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0401 RIVER ROAD - Health
401 River Road Marstons Mills CP y' A = 060 030 I i 4 �A l TOWN OF BAR�NSTABLE ` LOCATION 9 V! R l V-"C P6 SEWAGE# 2016— 0 3 7 t. VILLAGE (S' /W 1,v I/J' ASSESSOR'S MAP&PARCEL 3 a INSTALLER'S NAME&PHONE NO. —r®�f2 r SEPTIC TANK CAPACITY f !�00 Cs_A LEACHING.FACILITY:(type) �i,-�-►G "� (size) 33 NO.OF BEDROOMS OWNER O fZ ©r 11 PERMIT DATE: Z _�• /� COMPLIANCE DATE: leg" / Fs Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility Of 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) ' u©Ne Feet FURNISHED BY to ®rrt 84 s=' 67 / Ov yoI, a" g. 0 s-� V No. L� � l O 3,3 Fee o THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftplitation for Bisposal Opstem (Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) b on( ) ;N'Complete System ❑Individual Components Location Address or Lot No. Y0 1 V O 's Name,Address,and Tel.No. Sv 6 o G 8) S 4f 9C7 Assessor'sMap/Pazcel �o �0 f L©R`w W- W orie ll z1oi R,!vtr 126 Installer's Name,Address,and Tel.No. SOg'3 4 y h Y8 2 Designer's Name,Address,and Tel.No.6108.9 3 3, ov 9 1 Sc o /3 -t o rre s'4.,.j3c,j+c� M Y (/OA1 Ho J-'e - $'A -0W"C4, Type of Building: / Dwelling No.of Bedrooms Lot Size /6 sq.ft. Garbage Grinder(WA Other Type of Building )0, Flkmr► . No.of Persons Showers( ) Cafeteria( ) Other Fixtures / Design Flow(min.required) y C gpd Design flow provided - 6 gpd Plan Date �� /0 - Is- ^Number of sheets `'Z Revision Date P Z 1-C Title 0 V 0 ' ('� to-1 ,s � Size of Septic Tank �5D 0 fa rd Type of S.A.S. /��"� ! sly A , Description of Soil I ( S O q' L J5 Nature of Repairs or Alterations(Answer when applicable) L n,o jC e y A- 1 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 system in operation until a Certificate of Compliance has been issued by this Board of Health. _ Sign d Date gg I Application Approved by Date CJ` Application Disapproved by Date for the following reasons 06 b Permit No. 2o 0 31 Date Issued No. L O b D 3-3 Fee .p /d0 P,3 THE,COMMONWEALTH OF MASSACHUSETTS Entered in computer: . " s PUBLIC HEALTH DIVISION -,T:OWN,OF BARNSTABLE, MASSACHUSETTS application for Misposa-Y *pstettt Construction Permit J Application for a Permit to Construct( ) Repair( ) Upgrade( ) Alb don( ) 4complete System ❑Individual Components Location Address or Lot No. 4K � e O er's Name,Address,and Tel.No. So V -G S 4190 Assessor's Map/Parcel 3O (Air I L oR;N VJ- W urd Q l' y0) R:vfr /26 Installer's Name,Address,and Tel.No. S'Og• 3 6N- &Y8 2 Designer's Name,Address,and Tel.No. 08'g 3 3• 00`f S�a t°f A —r o rye 7 s'ANow;c _ A Mr VOV Ko NC - SA�-ot�•<<G, Type of Building: Dwelling No.of Bedrooms Lot Size —7 "7/6 sq.ft. Garbage Grinder(WA Other Type of Building FAn" . No.of Persons Showers( ) Cafeteria( ) a Other Fixtures Design Flow(min.required) —7 C gpd Design flow provided 4 y Q- 6 gpd Plan Date /0 . /s ^Number of sheets '-Z Revision Date N N e Title O 1 R , U f Z I ('3 M M $tip,-J ,S /M 111 Size of Septic Tank 1 '�D O GA A- Type of S.A.S. Description of Soil @ Q S i L Oct Nature of Repairs or Alterations(Answer when applicable) Z b "P It f� y_f to R''1 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 system in operation until a Certificate of Compliance has been issued by this Board of Health. Sign d (` D Date 2. y J/ �, Application Approved by Date Application Disapproved by Date " for the following reasons Permit No. O L — 0 32 Date Issued cam` THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS . Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abando�n�er�d( )by 'TO(ZfZE j F_ KfAVAfi0� [TV at 1 ,1 i u r R 0 M1+tS h t 11 J( has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit NoDW(r 'C' 3 dated Installer "fc A TO Designervy #bedrooms Approved de ' flow gpd The issuance of t 's pe r it shall not be construed as a guarantee that the system w' 1 fun c'on design . Date l Inspector .. No. 2O) D33 Fee /OO _ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS i�tJDBaI 6pstem Construction Permit Permission is hereby granted to Construct) Repair( ) Upgrade( ) Abandon / ( ) System located at `�0 ! R t V tr f'Q M A/1 S+,5/,",r 19 41r f and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must b- completed within three years of the date of this pe it. Date ' .5 �j Approved by I Town of Barnstable Regulatory Services • t Richard V. Scali,Interim Director sna►v ABM MASS. Public Health Division ��► " Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: /% —/6 Sewage Permit# n/6 ' 033 Assessor's Map\Parcel Designer: l/���SSd�,p'�P Installer: 5 71 7a' zq�igj l If Address: �J� �J�/J�/G' Address: On 51e 19— was issued a permit to install a (date) (installer) septic system at 'e/lprY ag,/ based on a design drawn by (address) dated �?_/I (designer) V I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed in com liance with the terms of the IAA approval letters (if applicable) ti(HOFMgSsgC+ AW (Installer's Signature) VOON 106 � a F r, 'ABTA. k Z(Efesigner's Signature) (Affix Designer s` tamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:\Septic\Designer Certification Form Rev 8-14-13.doc I To of Bkmsta.ble. P# °t Department of Regulatory Services$ g Public$ealhh Division Date 8 IMIX 200 Main Strati H pnis MA 02601 U (J(J Date Scheduled Time � Fee Pd. .Is • er, Foil Suitability Assessment for Sew e, 'sposal �. performed By: Witnesses Br ��t �� LOCATION INFORMATION . Location Address . jo/ //l/P� Q' Owner's Name plzL'E1 Address Assessors Map/P�. D v Engineer's Name NEW CONSMUOON REPAIR ! Telephone# ko".27-f Land Use Slopes m I 25 SurtaceStones ZZ� Distances from: Open Water Body —' ft Possible Wt!Ana _ft Drinking Water Well ft T)rainage Way •' ft. Prnpetty Line --2al—ft Other ft SKETCH:Otrect name,dimeasiod&lot,exact locations of 4t holes&pere tests,locate wetlands in proximity to holes) i II Parent material(gactlogie) Q'" Depth to Bedrock Depth to t3roundwaRer. Standing Water In Hole:' ,0'#(l/ 1. . Wceping Itom Pit Face Estimated Seasonal high Groundwater I79�Y/ I DATER1VM TION FOR SE OLL-- � AL HIGH wATh;R TALE r k Method Used: Depth to sell mottles: Depth obperved standingon obs.hole: In. D�. roundwn�r AdJueaiteet ft• ,` Depth toiweeping from side of obs.hole I Adj.Gnatndwnter Laval..,,_. r.} Index Well#_,_ Rading Date - Index Well ievei,—,.�.�.... A0J•tltator�„.� PERCOLATION TEST Data Observation' I Tinto at 9" Hole# • Depth of Perk "/Z•// . � 77me at b" ........._. Start Pre-soak 71me-La End Pre-soak T �� 7�V N��"r Rate MinAnch �a Site Suitability Assepsmemb Site passed t/ Site Failed: Additional Testing Needed(Y" Originak;Public Health Division Obsemadod ted Hole Data To Be Comple &I Back--- ***If percola ipn test is to be conducted within 100'of wetland,beginning- ou most first notify the Barnstable Co#servation Division at least one(1)wedlt:print'to I � Us D� DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture 'Soil Color' Soil ' Other Surface CID.) (USDA) Mottling (SaNM ;Stoaest Boulders, V YR r: DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, /0 V1.2 2, DEEP OBSERVATION HOLE LOG Hole# Depth from' . Soil Horizon, Soil Texture Soil Color Soil I other Surface(in.) 1 (USDA) (Munsell) Mottling (Structure,Stones,Boulders. -. I DEEP OBSERVATION HOLE LOG Hole# Depth from _ Soil Horizon Soil Texture Soil Color • Moil Other Surface(in.) (USDA) (Munsell) Mottling;, (Structure,Stones.Boulders. • . n F'S Flood Insurance Rate Mau: Above 500 year flood boundary No— Yes ►/ Within 500 year boundary Nov Yes Within 100 year flood boundary No—"No—Z Yes Death of Naturally Occurring Pervious Material Does at least four feet of Datttrally occurring pervious rial exist.in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervi us material? Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with ' the required training " e and ex cc described in 3:10 CMR 15.017. Signature Date P . rJ COMPLETESENDER::COMPLETE THIS SECTION l' • ■ Complete items 1,2,and 3.Also complete A. Signature item 4 if Restricted Delivery is desired. r O'Agent ■ Print your name and address on the reverse diessee so that we can return the card to you. Received by( rin Name) o" ivy ■ Attach this card to the back of the mailpi� (� or on the front if space permits. D. Is deli rya dres!�different fromitem 1? l�Yews 1. Article Addressed to: �`s� If YES,enter�d�4ve address belo�> ❑�d :� Loring W. Wordell %Wordell Realty Trust 401 River Road 3. Servicerype Ma'rstons Mills, MA 02648 ❑Certified Mail ❑Express Mail ❑Registered ❑Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number (transfer from service label) 7014 1200' 0001 0358 7573 r'`" PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540 UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid LISPS Permit No.G-10 • Sender: Please print your name, address, and ZIP+4 in this box • I Town of Barnstable _Public Health Division 200 Main Street Hyannis, MA 02601 Town of Barnstable Barlung es Regulatory Services Department ""ffWft = '"R' Public Health Division Q D 0 9. 200 Main Street, Hyannis MA 02601 200� Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL #7014 1200 0358 7573 August 26, 2015 Loring W. Wordell %Wordell Realty Trust 401 River Road, Marstons Mills, MA 02648 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 401 River Road, Marstons Mills, MA was last inspected on 8/01/2015 by Mark Polselli, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: • Leaching pit or cesspool with high liquid level, <12" below inlet (per Town Code 360-9). You are ordered to repair or replace the septic system within two (2) years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH (!�ZZc eat, R.S. C O Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\401 River Rd MM Aug 2015 Commonwealth Of Massachusetts Executive Office Of Environmental Affairs Department Of Environmental Protection TITLE 5 Official.Inspection Form - Not For Voluntary Assessments Subsurface Sewage Disposal System Form Part A Certification Property Address: 401 River Rd.Marstons Mills Ma.02648 0'o O 03 O Owners Name:Loring Wordell Owners Address:208 Lincoln Rd.Hyannis Ma.02601 Date of Inspection:9/8/2006 Name of Inspector(please pri;it)Sean M.Jones Company Name: S.M.Jones Title V Septic Inspection Mailing Address:74 Beldan Ln. Centerville Ma.02632 Telephone Number:508-7784597 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of 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: X Passes Conditionally Passes Needs further evaluation by the Local Approving Authority Fails Inspectors Signature Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sect to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments: ; ""This report only describes conditions at the time of inspection and under the cu le at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(cowwjED) Property Address:401 River Rd.Marstons Mills Ma.02648 Owner:Loring Wordell Date of Inspection: 9/8/2006 Inspection Summary:Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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: B.System Conditionally Passes:N/A One or more system components as described in the"Conditional Pass"section need to be replaced or Repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the_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 the 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 structurally sound,not leaking and if a Certificate of Compliance Indicating that the tank is less than 20 years old is available. ND explain: 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 obstruction is removed distribution box is leveled or replaced ND explain: 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 obstruction is removed ND explain: OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(corr wum) Property Address:401 River Rd.Marstons Mills Ma.02648 Owner:Loring Wordell Date of Inspection:9/8/2006 C.Further Evaluation is required by the Board of Health:N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system Is failing to protect public health,safety or the environment. 1.System will pass unless Board of health determines in accordance with 310CMR 15.303(1)(b)that the System functioning in a manner that protects the public health,safety and the environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a Surface water supplyor 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 less than 100 feet but 50 feet or more from a Private water supply well**.Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform Bacteria 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,provided that no other Failure criteria are triggered.A copy of the analysis must be attached to this form. 3.Other: OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(corrTmm) Property Address:401 River Rd.Marston Mills Ma.02648 Owner:Loring Wordell Date of Inspection:9/8/2006 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow 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. X 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 cesspool or privy is within Zone 1 of a public well. X Any portion of cesspool or privy is within 50 feet of a private water supply well. X Any portion of 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 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 pp,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] X (Yes/No)The system fails•I have determined that one or more of the above 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:N/A To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: 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 11 of a public water supply well If you 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 CM 15.304.The system owner should contact the appropriate regional office of the Department. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:401 River Rd.Marston Mills Ma.02648 Owner:Loring Wordell Date of Inspection:9/8/2006 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 X Were any of system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X_ _ Was the site inspected for signs of break out? X _ Were all system components,excluding SAS,located on site? _X_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tee,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _X _ 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: Yes No X _ Existing information.For example,a plan at the Board of Health. X_ 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(3)(b)] OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:401 River Rd.Marstons Mills Ma.02648 Owner:Loring Wordell Date of Inspection: 9/8/2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):-3— Number of bedrooms(actual):—3_ DESIGN flow based on 310 CMR 15.203(for example): 110 gpd x#of bedrooms): 330 GPD Number of current residents: 0 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no)_No [if yes separate report required] Laundry system inspected(yes or no)_N/A Seasonal use:(yes or no) No_ Water meter readings,if available(last 2 years usage(gpd):2004=1.45 GPD--2005=471 GPD Sump pump(yes or no): No Last date of occupancy/use: 4/� 2006 COMMERCIAL/INDUSTRIAL:N/A Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sg8,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping records Source of information: Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was this quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be Obtained from the system owner) Tight tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information:1976+/- Were sewerage odors detected when arriving at the site(yes or no): No f OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:401 River Rd.Marstons Mills Ma.02648 Owner:Loring Wordell Date of Inspection:9/8/2006 BUILDING SEWER(locate on site plan) Depth below grade: 5` Materials of construction: cast iron_X_40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): Joints were in good condition no sign of leakage. SEPTIC TANK:_X_(locate on site plan) Depth below grade:Tank 3 feet-Inlet cover 6 inches-outlet cover 18 inches Material of construction:_X_concrete metal fiberglass_polyethylene other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no):`(attach a copy of certificate) Dimensions: 8`6"X5`6"X4`10"= 1000 Gallons Sludge depth: 19" Distance from top of sludge to bottom of outlet tee or baffle: 2.5`� Scum thickness: 6" Distance from top of scum to top of outlet tee or bafIle:_4" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: opened covers and took measurements Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels As related to outlet invert,evidence of leakage,etc.): Tank needs to be cleaned,inlet tees and outlet baffle intact and in good condition.Tank was structurally sound and not leaking. GREASE TRAP: N/A (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels As related to outlet invert,evidence of leakage,etc.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:401 River Rd.Marston Mills Ma.02648 Owner:Loring Wordell Date of Inspection:9/8/2006 TIGHT or HOLDING TANK: N/A (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: N/A (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of Leakage into or out of box,etc.): PUMP CHAMBER: N/A (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): r OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:401 River Rd.Marston Mills Ma.02648 Owner:Loring Wordell Date of Inspection:9/8/2006 SOIL ABSORPTION SYSTEM(SAS):_X_(locate on site plan,excavation not required) If SAS not located explain why: Type X Leaching pits.Number: 1- 1000 gallons Leaching chambers,number: Leaching galleries,number: Leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternitave system Type/name of technology: Comments(note condition of soil,sign of hydraulic failure,level of ponding,condition of vegetation,etc.): Soil was dry no sign of hydraulic failure.At time of inspection,leach pit had 4 feet of available leaching with no visible stain lines.Pit is down 4 feet with a 2 foot riser. CESSPOOLS: N/A (cesspools 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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: N/A (locate on site plan) Materials of construction: Dimensions: Depth of solids Comments(note condition of soil,sign of hydraulic failure,level of ponding,condition of vegetation,etc.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:401 River Rd.Marston Mills Ma.02648 Owner:Loring Wordell Date of Inspection:9/8/2006 SITE EXAM Slope XXX Surface water Check cellar XXX Shallow wells Estimated depth to ground water 20+_feet Please indicate(check)methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Property is situated high above River Rd. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:401 River Rd.Marstons Mills Ma.02648 Owner:Loring Wordell Date of Inspection:9/8/2006 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent referencelandmarks or Benchmarks.Locate all wells within 100 feet.Locate where water supply enters the building B 0 1 O 2 FRONT OF HOUSE A 0 3 TANK A-1=35' B-1=26'6" A-2=32' B-2=29'4" LEACH PIT A-3=35'6" 8-3=46' t� WORDELL REALTY TRUST 208 Lincoln Road Hyannis, MA 02601 Tel. 508-778-4127 Cell: 1-508-328-8116 Town of Barnstable March 6,2006 Regulatory Services Public Health Division 200 Main Street Hyannis,MA 02001 Dear Sir/Madam: In response to your letter of February 24,2006, listing violatiL8,64:401 River Road,Marstons Mills,I enclosing a schedule of the work to be done. Metering of Electricity and Gas: As of February 1,2006,the meter was read and the electricity account was changed into my name. See attached bill for reference. No one is staying in the basement of the property. Provision of Oil: The tank was filled and the oil gauge was replaced on January 31,2006,by Scudder Taylor Oil. See attached bill. Washbasins,Toilets,Tubs and Showers: I will give the tenant written notice to get in to the apartment to scrub off loose paint and make it easier to clean the tub. Owner's Installation and Maintenance Responsibilities: An heating elements on the stove will be replaced at the P Y g P same time that I repair the tub. Owner's Responsibility to Maintain Structural Elements: The living room carpet has been torn and ruined by the tenant. She promised to do a seamed repair until she moves out. I will patch the carpet as best I can until she vacates the premises. Curtailment Prohibited:Two kitchen cabinet doors were torn off by the tenant's children hanging on them. I will re- attach them. Curtailment Prohibited: I will replace the missing storm door windowpane,which had been present at the time of the tenant signing the lease and during subsequent inspections by Housing Assistance Corp. You should be aware that none of these problems were reported to me by the tenant. Also,the tenant's lease expiid ._ 12/31/05,and she was properly and legally requested to vacate the premises by the end of January. Shelhas not va meted mw the premises and there are now legal eviction proceedings underway. Because of this legal action,access into they premises to do these repairs may be difficult. I will contact you if and when the repairs have been cojnpleted. M Lrj r, In the meantime,we are requesting a hearing before the Board of Health concerning this matter. Please eel free t contact me at 508-328-8116 if there is any further information you need to process this request. fff !y Sincerely, c1-t M Loring Wordell,Jr. Trustee NELSON OIL P.O. BOX 1210 HYANNIS,____MA _._02601 _ Charges and Payments _. __ i, after this date will appear 01 /31 /( I Account on next statement. Number 5-26890 = 508.-775_1765_J; CURRENT AMT. MR. LORING WORDELL JR. (2) NELSON OIL PAST DUE AMT. 208 LINCOLN ROAD P.O. BOX 1210 HYANNIS MA 02601 HYANNIS, MA 02601 NON-BUDGET ITEMS TOTAL DUE Enclose this portion of statement With remittance. Amount Enclosed $ , We accept MasterCard,[Visa Master-Card6 Account Number Date Of This Statement Last Statement Date Previous Balance 1 6 12 20 05 679 23 401 River Road I 01 /12/06 PAYMENT - THANK YOU4 679.23 •00i 01 /30/06 DELIVERY FUEL OIL i 201 .4 523.44 523.44TM* 4 I i I � � ! I I I � i _ FOR INQU�RIES: 508-775-1190 i LOYAL CU TOMER SINCE 9/02/05 0-30 DAYS CURRENT OVER 30 DAYS � � 523.44 .00 _ anrr 4004 unnrF•cFF RFvFRSF SInF FOR IMPORTANT INFORMATION. ao �—Account Number —t 12 7 0000035203 14 70 1433 981 0088 a LORING WORDELL JR Please Pay 208 LINCOLN RD HYANNIS MA 02601-2411 $352.03 IIIuu�I�I�IInIIun��IIuI�I�IuIn�IIu�IIIIneInInI�I�I Above Amount Includes Both Delivery and NSTAR Electric supplier Balances RETURN THIS PORTION WITH YOUR PAYMENT.MOVING?PLEASE LET US KNOW,OTHERWISE YOU MAY BE RESPONSIBLE FOR ENERGY USE AFTER YOU MOVE. HAVE QUESTIONS ABOUT THE SUPPLIER SERVICE PORTION OF YOUR BILL, CONEDISON SOLUTIONS OR THE CAPE LIGHT COMPACT? MORE INFORMATION IS AVAILABLE IN THE "CUSTOMER SERVICE" SECTION OF NSTAR'S WEB SITE, WWW.NSTARONLINE.COM. r r tn o Account Number Vlling-Date Next Read=Dater =1433.-g81. 0088 = F'eb 23,.:2..... .-. ....:.. Service Provided to Account Summary LORING WGRDELL JR Previous Bill 0.00 401 RIVER RD Total Delivery Charges 141.32 MARSTNS ML MA 02648 Delivery Svcs Balance 4141.32 Electricity Used Cost of Electricity Rate 32-Residential Nonheat - Annual Delivery Services Meter G022453 Customer Charge (Prorated) 2.7 Feb 22, 2006 Actual Read 36274 Distribution .04574 X 1631 KWH 74.6 Jan 31, 2006 Start Read - _3)I_643 Transition * .02927 X 1631 KWH 47.7 22 Day Billed Use 1631 Transmission .00695 X 1631 KWH 11.3 Renewable Energy .00050 X 1631 KWH 0.6 6022453 KWH 02/22 1631 Energy Conservation .00250 X. 1631 KWH 4.0 Delivery Services Total 141.3 * PART OF WHAT WE COLLECT IN THE TRANS/TIC CHARGE 1S OWNED BY CEC FUNDING LLC WELCOME TO NSTAR ELECTRIC. PLEASE CHECK YOUR NAME, ADDRESS AND RATE TO MAKE SURE THEY ARE CORRECT. PLEASE CALL US AT THE NUMBER BELOW TO MAKE ANY CHANGES. THANK YOU. IHIS BILL WAS PRORATED BECAUSE IT COVERS LESS THAN THE NORMAL ONE MONTH PERIOD. low CUSTOMER SERVICE CENTER 800-592-2000 I _ WORDELL REALTY TRUST 208 Lincoln Road Hyannis,MA 02601 Tel. 508-778-4127 Cell: 1-508-328-8116 Town of Barnstable March 6,2006 Regulatory Services Public Health Division 200 Main Street Hyannis,MA 02601 Dear Sir/Madam: In response to your letter of February 24,2006, listing violations at 401 River Road,Marston Mills,I am enclosing a schedule of the work to be done. Metering of Electricity and Gas: As of February 1,2006,the meter was read and the electricity account was changed into my name. See attached bill for reference. No one is staying in the basement of the property. Provision of Oil: The tank was filled and the oil gauge was replaced on January 31,2006,by Scudder Taylor Oil. See attached bill. Washbasins,Toilets,Tubs and Showers: I will give the tenant written notice to get in to the apartment to scrub off loose paint and make it easier to clean the tub. Owner's Installation and Maintenance Responsibilities: Any heating elements on the stove will be replaced at the same time that I repair the tub. Owner's Responsibility to Maintain Structural Elements: The living room carpet has been torn and ruined by the tenant. She promised to do a seamed repair until she moves out. I will patch the carpet as best I can until she vacates the premises. Curtailment Prohibited:Two kitchen cabinet doors were torn off by the tenant's children hanging on them. I will re- attach them. Curtailment Prohibited: I will replace the missing storm door windowpane,which had been present at the time of the tenant signing the lease and during subsequent inspections by Housing Assistance Corp. You should be aware that none of these problems were reported to me by the tenant. Also,the tenant's lease expired 12/31/05,and she was properly and legally requested to vacate the premises by the end of January. She has not vacated the premises and there are now legal eviction proceedings underway. Because of this legal action,access into the premises to do these repairs may be difficult. I will contact you if and when the repairs have been completed. In the meantime,we are requesting a hearing before the Board of Health concerning this matter. Please feel free to contact me at 508-328-8116 if there is any further information you need to process this request. Sincerely, Loring Wordell,Jr. Trustee C_7 rt`z O Co ZZ .Y V 7 .o r--Account Number —� 12 7 0000035203 14 70 1433 981 0088 LORING WORDELL JR Please Pay 208 LINCOLN RD HYANNIS MA 02601-2411 $352-103 I I I,111111111111 Ile III is I I„I,1,1„6„I Above Amount Includes NSTAR Electric Both Delivery and Supplier Balances RETURN THIS PORTION WITH YOUR PAYMENT.MOVING?PLEASE LET US KNOW.OTHERWISE YOU MAY BE RESPONSIBLE FOR ENERGY USE AFTER YOU MOVF HAVE QUESTIONS ABOUT THE SUPPLIER SERVICE PORTION OF YOUR BILL, CONEDISON SOLUTIONS OR THE CAPE LIGHT COMPACT? MORE INFORMATION IS AVAILABLE IN THE "CUSTOMER SERVICE" SECTION OF NSTAR'S WEB SITE, WWW.NSTARONLINE.COM. r 0) W o Account Numbew Bslling Date , Next Read IIa€e I433. 481 0088; t=eb.:2 J" 2.06.._ ..: Service Provided to Account Summary LORING WORDELL JR Previous Bill 0.00 401 RIVER RD Total Delivery Charges 141.32 MARSTNS ML MA 02648 Delivery Svcs Balance $141.32 Electricity Used Cost of Electricity Rate 32-Residential Nonheat - Annual Delivery Services Meter G022453 Customer Charge (Prorated) 2.; Feb 22, 2006 Actual Read 36274 Distribution .04574 X 1631 KWH 74.E Jan 31, 2006 Start Read - 34643 Transition * .02927 X 1631 KWH 47.; 22 Day Billed Use 1631 Transmission .00695 X 1631 KWH 11.3 Renewable Energy .00050 X 1631 KWH 0.E G022453 KWH Energy Conservation .00250 X. 1631 KWH 4.0 02/22 1631 Delivery Services Total 141.3 * PART OF WHAT W£ COLLECT IN THE TRANSITIG CHARGE 1S ONNED BY CEC FUNDING LLC WELCOME TO NSTAR ELECTRIC. PLEASE CHECK YOUR NAME, ADDRESS AND RATE TO MAKE SURE THEY ARE CORRECT. PLEASE CALL US AT THE NUMBER BELOW TO MAKE ANY CHANGES. THANK YOU. THIS BILL HAS PRORATED BECAUSE IT COVERS LESS THAN THE NORMAL ONE MONTH PERIOD. W llS?lsQ R CUSTOMER SERVICE CENTER RMS92-20Q V e NELSON OIL P.O. BOX 1210 HYANNIS,—MA- 02601 Charges and Payments - - —--- after this date will appear 01 /31 / tACGount on next statement 1765 -JNumber 5-26890 = • CURRENT AMT. MR. LOR.ING WORDELL JR. (2) NELSON OIL PAST DUE AMT. 208 LINCOLN ROAD P.O. BOX 1210 HYANNIS MA 02601 HYANNIS, MA 02601 NON BUDGET ITEMS TOTAL DUE rl Encose Enclose this portion of statement With remittance. Amount i We accept MasterCardfVisa M j =I Account Number Date Of This Statement Last Statement Date Previous Balance 131 12 20 5 679.23 401 River Road M 01 /12/09 PAYMENT - THANK YOU ' 4 679.23 .00, 01 /30/06 DELIVERY FUEL OIL 201 .4 523.44 523.44 F i f J f � I I ' i FOR INQUIRIES: 508-775-1190 LOYAL CU 'TOMER SINCE: i9/02/05 0-30 DAYS CURRENT OVER 30 DAYS A 'h 0 '+ A+ ±, k d 523.44 .00 ., to nunurc runor_c aaccn i ionid Atjmmu oFRCFNTAAF RATF 1R%NOTICE-SEE REVERSE SIDE FOR IMPORTANT INFORMATION. Town of Barnstable . ; .njuvsrnst.E, Regulatory Services Department Public Health Division , 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 7/6/15 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2)YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any"conditionally passed systems" (broken cover,relocation of a pipe, relocation of a driveway due to H-10 components, etc) Leaching pit or cesspool with high liquid level, <12"below inlet(per Town Code §360-9.1) OTHER Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc oA1_ 7 ° Commonwealth of Massachusetts /Vl/P zo.o3t) $ 015,� Title 5 Official Inspection Form Subsurface Sewage Disposal Syxterr Fronn-Not for Voluntary Assessments Property Address ON ner Owners Name I / /� � requiredfo a arS1rons !�/ i9 �a2 6�� /.� - 1 requ>red for every „u page. UyNown State Zip Code Date of spection I= 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. Imp°rtant:When A. General Information fOOng out forms S � , U� on the computer, use ony the tab 1. Inspector. key to move your /I cursor-do not a�� o e-,/ 1 use the return Name of Inspector Company Narne Company Address A'ly/Town State Zip Code go 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 16.340 of Title 6(310 CMR 16.000). The system: ❑ Passes ❑ Conditionally Passes Fails 171 Needs Further Evaluation by the Local Approving Authority Ins PL is 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 cgpd 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 aescribes 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. Srs•Y13 Tile 5 official Ire pecBm F mrz Subsuface Sewage DISp09 l System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Offi ,!al Inspection Form Subsurface Sewage Dls ptisal System Form -Not for Voluntary Assessments Property Address Ow ner Owners Name / �formetion is /'/ required for every ars onf v/11 page, City/Town State Zip Code Date of Inspecton B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E/always com plete all of Section D A) System Passes: ❑ 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or 1n 310 CM 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 forges", 'no"or"not determined"(Y,.N, ND) for the following statements. 9"not determined," please exglain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not)is structurally unsound, exhibits su antial infiltration or exfiltration or tank failure Is Imminent. System will pass Inspection if the existinb tank is replaced with a complying septic tank as approved by the Board of Healt h. *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): Me,an 3 T1Ue s 0Mdal irsPecea,F orm Subudwe sawepe Disposer Sy Om•Pape 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments Z-�0/ R,vt� Property Address (A/0 V- ON Infomtstion is Cwner's Name required for every Fag®. CigrlTown State Zip Code Date of insprecuoh B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. S) System Conditionally Passes(coat.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health.determines in accordance with 310 CMR 16.303(1)(b)that the system is not functioning in a mannerwhich 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 of a salt marsh Title Wftidel Inspection F art[Subwlace Sewage OlspoW System.Pape 30f 17 taro•3M3 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address D✓ Au rter Ow rcer's Name / required is ✓j vtf r required for every IFICA page. i*frown State Zip Code Date of Inbpecton B. Certification (coat.) Z 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 fleet 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 II inspections: Yes o B ckup of sewage into facility or system component due to overloaded or clogged SAS or cesspool scharge 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'/Z day flow M,3H3 TM860fhdellrnpectonForm Subswwe6ewape0ispwd System Page 4ofW l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 90/ Property Address / O✓ Ow ner Ow ner's Name �( Information is required for every ✓s Af - f page. City/rown State Zip Code Date of Insh o B. Certification (cont.) Yes No Required pumping more than 4 times in the last year NOT due to clogged or 11 tructed pipe(s). Number of times pumped: ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ L4� Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ C(� 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 certlfled laboratory, for fecal collform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 6 ppm, provided that no other failure criteria ate triggered. A copy of the analysis d 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. Id' U The system&il . I have determined that one or more of the above failure criteria exist as described in 310 CMR 16.303, 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 r regional office of the Department. �t19•�3 TiCeSOrGdal InspectionFonn SuCeufete SevrageOispoeel Sy6nem•PeyO 50f 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments R'operty Address (Alo Oar ner Om ner's Name f _ ,( / Information is AlCko-f 4V 45requiredforevery ----- page, Cityllown State Zip Code Data of trisoectidn C. Checklist Check if the following have been done. You must indicate'yes'or"no" as to each of the following: Yes No / ❑ L7 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? ❑ s 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 constriction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? e size and location of the Soil Absorption System (SAS) on the site has Z en etermined based on: isting 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)1 D. System information Residential Flow Conditlons: r r Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 C M R 15.203 (for example: 110 gpd x#of bedrooms): Ulm,3M3 Tide 50$6ellrspectionform SutsufaceSetMeDispoul SyGiem•Page 8of17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form =Not for Voluntary Assessments Property Address / ONner Inf onnation is owner's Name ✓S��vt J ! /� �✓¢ �� 6 $ / l required for every page. City/Town State Zip Code Date of Irkpoetion D. System Information Description: / �w / G( L, / �j f�.(! (G�i Tt o✓l e C� Number of current residents: Does residence have a garbage grinder? ❑ Yes M" No Is laundry on a separate sewage system? (Include laundri system inspection Cl Yes @- No information in this report.) Laundry system inspected? ❑ Yes �7 Seasonal use? ❑ Yes No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes o CC4 Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM R 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5 m•3M 3 tine 50f iel wapeetlon F am Suboutaoe Sewaae olopoed Svxtem•Peas 7 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments !V0 Property Address / (A10K�?/l ON rw ON nees Name // ,(� inforrnewn is A✓ R f A Oo2 6 �� !l /I .___..._...— required f or every State Zip Code Date of to c page. C 3 frown D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped. gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, - 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 UA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): 6M•3M3 noe 5omal impwoon f am SuDs OMO Sewepe Dlapaed System•Pepe 8of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments L�c /�I vee'_ Property Address 0 ✓ � Cw ner CW naps Name ) information is requirexfforevery S � page. City/Town State zip Code Date of Inspection D. System Information (conf) Approximate age of all components, date installed(if` J` d source of information: Were sewage odors detected when arriving at the site? ❑ -yes No Building Sewer(locate on site plan): Depth bellow grade: feet Material of construction: ❑ cast iron 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 0 feet Comments (on condition of joints, venting, eudence of leakage, etc.): Septic Tank(locate on site plan): +C4� FMatednal✓C,�r//s Dept below radu feet t r c ction: ncrete ❑ 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: Sludge depth: tans•31t 3 Title 5 ortdar lns peC§on F orm Subw1we Sev alge Dispoed Symm•Page$of t 7 r - Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments fO/ -_�tv,,ek— Property Address � o� Ow ner ON ner's Name infom>atlon is / required for every ✓s�Vnf page. City/Town State Zip Code Date of n D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle r 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 How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, eNdence of leakage, etc.): 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 One-M- T1050tfidW lnspecocnFarm SOWISoe Sewage Disposal Sysmm•Page 10d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address / o✓ P/G ON nor on nePs NameInforrnation Is p required for every �✓� KS lls �� D O U� page. CAyrrown State Zip Code Date of 11#000M D. System Information (corn.) 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 Deslgn Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in worldng osier: ❑ 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 We-313 T05Official UspoolanForrt SUDWIMO SewapeDlspowf SYMM-Pie 11 ar 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments (. o1 ��vie✓ Property Address Om ner ON r>er's Name Infotion is �1 ,L� requirreed for every G fs h S /J,/I/f ' / �� b �'� page, Ctyfrown �' �/ State Zip Code Date of lion D. System,Information (cunt.) Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc,): Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No* Alarms in working order. ❑ Yes ❑ No' Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): "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: Ons-yl3 T1Ue 5 0MC181 MSp8G#W FGm[SubWaoe Savage 014-459$YOM Page 12 OF 17 l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address / Cw ner ow ner's Name Information is / J`0✓t V ��— required for every page. City/rown State Zip Code Date of kipectibn D. System Informati n (cont.) T pe. X�o leaching pits / number. ❑ leaching chambers number. ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovative/altemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 14 /a C 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 tare•ana riive50McW UmpectonFom[Subxrlece SewegeDiepo d Sy*m•Page 13d 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments col ��VC, Roperty Address W D✓ Ow ner ow nees Name information is / i- requaedforevery Get ✓►1 �/ �a page. Cityrrown State Zip Code Date of lnspbctJo6 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.): On6.3M3 Tlae50fldal I spactlanFarm Sube+OWS Sewage0lapasal SYSMM-Pace 14 d 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments yo Property Address �✓ An net Ov nePs Nana ` information is / required for every Alasf4t4f ^�� page. City/Town State Zip Code Date of p tion D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below. ❑ hand-sketch in the area below ❑ drawing attached separately i i lBns Y13 Tige501fidel Inspecton Form SuosufaceSevMeolspoeai System•Pape toot 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address � Ow nor (/ t�lame Cy/fownO✓ 1. Information Is ow Hors k1ri required for every page. State Zip Code Date of n D. System Information (cunt.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water. aC feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, dat of design plan reviewed: pate ❑ erved site (abutting property/observation hole within 150 feet of SAS) Checked with local Board o Health-explain: ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: S— 'jV0Pf:— I i Before filing this Inspection Report, please see Report Completeness Checklist on next page. �� y13 Title50Maal impmlonFam SUb$W eeSewageDisposal Stat9m•Page 18d 17 f • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface. Sewage Disposal System Form -Not for Voluntary Assessments it 2 r�� R'oP'eKY Address � / // ON nor Owner's Marne iriforni8tim is regt*ed for every, a✓��n�I S l /� �To� b�� / / !f V page. �Y own State Zip Oaie Date of hspection E. Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked 2 hispection Summary D(System Failure Criteria Applicable to All Systems)completed 0--�Svysu Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate Me tile•SO Title6mcial kupectlmFarm a~aoe%%9eoivp"gyaem•pop A d ri 1 ,.,��� AsBuilt _ Page 1 of 1 TOWN OF BARNSTABLE LOCATION Sr0/ /t Kr %✓� SEWAGE M VILLAGE ASSESSOR'S MAP&LOT AN -G^o INSTALLER'S NAME&PHONE NO. Sob- Y''U—97s,? SEPTIC TANK CAPACITY LEACHING FACIL=; (type) /000 (size) 14 i) NO.OF BEDROOMS y BUILDER OR OWNER PERMITDATE: /. - I-o % 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 facili ) Feet Furnished by r-.- �;1=� .fi.�✓ - t Z, Lo e- / http://issgl2/intranet/propdata/prebuilt.aspx?mappar=060030&seq=1 7/17/2015 000 -U,,2, a '00,CA - J-P / G )9 ` /' N V / 1 b L Our . C FORM30 C&W HOBBSB WARREN M THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH A "t r1r.4 CITY O i F a DE ARTMENT �Da air► S 414Rff, 0Q66 / ADDRESS ELEPHONE Address UQ/ °p < �9�R<__�Occupant _. ire"I," So i' 1 Floor Apartment No. No.of Occupants_ No.of Habitable Rooms No.Sleeping Rooms-4 v Sot ff S 4 g,Je �7 ' 0� �r v�Pf � No.dwelling or rooming units--No.Stories 0 Name and address of owners �'�q W. sirOrC �I—J —�D �co�v� # G N41f � Remarks Reg. Vio. YARD Out Bld s.: Fences: Nd c,curr Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Lighting: STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Cat Vioni es ✓1 Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N E ui . Repair Qy� �Vtir ,,N o l�l/e TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.:._ ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen. Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen r , 9 Bathroom0,2Qf�a� Pantry Den Living Room cvr, Bedroom(1). Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities ove .rc e- Bathing,Toilet Facil. Ven ., Plumb., anit'n.: Wash Basin,Shower o ub: kLjfd K(ktt Infestation Rats, Mice, Roaches or r: Egress Dual and Obst'n: General Building Posted U0 Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSP TION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIE OF URY." INSPECTOR TITLE DATE TIME I o-"1 P.M. A.M. THE NEXT SCHEDULED REINSPECTION P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions,when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter II, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to.include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B) and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CUR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing,heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4), Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. FoRM30., Iiw HOBBS&WARRE'N'm THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH CITY/j 02W DEPARTMENT jo, �0 X 'ADD�ESS 6 I TELEPHONE tt Address- Occupant I'r,f ew 0" '9 Floor, Apartment No. No. of Occupants-- No. of Habitable Rooms—No.Sleeping Rooms—L ) No. dwelling or rooming units-----No.Stories Name and address of owner L,,! -4( At S jRemarks Reg. Vio. ,-YARD Out BIdgs.: Fences: N, Garbage and Rubbish r Containers: et Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n. El B El F El M Doors,Windows: Roof Gutters, Drains: Walls: Foundation.- Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Lighting: STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: If b-J Hall Lighting: Hall Windows: HEATING Chimneys: ",Central 0 Y El N Equip. Repair V)_ �-r,. I A 6 TYPE: Stacks, Flues,Vents: �'41 PLUMBING: Supply Line: OMS DST OP Waste Line: H.W.Tank(s)Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: 0110 0220 Fusing,Gmd.: 0 AMP: Gen. Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. Lgtng. Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Living Room Bedroom(1) Bedroom(2) Bedroom(3) Bedroom(4) Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Siok-- &6ve Bathing,Toilet Facil. V6bt" PIumb._,8anit'n..- Wash Basin,Shower oriTub: Infestation Rats, Mice, Roaches or Other`: Egress Dual and Obst'n.- General BuildiriPibsted Locks on Doom ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR. (See Over) "THIS INSPECTION REPORT,IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PERJURY." r j, -,T INSPECTOR TITLE DATE to s TIME P.M. A.M. THE NEXT SCHEDULED REINSPECTION P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter II, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B) and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300, (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. nconditionswhi h remain uncorrected for period of five or more days following the notice to or (0) Any of the following c p y g knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3)or any defect which renders therr, inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. WORDELL REALTY TRUST 208 Lincoln Road Hyannis,MA 02601 Tel. 508-778-4127 Cell: 1-508-328-8116 Town of Barnstable March 19,2006 Regulatory Services Public Health Division 200 Main Street Hyannis,MA 02061 Dear Sir/Madam: In answer to your requests for abatements of violations at.401 River Road,Marstons Mills,by David N.Stanton,R.S. Health Inspector,I would like to report the following corrections have been made: ; 105 CMR 410.354: Electricity is in the name of the landlord. See copy of bill attached for reference. 105 CMR 410.355: The oil bill has always been in the landlord's name. See bills attached. The basement area is not occupied by anyone. 105 CMR 410.150(D): All of the loose paint has been scraped off the tub,scotchbrited and washed down so the tub is free of peeling paint. 105 CMR 410.351: Two burners on the stove were burned out. A different stove has been delivered to the tenant, with all components in working order at the time of delivery. 105 CMR 410.500: In November 2005,Miriam Barton,the tenant,acknowledged that she had torn the carpet and told me,she,was going to.patch the carpet to get through December,when she was supposed to be moving out. She never fixed ib'61 V rpet as she had said she would,but instead covered the torn area with another carpet. We are currently in eviciioh`proceedings against this tenant. 105 CMR 410.620: The two missing kitchen cabinet doors have been put back on the cabinets. They had been removed in order to allow the sink cabinet to dry out due to a leak which was never reported by the tenant but was discovered during a Housing Assistance Corporation inspection. The leak was stopped and the doors were left off to allow ventilation to dry the cabinet interior. 105 CMR 510.620: The front storm door panel had been removed by the tenant herself and stored in the basement. It has now been re-installed in the storm door,even though all exterior doors are either steel or fiberglass insulated,doors and do not require storm doors.i. Hopefully,these repairs will satisfy the requirements listed in your notice of February 24,2006. Please feel free to contact me at 508-328-8116 or contact the tenant directly at 508-428-1245 if you would like to schedule a re-inspection of the property. Sincerely, _ a G�G1j 1 Loring Wordell,Jr. CO . ' WOrd�ell Realty_ Trust :; . �.;a `• s, !i' li"',. r %i11:'i', -- neS fT1 WORDELL REALTY TRUST 208 Lincoln Road Hyannis, MA 02601 Tel. 508-778-4127 Cell: 1-508-328-8116 Town of Barnstable March 19,2006 Regulatory Services Public Health Division 200 Main Street Hyannis,MA 02061 Dear Sir/Madam: In answer to your requests for abatements of violations at 401 River Road,Marstons Mills,by David N.Stanton,R.S. Health Inspector,I would like to report the following corrections have been made: 105 CMR 410.354: Electricity is in the name of the landlord. See copy of bill attached for reference. 105 CMR 410.355: The oil bill has always been in the landlord's name. See bills attached. The basement area is not occupied by anyone. 105 CMR 410.150(D): All of the loose paint has been scraped off the tub,scotchbrited and washed down so the tub is free of peeling paint. 105 CMR 410351: Two burners on the stove were burned out. A different stove has been delivered to the tenant, with all components in working order at the time of delivery. 105 CMR 410.500: In November 2005,Miriam Barton,the tenant,acknowledged that she had tom the carpet and told me she was going to patch the carpet to get through December,when she was supposed to be moving out. She never fixed the carpet as she had said she would,but instead covered the torn area with another carpet. We are currently in eviction proceedings against this tenant. 105 CMR 410.620: The two missing kitchen cabinet doors have been put back on the cabinets. They had been removed in order to allow the sink cabinet to dry out due to a leak which was never reported by the tenant but was discovered during a Housing Assistance Corporation inspection. The leak was stopped and the doors were left off to allow ventilation to dry the cabinet interior. 105 CMR 510.620: The front storm door panel had been removed by the tenant herself and stored in the basement. It has now been re-installed in the storm door,even though all exterior doors are either steel or fiberglass insulated doors and do not require stone doors. Hopefully,these repairs will satisfy the requirements listed in your notice of February 24,2006. Please feel free to contact me at 508-328-8116 or contact the tenant directly at 508-428-1245 if you would like to schedule a re-inspection of the property. Sincerely, ' Loring Wordell,Jr. r r ' Trustee Wordell Realty Trust , Cpa-� M THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I m DATA t---Account Number =--1 12 7 0000035203 14 70 1433 981 0088 IH LORING WORDELL JR 208 LINCOLN RD 7P71ease Pay HYANNIS MA 02601-2411 03 1131111111 Ills IIIII„J III I,IIIII1 Above Amount Includes NSTAR Electric Both Delivery and Stpplier Balances RETURN THIS PORTION WITH YOUR PAYMENT.MOVING?PLEASE LET US KNOW,OTHERWISE YOU MAY BE RESPONSIBLE FOR ENERGY USE AFTER YOU MOVE. HAVE QUESTIONS ABOUT THE SUPPLIER SERVICE PORTION OF YOUR BILL, CONEDISON SOLUTIONS OR THE CAPE LIGHT COMPACT? MORE INFORMATION IS AVAILABLE IN THE "CUSTOMER SERVICE" SECTION OF NSTAR'S WEB SITE, WWW.NSTARONLINE.COM. to o. Account Number 8 lln Date = Feb 23:g 2006 N Service Provided to Account Summary LORING WORDELL JR Previous Bill 401 RIVER RD Total Delivery Charges 140.00 MARSTNS ML MA 02648 Delivery Svcs Balance 141.32 Electricity Used Cost of Electricity Rate 32-Residential Nonheat - Annual Delivery Services Meter G022453 Customer Charge (Prorated)Feb 22, 2006 Actual Read 36274 Distribution 2.74 Jan 31, 2006 Start Read - .04574 X 1631 KWH 74.60 34643 Transition * .02927 X 1631 KWH 47.74 22 Day Billed Use 1631 Transmission .00695 X 1631 KWH 11.34 6022453 KWH Renewable Energy .00050 X 1631 KM 0.82 02/22 1631 Er>er97/ Conservation .00250 X_ 1631 KWN 4.08 Delivery Services Total 141.32 SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Signature iteni 4 if Restricted Delivery is desired. Agent X ■ Print your name and address on the reverse GL(,l• ❑Addressee so that we Can return the card to you. B. Receiv d by(Printed Name) C. Date of Delivery ■ Attach this card to the back of the mailpiece, t or on the front if space permits. D. Is delivery address different from Item 1? ❑Yes 1. Article Addressed to: If YES,enter delivery address below: ❑No U�/L�crDell N0cs� ; i tor;�) �._ �_._..._.__ c v(0 IQ� - 13 S*&'vide Type- Q aZb p J Certified Mail ❑Express Mail / r�7 F egiste d j*Retu�°Receipt for Merchandise 1 L'`Insi] Zail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number (Transfer from service labeq 7 0 0 5 1160 0000 0191 212 0 PS Form 8811,February 2004 Domestic Return Receipt 102595-02- -1540 UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid USPS 4 Permit No.G-10' • Sender: Please print your name, address, and ZIP+4 in this box • ub!ic Health Division Tm%ln of Barnstable 200 Main St Hyannis, Massachusetts 0260' cf Certified Mail#7005 1160 0000 0191 2120 , >r Town of Barnstable Regulatory Services sARNWA MF. Thomas F. Geiler,Director MASS . A Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Loring W. Wordell February 24, 2006 208 Lincoln Road Hyannis, MA 02601 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY CODE II - MINIMUM STANDARDS OF FITNESS-FOR HUMAN HABITATION. The property owned by you located at.401 River Road, Marstons Mills, was inspected on February 16, 2006 by David W. Stanton R.S., Health Inspector for the Town of Barnstable, because of a complaint. The following violations of the State Sanitary Code were observed: 105 CMR 410.354: Metering of Electricity and Gas: The tenant alleges that you have been staying in the basement of said location and there are not separate meters for electricity and gas and therefore she is paying for your utilities. 105 CMR 410.355: Provision of Oil: The tenant alleges that you have been staying in the basement of said location and there is no separate oil tank for heat and therefore she is paying for your heating oil. 105 CMR 410.150(D): Washbasins, Toilets, Tubs and Showers: The tub was observed with paint peeling off. 105 CMR 410.351: Owner's Installation and Maintenance Responsibilities: Some of the stove heating elements were observed inoperable. 105 CMR 410.500: Owner's Responsibility to Maintain Structural Elements: The living room carpet was observed worn out and torn. 105 CMR 410.620: Curtailment Prohibited: Two kitchen cabinet doors below the kitchen sink were not present. 105 CMR 410.620: Curtailment Prohibited: The front storm door windowpane was not present. You are ordered to correct the violations listed above within thirty (30) days of your receipt of this notice by paying for all the gas, oil, and electric bills at said location if you or anyone else is living in, or using any of the above mentioned utilities at said location, or by Q:Order letterMousing violations\401 River Road.doc t installing separate meters for each utility for each unit, by removing the flaking paint from the tub so the surface is smooth and free from defects that make it difficult to clean, by repairing the stove so all heating elements work, by replacing the damaged carpet in the living room, by replacing the missing kitchen cabinet doors, and by, replacing the front storm door windowpane. 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 OF THE BOARD OF HEALTH omas A. McKean, .�. Director of Public Health Town of Barnstable ��6�� Q:Order letterMousing violations\401 River Road.doc SENDER.-�--OMPLETE THIS SECTION ■ Complete items 1,'2,and 3.Also complete A. Signature item 4 if Restricted Delivery is desired. X ❑Agent ■ Print your name and address on the reverse Addressee so that we can return the card to you. ec ' ed by( ' me) C q e o elivery ■ Attach this card to the back of the mailpiece, or on the front if space permits. l D. Is delivery address different from item 1? ❑Yes 1. Articlle Addressed to: If YES,enter delivery address below: ❑No a�8 l lkcoiw 9C/, 3. Service Type t y�/r } ✓� o;?-6ol ACertified Mail [].Express Mail l ❑ Registered eturn Receipt for Merchandise ❑ Insured Mail LJ C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes � 2. Article Number (transfer from service label) {! 7 0 0 5,1160 .0000 ,0191 :217 5 PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540 UNITED STATES RRy.`r 4::5'1R(W!q'''4CE F;c';j; ti �t&T� rtsi tage&Fee 11 • Sender: Please print your name, address, > d ZIP+41' Mhis box • -wz f i. Public Health Division r\_' 00 Toxin of Barnstable CO n; 200 Main St. Hyannis, Massachusetts 0200' I +11rrtrrir1i11H III fitrri�r�rr�i�rrr�{r►rriir,��rlrt�irrr�rlr� I n Certified Mail#7005 1160 0000 0191 2175 Town of Barnstable Regulatory Services snN rrat Thomas F. Geiler, Director Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Loring W. Wordell March 17, 2006 208 Lincoln Road Hyannis, MA 02601 NOTICE TO ABATE VIOLATIONS OF THE TOWN OF BARNSTABLE CODE The property owned by you located at 401 River Road, Marstons Mills, was inspected on February 16, 2006 by David W. Stanton R.S., Health Inspector for the Town of Barnstable, because of a complaint. In your letter dated March 6, 2006, you stated you do not reside at said location; therefore you are also in violation of the Town of Barnstable Code: 170-7 of the Town of Barnstable Code: Owner\Pro ert Manager's name address and p Y g telephone number were not posted. P § 170-7 of the Town of Barnstable Code specifically reads as follows: An owner of a dwelling which is rented for residential use, who does not reside therein and who does not employ a manager or agent for such dwelling who resides therein, shall post and maintain or cause to be posted and maintained on the exterior of such dwelling within five feet of the main entrance or within five feet of the mailbox(es), at least four feet and not greater than six feet above ground level, a notice constructed of durable material, not less than 20 square inches in size, bearing his/her correct name, address and telephone number. If the owner is a realty trust or partnership, the name, address, and telephone number of the managing trustee or partner shall be posted. If the owner is a corporation, the name, address, and telephone number of the president of the corporation shall be posted. Where the owner employs a manager or agent who does not reside in such dwelling, such manager's or agent's name, address, and telephone number shall also be included in the notice. You are ordered to correct the violation listed above within thirty (30) days of your receipt of this notice by posting the property according to § 170-7 of the Town of Barnstable Code. 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. Q:Order letters\Housing violations\401 River Road,letter 2.doe Thank you for your written request for a hearing. You are scheduled to appear at the Town of Barnstable Board of Health Meeting on April 18, 2006 at 3:00 PM located at the Town of Barnstable Town Hall, 367 Main Street, Hyannis,2"d floor Hearing Room. PER ORDER O BOARD OF HEALTH i omas A. McKean, R.S. Director of Public Health Town of Barnstable Q:Order letters\Housing violations\401 River Road,letter 2.doc COMMONWEALTH OF MASSACHUSETTS u EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION A V I ti A� I y M v• ®B (SAP FARCE[ • b TITLE 5 LOT2- — OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 401 River Road Marstons Mills MA 02648 RECEIVED Owner's Name: Barbara Gomes Owner's Address: Same MAY 1 3 2004 Date of Inspection: April 12,2004 TOWN OF BARNSTABLE Name of Inspector: PATRICK M.O'CONNELL HEALTH DEFT. Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was perforined based on V%J1110111 training and experience in a l approved system inspector pursuane proper t toSection 15.340 nction and 1of Title 5(310 CMR 15.000). The system: ance of on site sewage disposal systems. I am' ••11'O�� ,�•. �i�°O°' P Passes ;�' TRI K _X Conditionally Passes M. ;"t Needs Further Evaluation by the Local Approving Authority Fails ��i� F�� •Q*� Inspector's Signature: �---Al Date: 04/12/04 _ _ 11f i 111 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. Notes and Comments: Residence has two systems,one failed and one passing. ****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. Title 5 Inspection Form 6/15/2000 page 1 r Page 2 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 401 River Road,Marstons Mills Owner: Barbara Gomes Date of Inspection: April 12,2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. 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: B. System Conditionally Passes: Pipe exiting basement to failed system needs to be connected to passing system and failed system abandoned. 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. Answer yes,no or not determined(Y,N,ND)in the 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. ND explain: 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 obstruction is removed distribution box is leveled or replaced ND explain: 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 obstruction is removed ND explain: r Page 3 of i l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENT'S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 401 River Road,Marstons Mills Owner: Barbara Gomes Date of Inspection: April 12,2004 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(l)(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 2. System will fail unless the Board of Health (and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well*". Method used to determine distance *"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free fi•om pollution'from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: I Page 4 of i 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 401 River Road, Marstons Mills Owner: Barbara Comes Date of Inspection: April 12,2004 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow _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. _X_ 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. _X Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X_ 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 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,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.[ __No_(Yes/No)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. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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—]WPA)or a mapped Zone I I 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. Page 5 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 401 River Road,Marstons Mills Owner: Barbara Gomes Date of Inspection: April 12,2004 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 _X_ Were any of the system components pumped out in the previous two weeks? _X_ — Has the system received normal flows in the previous two week period? _X_ Have large volumes of water been introduced to the system recently or as part of this inspection'? _X_ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X_ _ Was the facility or dwelling inspected for signs of sewage back up? _X_ _ Was the site inspected for signs of break out _X_ _ Were all system components,excluding the SAS, located on site'? _X_ _ 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 9 _X _ 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 h p y (SAS) as been determined based on: Yes no __ _X_ Existing information. For example,a plan at the Board of Health. X_ _ Determined in the fielc (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 401 River Road,Marstons Mills Owner: Barbara Gomes Date of Inspection: April 12,2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x##of bedrooms):440 Number of current residents: 2 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required) Laundry system inspected(yes or no): Seasonal use:(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): 2002—56,000 gal.2003—51,000 gal.=146 gpd Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMM ERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc,): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records: Last pumped August 2003 Source of information: Owner Was system pumped as part of the inspection(yes or no): No If yes, volume pumped: gallons-- How was quantity pumped detennined? Reason for pumping: TYPE OF SYSTEM _X_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) Tight tank _Attach a copy of the DEP approval —Other(describe): Approximate age of all components, date installed(if known)and source of information: 1176 Were sewage odors detected when arriving at the site(yes or no): No i Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 401 River Road,Marstons Mills Owner: Barbara Gomes Date of Inspection: April 12,2004 BUILDING SEWER: X (locate on site plan) Depth below grade: V Materials of construction:_cast iron X_40 PVC_other(explain): Distance from private water supply well or suction line: 1.2 Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: X (locate on site plan) Depth below grade: #1 tank 16"deep-#2 tank 3' deep Material of construction:—X—concrete____metal fiberglass__polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 8.5' long x 5.2' wide—1000 gal. (both tanks) Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: - Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: - Distance from bottom of scum to bottom of outlet tee or baffle: - How were dimensions determined: STICK WITH HINGE FLAP. 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#1 full to top.Tank#2 liquid level at bottom of outlet pipe,tees intact and clear. GREASE TRAP: No (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): _ Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): f Page 8 of l 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 401 River Road,Marstons Mills Owner: Barbara Comes Date of Inspection: April 12,2004 TIGHT or HOLDING TANK: No (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: No (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: - Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box,etc.): PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 401 River Road,Marstons Mills Owner: Barbara Gomes Date of Inspection: April 12,2004 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type _X_leaching pits,number: Two 6x6 pits.(One for each system) leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): Leaching pit#1 full and not leaching. Leaching pit#2 has F standing water. I CESSPOOLS: No (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 or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.): PRIVY: No (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 n Page 10 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 401 River Road,Marstons Mills Owner: Barbara Gomes Date of Inspection: April 12,2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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. M �1 VO to Page I 1 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 401 River Road,Marstons Mills Owner: Barbara Gomes Date of Inspection: April 12,2004 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 20 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record- If checked, date of design plan reviewed: _X_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: Septic location considerably higher than front of property and road. TOWN OF BA.RNSTABLE LOCATION L/ j2�L 101 SEWAGE # 2dv y—,2 R 9 'VILLAGE ASSESSOR'S/MAP& LOT NO INSTALLER'S NAME&PHONE NO. SoB- Y?O—9773,3 ✓os��`i D<l�ia��vS SEPTIC TANK CAPACITY /DOD LEACHING FACILITY: (type) /000 6�1 /0i r (size) IGDD c NO. OF BEDROOMS // BUILDER OR OWNER &w4ge,4 ra~ems PERMITDATE:f 9-o Y 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 facili ) Feet Furnished by �� �G//L�✓I/ i �a 1h Nil� • ,pysTG� No. 0 Fe THE COMMONWEALTH OF MASSACHUSETTS Entered in computer; Yes pATPUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Rpapliration for Migool *p5te trurtion Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon omplete System ❑Individual Components Location Address or Lot No. Clpf X"Vh`' 4 Owner's Name,Address and Tel.No. moeirrpi6 AWAY `6<grkj4,-r1 60A.r/5 Assessor's Map/Parcel ® / Installer's Name,Address,and Tel.No.SIB—y20— Q'7,39-' Designer's Name,Address and Tel.No. c%S�pit Ue L3.�rs-,os f , %l 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 gallons per day. Calculated daily flow gallons. 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) • O Ti9 k 2 T r �s 'ioo��, w o Cop 'n v 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 of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this oard f Health. Signed Date _ Application Approved by %ter. Date 6Z, d -- Application Disapproved for the"'following reasons Permit No. 2=00 Date Issued -_._—_------------------------ �_.--------- - ---- No' 2_ V I t Fe - THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 5� 2pplication for Migpog;ar *pgtem-C truction Permit Application for a Permit to Construct( . )Repair( )Upgrade( ��bandon omplete System ❑Individual Components Location Address or Lot No. Val w e Name,Address and Tel.No. Assessor's Map/Parcel 4-14 r'rr P't 6 "V/�y. (j��tr b7 AI".4 Installer's Name, 'Address,and Tel.No.S0?— 412Q 1'- 73,:F Designer's Name,Address and Tel.No. +� Type of Building: v Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. 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) 144 1C s �`�1'�r�oTi IG r! „ ri ✓ 1 rJfL,i e . S,-;��r.; 1�;,s t l�sr �,•f �J Ir nnrr ttI(A ,rc n� � i i P12ur - 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 system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed _ _� ... i,a A `*✓ Date -AP g plication Approved by `� 9 Vw -. -< } Date'"- Application Disapproved for the ollowin reasons 1 Pf 1 f Permit No. '� 0� `I ��� Date Issued 01 4 ------------- ------------- ---------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance T-HIS IS"W CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded( ) Abandoned.�j accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. �U�y'��� dated ���►�, �/ The issuance of thislermit shall not be construed as a guarantee that the system wiil nction as d s' ed. Date try 1/ / 1J Inspector !• 2,�. -------c/------------------------------_-- No. f J 0 U ' Jf 9 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Of 5pogat *p5tem Conn;tructi ivp rmit Permission is hereby granted to Construct( )Repair( )Upgrade( ) ando�, , System located at lroe V, 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 th�s-pe t. Date: /U Approved b f �1.�J- / S• � Y . i LyOCATION SEWAGE PERMIT NO. em o VILLAGE 19 LJL T� LLER'S N ME DDRE�S on BUIL R OR 0 DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED jo�r y 1 , ' �) r(� ti �,ya. .00 No.-••.................... FEs....$5..-..••••-......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF" HEALTH ..........---- own........OF....Barnstable . Appliratilan for Dis us al Works Tomitrurtion rrmit Application is,hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at: ........4Q1 . ,.Y.4' .. oad ............................... .............•=----•--•••.........--••-••••-•---------••----•-••-•-•-••-•-••••--•......_..._-•-•-- Location•Address Lot No, Manuel Pina Marstons Mils .....•-•••• _..................... ........---•••-•--••-••-••--•-••••--•-• -........•--------..._.............••••••••••......••-••...•-••--•••-•..._.....................•-_ ------------••-------•---•----•-Address Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons____________________________ Showers — Cafeteria a d Other fixtures ----------------------------=--------------------------------••--------------------------------__.._...._..._.__............----...----..........._... WDesign Flow___________________________________________gallons per person per day. Total daily flow_..______._____________•________._..._....__gallons. WSeptic Tank Liquid capacity___,dMllons Length________________ Width._.__.__.___.___ Diameter..._..___._.____ Depth________._._.__. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water--------------_......... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ . a •----------------------------------•--------------- -...........----------------••---••-•_••••--......................................................... O Description of Soil.......Sand.&... ravel--------------------•-•------------------------------------ V 1-1000 . - _. - := w------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iII= 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has ee i ued b the O and f lth. Date Application Approved By...... . Gu .-_____________ __ ---------------------------------------- " ✓ �-- Date Application Disapproved for the following reasons_...........................�/...... ._.__...................................................................... ..................•-.....------------•--•--------------------...-------....------•------•--••--------------------------...-•----•-----------------•-•-•----------------------------------------...._..._ / 9►pr Date PermitNo......................................................... Issued.... 1- -^F [ .............. Date No................-....... Fzim ?�...00.......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................._.-TO.Wn........O F...Barns tab le-..-----------___----------------------......_.._.__. ,�ppliratinn for Dispoo al arks Tomitrnrtiun Vprrmit Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at: ........?.Q.1._.Ri ex_..&ad-----------------•----------------........-•---•-- --•---...---------------•--.................---------.......----•-----...-----------...__......._ Location-Address Lot No. ....... u�1.._.P 1:��. Ma.rstons Mils .........- ............ Owner '.' Address Wd 1.... ... ........................ ..........••••--•-••____________-__-______- _____-__-___---_________----•--___________________- Installer :. Address Type of Building Size Lot............................Sq. feet 1.4 Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) �`k Other—T e of Building No. of ersons____________________________ Showers YP g ---------------•--------••-• P ( ) — Cafeteria ( ) QOther fixtures ------------------------•---•------•---------•----•-----••--•••••--••-•-•-•-••--------------••--••••••••••••••••-•.....-••••••....••--••....._•••... W Design Flow...................._.......................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench--No.____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area............_.....sq. ft. Z S Other Distribution box ( ) Dosing tank ( ) ~" Percolation Test Results Performed by_______________________________________ ____________________________ Date........................................ Test V t No. I................minutes per inch Depth of Test Pit..__._..__.__.____.' Depth to ground water......................... 44 Test Pit;No. 2...............minutes per inch Depth of Test Pit.................. _ Depth to ground water........................ N P 1� y O Description of Soil.......Saad---kAlrave 1...••-••---•----•.................• }'....---••••••-•••-••••--••••••.._.._...-••-••............---.-•_-- x UW' ------------------------------------------------------------------------------- ._.._._...-••••••••............ ................ Nature of Repairs or Alterations—Answer when applicable.___1-1000---gallon---Pit........................ ..........==-----------•--••-----------------•-----•--•------.....-------------•------....--------•--.....----------------------•----------------------------------------------:..._.__.........--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance witl- the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the''system in operation until a Certificate of Compl ,nce h been issued by the board of health. f f {% Application Approved BY !.... Date Application Disapproved for the following reasons:.........._.................................................................................................... - ••..... ......................c..•--•--•-------------•------------•--•••---------•-•...................................................................................... / Date................... Permit No.............. _ Issued------ /-5 .....----- D 4' THE.,COMMONWEALTH OF MASSACHUSETTS BOARD, .OF HEALTH { TOwn Barnstable � k OF........ .............:::.........................._.........._......._..:........... 4 arntiffxtt e of Toutplianrr THIS IS TO CERTIFY, That the Indvidual Sewage Disposal System constructed ( ) or Repaired,( X) bY•---•.JQJSe t...R,_: comber..&..Song _Inc . . ......... .....4.... .............:..:_. O1 River ad Marstons ffii11si` tauer .. -----.... ----... •------------------------•-••- -------- ----...,....,�„ ---------------- ----------•-----------------------------------------------------------------------: ----- has been installed in accordance with the provisions of T 5 of Tlae State Sanitary Code as described in the application for Disposal Works Construction Permit.No.. ...... ____ ✓ :_____..__. dated...... __/_,0._;._' _. ........... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE T9iAT THE SYSTEM WILL FUNCTION SATISFACTORY. � - y.rDATE...........................•------._......---........••.._...---•-•......--_.... Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS y+'� A BOARD OF HEALTH 7 own.........O F......BA.rns.table NO.........V...... FEE.. ,+.Q ....... Diovusal Vorks Tuanstrurtion rrmit Permission is hereby granted...:_J.0.0ePh..P�:_.N cOlTlbe '...&..Son_Inc........................................................ to Construct � ) or Repair. (X)) an Individual Sewage Disposal' System at No.:._9z_--_iyer..Road, .Marston M 11 Ping .. , ---•--------•-•--------•---•-----------•----•--....-••••-----••..... Street as shown on the application for Disposal Works Construction Per No... _______ Dated:____ + _ :`_ !....... C.Y ...................... f Board o Health �. e. DATE----- a FORM 1258 HOBBS & WARREN. INC., PUBLISHERS ;q . ti OCUS ASSESSOR'S MAP: 60 �� / 9• PARCEL., 30 PL. BK. 305 PG. 79 REFERENCE: 8 °� FLOOD ZONE: X Town of Barnstable M #250010541 J (07/16/14) ce 104.08 x 100.6! pde 07.09 a, m Sto RE w Y1oKeb c 111.37 110.42 I 1 4 )X( 0 :,:,,RESER` .;.;..::,:: .;,. : d :.... °y g2 p3 E I I7 ` O x 99. 5 Hl River tJ AS,O� / t i Regrad@ for Breakout Rood TH .1 0 1104 A as needed. oo LOCUS MAP N.T.S. 6-6 TH-2 101,60' Edgy' 109.95 3 24' pf .la,'^'` x 99,95 100.51 i; 03.1 E �V• I 71-26A Shed , \ Zet03.4� 109.82 C :BSTER .1 .5 c o e 2FT 8A 1 6.67 3 k/ 00.90 Benchmark set: 11o.25 IC EL 10 . \ 9 Top of Retaining WaII at End 30 \N \,,9,53D EL= 106.10 (Assumed) \ ' i9 ° ] 2,9 \ \ g9.26 m 0 r 7,98 x�07,1 y 07 \ 1 WELL OLD 781 \r O x 111,14 N NOTE: Contractor to confirm suitability and 1 .44 "B"Below slab \ \ x 99:02 elevations of existing pipes (both A and � ,o o°�� (EL. 102 "B" inverts) from foundation to existing tank to insure Title 5 compliant piping °-" (cast iron or Sch. 40 PVC). Replace as "A" EL 107.52 needed. Existing PVC pipes in existing ° \ �R'F-E ' x o6•)6 septic tank. Connect to existing pipes at \ Tao1 tank if ossible. Existin Tank and Failed \ / yste # ,dP x �0 3 / Leach Pit to be pumped and backfilled. N / ,J ao�edte\y 2°o TOF=11o.27 / �� oi.�_ ,:: .s'.:.::. .:..:... . . p ..... .'. ;: b Pbp 0px-a 109.11.; . . (Assumed) . 0/ z�. x 110.86 PPp 1Q9 f3 107/ q �tc� Woteryine a I ....., pc h. c • to 0 c c r ..x 5b } ipe on Map s o Z ... .. I , Parcel 30 ti.:..... .. ..... :..:•,. :,,< - ::1,;;:,' / I Lot 2 / " - x x 115,39 \... 67.716t S.F. 0 1s a t A � � ;;�: .�';>: : / / / s OF M9f I / / / 84�6 GB D�FND o AM L. { 21.70' CB DH FND VON H N r" 119.19 N 85-13'17" W NOTE: This plan is to be used for septic system purposes No. 1068 only and is not to be considered a property line survey. GENERAL NO ES: �;� TERM° �.� T � 401 RIVER ROAD 1. VERTICAL DATUM: ssumed LEGEND: V H M AR STON S MILLS, MA 2. MUNICIPAL WATER _ I __ AVAILABLE. L7� ' 3. SCHEDULE 40 PVC PIPE 0 BE USED THROUGHOUT �'-- sg-�- PROPOSED CONTOUR PREPARED associates SYSTEM UNLESS OTHERWISE NOTED. �, OF Mqf gg PROPOSED SPOT GRADE FOR: Lorin W. Wordell Jr. Tr. 4. ALL PRECAST UNITS TO CONFORM TO ����� fq`y - 40 - EXISTING CONTOUR sePnc srs�M oE�c s g d+ 320 Cotuit Road � AASH T0: .�-�_19_.$�-��_ o TERRY � Sandwich, MA 02563 Wordell Realty Trust „ o ANN X 30.23 EXISTING SPOT GRADE 508.833.00a1 401 River Road 5• PIPE PITCH-1/4 PER FOOT UNLESS OTHERWISE NOTED. WARNER �„ 6• ALL CONSTRUCTION DETAILS TO BE IN CONFORMANCE No, 38721 ® TEST PIT M arston s Mill, M A 02648 WITH MA ENVIR. CODE (TITLE 5) AND LOCAL , EXISTING WATER SERVICE Surveying by: REGULATIONS. / Terry A., P.L.S. 7• CONTRACTOR TO VERIFY LOCATIONS OF ALL UTILITIES A o°XIS WORK LIMIT LINE H rwich"MA o"5 DATE REVISED SCALE SHEET NO. PRIOR TO CONSTRUCTION. u (508) 432-&XM 0910 15/ / 1" = 30 1 of 2 Provide Riser over D-box NOTE: All components to be marked with NOTE: To prevent breakout, final T.O.F. (Full w/ Walkout) to within 6" of final grade I magnetic tape or similar prior to final cover. grade of EL. 100.5 to be carried EL. 110.27 (Cover to be watertight) 1 out a minimum 15' beyond edge F.G. EL: 107.6-109.0t F.G. EL: 105.0 F.G. EL: 103.5 Maintain Min. 2% slope over leach facility to of leach facility. Existin �- revent ondin F.G. EL: 102.0-103.5 Exist. invert Install risers w/covers over inlet and Min. 2" of 1/8" - 3/4" Washed Stone or In ection Port within 6" to grade ade "A" EL. 107.52 L=100'(Access Coveoutlet to rs inmin. 6" 2f0"fidiamr per Code) _ Geotextile Fabric 4" SCH 40 P L=15 is L=20, 3/4 - 1 1/2 Double Washed Stone • 4" SCH 40 PVC ; 4" SCH 40 PVC Top of Peastone or Geotextile Fabric EL. 100.5 6.7%(29.MIN >o• ®S=1.9% o jEr-r- asta• s 0.59.MIN �®®a epOS=3%EL. 100.56 ' 12p amum Install EL. 1 10.2 EL. 100.1 97.5 EL. 100.81 as Baffle PROPOSED DB-3 EL. 99.5 Use 3 - 500 Gallon Precast Chambers Exist. invert "B" H-20 DISTRIBUTION BOX (H-10) with Double Washed Stone 4.5' EL. 102.0f L=56' Watertest for levelness i 4'� Ends, 4'� Sides (Confirm Pipe) (Install PVC Inlet & Outlet Tees) SEPTIC SYSTEM PROFILE (33 x 12.83 x 2 ) Below Slab Flo ar PROPOSED 1500 GALLON if more than one CAS=2.1 2% H-10 TWO COMPARTMENT outlet EL. SEPTIC TANK N.T.S. Bottom off T THH-1 (1000 GAL/500 GAL) ADDITIONAL NOTES SOIL LOG DESIGN CRITERIA 1. Contractor to confim soil suitability prior to installation. Contact Number of Bedrooms: 4 Bedrooms SOIL EVALUATOR: AMY VON HONE, R.S. S.E. #2517 BOH and Design Sanitarian in the event of varying soils from original INSPECTOR: DAVID STANTON, R.S., BOH soil test. Soil Type: Class I DATE: SEPTEMBER 10, 2015 10:00 AM Percolation Rate: <2 min/inch PERMIT: #14811 2. Pump and backfill existing Septic Tank and Failed Leach Pit. Any PERCOLATION RATE:<2 MIN/INCH IN C1 contaminated materials within 5' of proposed Leach Facility to be Daily Flow: 110 G.P.D./Bedrm x 4 =440 G.P.D. removed. TH - 1 TH - 2 Design Flow: 440 G.P.D. (Min. Required) EL. 106.01 EL. 105.5 3. Water line to be sleeved at any sewerline crossings and within 10' Garbage Grinder: of any septic components, as needed, per Water Department Not Allowed Sandy Loam Sandy Loam requirements. Contractor to verify location of water line prior to Leaching Area 10YR4/2 10YR4/2 construction. Required: (440)/0.74 = 594.59 S.F. 7" 105.43 7" 104.92 g g 4. Septic Tank and Distribution Box to be placed on 6" crushed stone Septic Tank Required: 440 G.P.D. x 200% = 880 G.P.D Loamy Sand Loamy Sand or compacted, level base. Minimum 1500 Gallon (Proposed) 10YR5/8 10YR5/8 17" 104.6 18" 104.0 Use 3 - 500 Gallon Precast Chambers with 4' C1 Perc C1 Double Washed Stone: 33' x 12.83' x 2' Medium Sand ® Medium Sand t 2.Y7/6 42 Bottom 2.Y7/6 Porch cn Sidewall Area: 2(33' + 12.83')2= 183.32 S.F. L Bottom Area: 33' x 12.83'= 423.39 S.F. i BOG' 0 Total Area: 606.71 S.F. Dining Kitchen m Bed 2 Utllity �' Bar pp Desi n Flow Provided: 0.74(606.71 S.F.)= 448.96 G.P.D. Room Family o V 401 RIVER ROAD Living Room H MARSTONS MILLS, MA Bed 3 Room Bed 1 PREPARED associates FOR: Elect SM11C SYSTEM DESIGNS Lorin W. Wo r d e I I, Jr. Tr. 156" 93.01 120" 95.5 g Pone No Groundwater Observed 320 Cotuit Road Wo r d e l l Realty Trust 1 st Floor Walkout Basement Sandwich, MA041563 401 River Road <6" ® 07:30 minutes PERC RATE: <2 MIN/IN. ( C1 Horizon) I, Am L. von Hone, R.S., hereby certify that I am current) approved b M a rs t o n s Mill, MA 02648 y y y y pp y FLOOR PLAN S°�`' r the DEP pursuant to 310 CMR 15.017 to conduct soil evaluations and Terry A. Warner.P.L.S. that the above analysis has been performed by me consistent with the 22LongMnRoasas DATE REVISED SCALE SHEET N0. requirements of 310 CMR 15.017. 1 further certify that I have (Per Owner's Sketch) Harwich, successful) passed the Soil Evaluators Exam on November, 1994. N.T.S. (508) 432-8Wg 09 ' y p ' 1015 1 30_ / / = 2 of 2