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0240 REGENCY DRIVE - Health
240 RECENCY DRIVE, MARSTONS MILLS A = o ,- 0 i LOCATION �. SEWAGE PERMIT NO. VILLAGE A S. INSTALLER'S NAME i ADDRESS. ''nn Aj BUILDER OR OWNER ilia G5,-Y14 DATE PERMIT ISSUED � Z - � D - 53 + DAT E COMPLIANCE ISSUED � a ' �jUi L�IIV � SL�vil� f f �.. .� t THE COMMONWEALTH OF MASSACHUSETTS a e�/6 f BOAR® OF HEALTH .........................................OF............... ........................ ApplirFation for Uhipnsal Works Tonstrnrtinn ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal s7. �' �r� -.�lJ �//s. .............................. ..........--------------.....------------ ^. i oca�'on- ress _ or Lot No. W ` w er ���_ Address -•..... _...... . -•-•-- -•-----.......••- ----- ------ 1nstaI1er Address dType of Building Size Lot.YA_+AD .....Sq. feet V�'4+ Dwelling—No. of Bedroo - .Expansion Attic ' Garbage Grindert) pr Other—Type of Building3 �_. � ._.. No. of persons............................ Showers (� — Cafeteria (•—)- Q' Other fixtures ------------------------•--.....- . W Design Flow............................................gallons per person per day. Total daily flow.........220......................gallons. WSeptic Tank—Liquid capacity/,PX..gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No......... ..... Width R.................. Total Length.................... Total.leaching area....................sq. ft. Seepage Pit No..-_-/------------ Diameter...... ........... De th below inlet.................... Total leaching areaR61.19.sq. ft. Z Other Distribution box 1P,N• Dosing tank ft,A , Percolation Test Results Performed by......................................................................... Date........................................ Test Pit No. I................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........................ a .............................................................•-•-•-----•......................•••-•-................ .......---------------- --------•----.--- 0 Description of Soil-----•-••--•----------------------------•---•---------...-••-•----•-------•......----- x V •-•-----•----•-••••....................•--------•---...•--•----•-----••--••.....•-•••------...-••------•-...•-----••-•---•---•----•••-•-...•---•----•---••-............................................ W UNature of Repairs or Alterations—Answer when applicable..............................:............................................:................... -----------------------------------•------••--------......_._.....---------------.....--••-----------•--.....----------------------•--------------------------------------------------....-•••.••.... Agreement: The undersigned agrees to install the aforedescribed Individual Sew e Disposal System'in accordance with the provisions of iI'i U 5 of the State Sanitary Code— The undersigne f rth agrees not to place the system in operation until a Certificate of Compliance has been i ,u d by t b rd S'�ed-•--_---•- --...••.... --•••...... .... ........ •• •••••••.-----.../ C.�---....By...................... ,c--_--• �2. .... .. .............•----•--•------- ....................................... Disapproved for the following reasons-------------------------------------•--•----•-----------------•----------------•-----------------....----....._ --------------------------••----------------•-------•----•--------------•-•--------------....--------•----•-•-•••-•---•........--•-•----••----•----•-------••---•---•-•-••-----•-----------•------------ Date Permit No........ ................. Issued............ 2 JI:fJ.... . Date a; No.... FEB.............................. THE COMMONWEALTH OF MASSACHUSETTS 57 0-VIP, BOARD OF HEALTH Appliratiun for Biupouttl Works Tonutrn.ction famit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an 'Individual Sewage Disposal Systemt G •='--`�..«s' - /�' � s.......................................... -------------------•----...............-- ca:' n ddre s or Lot No. .................................... -•----•-•---.............................. ....----•-.............................. VVV c Address x , ..................• ... .............------.....--•-••---..........•..........................---- Ins ller Address Type of Building Size Lot!_ ______________________Sq. feet Dwelling—No. of Bedrooms--------. Expansion Attic, ) / rinder ) -------- p�-1 Other—Type of Building �.Jis No. of persons..................... Showers ( ) — CafeteriaNO) P4 Other fixtures --------------------•-•-•-----------•--- =-= z'" ^` W Design Flow............................................gallons per person per day. Total daily flow.......-. -. .. gallons. W Septic Tank—Liquid'capacity�� ....gallons Length................ Width................ Diam De pth th x 40 Disposal Trench—No..................... Width.................... Total Length.........._......... Total leaching area....................sq. ft. 3 Seepage Pit No..... .............. Diameter..__.f..r:.___.... Depth Below inlet.................... Total leaching area... _.......sq. €t. Z Other Distribution ox 1 )"losing tank* 07�0_1� �" Percolation Test Results Performed by.. Date = Test Pit No. 1................mmutes 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........................ ---------•-••• =:,•---•--------•---•..............•-•-•...........-•----•---.....................................-•------------....•. ODescription of Soil.........................................................................-.............................................................................................. 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 TITLE 5 of the State Sanitary Code—The undersigne rth agrees not to place the system in operation until a Certificate.of Compliancd:has been issued by t e bo rd o 1 1 Signed--------..��s. to ApplicationApproved By......... ---•-•--.......-•-•-----------------------•-•---•---•--•------------- 'v� /f i Date Application Disapproved for the o lowe rec s'on ..... . .........................................................�/ _.__._- -------•-•----------•-------•--•---•---------------••-•----................-•------•-•----•--•---•-....•----•--•••...•••--••--•-....----•-••--------•---••-•••-•••-••••-•-•-••--•---••--••......------•. Date Permit No.....--- -� ...... Issued_ Date THE C�MONWEALTH OF MASSACHUSETTS �P BOARD OF HEALTH ..........................................OF...................................................................................... TrrtifiraV of Toutplittnrr T IS 1 TO ERTIFY ,Tha t Individual Sewage Disposal System constructed ( ) m-,Repaired ( ) by... .,�{�....,�D. �- ---------------------•-•.•-------•••-----------• --............---•---•--••---.........---.....----•--•----------------. 11 Installer T at_ has be installed in acco:d24ce with ie rovisa TI Ty. >of e State Sa�j e as described in the p application for Disposal Works Construction Permit No......................................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE Sff*l,"T,!�,CON TRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCT ON SATISFACTORY. DATE---------------- -..I.. �.V................................. Inspector....... .....-- ----- ° ...................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OFHEALTH ..........O F..................................................................................... ---------- FEE....................•••. Diu alFor Tontrttrtion rrtnit Permission is hereby granted .•• ......... •-- -••--•-••.............••-••---•-•-•..............................------ to Construct( ) or Repair ( an In ividu Ta ; ystem t. at No/ i i �f ----- ----- ' � e5�,as shown on the applicationfof DisposaY�Vorks Construction 'ermo..................... to .._..•S.._.........:.._�._._.__..-.... ...............•---....-•----------------------------------------------------••-•••••---- DATE. ........ Board of Health FORM 1255 A. M. SULKIN, INC., BOSTON' (vA c A,-j-r- i �� L.IaT ie �occ�P I�J �� --, F p (\/A C A 7-) -4-7 0 ib Rj D TSA4 0 zp Fw 1) F A u / <\ COP' . '; AAA; OC_ / \00 0 a:, ti 4p FL, / \00 !V /�1 tv PQoR ec wAlr-au"lr-- /47 a I / 4) co / ,�/ 0 �� N �o / P ( 31 / -7 'Z OF MA \ �� / t REc.A cnGAilc.�_� I I i 3 9a � sms-mj4� wtLL -sar-- JOH 0 .29874 Ars fit s u Ti �A OF E-Xl'anQe= EMvA-ncw &c4=Q7cwZ p_ PLC=57 PL4kJ I DAVID PpcposetD rMLEMA-Incii 9t. COUTCYj Tlli�L!N No. 29�76 LET 4j,- L=.,.- Ej<Z-4,".bp,.\j , APPP,mva b B=vkP-D cfr 4eAL-r"i ION 10 ILLS nA-rE AGENT It S/8Yt CQLE I 4.,= r->AmE- 1 84 CLI BUT r-ap-ript/ --r�4A-r -THEE a 114(-iLiu Jbia os 84-r7c� FE=�J WbAMCD" C3fJ 71-41 --, 4-7e, Qz,,ne (.A Lc=lr tS L=CA-rEb t�-j To 6 Q.BY j ka EXrS-nW,6 Qmr-j- r� EAST 'Z-4uD\&/ici-4, MA - (34.RY SHEET I (zp 'L —DA7C— QED LAUD 5,J)IIE-ir/bIll �-rE I F 1=l-r H e�E T3-I E - PT I c 7-A-J v- o R �_ 2c FT. nn I.t. - - - LffAcININ6 P►T A-Pa MoR'E=- -n4A1--A 1 'L" fieLCD,� G PAa:fit= , A 24" D 1 A T>r P_ PaTE PL SHALL r'� BR.o�a614T -To GRP+D� ( DQIat=wAYS co lc R E-r� 4" Aic P 1 PE- ( D��,I P_ A w exTRA H EAv-4{ DLrr',* cA---5r 12c>w covE-Q / � �27a tin►u. co�..lcR�T� A �� � i�— USED ►,� (3AGKf=i L1. L IC;>J 4 D L1=.v F_L. 5 n / �O IRol-+ Pt PE g:SAL. v c , uv u wAms+4ED -3Toc— m l I.J. PITr�{ • o. rt M c , • o All 0 1. 6 1 • DI'ST• /4' P� Pr. �F�T•tG TAIJIL. Qom✓ I 1 1 • • • , 1 1 • 0. 4o D..L. o • 1 1 E�FFC('IVE ' . /4Y - r��•. 11J VT TO Pic R�LCN-/ C AYE--'-:IF . '0 1 ' C�prn-1 � / 1 1 1 •SI l.Zy Sv(3`� • • 1 , o o . o . 1 1 a - PR�A�r sE�A� EL 9I. I I-!�/E RT ELtt/ATIo►JS o 1 1 • 1 . • r 1 1 PIT oQ >A�-- F o AT BUILDiglCz q8 `� FrT. 11 3. I x I. o i 13 6� �3 ��, 6, PT:' D/AtA 3 l N LET SEPTIC TA►-I IL 96.0 FT• I IL- F-r. D I AM• � C ��E �AB�AT�►-�) PIT CAPACrrY 4-`lo err L.�T 'SE PTI.c TA r..l k 9-1-5 FT. _ iuLtT D1 5T�IF�tr�o1-1 � 9-7.2 FT• .ro" oF= GRouuD wATt=R_ Tf�c�L� psi aT Drtsl-pa_jr.L ' Box 9-1-0 FT SEWA4Sa D ISPa's>4L PIT 9 5 0 F=T. LEA cF-41Ob PIT :3 FT. CEO14 u G I T� r A -� : /a I D t tit ENS i o+_1 t3 4 F r. �1�,rnR:EL� of y��nns DIMEuSIoQ C 4 FT. L."I T" T�I A L ESrI M hTED FI.aW 330 6Pd-. l pAy •�1 L NEST N_ 1 So I L TILT I•I=2 '"�t L -fE�"ST P-E�_ G= LE AG-11"!=i P 175 ou E L■ `18.�• E L 1 cf"l.`� L hTc of So►L-TEST M A-f 8 I�i r3 a 11�13 L�A�HIu1E., FEp- ISo.B 5�. F'r. o�_, ' L_cAM F Po 1 D T�oM LEPr=H11-+r5 ��R�T 113. 1 159:7�. FT. I` 3'slt 1-f s.5. FERCc��a�o.� Ph TB 11= .I G 2• nn r u /1 uc�t t u TA L LEACH l/.l o AREA '�103.9 F-r. n PE R�oLnTo l-+ RATE N= �1 nn i u / I ucrl {= 1'-vE I�PCN 11 16 Aa A 2 C�?�•� . _ 4.5' P - 1/ LSN Qr /ij �n-Dsc. �.j-a OF Mq sAl+DEE .�1`'" 7 3' 13 WITH � Lc�T 4S - [��E/_IL-f L� `� DAYiD. �y �3�S y WITE I'- C. 5MALL ✓> I TrurrN R T �, roues 9976 0 $ y �? c vll p \ 0.29874 1=L L I S Pc Tl-1 L-)L I�-1 I ELT �NO SUR� 05.4 � �, a�g IC(� Q11'E � E A .SA wlc+-�Dl-1, MA. 6Qo�1-ID wA-r�R �/1cCl)1- Qx__D 1�AT-- . I I• %L I. 8cL • ///Z G fZovuD wAr�2 a EL GLl -�tr PQ A 7 T - n Commonwealth of(Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments I ..''y 240 Regency Drive, Marstons Mills, MA 02648 Property Address Karen Steele Owner Owner's Name information is required for every Marstons Millis, MA 02648 05/29/2014 page. Cityfrown 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.. Importarrt:When filling out forms A. General Information on the computer, I use only the tab 1. Inspector: key to move your V - cursor-do not REID C. ELLIS use the return Name of Inspector key. ELLIS BROTHERS CONSTRUCTION ffi Company Name 23 ENTERPRISE ROAD Company Address YARMOUTH PORT MA 02675 Cityfrown State Zip Code 508-362-6237 S121891 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 16.000).The system: asses ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority , ® � 144 lnsp ors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be,sent to the system owner and copies sent to the buyer, if applicable, and the approving authority- ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. �m - I t5ins•3113 Title 5 Official Inspection Form:Subsurtace sposat System• age 1 of 17 5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 240 Regency Drive, Marston Mills, MA 02648 Property Address Karen Steele Owner Owner's Name information is required for every Marstons Millis, MA 02648 05/29/2014 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: r X/�❑ 1 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: I-Ilk ❑ One or more system components as d 'bed 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 determ ned"(Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years Id*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or e Kfiltration or tank failure is imminent System will pass inspection if the existing tank is replaced wii I a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if i is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less t ian 20 years old is available. ❑ Y ❑ N ❑ ND(Explai below): t5ins•3113 Title 5 Official trsspection 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 240 Regency Drive, Marstons Mills, MA 02648 Property Address - Karen Steele Owner Owner's Name information is Marstons Millis MA 02648 05/29/2014 required for every + page. CityfTown State Zip Code Date of Inspection B. Certification (cunt.) El Chamber pumps/alarms not operatio al. System will pass with Board of Health approval if pumpstalarms are repaired. B) System Conditionally Passes(cunt.): ❑ Observation of sewage backup or break out r high static water level in the distribution box due to broken or obstructed pipe(s)or due to a b oken, settled or uneven distribution box. System will pass inspection if(with approval of Board of ealth): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replace ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 bi ies a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval c f the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): `t. Al 4-V C) Further Evaluation is Required by the Boad of Health: ❑ Conditions exist which require further evaluat on by the Board of Health in order to determine if the system is failing to protect public health, fety or the environment 1. System will pass unless Board of Healt i determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioi ling in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of surface water ❑ Cesspool or privy is within 50 feet of I bordering vegetated wetland or a salt marsh t5ins•3t13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17 . I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 240 Regency Drive, Marstons Mills, MA 02648 Property Address Karen Steele Owner Owner's Name information is required for every Marstons Millis, MA 02648 05/29/2014 page. Citylrown 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 functionin in a manner that protects the public health, safety and environment ❑ The system has a septic tank and soil at sorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributar I to a surface water supply. ❑ The system has a septic tank and SAS d the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS d the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and le 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 preser ce of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other fail a criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate Yes"or No"to each of the following for all inspections: - Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ElLiquid depth in cesspool is less than 6"below invert or available volume is less than Y2 day flow t5irts-3113 Title 5 Official trispetlion Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 240 Regency Drive Marstons Mills MA 02648 Property Address Karen Steele Owner Owner's Name information is Marstons Millis, MA 02648 05/29/2014 required for every page. Cityrrown State Zip Code Date of lnspection B. Certification (coot.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or / obstructed pipe(s). Number of times pumped: . ❑ M 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 pprn, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] 0 n/ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpa. ❑ 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 a Board of Health to determine what will be necessary to correct the fail e. E) Large Systems: To be considered a large S al 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"ye., °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 f t 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 mappE d Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes° in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Forth: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 240 Regency Drive Marstons Mills MA 02648 Property Address Karen Steele Owner Owners Name information is required for every Marstons Millis, MA 02648 05129/2014 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? M ❑ 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 f available note as N/A) L►i�/ ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? El Were all system components,eluding the SAS, located on site? M/ ❑ 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). DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 240 Regency Drive Marstons Mills MA 02648 Property Address Karen Steele Owner Owner's Name information is Marstons Millis, MA 02648 05/29/2014 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: I Number of current residents: �' garbage grinder? ❑ Yes L� No Does residence have a ga g Is laundry on a separate sewage system?(include laundry system inspection ❑ Yes Uj-"No information in this report.) Laundry system inspected? ❑ Yes No Seasonal use? ❑ Yes P- No Water meter readings, if available(last 2 years usage(gpd)): Detail: 0 � 13 �27 Sump pump? ❑ Yes VNo Last date of occupancy: , A Date Commerciallindustrial Flow Conditions: A f� 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,3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1240 Regency Drive, Marstons Mills, MA 02648 Property Address Karen Steele Owner Owners Name information is ' MA 02648 05/29/2014 Marstons Millis, required for every 1 State Zip Code Date of Inspection page. cityrrown j D. System Information (cunt.) Last date of occupancy/use: Date Other(describe below): i t General Information Pumping Records: / ©PialGiJ*��Gf � Source of information: Was system pumped as part of the inspection? Yes ❑ No O L.s 0 If yes, volume pumped: gallons How was quantity pumped determined? � J Reason for pumping: Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Altemative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3113 Title 5 Official Inspection Forth: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 ° 240 Regency Drive, Marstons Mills, MA 02648 Property Address Karen Steele Owner owner's Name information is required for every Marstons Millis, MA 02648 05/29/2014 page_ Cityrrown State Zip Code Date of Inspection D. System Information (coot.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes M/No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑cast iron W40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting,evidence of leakage, etc.): u 4�24 C< Septic Tank(locate on site plan).- Depth below grade: � feet Material of construction: concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is meta, ist age: yea is age con rmed by a Certificat =6f Compliance?(attach a copy of certificate) ❑ Yes ❑ No i� Dimensions: pZ Sludge depth: t5ins•3/13 Title 5 official Inspection Forth: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 240 Regency Drive Marstons Mills MA 02648 Property Address Karen Steele Owner Owner's Name information is required for every Marstons Millis, MA 02648 05/29/2014 page Cityrrown State Zip Code Date of Inspection D. System information (cunt_) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle C�=� Scum thickness r� Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle pr 4- ; How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 30 G_a r J. L 1 e .4 V AS Grease Trap(locate on site plan): N A 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 r baffle Distance from bottom of scam to bottom of oL Ret tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 officiat bspedion Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage oisposal System Form-Not for Voluntary Assessments 240 Regency Drive, Marstons Mills, MA 02648 Property Address Karen Steele Owner Owner's Name information is MA 02648 05/29/2014 required for every MarstOns Millis, page. Cityrrown State Zip Code Date of Inspedion 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 plimZ 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 swi hes, etc.): *Attach copy of current pumping contract(r quired). Is copy attached? ElYes ❑ No t5ins-W 13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 240 Regency Drive,-Marstons Mills, MA 02648 Property Address Karen Steele Owner Owner's Name information is Marstons Millis, MA 02648 05/29/2014 required for every page Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Distribution Box(if present must be opened)(locate on site plan): o quid level ab ove ve outlet invert f liquid o Depth p 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.): Alp CA kj b Pump Chamber(locate on site plan): Pumps in working order ❑ Yes ❑ No* Alarms in working order ❑ Yes ❑ No* Comments(note condition of pump chamber, ndition 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•3113 Tile 5 Official Inspection Forth: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 240 Regency Drive Marstons Mills MA 02648 Property Address Karen Steele Owner Owner's Name information is Marstons Millis, MA 02648 05/29/2014 required for every page- Cityrrown State Zip Code Date of Inspection ' D. System Information (cons.) 17 Type: zleaching pits number. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): ta� Cesspools(cesspool must be pumped as pa 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 ins.3H 3 Title 5 official Inspection Form:Sd=ffface Sewage Disposal System•Page 13 of 17 r— Commonwealth of Massachusetts -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 240 Regency Drive, Marstons Mills, MA 02648 Property Address Karen Steele Owner Owner's Name information is Marstons Milpis, MA 02648 05M/2014 required for every state Zip Code Date of Inspection page. City/Town D. System Information (coat.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): locate on site plan): Privy( p ) Materials of construction: I Dimensions j Depth of solids Comments(note condition of soil, signs of hydra lic failure, level of ponding, condition of vegetation, etc.): r t5ins-3M 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .' 240 Regency Drive, Marstons Mills, MA 02648 Property Address Karen Steele Owner Owner's Name information is , MA 02648 Page. 05/29/2014 Marstons Millis required for every sty Zip Code Date of Inspection Clty/Town D. System information (cunt.) 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 V� D i �rX f - t5iris•3113 Title 5 offidal inspection Form:Subsurfaw Sewage Disposal System•Page 15 of 17 I , Commonwealth of Massachusetts Tide 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 240 Regency Drive, Marstons Mills, MA 02648 Property Address Karen Steele Owner owner's Name information is M MA 02648 05/29/2014 arstons Millis, required for every State Zip Code Date of Inspection page Cityrrown D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells �,� 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: I 4Found � You must describe how you established the high water elevation: �t i Before filing this Inspection Report,please see Report Completeness Checklist on next page. Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 t5ins•3/13 I i Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 240 Regency Drive, Marstons Mills, MA 02648 Property Address Karen Steele Owner Owner's Name Information is Marstons Millis, MA 02648 05/29/2014 required for every state Zip Code Date of inspection page Cityrrown E. Report Completeness Checklist j Inspection Summary:A, B, C, D, or E checked dInspection 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 I t5ins 3113 Title 5 oificiai hupection Form:Subsurfaoe Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE !,LOCATION 0 R: -e h G�d pP r SEWAGE# .VILLAGE MG1 rSfo'n c,M I S ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO.�sT �-ecl dLtiS i1()c1()*A Can 1 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO.OF BEDROOMS OWNER I0,T-cr1 S�-e-eti PERMIT DATE: COMPLIANCE DATE: -Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY kq l Z9 v Tift 5Oftiol bV*-C iaoForto Sub-I=SW*P Dj,�W Wm.Page 15 of 17 f TOWN OF BARNSTABLE LOCATION X SEWAGE # (� _ VILLjRr3t ASSESSOR'S MAP & LOT ®� ''� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY ldP'd x LEACHING FACMITY: (type) (size) NO. OF BEDROOMS BtULDER OR OWNER PERMITDATE: 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 ^n site or within 200 feet of leaching facility) Feet F, of Wetland and Leaching Facility(If any wetlands exist thin 300 feet •'f 1 chin facility) Feet a ,shed by ' J 4 } . 43, ,�,� t Y DATE: 12/8/99____ PROPERTY ADDRESS: 240 Regency Drive Marstons Mills ,Mass . 02648 ------------------------ On the above date, I Inspected the septic system at the above address. This system consists of the following: 1 . 1-1000 gallon septic tank . 2 . 1-Distribution box . im 3 . 1-1000 gallon leaching pit . Based on my Inspectlon, I certify the following conditions: 4 . This is a title five septic system. ( 78 Code ) 5. The septic system is in proper working order at the present time . SIGNATURE: N a m e:-,i ------ Company: Jose.2h_P. Macomber & Son, Inc . Address:_ Box_66_--__ __CentervilleL Ma__02632-0066 Phone:...508 775_3338_______ THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY • :6E P. MACOMBER & SON, INC. in ks•Cesspools•LeachfleIdsPumped & Installed Town Sewer Connectlons 66 Centerville, MA 02632-0066 E 775.3338 775.6412 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIR.ONMENrAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDY COX) Secretar ARGEO PAUL CELLUCCI DAVID B. STRUH: Governor Commissione SUBSURFACE SEWAGE DISPOSAL SYST13A•INSPECTION FORM PART A CERTIFICATION P„WtyAd&eu:240 Regency Drive N.rn.ofownwRonald Tosti Bata.�t�sM 9 s s . 0 2 6 4 8 Address of owner: Name of inspector:(Please/ Print) J.P.Macomber Jr . I am a DEP approved system inspector punw&M to Section 15.340 of Title 5(310 CMR 15.000) company Name: J.P.Macomber & Son Inc . Mailing Address: Box 66 C nterville,Mags _ n2632 Telephone Number: _5 0 2 7�5=3 3 3.8 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 Inspection. The Inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: 2Passes } Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails c kmpectors Signature: n Date: The System Inspecto all submit a copy of this Inspection report to the Approving Authority(Board of Health or DEP)whhin thirty(30)days of completing this Inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the Inspector and the system owner 'Shall submit the report to the appropriate regional office of the Department ofrEnv(ronmental protection. The original should'be sent toVw System owner and copies sent to the buyer, if applicable, and the approving authority. . NOTES AND COMMENTS ilf t I� I revised 9/2/98 Page Iof11 ��Printed on Recycled Paper • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) PropertyAddress: 240 Regency Drive Marstons Mills ,Mass . OM/f1ef: Ronald ToSti Data ofinspection:12/8/9 9 INSPECTION SUMMARY: Check A, B, C, " A A.-'SYSTEM PASSES: hi i have not found any information which indicates that any of the failure conditions described In 310 CMR 16.303 exist. Any failure criteria not evaluated are Indicated below. COMMENTS: S. SYSTEM CONDITIONALLY PASSES: A One or more system components as described In the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Indicate yes no, or not determined(Y,N,or ND). Describe basis of determination In all Instances. If "not determined",explain why not. The septic tank Is metal,unless the owner or operator has provided the system Inspector with a copy of a Certificate of Compliance(attached)Indicating that the tank was Installed within twenty(20)years prior to the date of the Inspection;or the septic tank, whether or not metal,is cracked,structurally unsound,shows substantial Infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. 415 Sewage backup or breakout or high static water level observed In the distribution box la due to broken or obstructed pipe($) 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 fourtfines-aryeardue to broken or obst, cted pipe(s). The eystem Will inspectionif(with approval of the Board of Health): - - broken pipe(s)are replaced obstruction is removed revised 9/2/98 Page 2of11 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) PropenyAddre":240 Regency Drive Ma*rstons Mills ,Mass . owner: Ronald Tofti Date of hupecton l2/8/99 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: V0 Conditions exist which require further evaluation by the Board of Health in order to determine if the system Is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS'UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH.W1LL.PRQT.ECT THE PUBLIC HEALTRAND SAFETY AND THE EMBONMENT: Cesspool or privy Is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 60 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds Indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid).- 3) OTHER A1W revised 9/2/98 Page 3of11 i f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 240 Regency Drive Marstons Mills ,Mass. Ownw: Ronald TcJ-ti Date of Inspection: 1 2/8/9 9 D. SYSTEM FAILS: You must indicate either "Yes" or"No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of-sewage into component•dnetto an overloaded orcbgged•SAS-or"aspool. =j--'-.- Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. f� Static liquid levee_I init4e distLibution box above outlet invert due to an overloaded or clogged SAS or cesspool.eeesp Liquid depth in 13 less than 6" below Invert or available volume is less than 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). / Number of times pumped_. !/ Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ny portion of a cesspool or privy Is-within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for •►coliform bacteria,volatile organic•compounds, ammonia nitrogen•and nitrate nitrogen. - E. LARGE SYSTEM FAILS: You must indicate either "Yes" or"No" to each of the following: The following criteria apply to large systems in addition to the criteria above: AA The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No/ the system is within 400 feet of a surface drinking water supply the system•io-witWo 200 feetof*4fRwtsryr•to•a4urfaoedFink Ag+i mer-,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 upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further(nforpation. revised 9/2/98 Page 4of11 j SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PropartyAddrass: 240 Regency Drive M•arstons Mills ,Mass . Owner: Ronald T o S t i Deft of Inspection: 12/8/9 9 Check if the following have been done:You must Indicate either"Yes" or"No" as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health. _ None of the system-compoaants kawaiman pna>ped&#matJeasttwo-aweaka and-ths*vystsm hasbeeoasceieir+gwaanl flow rates during that period. Large volumes of water have not been Introduced Into the system recently or as part of this - � inspection. As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or Industrial waste flow. _ The site was inspected for signs of breakout. _ All system components,w cluding the Soil Absorption System,have been located on the.site. _ The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. The size and location of the Soil Absorption System orrthe site has been determined based on:- Existing information. For example, Plan at B.O.H. _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [15.302(3)(b)) _ The facility owner.fand.accup— if diiferep lnfnrmatioa flnthw�inper mintnnnn— f Subsurface Disposal Systems. a t i revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Prop"Addre3s:240 Regency Drive Marstons Mills ,Mass . Owner: Ronald ToSti Date of irupecdOn12/8/9 9 FLOW CONDITIONS RESIDENTIAL: Design flow: �M g.p.d./badro Number of bedrooms(desi l; Number of bedrooms(actual):1 Total DESIGN flow y�" 14 Number of current residents: Garbage grinder(yes or no): .?0-.4 Laundry(separate system) l ees or Q:_ If yes,sepacatelnspectlon.required Laundry system Inspected (0 or no) Seasonal use(yes or no):_ i44Q^ )�� Water meter readings,ifW- P (last two year's usage NO): 'f� /� __ l Sump Pump(yes or no): 6,c�Q a� " r08 Last date of occupancy: &vr 7'W� .�u3T w COMMERCIAL/INDUSTRIAL; Type of establishment: 444 Design flow: NII qpd ( Based��.203) Basis of design flow - Grease trap present: (yes or no),_ Industrial Waste Holding Tank present: (yes or no)A/f Non-sanitary waste discharged to the Title 5 system:(yes or no) Water meter readings,if available: Last date of occupancy:1Yg_ OTHER:(Describe) A* Last date of occupancy: WIf GENERAL INFORMATION PUMPING R ORDS and source of information: /� Y \7 J�14f�1?LI �.t..rJ la.� System pumped as part of inspection:(yes or no),, If yes, volume pumped: a gallons Reason for pumping: AW TYPE OF YSTEM Septic tank/distribution box/soil absorption system 4)6 Single cesspool Overflow cesspool iw Privy Shared system(yes or no) (if yes, attach previous inspection records,If any) I/A Technology etc. Attach copy of up to dateoperation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date Installediif known)-and source of.Mformation: i Sewage odors detected when arriving at the site: (yes or no) k revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PropertyAddres.s: 240 Regency Drive Marstons Mills ,Mass . Owner: Ronald % t i Data of Irupection: 12/8/9 9 BUILDING SEINER: (Locate on site plan) Depth below grade: Material of construction:_cast iron 3/40 PVC_other(explain) Distance from��Ivate water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakese,-91c.) — "- Joints appearLight - No evi r ehap of leakage SEPTIC TANK: 00 9 (locate on site plan) 1) Depth below grade: Material of construction:4/concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is Instal,list age Js.age.confwmed bye 7Certificate of Compliance_(Yes/No) Dimensions: 171p it , /'12-A "41 Sludge depth: Distance from top off sludge to bottom of outlet tee ortaffle Ld — Scum thickness: Distance from top of scum to top of outlet tee or baffle:2 .� Distance from bottom of scum to bottgUn of outlet to or baffle:,,[ How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or-baffles, depth of liquid level in relation to outlet invert, structuraltintegrity, evidence of leakage,etc.) Pump septic tank annually- Garha2p di anosal ; G prPRPnf Tnl at R otttl of t000 mro pragant- Liquid level aT T149 911'-1-9T GREASE TRAP: (locate on site plan) Depth below grade: -/ Material of constructionrf�concretw4metaO#Fibsrglass.V4polyethylen&Oother(explain) Dimensions: Scum thickness: AN Distance from top of scum to top of outlet tee or baffler, Distance from bottom of scpm to bottom of outlet tee or baffle: 14W Date of last pumping:L(J� Comments: (recommendation for pumping, condition of Inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Grease trap is not present revised 9/2/98 Page 7orn I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contirwed) Property Address: 240 Regency Drive Marstons Mills ,Mass. Owner: Ronald ToSti Date of inspection: 12/8/9 9 TIGHT OR HOLDING TANK.-AI WC(Tank must be pumped prior to, or at time of, Inspection) (locate on site plan) Depth below grader Material of construction-4concreteA mmetal�J Fiberglass W Polyethylens��other(explain) AIA AIA Dimensions: Alh Capacity: gallons Design flow: gallons/day Alarm present Alarm level: JV Alarm in working order:Yeses NOVA Date of previous pumping: A — Comments: (condition of inlet tee, condition of alarm and float switches,etc.) 1Q t or holding tanks are not present . . DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: /10 Comments: (note•if level and distribution is equal, evidence of solids carryover, evidence of leakage Into or out of box, etc.) — -Distribution box has one laterai .No evidence of solids carry over No evidence of leakage into or out of the box . PUMP CHAMBER:�N�, (locate on site plan) Pumps in working order:(Yes or No) AM Alarms in working order(Yes or No) /, Comments: (note condition of pump chamber,condition of pumps ond,appurtenances,etc.) Pump chamber is net present _ revised 9/2/98 Page aof11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Propertyaddress: 240 Regency. Drive Marstons Mills ,Mass . owner: Ronald T oet i Date of kwPOcdm:l 2/8/9 9 SOIL ABSORPTION SYSTEM(SAS);, (locate on site plan,If possible;excavation not required,location may be approximated by non-Intrusive methods) If not located,explain: Type: , leaching pits,number:_ leaching chambers,number: Q leaching galleries,number:_ leaching trenches,number,length: leaching fields,number,dimeelons overflow cesspool,number: Alternative system: A r Name of Technology: L Comments: (note condition of soil,signs of hydraulic failure,level of ponding, damp soil,condition of vegetation, etc.) Loamy sand to fine sand No signs Of Hydraulic Failure or pnndi no Rni l i c �irv�_jjenot v�y 3,8 normal CESSPOOLS: K— (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: AN Dimensions of cesspool: Materials of construction: Indication of.groundwater: inflow(cesspool must be pumped as part of Inspection) —Cesspools are not Dresent h Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of,vegetation,etc.) PRIVYA (locate on site plan) Materjals of construction: Dimensions: ry� Depth of solids: Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation;etc.) rivv is not present ,I revised 9/2/98 Page 9of11 f r i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PropertyAddress: 240 Regency Drive Marstons Mills ,Mass . Owner: Ronald Tolti Date of Inspecti : 1 2/8/9 9 SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes Into house) i G revised 9/2/98 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 240 Regency Drive Marstons Milrs ,MaSS . Owner: Ronald Totti DoU of Inspection. 12/8/9 9 NRCS Report name Soll Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep _ SITE EXAM Slope Surface water Check Cellar Shallow wells r Estimated Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record ]:%b� 'rs' ite(Abutting proport , observation hole, basement sump etc.) termined from local,conditions ' Checked with local Board of health Checked FEMA Maps Checked pumping records zchecked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Used water contours Map . Gahrety & Miller Model 12/16/94 yf`y revised 9/2/98 Page 11of11 �I •rm+•.sw.-pre•�r.r- rnrmrrnsm�rt+�nrs+mr.•R+ns.►�+RnTnRa�rti�t�rtww rn•,T•r�.�r„-•...-.r•� TOWN OF Barnstable WARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION I •.•rn-T.•.•;e•--.pia- rnrr.+n•rrnsi rt�ae+ra+Derrr-arty+nr�snr�T�'e�awr.�r�r�'�e7 twnmilt •.rare-r•-•r.-- -...A -TYPL OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 240 Regency Drive Marstons Mills ,Mass . ' ASSESSORS MAP, BLOCK AND PARCEL # 64-61 OWNER' s NAME Ronald Tbfti PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr . COMPANY NAME J. P.Macomber. & SoYi` Inc . COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 , Stravt Town or City Stat• LIP COMPANY TELEPHONE ( 508) 775 - 3338 FAX ( 508 ) 790 - 1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposa'l system at this address and that the information reported is true , accurate, and omplete as of the time of .-inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent witli my training and experience in the proper function and maintenance of on- site sewage disposal systems . Chec one: ,, • • System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 16 , 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have con toted has found that the system fails to Protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303, and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature Date /oA "7� ne copy of this ce tification must be provided to the OWNER, the BUYER ( where applicable ) and the I30ARD OF HICALT1I. * If the inspection FAILED, the owner or operator shall upgrade ' the system. within one year of the date of the inspection, unless allowed or required otherwise as provided in 3.10 CMR 16 , 306 . partd.doc