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Home My WebLink About0290 RIVER ROAD - Health 290 RIVER ROAD, MARSTONS MILLS A= 060 005 \ I i No. D� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Rpplitation for Migonl *pftem Con.5truction Vermit Application for a Permit to Construct( ) Repair( ) Upgrade( Abandon k ❑ Complete System ❑Individual Components Location Address or Lot No. / Owner's Name,Address,and Tel.No. 2 910 /�r!/�/' �G/ i Q B B Assessor's !P cel a�9tays �f�L/J Sates y�� _&.,yF-o Installer's Name,Address,and Tel.No. J�d�, troy Designer's Name,Address and Tel.No. 35-6 Way d OR- 77s`- Type of Building: Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder ( ) Other Type of Buildiri'g'.S;�� f,e„'w No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions Title 5 of th En ironmental Code and not to place the system in operation until a Certificate of Compliance has been issued by thi Board o h. Signe 0' o Date 'Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Ila, I Date Issued _No. DV Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pplication for Mi5pont *pztem Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon Complete System ❑Individual Components Location Address or Lot No. / Owner's Name,Address,and Tel.No. 4 e e Sr-fa!/ Assessor's 1Lo Address,and Tel.No. Designer's Name,Address and Tel.No. Yee_S Installer's Name, 735-0 �- 0 Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building � ,�^ No.of Persons � Showers( ) Cafeteria( ) Other Fixtures %-Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) S A_IJ 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 o Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by hi BoarZh. Signe (> fin r Date 06 Oy 0 y Application Approved by Date v Application Disapproved by: ,71 Date for the following reasons Permit No. '� Date Issued t ------------=— ---------------- ---`------=— I THE COMMONWEALTH OF MASSACHUSETTS l ` BARNSTABLE, MASSACHUSETTS (0S �1 ' Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed' ) Repaired ( ) Upgraded ( ) Abandoned( )by �roS i t3k/e at 00 l2; 0P-A has beeff ct d in�soordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Y �o a`s e GL.1a Designer Installer 7��f / 1 �✓�i, '1 g #bedrooms Approved design floton n� gpd The issuance of this pie `it sha'I not be construed as a guarantee that the system ill f� as desig 4e Date �n t o D Inspector y tv- ej --------------------------------------;� --_--- No. / Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Migpomll*p5tetu Construction Permit Permission is hereby granted to Construct ( ) Repai )/'�U rad ) Abandon (K System located at °)O 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: Construc on giust be completed within three years of the date of this 't. f Date Approved by ) Town of Barnstable pFVE raw Regulatory Services Thomas F. Geiler, Director * rSA RMASS. + public Health Division 9 MASS. AIfD MAC Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-8.62-4644 Fax: 508-790-6304 March 27, 2009 Margaret Fieland Jane E. Small 290 River Road Marstons Mills, MA 02648 NOTICE TO ABATE VIOLATIONS OF 310 CMR: 15.000 THE STATE ENVIRONMENTAL CODE TITLE V: MINIMUM REQUIREMENTS FOR THE SUBSURFACE DISPOSAL OF'SANITARY SEWAGE The property owned by you located at 290 River Road, Marstons Mills has recently had a Disposal System Construction Permit completed for the replacement of a sewer line. According to the installer as told to Donald Desmarais R.S. a Health Inspector the pipe was actually rerouted from a single leaching pit. If in fact that single leaching pit still exists it must be abandoned. The following is a violation of the State Environmental Code: 310 CMR 15.354: Abandonment of Systems You are directed to correct the violation listed above within thirty (30) days of your receipt of this notice by obtaining a septic abandonment permit from the Town of Barnstable Health Department and properly abandoning the single cesspool. You may request a hearing before the Board of Health if written petition requesting same is received within ten(10) days after the date the order is served. Non-compliance will result in a fine of$100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. PER ORDER O THE BOARD OF HEALTH omas A. McKean, R.S. Director of Public Health Town of Barnstable Q:\Order letters\Sewage violations' :. b �19d No. / � Fee yv THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes applicattou for Bi5pont 6p5tem cow5truction ermit Application for a Permit to Construct( ) Repair(� Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. q Q /ini vE�p / Owner's Name,Address,and Tel.No. S'o c/sC,9' e9"6 Assessor's Map/Parcel o bo 00 S a 9,d ,""- 5c�u Installer's Name,Address,and Tel.Nod, �52 Designer's Name,Address and Tel.No. �fJZ✓ � t Type of Building: u d$- a y�3a T° s - -G °t Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provAts 5 of the E ' onmental Code and not to place the system in operation until a Certificate of Compliance has been issuard of a SiDateApplication Approved byV DateApplication Disapproved Date for the following reasons Permit No. P-Qd" 1 3,& Date Issued S 9 O 7 t No. C�� r ""'' Fee /Vc/ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pplication for -Migogal 6pgtem Cow5tructfon Permit Application for a Permit to Construct O Repair(� Upgrade O Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. �' 9, /v i"e, r,/ Owner's Name,Address,and Tel.No. jS ev&0— 9�S01'-'— 6�P,1 • •�riforyfUs�S _�1•//S �er a� .f n'tcr/� Assessor's Map/Parcel 0 60 Od 5 Gr.5UA Installer's Name,Address,and Tel.No.� ,Je KJw t/t S a�4,'�, Designer's Name,Address and Tel.No. Type of Building: 5 ) ��- 1; G/ ;.x -j,f To Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building /�f,�,/„ �� No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) /Jcrf<iroorz i.s�D yft/,srx,,.og/ / . �/� G sfrlyr•r 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 o Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by th's Board off a ti T Signed r' Date Application Approved by Date Application Disapproved Date for the following reasons Permit No. A ad"/ _ 1 3,& Date Issued ———————————————————————————————————————————— r THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Se/wage Disposal System Constructed ( ) Repaired ( ) Upgraded ( ) Abandoned( )by-!, '/, 5ee�,Yic at �90 /'e/ _��4/Sfd!/S /�1./%1' has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. a O� dated S 0— G� Installer i sr, 1e / ✓e/r%/-tL S,c fA L Designer #bedrooms /y Apprroved design flow gpd The issuance of this permit shall not be construed as a guarantee that the system wi�lirfunction as,designed. Date pe/ Inspector•__\_ ———————————— No. " 9 Od 1c� 13� . _ .. _ Fee 0 V THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS 1=i5Spogal,*pgtem Con.5tructfon Permit Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) System located at �?�►0 1�-~�-`'�— ��-�'( 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 permit. Date S I Approved by �� V TOWN OF BARNSTABLE /� a� LOCATION ,� �--' !`AIL?C,'L, '„ SEWAGE # - ' VILLAGE zrl; art ASSESSOR'S MAP & LOT �4-a —0&5 INSTALLER'S NAME & PHONE NO �i SEPTIC TANK CAPACITY l P,a LEACHING FACILITY:(type) � (size) X JIV NO. OF BEDROOMS OR PUBLIC WATER OR OWNER ,A v , ft A4— DATE PERMIT ISSUED: 1J —�. — $'7 DATE COMPLIANCE ISSUED: 45�0, -161 VARIANCE GRANTED: No / Lk - r ego No....V.:... I.P_ ... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............OF..... ..... Appliration for Bhipasal Marks Ton arlartion ramit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: ......................P ......... ...... .................................................................................................. yynn 'toca n-A dress or Lot No. ne LlY .................................................... ..................... r Z Jrf.......41�..'........... .................................. ....... Installer Address Type of Building Size Lot.w. .....................0 0 Sq. feet U DwellingIZNo. of Bedrooms............................................Expansion Attic Garbage Grinder Other—Type of Building ............................ No. of persons....._........_......______. Showers Cafeteria Otherfixtures ....................................................................................................................................................... Design. Flow.......................................----gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid*capacity/O"iallons Length...J.Z.... Width....V....... Diameter---------------- Depth................ Disposal Trench—No..................... Width.........._.._.__... Total Length..__........__...__. Total leaching area--------------------sq. f t. Seepage Pit No--------------------- Diameter........._._.___.... Depth below inlet....._.............. Total leaching area..................sq. ft. Other Distribution box Dosing tank ( ) '_q A- Percolation Test Results Performed by.......................................................................... Date.Y-------------------------------- Test Pit No. I................minutes per inch Depth of Test Pit_................... Depth to ground water_._._........._....._._. G14 Test Pit No. 2................minutes per inch Depth of Test Pit................._.. Depth to ground water......_..__._-_......... P4 ........................................................................................... 0 Description of Soil------.: d.:-.4i*�t...................................................................................................0--------- x ----------------------------------------*----------------------------------------"-----------*------------------------------------------------------------------------*--------------------------............................................................................................�pi .......... ---- --------------------------------------a-------------- --------------- r ica .5 ------------- U Nature.2if..Repairs or Alterations—Answer Wh n Ii ble--- . ...................... ---------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with r"Trn the provisions of 0 A th e e operation p TE 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,b7 the board/of health. Signe ... ..... ............ .................................... ...I-----------------------/ Date Application pplication Approved By....... ........................................ Date Application pplication Disapproved for the following reasons:...............0.............................................................................................. ......................................................................................................................................................................................................... Date Permit No........FFJ.......1.20...................... Issued.--..... ...................../.................. Date No..-•`_..-?----�7U Fes$.... ... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........ ... . ..................O F............................._......... Appliration for Diipuiittl Works Tanutrnrtinn ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ....... � . "n` d ...... .....---- ac .on-. ddress or Lot No. ----------7---------------------•----•-- ------w r Address W / --•-••-•• ---�� f ns. ,per Q Type Buildi Size Lot__. __ ._ Sq. feet Dwellin No. of Bedrooms............................................Expansion Attic ( ) a bage rinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures W Design Flow................_______________ DO gallons per person pe day. Total y flow................................_...........gallons. WSeptic Tank—Liquid capacity_________.__gallons Length...._/______..... Width_______________ Diameter................ Depth................ x Disposal Trench—No_ ____________________ Width_____...____._______ Total Length______.__._.___..___ Total leaching area....................sq. ft. Seepage Pit No------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box (� Dosing tank ( ) g `" Percolation Test Results Performed by----------------- ........................................................ Date........................................ a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_______-_____________._. fxq Test Pit No. 2................minutes.per inch Depth of Test Pit....................; 'dp to; round wte -______-______________ xDescription of Soil.................................... ._... .................. ` `===' t U -------------------------- •------------------------- •----------------------------------------------------- _--------------------------------------------- _----------- ------ ---------- -__----------•-•--- UW ---••---••------------------•----•••-------•--•-•--••---------------------------•-•----...--•-••••••---•--••-•-•---------•-••••••-•----•------•••-----• - - ----••--•• •1- Nature of Repairs or Alterations—Answer when applicable&y� .� . -__ e The undersigned agrees to install the aforedescribed Individual Sewage;` isposa'Sys m in Gordance with the provisions of L-TLC' ` y p dz,the State Sanitary Code—The undersigned't melt tees not`td actsystem in operation until a Certificate of Compliance has been issued by the boa of health. Gam' Sign p�,D •.-----••••- Application Approved By............ --.......'•-• Date Date Application Disapproved for the following reasons_____________________________________•_______•___•___-_______---------------------------.•--•._•.••--_....._..._ --...-•--------------------•-•----------•-------------••--•--•-•---•-•-•---•--••-••-••--•-•--•••-------•-•-••••-••-•-••.._..•-•---•--•--••--•-•-•-•••--•-••----••--•••--•-•--••••--•-••_.._•••--•••-•--- Date Permit No. --...... 7 -.... Issued. 1.......................' .................... Date �^ THE COMMONWEALTH OF MASSACHUSETTS J BOARD OF HEALTH Tiirrfifiratr of flrrntpliaurr THIS IS�C}�CERFF hat he Individual Sewage Disposal System constructed ( ) or Repaired ( } ��''�� ---- -------- ------------------------------------------ -------------- --------- at...................... -•--••-•-•-•••-•--•--•--•-•--•-•----•••• has been installed in accordance with the provisions of i O -The State Sanitary Code as described in the application for Disposal Works Construction Permit No.... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL UNCTION SAA5FACTORY. l DATE... f J_v `J- ---•-•------------ --•---. Inspector.... . ..................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................OF.._............. _..._............. No._._....-•............... FEE.A....... disposal Works Tontrnrtion Vvrrmit Permissionis hereby gra ted----•••-•--•-•---••---•--••--•-•--------------.--••-•••-•---••-••-••-•-•-••--•--•--••-------•••••-•-••._...•---•--••••-•..........._•---•-•-•- to Construq (cq�or Rftai ) an �}dilyidual,,,S�.,A isposal,SyPtem �-J---- ----- ........................-...................................................... Street as shown on the application for Disposal Works Construction Permit N ..................... Dated.......................................... ......................... ................--........oard of Health DATE. FORM 1255 HOBBS & WARREN, INC., PUBLISHERS COMMONWEALTH OF MASSACHUSETTS f EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ? ONE WINTER STREET. BOSTON. MA 02108 617-292-5500 o` WILLIAM F.WELD TRUDY COXE Governor _ Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION Property"Address: 290 Riv r Rd, Marstons Mills Address of Owner: Joan Misho Date of Inspection: /'A 9 17- (If different) Name of Inspector: Wm E Robinson Sr 1 am a DEP approved system inspector pursuant to Section 15.340 of Titl70 .01130) Company Name: Wm E Robinson Septic ServicMailing Address: PO Box 1089, Cr, 5 5 entervi 1 1 P� NIA 02632aTelephone Numbe08 ; 77 -$ '7b 7 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that t formation reported is true, accurate and complete as of the time of inspection. The inspection was performed based on my training an exp ce in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: 6tJ Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority 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. INSPECTION SUMMARY: Check A, B, C, or D: AJ SYSTEM PASSES: 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: 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. Ind"cate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: http:/twww.magnet.state.ma.us/dep ej Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 290 River Rd, Marstons Mills Owner: Mi sho Date of Inspection:/ — p'C9—11 SYSTEM CONDITIONALLY PASSES (continued) 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 pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FU THER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: onditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the ublic health, safety and the environment. 1) S STEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER HICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT 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 to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 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 is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) THER (revised 04/25/97) Page 2 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 290 River Rd, Marstons Mills Owner: Mi s ho Date of Inspection: / —�L g D] YSTEM FAILS: You m st indicate ei;!,er "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis or this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct e failure. Yes o 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 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 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] LAR E SYSTEM FAILS: You ust 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 o the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area- IWPA) or a mapped Zone II of a public water supply well) The o ner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program require ents of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 290 River Rd, Marstons Mills Owner: Mi sho Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. V _ 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. As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. V The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. / The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of / Sub-Surface Disposal System. y Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)] (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 290 River Rd, Marstons Mills Owner: Mi sho Date of Inspection: )—iI—q FLOW CONDITIONS RESIDENTIAL: Design flow: 33 8 g.p.d./bedroom for S.A.S. Number of bedrooms:J--3 Number of current residents: Garbage grinder (yes or no):LO Laundry connected to system (yes or no): - Seasonal use (yes or no): A, v Water meter readings, if available (last two (2) year usage (gpd): 96 — 57, 000g Sump Pump (yes or no):_,4-d 97 — 25, 000g Last date of occupancy:/► 0—9 CO ERCIAUINDUSTRIAL: Type establishment: Design low: gallons/day Grease ap present: (yes or no)_ Industria Waste Holding Tank present: (yes or no)_ Non-sani ary waste discharged to the Title 5 system: (yes or no)_ Water m ter readings, if available. Last date f occupann: OTHER: Describe) Last dat of occupancy: GENERAL INFORMATION PUMPING RECORDS and sourcs of information: C�< —c `2 System pumped as part of inspection: (yes or no)h-v If yes, volume pumped: Ayy gallons Reason for pumping: TYPE.OVSYSTEM V 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) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 290 River Rd, Marstons Mills Owner: Mi sho Date of Inspection: BUILDING SEWER: (Locate on site plan) 1 Depth below grade: Material of constructs n: _cast iron _40 PVC _other (explain) Distance from priv to water supply well or suction line Diameter Comments: (co it n of joints, venting, evidence of leakage, etc.) SEPTIC TANK: (locate on Site plan) 1 Depth below grade: Material of construction: _L/C101"crete _metal _Fiberglass _Polyethylene —other(explain) If tank is metal, list age — Is age confirmed by Certificate of Compliance —(Yes/No) Dimensions: ' O Sludge depth: !—�.' ' >` Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: / Distance from top of scum to top of outlet tee or baffle: , Distance from bottom of scum to bottom f outlet tee or baffle:_A-I How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to ou let invert, structural integrity, evi ence of leakage, etc.) to b-0 G3 "` I` a o cA o - `J T Tn- s vo l!N .0 G J, GREA E TRAP: (locate on site plan) Depth elow grade: Materia of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimen ions: Scum ickness: Dista ce from top of scum to top of outlet tee or baffle: Dist ce from bottom of scum to bottom of outlet tee or baffle: Dat of last pumping: Comm ts: (recom endation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integri , evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 290 River Rd, Marstons Mills Owner: M' sho Date of Inspection: /s�� —q TIG TOR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (locat on site plan) Depth low grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimen ions: Capac : gallons Desi n flow: gallons/day Alarm�fevel: Alarr-i in working order_Yes; _ No Date of revious pumping: Comme ts: (conditi n of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_v (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is aoual, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUM CHAMBER:_ (locat on site plan) Pump in working order: (Yes or No) Alarm in working order (Yes or No) Com ents: (not condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 290 River Rd, Marstons Mills Owner: Mi sho Date of Inspection: / —d'Lg-9 2 / SOIL ABSORPTION SYSTEM (SAS): 1/ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ 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 f ilure, level of pon ing, condition of vegetation, eSc.) , CE POOLS: _ (locat on site plan) Numbe and configuration: Depth-to of liquid to inlet invert: Depth of solids layer: Depth of cum layer: Dimensio s of cesspool: Materials of construction: Indication of groundwater: inf:ow (cesspool must be pumped as part of inspection) Com ents: (note c ndition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate o site plan) Materia of construction: Dimensions: Depth f solids _ Com ents: (not ondition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 290 River Rd, Marstons Mills Owner: Mi sho Date of Inspection: 9_ g g— SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) i 1 J ) /A/- a/W C Lb e i l a 4 �b o- (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 290 River Rd, Marstons. Mills Owner: Mi sho Date of Inspection: t Depth to Groundwater g Feet Please indicate all the methods used to determine High Groundwater Elevation: i/Obtained from Design Plans on record ✓ Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Descri e in your ow nvy orris how you established the High Groundwater Elevation. (Must be completed) (revised 04/25/97) Page 10 of 10