Loading...
HomeMy WebLinkAbout0040 RIVER ROAD - Health 078-018 Marstons Mills t r f�` Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ITi 40 River Rd , Property Address h5.: RJB Management ` Owner Owner's Name information is required for every Marstons Mills J/ MA 02648 12-6-18 3:, page. City/Town State Zip Code Date of Inspection �! F- C"? 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. A. Inspector Information St 0 13611 Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number v B. Certification I certify that:l am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000);1 have personally inspected the sewage disposal system at theproperty address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 12-6-18 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0 y�y ,V 40 River Rd Property Address RJ'B Management Owner Owner's Name information is required for every Marstons Mills MA 02648 12-6-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. 2) System Conditionally Passes: El One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑N ❑ ND (Explain below): ,,, t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �x 40 River Rd Property Address RJB Management Owner Owner's Name information is required for every Marstons Mills MA 02648 12-6-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y El ❑ ND (Explain below): ❑ obstruction is removed ❑ Y El ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑Y ❑N ❑ ND (Explain below): ❑ obstruction is removed ❑Y ❑N ❑ ND (Explain below): 3) Further Evaluation is Required by the 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. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page.3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 River Rd Property Address RJB Management Owner Owner's Name information is required for every Marstons Mills MA 02648 12-6-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) dgtermines 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. r. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ® ' Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 River Rd Property Address RJB Management Owner Owner's Name information is required for every Marstons Mills MA 02648 12-6-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ 0 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Z Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Z Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ❑ Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliforn 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.] ❑ [E The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ 0 The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The - system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems:To be 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 CA. 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 River Rd Property Address RJB Management Owner Owner's Name information is required for every Marstons Mills MA 02648 12-6-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal'flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Wasthe facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® Determined in the field (if any of the failure criteria related to Part C is at issue❑ approximation of distance is unacceptable).[310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 River Rd Property Address RJB Management Owner Owner's Name information is Marstons Mills MA 02648 12-6-18 required for every j page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flowbased on 310 CMR 15.203 (for.example: 110 gpd x#of bedrooms): Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Does residence have a water treatment unit? ❑ Yes ❑ No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No E Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 River Rd Property Address RJB Management Owner Owner's Name information is required for every Marstons Mills MA 02648 12-6-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Office Design flow (based on 310 CMR 15.203): 300gpd Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): 75gpd per 1000 sq ft Grease trap present. El Yes ® No Water treatment unit present? ❑ Yes ® No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No Water meter readings, if available: Last date of occupancy/use: Date 8 Date Other(describe belowi): 3. Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 River Rd u _ Property Address RJB Management Owner Owner's Name information is required for every Marstons Mills MA 02648 12-6-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1980's Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan)'. Depth below grade: 24"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.): Good condition. t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 River Rd Property Address RJB Management Owner Owner's Name information is required for every Marstons Mills MA 02648 12-6-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont) 6. Septic Tank(locate on site plan): Depth below grade: 18"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 gal H-20 Sludge depth: 12" Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape 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 is in good condition with baffles installed and no sign of leakage. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments U 40 River Rd Property Address RJB Management Owner Owner's Name information is required for every Marstons Mills MA 02648 12-6-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of Fast pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): r 8. Tight or Holding Tank (tank must be pumped at time of i nspecti on)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 River Rd Property Address RJB Management Owner Owner's Name information is required for every Marstons Mills MA 02648 12-6-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from pit. s t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,za 40 River Rd Property Address RJB Management - Owner Owner's Name information is required for every Marstons Mills MA 02648 12-6-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: i ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: _ Type: ® leaching pits number: 1-1000 gal ❑ Teaching chambers number: ❑ Teaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts ,� Title 5 Official Inspection .Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 River Rd Property Address RJB Management Owner Owner's Name information is required for every Marstons Mills MA 02648 12-6-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit in good condition and holding 12" of water with no other stain lines. k 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration t 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. 40 River Rd u Property Address RJB Management Owner Owner's Name information is required for every Marstons Mills MA 02648 12-6-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): ' Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 it Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 River Rd Property Address RJB Management Owner Owner's Name information is required for every Marstons Mills MA 02648 12-6-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately ­ �k i, 40. 1 ilk .. 10 0. T >.� r t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 r Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �. � 40 River Rd Property Address RJB Management Owner Owner's Name information is required for every Marstons Mills MA 02648 12-6-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. 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: USGS and town maps show groundwater at greater than 20'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspecbon Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 'u— 40 River Rd Property Address RJB Management Owner Owner's Name information is required for every Marstons Mills MA 02648 12-6-18 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on . 16 or attached g P Y P9 For 15: Explanation of estimated depth to high groundwater included ,r r t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 LOCATION L � SEWAGE PERMIT VILLAGE I N S T A LLER'S N E j AD RESS e �d R 0R OWN ER &—,Vull Y' ,. A "Liu, DATE PERMIT ISSUED _ -fI.- ` DATE COMPLIANCE ISSUED ��� _ } r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 River Rd. Property Address Dan Barry Owner Owner's Name information is required for every Marstons Mills MA 02648 3/18/14 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 n I �— on the computer, —v\ '[ 5b6 use only the tab 1. Inspector: key to move your p cursor-do not Robert Paolini use the return key. Name of Inspector Robert Paolini Septic Service "ICI Company Name 17 Playground Lane Company Address mlyn F�n�A Yarmouthport MA 02675 City/Town State Zip Code 508 362-3555 S14454 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: RZI Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Ev ation b he Local Approving Authority 3/18/14 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional 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. L�A" "d 11;5 11 t5ins-3/13 Title 5 Official Inspection Fo .S urface Sewage Disposal System•'Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 River Rd. Property Address Dan Barry Owner Owner's Name information is required for every Marstons Mills MA 02648 3/18/14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑x 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 River Rd. Property Address Dan Barry Owner Owner's Name information is required for every Marstons Mills MA 02648 3/18/14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ required pumping more than 4 times a year due to broken or obstructedpipe(s). The The system eq p p g y system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .' 40 River Rd. Property Address Dan Barry Owner Owner's Name information is required for every Marstons Mills MA 02648 3/18/14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ 0 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ 0 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ 0 Liquid depth in cesspool is less than 6 below invert or available volume is less than 1/day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 l_ Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 River Rd. Property Address Dan Barry Owner Owner's Name information is required for every Marstons Mills MA 02648 3/18/14 page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) Yes No ❑ ❑x Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ❑x Any portion of the SAS, cesspool or privy is below high ground water elevation. FX1 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ❑x Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ F-I Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 0 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. ❑ n 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 River Rd. Property Address Dan Barry Owner Owner's Name information is required for every Marstons Mills MA 02648 3/18/14 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 ❑x ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ 0 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? ❑ 0 Have large volumes of water been introduced to the system recently or as part of this inspection? 0 ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) 0 ❑ Was the facility or dwelling inspected for signs of sewage back up? 0 ❑ Was the site inspected for signs of break out? 0 ❑ Were all system components, excluding the SAS, located on site? 0 ❑ 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: ❑ 0 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): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 40 River Rd. Property Address Dan Barry Owner Owner's Name information is required for every Marstons Mills MA 02648 3/18/14 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: na 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 Seasonaluse? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage (gpd)): na Detail: Sump pump? ❑ Yes ❑x No Last date of occupancy: 3/18/14 Date Commercial/Industrial Flow Conditions: Type of Establishment: Post Office Design flow(based on 310 CMR 15.203): 440Gauons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): 7390 Sq. ft. Grease trap present? ❑ Yes ❑x No Industrial waste holding tank present? ❑ Yes ❑x No Non-sanitary waste discharged to the Title 5 system? ❑ Yes 0 No Water meter readings, if available: NA t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 River Rd. Property Address Dan Barry Owner Owner's Name information is required for every Marstons Mills MA 02648 3/18/14 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: 3/18/14 Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ❑x No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: FX1 Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17. Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 River Rd. Property Address Dan Barry Owner Owner's Name information is required for every Marstons Mills MA 02648 3/18/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes 0 No Building Sewer(locate on site plan): Depth below grade: 1' feet Material of construction: ❑ cast iron 9 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the building vents. Septic Tank(locate on site plan): Depth below grade: 18" feet Material of construction: ❑x concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gl 6" Sludge depth: t5ins•3/13 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 40 River Rd. Property Address Dan Barry Owner Owner's Name information is required for every Marstons Mills MA 02648 3/18/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 32" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 7" I Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump tank every 2 years.Inlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. 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 Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .° 40 River Rd. Property Address Dan Barry Owner Owner's Name information is required for every Marstons Mills MA 02648 3/18/14 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 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•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 40 River Rd. Property Address Dan Barry Owner Owner's Name information is required for every Marstons Mills MA 02648 3/18/14 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 No 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.): Box is level.Box has one outlet lateral.No evidence of leakage. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 River Rd. Property Address Dan Barry Owner Owner's Name information is required for every Marstons Mills MA 02648 3/18/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑x leaching pits number: 1 6'x6'w2' stone ❑ 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.): Sandy soil.Leaching Pit water level was 50"below invert at time of inspection.Stain line 48"below invert. 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-3/13 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 40 River Rd. Property Address Dan Barry Owner Owner's Name information is required for every Marstons Mills MA 02648 3/18/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts 9 --- Title 5 Official Inspection Form �1 r, e e Subsurface Sewage Disposal System Form Not for Voluntary Assessments y� 40 River Rd. Property Address Dan Barry Owner Owner's Name �_- information is required for every Marstons Mills N MA 02648 3t18114 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 El drawing attached separately p I j V �G,� t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 River Rd. Property Address Dan Barry Owner Owner's Name information is required for every Marstons Mills MA 02648 3/18/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: Check Slope Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of leaching 18' 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) 0 Checked with local Board of Health-explain: As-Built ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS observation well data.USED:Technical bulletin 92-0001 annual ranges of groundwater elevations. 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 River Rd. Property Address Dan Barry Owner Owner's Name information is required for every Marstons Mills MA 02648 3/18/14 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked ❑x Inspection Summary D (System Failure Criteria Applicable to All Systems) completed System Information—Estimated depth to high groundwater Fx1 Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 lltl . 7.GUsJG 1 fib*I" PHY51llt+1JUlLU111 l 11. lrJti((5b15� ;hY�IJ.d41; t'.G lb�$ 1-888.450.OMNI (508).,W&Q343 - OrMCE C ALI COL),MAS, .� � H41VUf ilfMIRmo-"(,.AFf;G'Q'A,bfAss. P.O.Aux 126 R S�I I 4 lalnrofntr iNo11)lalo �4rrsk- fcMa J�ntr�xr I6,f rwa!Efiblaiah JJlyhunp y.�y� �Yy S20 7ltanwc A laM*F.VAgd Kass 1-14mo A,AfA o2SN,, l.J��jlit j fAv Aah wHth,A44 02536 'Rovlrorlrmolval'Vole 1p.m,fire, �JN�II:IdPi:R�+h <_.,,k:,;�,I-!i4r�_t_ ., r _ ._--'- , . �,a;s'�;r;•',.,,n.'ul',s;s:l-. 11 OR�R. T RI E PmPortY Brian T. Daey ProlnY "of 6 Unit 2 Route 1$9 Owner: LoWon, Address: P. O, Box 95 T—: Barnstable PrapBrty Phone: N I A CRY, Centerville, MA 02632 Alternate phone; N I A $tot$zip I f dli' i!,„,I1iiA�il iN811,�s11'�illti^+IIIIJ.Ii;'llt:�tl'I} !I'+II p , - �, _._......... Y -.i �I��;+ �q 1 {+ r i ,1 I tNll,Ijlllla'f{I I'I,'rllfl��ai d � !1 { •r a- ,t c� ,auv• i, a,i r n ,sa,,l!� �� :I-I,,f� ,,. _ ,_�,.,.. ,::,,';',,,, 'u',�,.��..:ya,,`��,ail,?�+i��l��e��, �,�rl��:l��, °:�,;;•,.,:, s(art 11/15/02 cnd 1111/15103^ Per $0.00 Total Cost Date: pate: Incident Terms and Agreament for Effluent Testing OMNI 2000 ReelfrotdAing Sand Filter You are hereby authorized to redder Effluent Testing for the OMNI 20DO(recirculating Sand ptlter_listed at the above address for the contract period of two years,.This agreement maybe extended by*a landowner for On addltlonal agreed upon term by providing OMNI Environments)Systems,Inc.-with'30 days written notice of Intent to extend. OMNI will provide the landowner with notice of it's current pricing schedule should the landowner elect to extend this agreoment• This agreement consists of bi-annual testing for;Total Suependad Solids(EPA 100,2),Total Nitrogen (EPA 350,1-351.4),Total phosphorous(EPA 305,1)and Biochemical Oxygen Demand EPA(405_1). All testing shall be performeol by$laboratory certified by the Commonwealth of Massachusetts. OMNI Environmental Systems, Inc, shall provide the landowner and local approving authority with test results. In consideration of the services contained in this agreement we agroa to poly OMNI Envlronr>r ontol Systems, Inc,the sum of$350,00 per Incident,Payment Is due 10 days from Invoice date. This agreement is not In effect until payment has been received by OMNI Environmental Systems, Ins This agreement Is not assignable by Either party without prior written consent of the other party and is neither non-cancelable nor non-refundable. . Please Print Name Au z Sig ur D to Land Owner's ismature pate OW ChWor,marnrat S!Mfams.Inc, f TOWN OF BARNSTABLE -CC ' � ►}) LOCATION ' AGE VILLAGE ASSESSOR'S MAP & LOT-02JLOI INSTALLERS NAME&PHONE NO. ,� 4/J'! Q Jf2i� �2/� 520 SEPTIC TANK CAPACTTI' LEACHING FACILITY: (type) 1 T�!��'I� (size) NO. OF BEDROOMS BUILDER OR OWNER ... I> PERMITDATE: — COMPLIANCE DATE: U Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i 3 ®. `� ., A LOCATION r l� _ , AGE P-0o�_ VILLAGE fbf ASSESSOR'S MAP & LOT 1-0 INSTALLER'S NAME& PHONE NO.1,,{11 -L A1n DM2 6AM SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 4 t rV k:AZ Ih (size) 4:�b V --2 1 i NO. OF BEDROOMS_ BUILDER OR OWNERCog r> ._ PERMITDATE: a �� COMPLIANCE DATE: U Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by it �sA 3, t .3 5 v R=y �3 67 TOWN QF AI STABLE '� z �a R r� Rif SEWAGE# LOCA�E'if}Id ViLf.a a.fs s � ``�l.S A.SSE.SSOWS i o° Ti .L ` 1�tAt1r &PHONE No Sr TA1QI�CAL�A 't'X // (sine) .�000 -L£ACF3I1 OTACIL . � } p� Pi0 O �EDt O{3MS CPd S C.e PER11hITDl4'£t: f )1t+�Lli�NMU � SoparsuonDrstai►cegetwespahc : : .. Maxunum Ad)astecl drw Wwater TAble to the Boitotnof Leachtn Fa itty Feet ]?neat Water uppiy 3Neli andLeaci ng Fac iit3t any.wens exist on seta cr royizfiia?A�feet of ler �g ficy) Edge of Wand and Leaching Fact'ltty(If anY wetixrids exist Feet with;a 3QtI,feet f lewhin.g fActlitY) Fwnshed by. . _ . __ Ld ck no V $ �a t /4 3 -y41' . de AMSTABLE ►r " V LOCATION W IkjGg RON PJAC��� SEWAGE # es VILLAGE I ASSESSOR'S MAP & L/OT INSTALLER'S NAME&PHONE NO. W/keC.lk'n / )I SEPTIC TANK CAPACITY /.W Q ask —e® _ — :541UD 9/�73;- LEACHING FACILITY: (type) (size) NO. OF BEDROOMS [BUILDER OR OWNER ✓� � � PERMITDATE: L COMPLIANCE DATE: �) Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within..200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by � On � � A-1 - �� � � 51 �_ .� SO h r No. Y/ � t �� _ Fee 'Ay Ido• i THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: � Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZippYication for Migpozar *p.5tem Com5truction Vermit Application for a Permit to Construct(✓)Repair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. n Owner's Name,Address and Tel.No. 2�1e /y9 Assessor'sMap/Parce I�¢.9W��i��S� �A P� (3�� CIS Installer's Name Address,and Tel.No. cT6s 771`7Yl0 Designer's Name,Address and Tel.No. 1.111vU -'IT?613— ��b GrJo/%�o J� l G l� •Ce r� ee.e— a ss •�d Type of Building: Dwell No.of Bedrooms _ Lot Size X��5'sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow _3 31) gallons per day. Calculated daily flow gallons. Plan Date /��7/a&o o Number of sheets e:;Z. Revision Date Title A o J 4- F Size of Septic Tank /,1276 69hlow- Type of S.A.S. Description of Soil " �6���,p U /�fF Q" 23 10-A-19t sgAm Nature of Repairs or Alterations(Answer when applicable) k7�l17<) Date last inspected: DESIGNING ENGINEERCERTIFY IN WRITING Agreement: INSTALLATION AN DIN STRICT THE SYSTEM WAS INSTALLS The undersigned agrees to ensure the construction and maintenance of the OW(MAN&FoAgAeNikage disposal system in accordance with the provisions of Tit f the Environ ental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued oard of Signed a"lee e.e L:Z Date ao Application Approved by Date �. Application Disapproved for the ollowing reasons Permit No. 2u U I — 3 Date Issued 3 o}. °• i ry _ ? Fee f Entered in computer: THE COMMONWEALTH OF MASSACHUSETTS Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS =.M 2pplication for Migool bp5t mt Con!Aruction erntit.* . Applic tion fora Permit to Construct(✓).RepairT )Upgrade( )Abandon( ) O Complete System ❑Individual Components', Location Address or Lot No. Owner's Name,Address and Tel.No. iwe /y9 de(�r19�M�e G3aa{stde dot(&kgNq Assessor's Map/Parce i/�S ,¢ O gOX �f5 r✓IA�J�o�✓.� � � 7P iYIke-, l�l J Installer's Name Address,and Tel No. —Derr '3Q' , ©�; signer's Name,Address and Tel.No. F-03"' �'`' S�'D Greif/ago � �'" �� z9 �'.2'✓�' �/� c. . � �/G/ ,, t.(� �.�/ Gem ,�Ft/•�'1 1�.n. type of Building: - " Dwelli No.of Bedrooms Lot Size J/ Y�3G X q.ft. Garbage Grinder, ( ) Other Type of Building ''No.of Persons Showers( ).Cafeteria( ) Other Fixtures `.� Design Flow .3-3 e3 gallons per day. Calculated daily flow .a 2 gallons. Plan Date /i/�'7d/a 6,0 o Number of sheets eA Revision Date h cJan Title `_1AAf 1P:t'4?As'to /,/0 S� Ae�< .. P'W.4.s'E %211�1faa4/ '4u r Size of Septic Tank Type of S.A.S. Description of Soil ©- A !*A/bla lh,4 AC e -,:36'' 13 /DA/.t,_N -TAA& 6 — Z3-2�' (2 apt�O a. ss,,Ar1� - Nature of Repairs or Alterations(Answer when applicable) ��{ � r�n & Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title/5/8f the Enviro �ntal Code and not to place the system in operation until a Certifi- cate of Compliance has been issued Board of Heaa,jt . Signed i _ // .0 _ Date O Application Approved by Date . 0 Application Disapproved for theTo—flowing reasons .i Permit No. 2 U Date Issued 3 a S o*1_ I --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed(Repaired( )Upgraded( ) Abandoned( )by A:9-1r 04 Z/0A) at Aa 4 g4 , .P_ s/T 4&XZ 6 c.t.f M/b has been constructed in a cordance with the provisions of Title 5 and the for Disposal System Construction Permit No.�W/'3��, dated ��.Z1- 0 Z Installer Designer The issuance of tvis pe t shall not be construed as a guarantee that the sy m will unction a d igned. Date U l I1 l Inspector '�r/ -C No. !� r / Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 'Wi0pogal 6potem Construction Permit w Permission is hereby granted to Construct( I )Repair!( )Upgrade( )Abandon System located at &AQ aZ / and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this it. Date: J� Approved by �n _ v , s No. xee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: T L,r-, Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Application four Migogar *pgtem Con6truction j3ermit Application for a Permit to Construct( V)Repair( )Upgrade( )Abandon( ) Vcomplete System O Individual Components Location Address or Lot No. Rv aie. yq M4 rs'iorl S!19 ll5 Owner's Name,Address and Tel.No. [iS Nam dom Rea l-iY, Tra 711-39/J Assessor's Map/Parcel g/ /8 1, r �1 J i s /o�o�y /� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Car/ �4vossa,7r SAF-5/a -39.-Y3 13-0 Design, XnG ol57 A Aner Ave �a/�nosefh /31� 16Y ,Wiarihe iee QafP1 Pd, ®uf�J- Type of Building: welli - No.of Bedrooms_ 3 Lot Size 1/4J,�sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 330 gallons per day. Calculated daily flow 5 -3® ZG gallons. Plan Date .27Z,2060 Number of sheets ,2� Revision Date S/ o2UD l Title >A/off la n ro Lbs Pd r�ou r� Sa6 Su rfa ee_ .�raJet4 e_J,(4" S vs � Size of Septic Tank /500 64//yr! Type of S.A.S. /'e/S�SG:re- 11/S f'/'i u fi or1 Description of Soil A S andv /0 a.'1'I � -3l3 a U 4&am ..SL nd 30 -/,L1 '' L/ /YI e�iltm !SO Z2d Nature of Repairs or Alterations(Answer when applicable) N 1°LcJ do S�_ru C7.10A- Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the' in operation until a Certifi- cate of Compliance has been is ed y this B and of alth. r Signed Date -1�.' Application Approved Date 0_ Application Disapproved for the following reasons Permit No. any Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUS, 63 ENGINEER MUST SUPERVISE lS INSTALLATION AND CERTIFY IN WRITING Certificate of �CLonY 1[�ajXjeSpTEM WAS INSTALLED IN STRICT PLATHIS IS TO CERTIFY,that the On-site Sewage Disposal System Cons 0ru`Rcfeq(�C TRepaired Upgraded g P Y �i��) P ( ) ( ) Abandoned( )by at "1 r has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No:�1)31--Z-S-1 dated 61-_X--, r, � Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector f _ tit •. ,� �'� ,� � � �- 7 `�.�.. v' tA dJ No"~ • G9 -+;Fee t' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes wPUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ;[pprication for M.5pont bpgtem Construction Permit Application for a Permit to Construct( V)Repair( )Upgrade( )Abandon( ) Li/Complete System ❑Individual Components Location Address or Lot No.Ro a f'e M Owner's Name,Address and Tel.No. " SS Na m loom Rea 7')/•3 s/y Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ear/ e4v0.5Sa , T,- S4-5y0 -,3933 13S.S design, znc Sod':g/a-F�oS 257 10a1rneP- 19ve a lmoufl InA /6 y t;a>L/i,'ri.7e fee �afPs.Pd, �a/mouth Type of Building: �. wellin No.of Bedrooms Lot Size /�_S6�sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 33 gallons per day. Calculated daily flow 3 © "Z 4+ gallons. Plan Date % G lumber of sheets � Revision Date 1V1.260/ Title /o�P�n >OrO�bs au.ie Sa6�ur�a�1° uw_ l�i 'oorr/ Sv fP�� Size of Septic Tank /50.0 Ga f� //on Type of S.A.S. 't'Su.Sr-i� _A1S fri u fio.� Description of Soil o ' , A .sonlzv lD oNi 5 -3o 'z 9 Nature of Repairs or Alterations(Answer when applicable) N eai !�Dn .Sfru C v Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the in operation until a Certifi- cate of Compliance has been lVied by this B azd of alth. �j / Signed Date Ci l Application Approved - Date 0 Application Disapproved for the following reasons Permit No. -� ~� c 1� Date Issued ) 1 --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certif bate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed' )1Repaired( )Upgraded( ) Abandoned( )by "i) at t I kA C__-A7 0 4. hit t has been constructed in accordance t with the provisions of Title 5 and the for Disposal System Construction Permit No.-,I)2 �-�ci``� dated to f Z(��tl Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date r F `' Inspector J --------------------------------------- No.e;;;,G 0 I 39y Fee THE COMMONWEALTH OF MASSACHUSETTS t PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS wiopogal 6potem Corigtructfon Permit Permission is hereby granted to Construct, Repair( )Upgrade( )Abandon( ) System located at t AA f �.4 �L -% and asdescribed in ttae above Applicau�norDlsposalstem Costructio:Pe t. a appj'icant recognizes his/her duty to K comply with Title 5 and the followingocal provisions o special conditions.*,{ .. �., tided: > 'e^.r Construction must be completed withinthree years of the date of hispermit tea..,,,, I(-) i , I Date. i(-)I "> f 1 Approved by n ca :k No.__P.. A-a- ........... THE COMMONWEALTH OF MASSACHUSETYS BOAR® OF HEALTH .e OF... _ ............... Apli iration for Disposal Works Tun,strnrtinn ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: epee-."', y.-°-C )_V_fL_ /..0.. M.....tnu v.5 /� ......................................f'y�� Location-Address or Lot No. Wa ..... ............. ......1"_.... 4uL&...------ ...........-----------------............... Ow.n.er Address •••. --•---........-•---•----•-.....---....----........................................................Installer Add d Type of Building Sizeres r-45L ......Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) per, Other—Type of Building Fb%r F—Pi.AI No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ........................................................ ------------ ------------•-------- i C?OO �� -- -- W Design Flow.......7.;�..Grjb_--------•----_gallons per r,at..as y. Total daily flow.......... .. .....................gallons. WSeptic Tank—Liquid*capacityl.WD...gallons Length.121.�Q!_... Width._'..Q". Diameter................ Depth..6_.4-__. x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..........I......... Diameter.......l.D-....... Depth below inlet............... Total leaching area..7- 2.77....sq. ft. z Other Distribution box (4 Dosing tank ( ) ►-' Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1__242.__.minutes per inch •Depth of Test Pit------!:Z�!..... Depth to ground water.rlQ�.iAF..._.. Test Pit No. 2...*-.Z-...minutes per inch Depth of Test Pit.......Ue...... Depth to ground water.0' P4 .................................V••-•-•••••-••-•-•--••-•-•••-•--•-•••-•.................•••--•--••........................................................ 0 Description of S il...... ......,DA:t...In.... ----------------------------------------- x Z''_1��----.C%-C�_ .1�:(...Cv� ---�6A.. . o--. ----T �Nt s. ..F c C............. W - ram-0 '------ ----- 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 TITHE 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 Ae boa of e th. Da e Application Approved BY :.14 -`------------------ Application - ......--•-•---.... --•••--------- Date Disapproved for t e f ollowing reasons:----•---------••----••-•-------•------------------------------•-----------------•---........Da-•.............. ---•--•--•-••--•-•-•--••-•-----•--•-••••...•-•--.....----•--------••...................................... Date PermitNo......................................................... Issued....................................................... Date l jj Flcs.. ............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _T4 .W-1t...........OF..i� A(.�;f` I..S.rT`>�..�..�-.t................... Appliration for Disposal Workii Tontrurtion ami# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at. r.0coo./" Levu/< 0 0 �! . r/rGmp� ^� Location-Address or Lot No. ............................• ..................1 h't i l 1 - ---------------- --z......-------•---....._.._......................... Owner Address W .... i`t.eYre!.... ...... --•-------------------------•-- .......---------------------••----- ....................................................... Installer Address l j'E d Type of Building Size-art__" .......Sq. feet L V Dwelling—No. of Bedrooms............................................Expansion Attic ( )`<, Gar5a e.Grinder r Other—T e of Building No. of persons.........--------------------- Showers — Cafeteria Other fixtures ..................................... ------------------=--------------=-----•-----=-.-.--•------------=--:::-........--.-------- i c;x v S W Design Flow.......7.5..(z '0.................gallons per per-may. Total daily flow....... _`�---S..._...................gallons. WSeptic Tank—Liquid*capacity!(Y2a....gallons Lengthje�'.�--- Width2�.10".. Diameter---------------- Depth.5_'A_: x Disposal Trench—No..................... Width.................... Total Length.................... Total.leaching area....................sq. ft. Seepage Pit No..------_1.-.------- Diameter........O....... Depth below inlet......j'.......... Total leaching area.:�h7.....sq. ft. z Other Distribution box (4 Dosing tank ( ) '-� Percolation Test Results Performed by.......................................................................... Date........................................ ,aa Test Pit No. L. .....minutes per inch Depth of Test Pit...... ...... Depth to ground waterna0l-�4.d......--. fi Test Pit No. 2.. _Z._._minutes per inch Depth of Test Pit...._.) _ __... Depth.to ground water .N t cJvl...i r 2t P4 ..........------------------ ----•..................•---•-----••••------•--....._..--•-----••-..........---...--•-•----•••------•-----•..........---•••--•-- ODescription of S(oil----- -m.?.�...._l.[� `...5`:.... -�-�---------------••------------------ --------------------------------------------------.......---------- �" '°�----•�z --1.`f-----�.. .1............C..(..U2 t�`1 S_G��... t ----------- ��� -------- l -------------------•-------------------------------------------------------------.........-------••-C�2 �; U Nature of Repairs or Alterations—Answer when applicable................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIS 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by e boa , of lth. Signed ---- ----•-•---- ---• - .. Application Approved By------..... -z<............................................................................... ------------------ Date Application Disapproved for t e f ollowing reasons---------------••----....--------------------•-•--------•-------------------------------.... a---------------- -•------------•---••----•.....---••-•--•-----•--•--------•--....-•--•-...•--••---------•-..........•--•••-•---•---•----------•-•••--•--•---••---•••-•---••---•--•-•--••-----•------------•-------------- Date PermitNo................................................... Issued•....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF...................................................................................... i�l�B�?...9..,�Gc.. Trrtifiratr of Tootplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ("'n or Repaired ( ) -by..............................AL. P.: ....... -------------------------------------------------------..---------------------------------------.-------------- Installer at.............. _ has been installed in accordance with the provisions of TITTLE 5 of, e State Sanitary Code as described in the application for Disposal Works Construction Permit No.._.'::.. 1-c .:14.1f....... dated__ -r.., _..'°.X''............ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. o... .....--•---•-•------- Inspector...-•------=-------- DATE...............:.......•--- � -----�_ _ -------------- 4' THE COM40NWEALTH,OF MASSACHUSETTS BOARD OF HEALTH ......:��fs r...........O F....... ................................ /s"a r„ ........ ...... ............................... No......................... FEE 4.0. Uioposa1 Works Tontrudion rrntit Permission is hereby granted................ .........to Construct ( ) or Repair ( ) an Individual Sewage Disp�osal�ystem��r(y'��r at No. dr �c .? .'Ift �' M - .................................. Street V as shown on the application for Disposal Works Construction Permit N .. �...` Dated .......... 1 ''h:•'.MMR Y Board of Health DATE.................. 3&. FORM 1255 A. M. SULKIN, INC., BOSTON 362,4541 926 main street yarmouth mass. 02675 down cape en�inee�ing civil engineers& land surveyors structural design Arne H.Ojala P.E.,R.L.S. land court Richard R.Fairbank P.E. surveys site planning sewage system designs September 26, 1985 Barnstable Board of Helath inspections Barnstable Town Hall South Street Hyannis, MA 02601 permits Gentlemen: On September 19, 1985, ,Down Cape Engineering inspected the installation of the sewage system for Lot 1 River Road in Marstons Mills ( The new Post Office Building), and we certify that it complies with the intent of our site plan # 85-057 dated April 30, 1985. Thank you for your attention. Sincerely, Arne H. O,jala, P.E. , R.L.S. kmk cc: Ed Barry Please complete all items marked' including three signatures. Mail signed original contract to: J&R Sales&Service,Inc. 44 Commercial Street Ravnham,MA02767 J&R SALES & SERVICE, INC. INSPECTION AND EFFLUENT TESTING AGREEMENT Agreement entered into by and between J&R Sales& Service,Inc. (herein called MR)and the FAST' System OWNER(herein called OWNER)for the inspection by J&R of certain equipment of OWNER which is described below. Upon acceptance of this agreement at J&R's office, J&R will render the following services only: Equipment will be inspected at least 4 times per year that this Agreement remains in effect, with the first inspections beginning These inspections will include: 1) Testing of the sludge depth in the septic tank. 1) Inspection, power testing and clean/replace intake filter of the air blower. 1) Inspection of the alarm system. 1) Inspect overall condition of FAST* System. 1) Notification to OWNER of any problems encountered. 1) Service other than routine maintenance will be billed at an hourly rate, plus travel and parts. J&R shall notify the local board of health and Department of Environmental Protection in writing within 24 hours of a system failure or alarm event including corrective measures that have been taken. OWNER will be billed standard J&R charges for any parts used in repairs or maintenance. Any additional labor time will be billed to the OWNER at standard labor rates of$68.00 per hour. Emergency service between regular inspections will be provided at standard labor rates during normal business hours; at time and one-half after 5:00 PM and on Saturdays; and at double time on Sundays and holidays. Emergency service charges will include a minimum four(4)hours of labor, plus standard J&R charges for parts, plus mileage and travel charges. The annual rate includes routine maintenance, but does not include repairs required for damages caused by abuse, accident, theft, acts of third persons, forces of nature, or alterations made to the equipment. J&R shall not be responsible.for failure to render the agreed services if-caused by strikes, labor disputes, non-cooperation by OWNER, or other factors beyond the control of MR. OWNER understands and agrees that J&R is not responsible for special, incidental or consequential damages, including loss of time, injury to person or property, or equipment failure. OWNER agrees that J&R may enter OWNER's property and have acceptable access to all areas deemed by J&R to be necessary or appropriate for J&R to perform its duties hereunder. 44 Commercial St. Raynham,MA 02767 Tele.508 823 9566 Fax 508 880 7232 pd This is a.two-year contract which will be billed annually. All payments are non-refundable. OWNER's failure to pay invoices promptly or to otherwise comply with this contract may result in suspension"6f service, cancellation of contract and/or nullification of warranties, at the election of J&R. This . i not assignable without the consent of J&R and will remain in force until canceled b either agreement s gn z' y party through written notice. MANUFACTURER MODEL NO. SERIAL NO. LOCATION ANNUAL RATE Bio-Microbics MicroFAST Marston's Mills, MA $370.00 EQUIPMENT OWNER J&R Sales & Service,Inc. *Signed by OWNER: John Falacci igned: *Address: 195H Route 149 44 Commercial Street Raynham, MA 02767 Tele: (508) 823-9566 *City: State: Zip: Fax: (508) 880-7232 Marston's Mills MA 02648 Telephone Effective Date of Agreement OWNER understands that(1)ANNUAL RATE payment is for one year only of this two-year agreement and is non-refundable; and(2) Current law requires OWNER to maintain a service agreement for the life of the FAST'System. I HAVE READ AND UNDERSTAND THE FOREGOING. *Signed by OWNER: Effluent Testin Effluent sample taken 2 times per year for two years and delivered to a qualified testing lab for evaluation. Results sent to State and local Agencies as well as the OWNER. OWNER is responsible for providing acceptable access to effluent to enable a grab sample to be taken for laboratory testing performed. PERMIT: *(PLEASE CHECK ONE) ( X ) GENERAL ( )REMEDIAL ( )PROVISIONAL: *SPECIAL CONDITIONS PER LOCAL BOARD OF HEALTH(Y) or(N) if YES,`please attach copy of permit (X) BOD5, TSS,Nitrate, Ammonia O Total Nitrogen Nitrate,Nitrite, Ammonia ( )Other: i *Cost for testing: $I70.00/Visit Operator assigned: William.Everett P g Telephone* (508)400-3868 *Engineer: B.S.S. Design, Inc. *Approval for Effluent Testing Homeowner's Signature .:man-Msv_z.. d &R SALES & SERVICE, INC. July 24, 2001 Hamhom Realty Trust ATTN: John Falacci P.O. Box 1224 Hyannis, MA 02601 Subject: FAST Treatment System 195C Route 149, Marston's Mills, Massachusetts Dear Mr. Falacci: Enclosed is the revised Inspection and Testing Agreement for the MicroFAST Treatment System to be located at 195C Route 149, Marston's Mills, Massachusetts. The annual maintenance cost of this agreement is $370.00/per year. The cost for the first year's testing is $340.00. Both will need to be paid in advance to J&R Sales and Service, Inc and returned with the signed Inspection&Testing Agreement to our Raynham, MA office prior to the order being processed. Thank you for your order and we look forward to working with you. If you should require any additional information please do not hesitate to call or write. S' c rely, aMhitman Enclosures 44 Commercial Si. Raynham,MA 02767 Tole.508 823 9566 i Fax 508 880 7232 I Ct I= F 4> . - " , g f � Y o 77 Co m "Cf • oil � �. 4. � .. N 471 ct CAI n CD W O C C r �/� fit' J•O'r 1V1 t - WB• (•. - 1: Ijlr 1 � o _ � . o j 1 _ 1_K The. ESsex: I t. :.. F l ti°•• s...i sva.xr urn•. 508-428.6191 KfievlT b'1 hL h�lWC4.+ uoaas 77 t@ustin ril Nij_,_ ........ yeet,ocr f Ignf yy 1�• N'T�t.T•MYQOIa .. _ .. �. 4 r o..�.. i•ro�r.er oco• nay a ...y p.m.". 'v - ya e •.1 1[na x y:l CC4„plys d..11:o Mql:. :- ew uc..loum. ...... . 4 1 ' � 'L.1 a1.g1W�LIsIWaa. . .'a/Y T44 PVF 4il7�__ A—q in 14,Iv s f • � i Y —sow '-AK- . I I 11 1 I a '-AK-I 'K c.0 o.n _ 13 - w. 77 608•4.29-6191 I Itesigns ` RI t II tog l Ippp ' 1- � • � i � Al,All yntl i I' : d i II Fo • mod, ' � .."110" ... � ... ' ar ' •.y pun.ma byeml ey oco. of 1 only.Anr oma r.n unary p.om en. a>,r!at:Daea.a►f.:�_--;. 1 � '.fi:_A1.!rLLV4:':.-'::.'_:::.::':.:, yypaa.. � •�L�i�;R:s7MD[ a_-r.n_-W_xNL___._ _ ._ !ii - � __..:.._.MUFF TA`a•.sc�. .. �;� .2F_ .r 11 -'-A 179 508•428.6191 - _ c3us►om s`losigns i roMwnn�maiaawExt Al ' �min,rf Dum•nD iryomf ey oc o.m rer f or f mf.any o r if uri<ny promm�r 05x10/02 08:05 2 5085480350 LC;, INC P.05 i 1.888-45,0-OMN) (508)548-0343 0 rr,ICLE-CA P E COD,MASS, AVINVI-ACM)RING• GAPE C:01), MASS. P.O.Box 126 .1inology Park-@�dvmv Peeco.-.a valinouth Tec. 465 Easl Falitiouth Ifighlre?), 520 Thomas 11.Landers Road Easi rainjouth,MA 02536 OMNI'4& had ralinozeth,MA 02336 Environmental Systems, Inc. ENANCE AGREEMENT 7.;7;,.1 Property Owner: Bayside Building, Inc. Property Location, Unit 4, Herring Run, Route 149 Address'. P,O. Box 95 Town, Marston Mills Property Phone: N/a Clty,State ZIP: Centerville, MA 02632 Alternate Phone: 508 771-1040 . .......... .................._........ ....... Start Date: 519/2002 End Date: 5/9/2003 Terms: $350.60 Terms and Agreement for Standard and Preventative Maintenance OMNI 2000 Recirculating Sand Filter You are hereby authorized to render Standard and Preventative Maintenance for the OMNI 2000 Recirculating Sand Filter listed at the above address for the contract period of (1)Year(s). This agreement may be extended by the land owner for an additional agreed upon term by providing OMNI Environmental Systems, Inc, with 30 days written notice of intent to extend, OMNI Environmental Systesms, Inc. will provide the land owner with 30 days written notice of its then current pricing schedule should the land owner elect to extend this agreement. The agreement consists of all Standard and Preventative Maintenance listed In the Operators Manual. The OMNI 2000 Recirculating Sand Filler has a 3 year manufacutros warranty against all defective components including parts and labor. This agreement includes semi-annul site visits and does not Include costs occasioned by neglect, misuse and accident or consurnables. This agreement does not Include travel costs for the Islands any locations not within a 20 mile radius of East Falmouth. In consideration of the services contained in this agrrement we agree to pay OMNI Environmental Systems, Inc, the sum of$$350.00 for the above maintenance agreement. Payment is due 10 days from Invoice Date, This agreement is not in'effect until payment has been received by OMNI Environmental Systems, Inc. This agreement is not assignable by either party without the prior written consent of the other party and is neither non-cancellable and non-refundStle. 214,Al T, Please Print Name • ;Vz 4910 1fip(rl7efi tignakuVe at. Land Owner's Signature Date PMN J EnWiDnmental Systems, Inc. 05/10/02 08:04 S 5085480350 L:R, IN0 P.03 1-888.450-OMNI ® (608)648.6424 OFFICE � 'r P.O. Box 126 �MJ r l� MANUFACTURING 465 East Falmouth Highway Falmouth Technology Park East Falmouth, MA 02536 Erruironme.ntal Sys►ems,lnc• East Falmouth, MA 02536 May 10, 2002 Attn: David Stanton Barnstable Health Department 200 Main Street Hyannis, MA 02601 RE: ROUTE 149, LOT 18, UNIT 2 — BARNSTABLE, MA Dear Mr. Stanton: The OMNI 2000 Recirculating Sand Filter at the above referenced address has been installed and is operating in accordance with the engineers design plan. It has a maintenance agreement in place and will be maintained as outlined in the attached "Maintenance Agreement". If you have any further questions don't hesitate to contact us. Sincerely, Matthew C. Costa CC: John Bowes, Bayside Building, Inc. D.C.P.Certified Wactowstar Apor2tors Rociroulating Send Filters Manufuutut;ng • Testing • Mainlenenoc . Inetallationc '1'uwn u1*11"11•11slahle P rr Qo� Department of Itealth,Safety,and Environmeninl Services Public 11calth llivision Date /a/ /9 7 367 Main Street,Ilymutis MA 02601 MRNRiAn14 MARS. IN Date Scheduled 7/9 7 Thne I J�3 O pee I'd. Soil Suitability Assessment ford Sewage Disposal , 4 r L` witnessed By: J �' r 1�. can✓���'1.g �1 Performed By: C r G 5 .S� �------ LGCA.TION & GC 1 RAL INt+URNIA`ION Location Address o T 3 �Z t r�9 Owner's Name f o,..o-e.S )3-a�''✓'y �Y T,-,jSree. af-Lf4revj 7. UDI� /►�a r^.SZ�n s �.//�' Address )16 S r" w1 a O-.i to a.s Al G Z.414a Assessor's Map/Parcel: ®� ® C 1Q/o� Engineer's Name C e- G r 5 /I - NEW CONSTRUCTION REPAIR Telephone H S© 8 39 8 - Land Use L*,S r r�-e 07 r-i C./ Slopes(%) / " /'0 7- Surface Stones N 4­1 Dislnnccs from: Open Water Body "/4 R Possible Wet Arca -R Drinking Water Well Drainage Way /V A R Property Line G 1 R Other 7S- Ca*e R c,t/7 SKETCH:(Street name,dimensions of lot,exact locations of lest holes perc tests,locate wetlands in proximlly to holes) i q N Po S7- --4 t.Ea 34 11>�� TO 0z' Pnrcnl material(geologic) C a r��r� C�� Depth to Bedrock 1 t Wce}in front Pit race AIG 17 P Ucpth to Groundwater. Standing Water in I tole: / /• —„_ ! 8 —._—....—. .-- Estimated Seasonal I ligh Groundwater DETERMINATION FOlt St".ASUNA L i►.II.(, 11!A'I`E I .I AltlF, A ethod Used: Depth Observer)sl.mding in ob.a.hole: in. Ucpth to weeping from side of olrs.hole~ ht. Groundwater Adjustment Indcx Nell•B_ .!trading Date: Index Well level __—_— AdQ:Iaclor_ Adj.Groundwater bevel ij�1.Z1 —Wt Nflli._� _ Obscrvntlon ItnlcN 7hoc•s l9" 12_a2_.�_/a: 26"m 4 6-�410 q6-�a'� Tirne at 6" l2:y3:19 i.4pth of 1 crc _ . w. ..r........a r�....aa //:fs30 12:/J';3C �.► � GSee L'od Pm-sonk /Z ----- Rate Min./Inch Sile Suitability Assessment .Silc t'asi•1:d_­11� Site tailed:______._._ Additionil Tesling Nceded(YIN) Original: Public Ilcalth Divisiun Observation 1101e Dala TO IIe Completed on 13ttcic- j Copy: Applicant JEEP OBSERVATION MOLL LOG 11o1e # Depth front Soil I lorizon Soil Texture Soil Color Soil ()(her Surface fin.) (USDA) (Munscll) Mollling (Slrucluic,Stones,nouldcres. y 12.-3L � Sandy l.v e ` i�- r � a Nt a o„�.r. �o YA 3L'1 P.G L' ' C oaeue r3 Cs1 r�vE/ _.._...-..—............ DEEP OBSERVATION MOLL LOG Hole # 2 ' Depth from Soil I lorizon Soil Tcxturc Soil Color Soil udter Surfnce(in.) (USDA) (Munscll) Willing (Stmtcttrc,Slopes,Ilouldcies. ,San a� 2,S n/o- /2-3R I3 38-48r� C me"�Sothd 10y'eil4 y - 48- /3 2 �'2 G o .r e _ _ 714 --- J 4L DEEP OBSERVATION I10111, LOG Depth from Soil Ilorizon Soil•Texture Soil Color Soil 01lier Surface(in.) (USDA) (Munscll) Willing; (Slruclure,Slopes,Iloulderes. _ tSiSl4t��Y.lg.(i)�yS� F,71 DEEP OBSERVATION HOLE LOG I10lc 11 . Depth front Soil I lorizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munscll) Mottling (Stntclutc,Stapes,1louldctes. ts(aIc�14Y 1�_(it.aycl) { i ;loud Insurance ltalc . ' ,tv ., Ahove 500�ear flood boundary. No_ Yes X within 500 year boundary No Yes j Within 100 year flood boundary No Ycs 1cp II I of N-a0!r;l.l.iy Occurring Pervious Materia Does at least four feet of naturally occurring pervious material exist in all areas observed onouglimil the area proposed For the soil absorption system? Ye j If not,what is the depth of naturally occurring pervious material? t certify that on // 4— (date) I have passed the soil evaluator examination at�prove<I Its file Department of l:n ronmental Protection and that the above analysis was perflo nted by me cnnsislenl with the required,training,expertise and experience described in 310 CMR 15.017. Signature__. Date* 57 n i E r' HEAVY DUTY CAST -Cr Tc) 61 et,:;->E- -�• �' ± ` ---- .._ �2" T. ALUM, MIL ? POLY 0R EQUAL i \ t , j A I i �.\i ti i_._ -�- /� -_ram.. ! _ - -.•„ -_ _-- -1.• i 7"oP OF S2 •G' i U�+� �c_� 40 P,vc t bASr.;rs� i M 1:� 2'OF ' \ .F�yE.• R 1 s , c t,�,T�•t ... .E...t�"T F l�'�,, L7�" 1 t �i.- 7'� 1 �,` r }.,. 'r- ••` a.- •C.:^tom 'e I j f` ' ti • f /1 Vj- S i 1 i 1 P p r' i j .,.ham E;7-- T,,sml) Ar- Poo - 7.- T`E: PIT In -4�n _ `` % �-•. ;i I //1011 N. �•/�-�� `�` ,� / / / / /_ � � Jg"gyp a i-^ 1 .G i i ✓ � S ' / � �/ � y'/ �' 1 ! % _ .1.1J'f.+ �. ♦ �JC'.!",s�.!• o fs+i t+,tt %1 / / ��_ ,r t� / .•� I / ! Jt.'. tom••-'✓fir .-�. .1 / I F g �. 4o E DiA►�. \ `• �- - � ),// I ! c /^,�!#• fl "� t f cceer`� t- ,C t t -I' F—r.A ;�ICP�T F- C*VE2 -LF-VA7 i C ) = 45.7 �''` / � ;/�A r Tr). 0O/2 - 7'9 x 1 G - 79 r1 51 ,n 43 f ' _ it k 1 00 y ! ' :a�- 'd- (� �V���,,�.�, .ors.._�c'_.rc=:__�s�.j 4•- sue, ,1 —' . ice'.�-•� ���, �'�� ' Gti^(.ti. ,• i - "aR'l,^,� cL—•C"—!- '� J , \�y_\r r. r T(R4,/� � 4