c9 i3o
Scum thickness: iVON67
Distance from top of scum to top of outlet tee or baffle: IVO
Distance from bottom of scum to bottom of outlet tee or baffle: "-+
Comments:
recommendation for pumping,.condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
ntegrity, evidence of leakage, etc.) d H C. c mac,7�� s 61
a� �✓.� c v O r��✓. _5 c -c
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o9
GREASE TRAP;[/jq
locate on site plan)
Depth below- grade:
Material of construction: _concrete _metal _FRP —other(explain)
7imensions:
,cum thickness:
Distance from top of scum to top of outlet tee or baffle:
)1°tance from bottom ni «tim to hnnnm OI Ou!to! tee O, tame
omments:
,ecommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
ntegrity, evidence of leakage. et(.)
revised "'"51 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: a 3 �y c+.1 c,y
Owner. C l l C " .
Date of Inspection:
TIGHT OR HOLDING TANK:Z�//-
(locate on site plan)
Depth below grade:
Material of constriction: _concrete_metal_FRP other(explain)
Dimensions:
Capacity: eallons
Design flow: gallonstday
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_ /19
locate on site plan)
Depth of liquid level above outlet invert:
Comments:
.note if level and distribuiior. is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
/✓ D—C>U . S h c /c c CJ( %�, ¢ 01: V
i
PUMP CHAMBER:2 iL
locate on site plan)
Pumps in working order:(yes or no)
I_omments:
-note condition of pump chamber, condition of pumps and appurtenances, etc.)
.revised 8/15/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: c2 3 �`y-e-et c
Owner. C1.) I l e h
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):_e`
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type.
leaching pits, number: ��a r4�—t �x �� �� �+/w• ::;"O,�s
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of pondin condition of vegetation,etc. �(
i—o 4- v S .
CESSPOOLS:
.locate on site plan)
number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
materials of construction:
ndication of groundwater:
inflow (cesspool must be pumped as part of inspection)
omments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
P R I VY: )V//�l
locate on site plan)
-,Aaterials of construction: Dimensions:
)epth of solids:
,:omments: (note condition of soil, signs of hydraulic failure, level of podding, condition of vegetation, etc.)
revised 8/15/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
,p SYSTEM INFORMATION (continued)
Property Address: 3 /� .-f -Cti C.y
Owner: ` Gv H G to
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
00 o q 41 4cxb%h
21
�b0 U (�r. t $c,o�yc ❑
+l u�d k
02 a3'6
0
i
G X6
w �S froth e
DEPTH TO GROUNDWATER
)epth to groundwater: — feet adjusted high groundwater level
method of determination or approximation: CA
hn Wa �cr ^al � 4ri iAle /3
revised 8/15/95) 9
LO-CAT I-O-N SEW-D,C�E PERMIT-ICJ O.
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No.%......77> . Flzs...... l�C�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
._ -..... .oF ... .. ...i2.. .s 77; -------------------
Apphratiuu -fur Ui,ipuutti Norks Totuitrurtion Vrrtuft
Application is hereby made for a Permit to Construct ( "or Repair ( ) an Individual Sewage Disposal
System at:
.!7xl.v. �? - Q __.ws_ fit'
...------'-- --- ----------
----------------- ------
�/J Locafi n.Address or Lot No
l.!.1..✓ _�2..�..�i r/!...... •---'--'....................... .... �3�' �%1. �Y `�o�'
Owner Address
Installer 4 Address1. 7�
Q Type of Building Size Lot_.._.__��(3----_--__-____Sq. feet
U Dwelling—No. of Bedrooms-----------J. ............................Expansion Attic ( ) Garbage Grinder ( )
pa, Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Q, Othersfj�ctures ------------------------------
W Design Flow.................................... ....... allons per person per day. Total daily flow--------------------------------------------gallons.
P4 Septic Tank�iquid capacity_. iplons Length---------------- Width................ Diameter---------------- Depth_____.__.-----
x Disposal Trench—No..................... Width------------ �Jngwl
hw_.......__ .__-. Tot leachi area-------.............sq. ft.
Seepage Pit Noy . Diameter_. fl t� _._ ligg area.-.-.___.__-_--sq. it.
z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by------- -----------------•-------------------------•-•-•'--...-•--•----_.. Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water...--------------.......
4q Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.-.-.----_---------...__
P4 --------------------------------------------------------- ................................................................... ------------------------------
0 Description of Soil____________________ ___________
�T r 7: _-A' ---------------------
--------------------- -
W �------------------------ -------------------------------------------------------------------------------------------------------------------------------
VNature of epairs or Alterations—Answer when applicable............_____-----------------------______________________________________________________.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further'agrees not to place the system in
operation until a Certificate of Compliance has bee issued by the board of health.
Signed- ..........................� � � -
\�
ApplicationApproved By-------------------------------------------------------------------------------------------------- -------------------.D..- -----------•-
Date
Application Disapproved for the following reasons-----------------------------------------------------------------------------------------------------------------
J
____________________________________________________________________47/
____ ___ ................................................... ___ _____._____ _ ..._..............
ate
Permit No......l Issued----
--------------• Date
' r
No.--------......2---- Fs$............:C�`�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...--------- -- OF... , 7... .r!?.. ?.(. ...- --/-tz .........
Appliration -fur M_npoiittl Works Tow9#rurtion Punfit
Application is hereby made for a Permit to Construct (,-<Or Repair ( ) an Individual Sewage Disposal
System at: -�'"
a-__ y -------•_..._ ----------------------------------
Location-Address or Lot No
Owner Address
Installer Address �� _ 7�
d Type of Building Size Lot-----.._".�--------------Sq. feet
U Dwelling—No. of Bedrooms----------_3................ .............Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
Ga Other fixtures ------------------------------ - . .
W Design Flow......................................______gallons per person per day. Total daily flow-------------------------------------------.gallons.
WSeptic Tank—Liquid capacity_ 1�gallons Length................ Width................ Diameter----------.----- Depth____.____.._.
x Disposal Trench—No--------------------- Width-------------------- Total Length-------------------- Total leaching area--------------------sq. ft.
Seepage Pit No-.--.--- ..... Diameter.................... Depth below inlet-------------------- Total leaching area------------------sq. tt.
z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed bY-------------------------------------------------------------------------- Date----------------------------------------
a Test Pit No. 1----------------minutes per inch Depth of "Pest Pit-................... Depth to ground water....-.._..-------....._-
(_, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
---------------------- ----•----------------------•-•-•-------•-•--•--•-•-----------••--•-••--••••-•.....................................................
Description of Soil t
-- ------- •---•---------------_, ;�-----------
�i ,/C - L , T-�_j---- �lc..� .5 ?---_-
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
---------- --------��.,-1 1r'` ---------------------------------- --•-- -•-•----- ----•-----------------•--•---------------- --------------------- -•----••---. .............
U Nature 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 Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed-- .. ` ° `.."""" r .... .._
Date
ApplicationApproved By------------------------------------------------------------------------ .........................................
Date
Application Disapproved for the following reasons:............................•-_-._---_._._..__._._..--.._...._._----._.-__-_._--_-..._......._.__--------_:____.
--••------------------------•---••-------••--•----------••-•• ----------...-•-•-•---•---••-••---------•-----•-•-•-•----_..---------....-•------•---•-----------•-----------•-•.........................
Date
PermitNo.•-•-•• �'........................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...0....�.v...................OF.... �. .-. .=.. .. .........................
Trr#if ira#r of f�Impliatta _
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
byG '" - ---.�--=.=!•_C'=---- - -----------------------------------------------------------•--•--------------•-.-..---------•------
Installer / /
at r' c_.. �«.✓----�---- I '' p '" �'" '��' �6' _!!�'"'` 'F '�
has been installed in accordance with the provisions of Article XI o 16
'77f„The State Sanitary Code as described in .the
application for Disposal Works Construction Permit No...-.-._._ _ ._....._•_._....._ dated...............................
THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........................................----------------•••-•-•-•••------------ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.........4....w.:•�" ..._......OF...�,..�..:�3?..�.��S..L:-�... .........ems---------------- �j �_..,_.
No.... �l......... FEE_c --------•------•--
Dinpaiittl lVarkii Oxmifrurtion rrrutit
Permission is h reby granted----- . ....!f_.r _ ___ _�.-..y............. ..__/_ ..c:.'.. -
e-.�
to Construct (. or Repair ( ) an Individual Sewage Disposal System _
at No. ? cf'.v G f r. ,✓ r i7 ' f a/ r �s
/ •-.- y----- Street /•- ry
as shown on the application for Disposal Works Construction Permit No--- Dated-.-.._. - 1-- •._----
-------------------------------------------------------- --------------...............................
Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
- `;v4 >�4�-Fr'.'J1� J✓fa�xyti^iAFSu.✓c4 ., '
afro
BARNSTAXIaE COUNTY gIEAT T -I DEPARTMENT
THLEPNOF465
362 2
Ex 4 a 31
Date: November 15, 1973
To: March Inc.
P.O. Box 316
Waquoit, Mass. 02536
On the basis of a sanitary survey and a laboratory examination on
the sample of water taken from a _...well....... ., ._..,_.._...located on
the premises of . _ .Ma�reh.Tne _.. . .. . . __.. . . . ._, ..... ._... ... . . . ... ...... ._ located at
Lot #33, Regency Drive, Marstons Mills on,�,_ November 13, 1973
.a .. .., . ... . . (Place). _.. .. - (Date) v__ .
this supply is approved for domestic purposes at the time the examination
was made.
If you wish further information regarding this supply, please contact
us at the County Court House, Barnstable, Massachusetts (Tel: 36.2-2511
Ext. 331), and we will be glad to assist you in any way possible.
Signed°
✓Y •
°Public Health Sanitarian _..
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
I M ^C&L
DATA
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