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HomeMy WebLinkAbout0005 RIVER ROAD - Health ^C�' RIVER ROAD, MARSTONS MILLS Commonwealth of Massachusetts M/P - Do7- o o Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments •'r 5 River Road Property Address John Dowling Owner Owner's Name / information required for every Marston Mills J MA 02648 5-27-15 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 A. General Information filling out forms �Utlttlllrry� on the computer, q ��� niis use onlythe tab I # ,o o, i 1 `��������ZH OF�L4S•4��4 1. Inspector: .`�S� •' •.sy 1% key to move your 2; cursor-do not James D.Sears ?�� JA M ES• c5N use the return Name of Inspector — key. '�: SEARS CapewideEnterprises,LLC *:, �o VQCompany Name %,�1' RTIF� O 153 Commercial Street %,�F'S�NsPEG``�O`` Company Address nano Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 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 15.000).The system: j ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 6aWU_'-z' 5-29-15 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional 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(� V t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 River Road Property Address John Dowling Owner Owner's Name information required for every Marstons Mims MA 02648 5-27-15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® [ 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 1000 Gal.Tank and pit. 13) 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 I i i t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 5 River Road Property Address John Dowling Owner Owner's Name information is required for every Marstons Mills MA 02648 5-27-15 page. Cityrrown 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 o y g t protect public health, safety or the environment. i 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-3/13 Title 5 Official Inspection Form: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 5 River Road Property Address John Dowling Owner Owner's Name information required for every Marstons Mitts MA 02648 5-27-15 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: i 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 &/4 ❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in sampoW is less than 6" below invert or available volume is less than '/day flow pj7— t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 5 River Road Property Address John Dowling Owner Owner's Name information is required for every Marstons Mills MA 02648 5-27-15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system farts. 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 foffowing, in addition to the questions in Section D. i 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 !i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M r 5 River Road Property Address John Dowling Owner Owner's Name information required for every Marston Miffs MA 02646 5-27-15 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? 0 ❑ 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? ❑ 0 Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)1310 CMR 15.302(5)) I D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 i t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M ° 5 River Road Property Address John Dowling Owner owner's Name information is required for every Marstons Mills MA 02648 5-27-15 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal. Tank and pit. Number of current residents: 2 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 d 2013-136,000Gal 9 ( y g (gP )�' 2014-114,000Gal,s Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present 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•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 River Road Property Address John Dowling Owner Owner's Name required f n e every Marston flf4rlts required for eve tWIA 02648 5-27-45 page. Cityfrown 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: 5-13-15 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 I ❑ 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 C i I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 5 River Road Property Address John Dowling Owner Owner's Name information f e every Marstons Mills re wired for eve MA 02648 5-27-15 � 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: 1993 Permit # 93-289. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2'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.): I Pipeing is 4" PVC SCH 40. j Septic Tank(locate on site plan): ' Depth,below grade: 1 feet I Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) I i If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000Gal.Precast H-10 Sludge depth: 0" t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 i ! f Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 River Road Property Address John Dowling Owner Owner's Name information is required for every Marstons Mitts MA 02648 5-27-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 181. 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 covers at 1' below grade. Inlet two tee's,outlet tee. 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•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments yt 5 River Road Property Address John Dowling Owner owner's Name information is required for every Marston Milts MA 02648 5-27-15 page. City/Town 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 I Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): 4 "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t t5ins•3/13 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 M r� 5 River Road Property Address John Dowling Owner Owner's Name information required for every Marstans Mitts MA 02648 5-27-15 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 No Box 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.): PumpChamber locate on siteplan): ( Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): I I i *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: 1 i t5ins•3/13 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 M r 5 River Road Property Address John Dowling Owner owner's Name information is required for every Marstons Mills MA 02648 5-27-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 E leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is a 5' H-20 precast pit w/cover at 16"below grade. Level in pit at 30"below inlet. No sign of over loading or solid carry over. i Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert i Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of roun w g dater Inflow El Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "< 5 River Road Property Address John Dowling Owner Owner's Name information required for every Marston Mills MA 02648 5-27-15 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.): I i i t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 i i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 River Road Property Address John Dowling Owner Owner's Name information is required for every marstorrs Mills MA 02648 5-27-15 page. City/Town State Zip Code Date of Inspection D. System information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.Check one of the boxes below: hand-sketch in the area below wAY P � i [3-3 i �3 l5ins•3113 Title 5 offiaal hapection Foam:Subsurface Sewage Disposal System,Page 15 of 17 ._...........-._.....--...-......__.__...__.. i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments MY 5 River Road Property Address John Dowling Owner Owner's Name information required for every Marston Mfffs MA 02648 5-27-15 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells No Estimated depth to high ground water: 25'+ 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 1 ® 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 1 You must describe how you established the high ground water elevation: Lot and area high from road .No G.W. problem 25'+. I i i i' i Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 pfp t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,•�'"p 5 River Road Property Address John Dowling Owner owner's Name information required for every Marstorts Mills MA 02648 5-27-15 page. Cityrrown 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 I i I i I I t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 i TOWN OF BARNSTABLE LOCC'ATION S- V-9 SEWAGE # �' VILLAGE ,aSSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. � � p� �CS,�esS� �7,�sSui I SEPTIC TANK CAPACITY ''LEACHING.FACILITY:(type) (size) .NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER l BUILDER OR OWNER Dou /1 DATE PERMIT ISSUED: X., DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No (� ti 29 AXE lax) /-iaT.P.. F>l:a.... o......... THE COMMONWEALTH OF MASSACHUSETTS APPROVED BOARD OF HEALTH Barnstable Conservation MXt 11191 t JOWN OF BARNSTABLE ncd ir0 ur Diripwial Works Tomitrnrtinn 1hrmit Application is hereby made for a Permit to Construct ( ) or Repair (V_�an Individual Sewage Disposal System}}��at: ( . .,!L.i V .... L Cl......_ rt'SIS M t. �>S r.... ............................................ ..... ... ..... .. •. --•- Location-Address or Lot No. -.---- ----------------------------- .............. -................................................................... MV owner �� ^ p Address ,W� 1 5 ••-- 'G tLe-.-._�rl! 5�..._ �1=------------•-----. ---t -`�..Y--�S�i�. __.. _ _ _11a........................ Installer Addres Type of Building Size Lot............................Sq. feet r Dwelling— No. of Bedrooms--------- Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons.....................__._.._ Showers ( ) — Cafeteria ( ) a Other fixtures ------------------------------------------------------- - ----------------- - --- ---------------- ----------------------------------------- W Design Flow............................................gallons per person per day. Total daily flow_._____-____-_.,__----__-________----•----__gallons. WSeptic Tank—Liquid capacity.W.W_galIons 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. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......-.................................................................. Date......................................04 .. Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.................. L% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Q+' -••-----•--•-----•--------••-•----•••-------•••------••------•-••-•---•..................................•------.................----•-.......---------...... 0 Description of Soil.....................................................................................--................................................................................. x UW ----•--•-•-------------------------•----------•----------•--------------•---------•--•-------------_----- ......................................................... Nature of Repairs or Alterations—Answer when applicable.-�? C�.:__C .LS._-__.W-��...... .......... L � ..CG S i.t .t�c � ` - ---- ?���--- �- e `...s:.:�iJ/ e Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compli ce has been ssue y the board of health. / Signed ..... .. ...... ... .... ...... ............-----...-------........-----............ .. .........ate...---.........-. Application Approved By ----------bo—tr..... ----- ----------.... -�.�..-..zo�.. --------------....----------................. Dare Application Disapproved for the following reasons: ............................................................................................... ........................... -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------- ...... ---------------- *....... ...... � Dare PermitNo. ------7.5 ' ..a'.. .9...................... Issued ................................... ..............--.............. Dace t�,,..,v-+./`.'v`' •v,.r " . .w••..N.�a.�.. ...'v :. - : �.+ a..1 w.r v�, a.+ .yam �.�,_„_ v .�. .. _... "`1 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH G �� S3TOWN OF BARNSTABLE Applutttion for Dirpoml lVladw Tomitrnrtinn.. rrmit Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal • System at: . 1-_v..er....RJ-............./_� S 0 �/�5�.... ••-•--------•-------••••••--••-------------•--•-•---••...--••---•--••-••--•----•••---.....-------• Location-:address or Lot No. ...?....:�.: A-------------------------------------------- J�.. ./.�.tL_.:_......_•___.__..:_... C ...--------------------------------------- Owner W Address Installer Addres Q Type of Building Size Lot............................Sq. feet Dwelling �10. of Bedrooms......................................._---Ex ansion Attic Garbage Grinder —; P" ( ) g ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures --------------------------------------------------------------••••........---.......... ---••--•••--••--•------•----••-•-•••......••---..........-•-• w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacityk(M4 ..gallons Length________________ Width................ Diameter................ Depth................ x Disposal Trench--No. .................... Width.................... 'Total Length.................... leaching area....................sq. ft. , 3 Seepage Pit No------- ------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ 4 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ GZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 ._........................................................................................................................................................... 0 Description of Soil....................................................................................................................................................................... x U ----•-----------•----------•••-•••-•--•--•---•--•-•--•--------••-•---•-••-••------••._........•--•----•--•---•••--•••-••----••••-••-•---••-•-••••-••.._...----•••---••--•••-•••••-•----•-•--••--•-...... w ? x .......................... • -...---•-'-----••------•--••-----------------•......------•. U Nature.of Repairs or Alterations-Answer when applicable.C ��G, .'-C�- ,.�5_._..__c.J.'�1r..,______..__.____... ... Agreement. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5.of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compli -ce has been 'ssue byy the board of health. I Signed .... - � -�........... ....................................................... .. n...l /.CL ......... Date Application Approved By ---------- '-' ........................_............... Date Application Disapproved for the following reasons: ...... .. ....................................... '........... ......................................--.....---.................. ................................................................. "-............ ' ' ' ' ' . ' ...................................................... .---------------......,.........--..--.. Date PermitNo. ........7 3 ------1;L3.9...................... Issued ..............................................----....---...-....... Date ----------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE V��rTT 1ertifirate of Tompliance THIS IS TO CERTIFY, That the Indivjual Sewage Disposal System constructed ( ) or Repaired (✓ ) Y at _........�......!`ls' _ ----........ ---- ----------- `_. `. ' ............ ..... ....--............ has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in G 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 .._..._......._-.41.._'_�®.. _................. .. Inspector ........ --.'- ._....:-------------_.-------------------------.._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No....a 7l?7 FEE....1.:.LC�....... Diiiposal Workv Tnnitrudion ran it Permission is hereby granted ' `7G ......Cone n ................................ ................................ to Construct ( ) or Repair an Individual Sewage Disposal System at No.•-•---.7_ `a t ......r -`_...------.im , n'` �.�..5. ---------------------" .......................... Street as shown on the application for Disposal Works Construction Permit No.5. :19_`l_.. Dated........................................... ................................. J..r_S�....................................................... DATE. fs/ 1 ................................... Board of Health �i i FORM 36508 HOODS♦k WARREN,INC..PUBLISHERS i TOWN OF BARNSTABLE LOCATION c. S SEWAGE # �� I VILLAGEI�ASSESSOR'S MAP & LOTAYS Q©� INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY_ `Qo' t) LEACHING FACILITY:(type) ( - (Size) n .NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER r i BUILDER OR OWNER .1 DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED:_ I VARIANCE GRANTED: Yes No I/ I L)c r ! i i 29 1-13 � Y I _} nJ�I a z c)a Mnssnca a usa�7�I �.UM MUN Wi; ;'IA"i I';XIsCtJ'1'IV1; OFa lCa, OF I�NV(I2,pNMl?,N'I'A AF a, TALR.S !l I)EPAIt'_t'MI�W.J' Oa! I'_;NVI_I2ONM_I�,N'I'AL PRO'1't�,C'l'ION ON17 WINT R TRf L.I', TTC)S'I'ON ntA 021f1A (f 17) 7.i)I,!i5g0 1'RItT)Y COXII, 350 MAIN STREET Se,tpr.av j ARGE0 PAU1, f;1;l.Lt_If.;CI WEST YARMOUTH, MA DAVI1) R. sTliHtis Go rrnnr 508-775-2800 �.rnllin lSSlnitrt' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION MAP 078 PAR 007 PROPERTY ADDRESS: ONE RIVER ROAD, MARSTONS MILLS ADDRESS OF OWNER: DATE OF INSPECTION: NOVEMBER 19, 1999' MARJORIE DOUGHAN NAME OF INSPECTOR : JAMES D. SEARS am a DEP approved system inspector pursuant to Section 15.340 of Title 5 9310 CMR 15.000) COMPANY NAME: A&B Canco MAILING ADDRESS: 350 Main Street,West Yarmouth,MA 02673 _ IELEPIIONE NUMBER: (508)775-2800 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: X PASSES CONDITIONALLY PASSES NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY FAILS LL// INSPECTORS SIGNATURE: DATE: The system Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 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 of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. NOTES AND COMMENTS: SITE OVERALL PASSES,INSPECTION OF SYSTEM IS BASED ON CONDITION OF SYSTEM AT CIE TIT E OF THE INSPECTION.THERE IS NO GUARANTEE ON THE LIFE OF THE SYSTEM. ~ TL9 revised 9/2/98 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ONE RIVER ROAD, MARSTONS MILLS Owner: MARJORIE DOUGHAN Date of Inspection: NOVEMBER 19, 1999 INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: YES I have not found'any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B SYSTEM CONDITIONALLY PASSES: N/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 is 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. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will pa pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is leveled 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 revised 9/2/98 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: ONE RIVER ROAD, MARSTONS MILLS Owner: MARJORIE DOUGHAN Date of Inspection: NOVEMBER 19, 1999 C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N/A 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 15.303 (1)(b)THT 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 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 1 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 50 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 and is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ONE RIVER ROAD, MARSTONS MILLS Owner: MARJORIE DOUGHAN Date of Inspection: NOVEMBER 19, 1999 D] SYSTEM FAILS: N/A 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 facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an over- loaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed 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 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. E) LARGE SYSTEM FAILS: N/A You must indicate either"Yes'or"No'as to each of the following: The following criteria apply to large systems in addition to the criteria above: 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 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 mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accofdance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: ONE RIVER ROAD, MARSTONS MILLS Owner: MARJORIE DOUGHAN Date of Inspection: NOVEMBER 19, 1999 Check if the following havebeen done:You must indicate either"Yes"or"No"as to.each of the following Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X 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. X As built plans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. X All system components,including the Soil Absorption System,have been located on the site. X 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 on the site Has been determined based on: X Existing information. Ex.Plan at B.O.H. X 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)] X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal System. { revised 9/2/98 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: ONE RIVER ROAD, MARSTONS MILLS Owner: MARJORIE DOUGHAN Date of Inspection: NOVEMBER 9, 1999 FLOW CONDITIONS RESIDENTIAL: YES Design flow: 440 g.p.d./bedroom for S.A.S. Number of bedrooms(design) 4 Number of bedrooms(actual): 4 Total DESIGN flow Number of current residents: 1 Garbage grinder(yes or no): NO Laundry(separate system) (yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no): YES Seasonal use(yes or no) NO Water meter readings,if available(last two(2)year usage(gpd): 1998—142,000 11997—146,000 Sump Pump(yes or no): NO Last date of occupancy: N/A COMMERCIAL/INDUSTRIAL: NIA Type of establishment: Design flow: Gpd(Based on 16.203) Basis of design flow Grease trap present:(yes or no): Industrial Waste Holding Tank present:(yes or no) Non-sanitary waste discharged to the Title 5 system:(yes or no) Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: 95-98 BARNSTABLE PLANT System pumped as part of inspection:(yes or no) NO If yes,volume pumped: gallons Reason for pumping TYPE OF SYSTEM X Septic tank/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract. Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed (if known)and source of information: UNKNOWN Sewage odors detected when arriving at the site:(yes or no) NO revised 9/2/98 6 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ONE RIVER ROAD, MARSTONS MILLS Owner: MARJORIE DOUGHAN Date of Inspection: NOVEMBER 19, 1999 BUILDING SEWER: N/A (Locate on site plan) Depth below grade: Material of construction _ cast iron _ 40 PVC _ other(explain) Distance from private water supply well or suction line Diameter Comments:(condition of joints,venting,evidence of leakage,etc.) SEPTIC TANK: YES (Locate on site plan) Depth below grade: Material of construction X concrete _ metal _ Fiberglass _ Polyethylene _ other(explain) If tank is metal,list age Is age confirmed by Certificate of Compliance (Yes/No) Dimensions: 1,000 GALLON PRE CAST Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 31" Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: 5" Distance from bottom of scum to bottom of outlet tee or baffle: 18" How dimensions were determined TAPE 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.) TANK AT WORKING LEVEL,OUTLET TEE TANK&COVER 12"BELOW GRADE GREASE TRAP: N/A (locate on site plan) Depth below grade: Material of construction _ concrete _ metal _ Fiberglass Polyethylene _ other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (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.) revised 9/2/98 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ PART C SYSTEM INFORMATION(continued) Property Address: ONE RIVER ROAD, MARSTONS MILLS Owner: MARJORIE DOUGHAN Date of Inspection: NOVEMBER 19, 1999 TIGHT OR HOLDING TANK: N/A (Tank must be pumped prior to,or at time,of inspection) (Locate on site plan) Depth below grade: Material of construction _ concrete _ metal _ Fiberglass Polyethylene _ other(explain) Dimensions: Capacity: Gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order Yes; No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: N/A (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc,) PUMP CHAMBER: N/A (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) revised 9/2/98 8 I • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ONE RIVER ROAD, MARSTONS MILLS Owner: MARJORIE DOUGHAN Date of Inspection: NOVEMBER 19, 1999 SOIL ABSORPTION SYSTEM (SAS): YES (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not located, explain: Type: Leaching pits,number: 1 Leaching chambers,number: Leaching galleries,number: Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number, Alternative system: Name of Technology: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) ONE 5'PIT.2"WATER IN PIT NO HIGH WATER MARK PIT&COVWE 22"BELOW GRADE CESSPOOLS: N/A (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(cesspool must be pumped as part of inspection) Comments:: (note condition of soil,signs of hydraulic failure,,level of ponding,condition of vegetation,etc.) PRIVY: N/A (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.) revised 9/2/98 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ONE RIVER ROAD, MARSTONS MILLS Owner: MARJORIE DOUGHAN Date of Inspection: NOVEMBER 19, 1999 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locale all wells within 1 00'(loca(e where public water supply comes into house) 3-s , 10 L ID / n revised 9098 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ONE RIVER ROAD, MARSTONS MILLS Owner: MARJORIE DOUGHAN Date of Inspection: NOVEMBER 19, 1999 NRCS Report name Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Ground water depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to no groundwater 30 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record X Observation of Site -Abutting property Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators,installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(Must be completed) NOTE: DEPTH ON GROUND WATER OBTAINED FROM SITE AND ABUTTING PROPERTY i revised 9/2/98 11 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments tip 5 River Rd. Property Address John and Kathleen Dowling Owner Owners Name information is required for every Marstons Mills Ma 02648 6/17/2009 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. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector ✓ '� I ' key to move your cursor-do not Sean M. Jones ' use the return Name of Inspector key. S.M.Jones Title V Septic Inspection �y Company Name 74 Beldan Ln. Company Address Centerville Ma 02632 Citylrown State Zip Code 774-248-4850 SI 4522 Telephone Number License Number j B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 16.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further.Evaluation by the Local Approving Authority 6/17/2009 Inspectors 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. i ****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. 15ins-09108 Tide 5 Official Inspection Form:Subsurface Sewage Dil System-Page 1 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 5 River Rd. Property Address John and Kathleen Dowling - Owner owner's Name information is required for every Marstons Mills Ma 02648 6/17/2009 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: 13) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-09/08 Title 6 Official Inspection Forth: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 �e 5 River Rd. Property Address John and Kathleen Dowling Owner Owner's Name information is required for every Marstons Mills Ma 02648 . 6/17/2009 , page. City(Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N' ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken 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: El 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•09f08 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form jmw Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 River Rd. Property Address John and Kathleen Dowling Owner Owner's Name information is 'required for every Marstons Mills Ma 02648 6/17/2009 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply,or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well"*. Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or,cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow t5ins•09108 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °e 5 River Rd. Property Address John and Kathleen Dowling Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/17/2009 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 N 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-09r08 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 River Rd. Property Address John and Kathleen Dowling Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/17/2009 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. ® 0 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): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd t5ins-09/08 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 5 River Rd. Property Address John and Kathleen Dowling Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/17/2009 page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current 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: Lt�5,n. 9/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts UTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 River Rd. Property Address John and Kathleen Dowling Owner owners Name information is required for every Marstons Mills Ma 02648 6/17/2009 page. Cityrrown State Zip Code Date of Inspection D. System ,Information (cunt.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 J Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 River Rd. Property Address John and Kathleen Dowling Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/17/2009 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information:- system installed 1993 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 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.): Joints ok, no leakage, vented through roof Septic Tank(locate on site plan): Depth below grade: .5 feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons Sludge depth: 10" t5ins-09108 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 5 River Rd. Property Address John and Kathleen Dowling Owner Owners Name information is required for every Marstons Mills Ma 02648 6/17/2009 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 3 411 Scum thickness Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 811 How were dimensions determined? Opened covers and took measurements Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): . Inlet and outlet baffles intact and in good condition. Septic tank should be cleaned soon and again every 2 years as maintenance.Water level in tank at bottom of outlet invert. Tank not leaking. 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-09= Tide 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title .5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 River Rd. Property Address John and Kathleen Dowling Owner Owners Name information is required for every Marstons Mills Ma 02648 6/17/2009 page. Cityrrown state Zip Code Date of Inspection D. System Information (cunt.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Forth: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 5 River Rd. Property Address John and Kathleen Dowling Owner Owner's Name information is Marstons Mills Ma 02648 6/17/2009 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): 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.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•Og/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of W Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 River Rd. Property Address John and Kathleen Dowling Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/17/2009 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ 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.): Soil was dry and no lush vegetation. No sign of past hydraulic failure. At time of inspection the leach pit had 1.5'of available leaching. 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-09108 Title 5 official Inspection Forth:SubsuAece Sewage Disposal System Page 13 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 River Rd. Property Address John and Kathleen Dowling Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/17/2009 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) 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•09108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 River Rd. Property Address John and Kathleen Dowling Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/17/2009 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately t A-! . � "M` A�� i3 fit 11 ti P� A- `�' 13 may ' 0 t5ins.09= Title 5 Ofhdal Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 River Rd. Property Address John and Kathleen Dowling Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/17/2009 page. Wrown State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ® Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20+ 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: Property is elevated high compared to adjacent area. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09= Title 5 Offidal Inspection Form:Subsurtace Sewage Disposal System•Page 16 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 River Rd. Property Address John and Kathleen Dowling Owner Owner's Name information is Marstons Mills Ma 02648 6/17/2009 required for every. page. Cityrrown 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•09/08 Title 6 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17 m Ln , M Postage $ E3 P()26 0 7 Certified Fee r-I Postmai O Return Receipt Fee (, He O (Endorsement Required) Restricted Delivery Fee (Endorsement Required) - v7 C3 li QQ Lja fu Total Postage&Fees r9 , r- _ o Daniel P Levesque 15 Pequot Road Mashpee, MA 02649 Certified Mail Provides: ., n A mailing receipt ' n A unique identifier for your mailpiece n A record of delivery kept by the Postal Service for two years Important Reminders: ■ Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail®. ® Certified Mail is notavailable for any class of international mail. . n NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. n For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Retum Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. n For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery" n If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT.Save this receipt and.present It when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 SECTIONCOMPLETE THIS ON DELIVERY ■ Complete items 1,2,and 3.Also complete ignatu item 4 if Restricted Delivery is desired. 0 Agent ■ Print your name and address on the reverse ❑Addressee so that we can return the card to you. eceiv Printed Name) C. Date of De�ery ■ Attach this card to the back of the mailpiece, t i_�j�S or on the front if space permits. `i 1 D. Is delivery address different from item 1? ❑Yes 1. Article Addressed to: If YES,enter delivery address below: 0 No Daniel P Levesque 15 Pequot Road 3, Service Type Mashpee, MA 02649 0 Certified Mail® El Priority Mail Express- 0 Registered 0 Return Receipt for Merchandise ❑Insured Mail ❑Collect cn Delivery 4. Restricted Delivery?(Extra Fee) ❑Yes ---------------------- 2. Aransferle Number oms 7014 1200 0001 0358 3797�V � (transfer from service labeq PS Form 3811,July 2013 Domestic Return Receipt l UNITED STATES POSTAL SERVICE � First-Class Mail Postage&Fees Paid USPS Permit No.G-10 ° Sender: Please print your name, address, and ZIP+4®in this box* Town of Barnstable Public Health Division 200 Main Street <, Hyannis, MA 02601 I it1!lllilJl Jill!,111111l,1.11i-ltlli.Ill'III1'���1��j!'I � Vi go Town of Barnstable Barnstable Regulatory Services Department mannWaM 1 ~� 6;y Ate ' Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX• U1R-70l1_F1nA Th--A AA,V— rt4r) CERTIFIED MAIL# 7014 1200 0001 0358 3797 April 6, 2015 Daniel P Levesque 15 Peq not Road Mashpee, MA 02649 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 25 River Road,Marstons Mills,MA,was last inspected on • 6/18/20079 by Jason Burnie, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Conditionally Passes" under the guidelines of 1995 TITLE 5.(310 CMR 15.00) due to the following: • It was observed that one of the sewer lines was not connected to the system. • This line must be connected and the cesspool abandoned (pumped and filled in) in order to receive a passing inspection report. You are ordered to repair the septic system within thirty (30) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BO OF HEALTH ean, R.S., CHO Agent,of the Board of Health • Q:\SEPTIC\Conditionally Passes Ltr\25 River Rd MM Apr 2015.doc r n y{ r 01 - s ®Parcel Detail ie a 3 E- 4 C i u 1ssg12/1 tear!1_t'r;rop(jai_a,,ParcelDp--'!-ail,asp, ID=469c Apps ,http-•www,town.barn... Application Center Suggested sites Imported From IE Parcel Loolwp New Tab,_� ,� �Bin Video:5 Incredible Tin... h - r } • Parcel Info 4 Parcel ID 078-002 Developer Lot LOT B Y 4 Location 25 RIVER ROAD Pri Frontage 4300 Sec Road Sec Frontage Village MARSTONS MILLS Fire District C 0 MM Town sewer exists at this address No Road Index 1373 t Asbuilt Septic Scan; p Interactive Map C1718002 1 m — • Owner Info owner LEVESQUE,DANIEL P Co- Owner streets 15 PEQUOT ROAD street2 i city MASHPEE state MA Zip 02649.2346 country i vLand Info Acres 1.75 use Multi Hses MDL-01 J Zoning RF Nghbd 0106 Topography Above Street Road Paved utilities Public Water,Gas,Septic Location i i f � v Construction Info Year Roof Ext • 1R5f1 GahlelHln „Wnnd`;hinnlP f Start Q 15EPTIC1Letters Septi„ Q:IHPTI%etters Sepb Q�KPTIC1Conditionally 24 Pen Ln Cent 2014,do Parcel Detail Google Ch,., ® 11,47 AM' Computer name : HEALTH899JF User name : flvnni Operatinq System : Windows NT (5.1) � 1y Town of Barnstable . ,. Barr stw b1l Regulatory Services Department AHMM%a= MAM 63g. ,. Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Second Notice Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL #7014 1200 0001 0358 0277 April 6, 2015 Mr. &Mrs. Robert Rosata 48 Mary Chilton Road Needham,MA 02492-1138 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5. • The septic stem located at 47 Sharon Circle Marstons Mills MA wa p y s last inspected on 3/13/2014 by Ricky L. Wright, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that,the system "Fails"under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: • Backupof sewage into facility or stem component due to overloaded or g tY Y P clogged Soil Absorption System, the system must be repaired. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDWean, BOARD OF HEALTH as CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\47 Sharon Cir MM 2014.doc ter S TOWN OF BARNSTABLE LOCATION Z f Q-& SEWAGE #�T� VILLAGE =10 S 121 CUSS ASSESSOR'S MAPP LOT INSTALLER'S NAME & PHONE NO.CA07,ow--r-7T[ SEPTIC TANK CAPACITY I �C LEACHING FACILITY:(type) 1. P. (size) NO. OF BEDROOMS 1-3 PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE .COMPLIANCE ISSUED: /�v VARIANCE GRANTED: Yes No �' w � t s i OF ci �9 J THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ................OF......�.�A�'zN STA�f1..E"__...................------------ Applira$ion for Disposal Works Tonstrnrtinn Permit Application is hereby made for a Permit to Construct ( V� or Repair ( ) an Individual Sewage Disposal System at .Lc->T-_2..." .. .. V42AD..................... A(........A.. .Ll........................................................ a.tion-Address ...............................or Lot No. 1 ACa�AT� �c�LI. R.C.,J1;2i------------- -------.............................................. Owner Address Installer Address d Type of Building Size Lot.G A.E� 5---•Sq. feet U Dwelling—No. of Bedrooms................ ._......_...._....__....Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons.........Co.............. Showers ( ) — Cafeteria ( ) p' Other fixtures -----------•••• •-•---•--•----- - w Design Flow................5_cJ._..................gallons per person per day. Total daily flow____-__-5Q......................gallons. 1:4 Septic Tank—Liquid capacity.1000.gallons Length.6_".G... Width.4_-.10 Diameter________________ Depth.5-4.... Disposal Trench—No..................... Width..........._._.... Total Length..................... Total leaching area....................sq. ft. Seepage Pit No....I---------------�- Diameter.10----0... Depth below inlet.....(Q.......... Total teaching area...ZCP 1-._sq. ft. Z Other Distribution box (V) Dosing tank ( , Percolation Test Results Performed by._G.A� .._ .� _..- ✓VI y YClDate..MAY-1 �11•5:1 aTest Pit No. 1........z....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........................ x ------------------• •--•••••••_•............••....__....„............................................................... Description of Soil.. ��� MAN. ......... �,G?1 -------0.0---------•----•----------••----------•--•.....................•--- x w UNature of Repairs or Alterations—Answer when applicable................................................................................................ ---------•--------------------------------------•-----------------------------------•-------•---.....---•--....---------------------------------------------------------------------••-••-•-............ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b en issued by the board of health. Signed = t ---•----- ....-- ---------------•--.......---•-- Date Application Approved By•••• `"`� `� .-•.•. •. .................................. ---------------------------------------- Date Application Disapproved for the following reasons--------------------------------------------------------•-----------------------------------------------••-•..... -••-------------------------••---...-----pp..,,....--•-....................................................................-------•----------..................................----... ••......._._.. Date Permit No.......{2...7 r ------------------- Issued...............-..........•.......................... Date No.---�.7; -x Fps... ."... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TC�k/N... OF...... c�.5-r�,r ------------------------------ Appliration for Disposal Works Tontrnrtion Prrutit Application is hereby made for a Permit to Construct ( 1/5 or Repair ( ) an Individual Sewage Disposal System at: TM iA P�--C�..0460---------------------- --------------- _ " .....t/ .................................... - ------------- -Address tZAC 1 T :... ation or Lot No. -------------- - ----------- -----......--.----•------------------------..-----. Owner Address W Installer Address 2 d Type of Building Size Lot.4G,J.'5:5... feet U Dwelling—No. of Bedrooms................�-a........................Expansion Attic ( ) Garbage Grinder ( ) P-4 Other—Type of Building ............................ No. of persons....................... Showers ( ) — Cafeteria ( ) Q' Other fixtures -----------------------------••• . .._..:_..._ W Design Flow.................5....5.............0......gallons per person per day. Total daily flow._._...�J 30.....................gallons. WSeptic Tank—Liquid capacity. gallons Length. '_F.�_". Width.'.-.l Diameter ________ Depth.... A. �'.._ x Disposal Trench—No..................... Width...........,......... Total Length.................... Total leaching area..... sq. ft. Seepage Pit No.....I......_-------- Diameter..10-'_C�.. Depth below inlet.....-......... Total leaching area.... __sq. ft. Z Other Distribution box ( V) Dosing tank '-' Percolation Test Results Performed ,tea Test Pit No. 1........ -...minutes per inch Depth of Test Pit----�.`�2 Depth to ground water------"_--'-____.. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-___-_____--_-_._._____- �+ ......••----• ----• ..........-•-..........f ..................................................................................................... O Description of Soil... E P' I QM------....!�_�.. ........--•---�J..ELQ ......... .0.............•........... x V -----------------------•--•-------------------...----•--------•-------•--•-------•-----------•-•--•-•---••--•----•------•------------------•----•--------.........--•------------ --------- W --•----•-•-•-------------------••-•...-•---•--•-••-•----••-•-------••....---•......................•--•-•--...••-•-••---------•-.........--•--•--...••---•--••••--•--•---•-•......••--•-•--•---••---_... U Nature of Repairs or Alterations—Answer when applicable.................................................................................0._........... ...--••-•-•------•••--•-•••••-•••-----•••-•--••---••----••-•---•---------•-•••--••-•••••...............0._......--•••---...--••---••••••--..........-----•----•---••........-•-•-••-••-•............••-- 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 undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed..............................•--...............---•----•-••-•••---•-•----•-•-------.. -............................... Date Application Approved By........�.-- 3 Date Application Disapproved for the following reasons:---...-•------------------------------------------------------•-------------.....---•••••......._...-••-._..... •..........................•-------.................----•-•--------..........----•---------......--•-•----•--•-•••--•-•........_....••---••------••••••---•----••--••...........-•-•---•---••••••••••. c Date PermitNo........A.......::...�1. .._.�.................. Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT/H� Q�^--o.r........OF........... .................................. Trrtifiratr of Tompliunrr /'n•. ...........•.......Insta �-----•P--•--.... -••-----••---•---------•-ed (�} or Repaired by...................... ( ) c . THIS IS TO ERTIFY That the Individual Sewage Disposal -stem construct at...................L,jp- .-----.�...._�*_......... ••---- ........ �' s"`..........At....................................----------------- has been installed in accordance with the rovisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No........S'.7......Y 5�/...._ 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 HEALTH4:F Tt.:......OF.......... ............................... No.... = .yr�1' / FEE....:......✓`....---- Disposal Work/s. Tontrnrtion amit Permission is hereby granted------.. ...L x 4 ---------------•-•-----•---------•-------------.................---............-------- to Construct or Repair ( ) anrJndividual Sewage Disposal System atNo.......... ..7-----.�..... .- ._... Street as shown on the application for Disposal Works Construction Permit No..Z Dated.......................................... -.......... -------•-----.--- and of Health DATE.................... •--•---- FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS VV(it t ri o r. Ile iJ A S— /7' rnsiry2cl�� f2Poti-1' ow. '�-�UY�-- law✓r+2v�T (3 w T rya[[---✓S b LOCATION -SEWAGE PERMIT NO. VILLAGE INSTA LLER'S NAME i ADDRESS UILDE,R OR OWNER DATE PERMIT ISSUED �pC [�t lc� DATE COMPLIANCE ISSUED e: � •. r5 .�, »..�...e.., Y .. ./ � �� `�, �� a ,f k�, 71 77 I �6 k C 11 -�,2 7� Xv "t A;, �5, J, TEM """"� Z YS 771 �W 7 -SC ALf"':, J, ti - ;�t 7 Ol/ A o.& TOP DN F7XtS 1,FIN ADE? k 0 PER— FIN "e"O 77' FINISH 687 VER --.rSH RADE,, _-SE TL Nk EA�Hms ,Pl T�- WiA I-AVY 77 'T;Zq _4 7A _4 RIES �77 Z� -CONC. PRECAST: .0 Ax' "D 6 bWED PEAS 'A' EVELI��­ -BRICK'-9­tMOR TAR, 0 �3 I LL' 4: IDE`�� A -0,JJ 4, tKp..67 A4 0. kt",_ r 'C I .0 V Y t, DOD—. q. 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