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HomeMy WebLinkAbout0070 ROSA LANE - Health 70 Rosa Lane Marstons Mills --- - A= 061013 -- I i TOWN OF BARNSTABLE LOCATION �0 0`�� SEWAGE # o®� . VILLAGE / ` �/v ��GASSESSOR'S MAP & LOT ��/3 INSTALLER'S NAME&PHONE NO. 47J�l SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNER '���PERMIT DATE: � COMPLIANCE DATE: /•�W ©`� 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 leachin facility) '� Feet Furnished by jai' e'Ot? A ZI - O No.. 575 U V t Fee ?` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pprication for Mi5po5or *p5tem Cow5truitiou Vernnit Application for a Permit to Construct( ) Repair(Upgrade/ Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No`.,;70,edJj4 Z.U. Owner's Nam,Address an�% Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No,of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building �' No.of Persons Showers( )' Cafeteria( ) Other Fixtures Design Flow(min.required) :��O gpd Design flow provided gpd Plan Date O—_;r y o 5 Number of sheets Revision Date Title Size of Septic Tank Jg"G?6' S!M2o Type of S.A.S.f� ^�6 �X -S. •�'�l'� r Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions 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 He,31 S' a Date /� ��— _ Application Approved b Date ! l�114 5 Application Disapproved by: Date for the following reasons Permit No. y s J� Date Issued �L No. O`L'� S U U ` Fee ) � :�,. ,�n l V THE COMMONWEALTH OF MASSACHUSETTSEntered in computer. PUBLIC HEALTH DIVISION -TOWN`0F BARNSTABLE;-MASSACHUSETTS Yes Rpprication for Migpogal *pgtem Cottlg rury'tion Permit Application for a Permit to Construct O Repair(Af/Upgrade�(,�/ Abandon O ❑Complete System ❑.Individual Components Location Address or Lot No.70��J�4 Z.0 /�, Owner's Name,Address and Tel N i� Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. p 7;0�.O_f 6'7� Type of Building: + Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder..( ) Other Type of Building g ��Gt� No.of Persons , Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) �! a gpd Design flow provided �� gpd, Plan Date Number of sheets Revision Date { Title Size ofliSeptic Tank fS"OG Sal' Type of S.A.S. ���-�f7 •�X -� •T�C-� l w Description of Soil y r Nature of Repairs or Alterations(Answer when applicable) ' Date last inspected: y 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 Hea S' d ;; � Date A/, p Application Approved by-_ Date 1 Application Disapproved by: Date fbrthe following reasons 3.'• t Permit No. S D Date Issued —1 5 --------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( v) Upgraded ( v) Abandoned( )by at 70 ,f0 J,4 1 A.- has been constructed in accordance l with the provisions of Title 5 and the for Disposal System Construction Permit No.�!j 5 R 0 dated Installer V>�y� �G�l 4G Designer .�,�I//O Q• #bedrooms Approved design flow © gpd The issuance of this permit shall not be construed as a guarantee that the sy ern will`« c n esigned. Date �, Inspec r, o No. d m Jv Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS Migpoga1 ,*pgtem CCon5truction Permit Permission is hereby granted to Construct ( ) Repair (Z"J'00'Upgrade ( � Abandon ( ) System located at '© I 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 condit, ns Provided: Constructi n must Pe completed within three years of the dat of this p it. Date � � [ Approved b U0/la/D, Ault la:a7 IAA *V04444490 nvuc,v u. vw w. • S115/01 Notice: This Form-Is To Be Used For the Repair Of Failed Septic Systems Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM 112 hereby certify that the engineered plan signed by ran dated /® O-'rc'oncarmng the property located at 0 q�05AI > M 1�1�� meets an of the following criteria: ', • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. i o The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude,this factor may conduct preliminary tests at the site without a health agent present. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the frimptor method when applicable] Please complete the following: eYD A) Top of Ground Surface Elevation(using GIS information) Woo � 2 B) G.W.Elevation +adjustment for high G.W. "/ 1 DIFFERENCE BEr'V M A and B ' I SIGNED DATE: �0/zs PKMCE Based upon the above information,a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system pis. 6DO 2.5 qt hcxlb folft V=cFxmp . Town of Barnstable �pIKE Regulatory Services Thomas F. Geiler,Director • etrtrtier e. Public Health Division _ Thomas McKean,Director Zoo Main Street,Hyannis,MA 02601 Fax: 508-790-6304 Office: 508-862-4644 Installer& Designer Certification Forth Date: #� � Designer: 1 D 13. V V` �U� Installer: _ j Address: ,c.l ��,toK,� Address: � t � 11G4 wIW �Z57 On /� -' .. was issued a permit to install a date) j (installer) s tic system at "� )gsed on a design drawn by eP dress) MilcSo3 dated ' 0� (designer) 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. 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. st ler's Signature) L f sl ees ignature) (Affix Desigh s Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTEL BOTH THIS FORM AND && BUILT CARD ARE RECEIVED BY THE BARNSTABLE P R LIC SEALTH DMSI THANK YOU, Q:Health/9eptic/Desiper certification Form t it io be �c.,.a-<✓._._P.-YSi(.. Cr4.-1,sp„Cs TT� f i I I i I I "6 Inz- 1(�tTa-3°FTn�rtIVh 7n 1`er�c.�_------- ,a-.kaaf..:._ _____. .-P Oa-<•d r i 4.s7ni ,'ln MR. ill I �9 10 12 Nh?=1✓.15M�.._ 1 � 17 //\ 30 Win._Q_F I�.�.-_. 54-51 r I / 1 3/� ED _�atfbfR�._Ccwr I 2 -3�ity Alm_.. 1 �,FcaR:� pi 1P����+�W_e.f goo' � �•f4 / �f;o� __PeFe,s ,R®s-duce '70 Ross the wrt: /If �isen o..run.,ur.in _ � F:I jigf T-1 �►�1 ILI il --A-1 et- eIce'. 7o ;e sq �soe Q7T oar[: 7�� •cveuD is a r Commonwealth of Massachusetts 1100159746 Asbestos Notification Form ANF-001 Decal Important: When filling out .A. Asbestos Abatement Description forms on the computer,use 1. a. Is this facility fee exempt-city, town,district, municipal housing authority, owner-occupied only the tab key residence of four units or less? .✓Z Yes ❑No to move your r--•_—�._- m�.... - _._. ,� cursor-do not b. Provide blanket decal number if applicable: �- use the return Blanket—Decal Number. keiy. 2. Facility Location: PETERS 70 ROS- LANE - a�...,•., E F70 Oi ...w...._ ....._..._..._ .__._ .. fa.Name of Facility .—. __ b.Street Address 3 MA 02648 c.City/Town d.State e.Zip Code f.Telephone Number INSTRUCTIONS 3. Worksite Location: 1.All sections of this EXTERIOR �� form must be a.Building Name/Building Location b.Building# c.Wing " d.Floor. " e:Room completed in order to comply with 4. Is the facility occupied? I✓)Yes. No DEP notification requirements of 310 - CMR 7.15 5. Asbestos Contractor: _ and the Division of occupational ;NEW ENGLAND_SURFACE MAINTENANCE 1850 WASHINGTON STREET Safety(DOS) a.Name b.Address notification I WEYMOUTH 02189 7813372117 requirements of 453 �� A• M,•,1 � i CMR 6.12 c.City/Town" ' d:Zip.Code e.Telephone Number AC000196 .., Contract T e` Imo. - q Verbal f.DOS License,.N.umber:, yp ,-"Written'9 h.FacihtyContact Person is ContacYPerson s Title BROWN:; �A$061945 6' a.Name of On-Site Supervisor/Foreman 6..Su ervisot/Foreman DOS Certification'Number N/A 7. m N/A -m - w a.Nae of Project Monitor'.:' b.Project Monitor.DOS Certification Number N/A t: - _ f N/A 8' a.Name of.Asbestos Analytical Lab b.Asbestos Analvtical Lab DOS Certification Number T 10/16/20 . 10/16/2012 9" 12 a.Project Start Date mm/dd�i rWj b.End Date mm/dd/ yyy 0 8-4 1 `. �N c.Work hours Mon Fri. d.Work hours Sat-Sun. ➢v C _o 10. a.What type of.project is this? =o El Demolition Renovation " '' [✓ Repair []Other, please specify: b.Describe 11. a. Check abatement procedures: ,. =o ❑ Glove bag [] Encapsulation _ o [1 Enclosure.': - [] Disposal only 1U- [].Cleanup 0 Other, specify. ._ SHINGLES Full containment b.Describe =Q 12. Is the job being.conducted: 0 Indoors? Z Outdoors? anf001ap.doc•10/02 Asbestos Notification Form•Page 1 of 3 T Commonwealth of Massachusetts p ■ g100159746 Asbestos Notification Form ANF 001 Decal Number -----s A. Asbestos Abatement Description (cont.) 13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed, or enca sulated: •-�--•�� a.Total pipes or ducts(linear ft) b.Total other surfaces(square c.Boiler,breaching,duct,tank d Insulating surface coatings Lin.ft. Sq.ft. . g cement Lin.ft. Sq.ft. e.Corrugated Or layered paper :r. _.,I I �ej f.Trowel/Sprayer coatings pipe insulation ., Lin.ft. Sq.ft. Lin. ( ft.��� Sq.ft. g:Spray-on fireproofing I- h.Transite board,wall board --••--•--_� Lin.% Sq.ft. Lin:ft. Sq.ft. i.Cloths,woven fabrics j j.Other,please specify" , I 400I } Lin.ff. Sq.ft. -�, Lin.ft. so.ft. k.Thermal,solid core pipe �. SHINGLES j insulation Lin.ft. Sq.ft. i.Specify 14: Describe the.decontamination system(s)`to be:used: jAS.REQUIRED_...,...�.._�....�...d.� �.-.._._.-�. `.._ - -- � 15. Describe-the containerization/disposal methods to comply with 310 CMR.7.15 and 453 CMR. 6..14(2) (9)* 16: ForEmergency Asbestos.Operations, the'DEI?and DOS officials who evaluated the emergency: a.-Name of DEP Official -71 b.'Title T" , . _777I { I c.Date,(mm/dd/yyyy)ofrAuthorization d.'DEP Waiver# I L� I je.,Name of DOS Official f.DOS Official-Title �N g.Date.(mm/dd/yyyy)of Authorization h.DOS Waiver# _0 17. Do preyailing wage rates as-per M.G.L. c_149,§26,27 or 27A77F apply to this project? %Yes FV� No B. Facility Description �N =0 1. Current or prior use of facility: RESIDENCE v �0 2. It the facility owner-occupied residential with 4 units or less? Yes' SAME -- 3' a:Facility.0wheir Name. b.Address ——� I o c.City/Town d.Zip Code e.Telephone NumbeC(area code and extension) �---- -� �---Q - _LL 4 a.Name of Facility Owners On-Site Manager bb.On-Site Manager Address �Q C.City./Town > d.Zip Code e.Telephone Number-(area code and extension). ■ anf001 ap.doc•10/02 Asbestos Notification Form•Pa e 2 of 3■ e Commonwealth of Massachusetts -� 1100159746 Asbestos Notification form ANF-001 Decal Number B. Facility Description (cont.) 5. i a.Name of General Contractor (b.Address. c.Ci /Town d.Zip Code e.Telephone Number area code and extension i f.Contractor's Worker's Comp.Insurer g.Policy Number h.Lxk_Date(mV/ dty�r_y_y) 6: What is the size of this facility? � � E � 1 a.Square Feet b.Number of floors C. Asbestos Transportation and Disposal I. Transporter of asbestos-containin material from site to temporary ora storage site If. necessary): P 9 P rY . 9 _ �� NESM, LLP a.Name of Transporter b.Address Note:Transfer �--�-----9 y �. .�_._._..._. Stations must comply with the c'City/Town d.Zip Code e.Telephone Number Solid Waste Division 2, Transporter of asbestos-containing waste material from removal/temporary site to final disposal site: Regulations 310 cMR la000 RED TECHNOLOGIES a.Name of Transporter _ b.Address cc.C� ity/To� . d Zip.Code ' e Telephone Number 3 - r Y a Refuse Transfer,Station and Owner b Address - _ c Ci own d.Zip Code a Tele bhon e Number 4 MINERVA'ENTERPRISESINC a..Final Dis osal Site Location Name b Final-Disposal Site.Location Owner's Name .' 00-MINERVA ROAD ~ -��- � WAYNE 90 SBURG =„ . c Final Disposal Site Address = _ d.Ci /Town _ rFOH 44688 �M e.State f.Zip Code g.Telephone Number �o �o D. Certification �N The undersigned hereby states,under the. KEN FURTNEY �0 penalties of perjury,that.he/she has read the a.Name b.Authorized Signature Commonwealth of Massachusetts regulations 9/26/2012 for the Removal, Containment or c.PositioNTitle' - d.Date(mm/dd/vvw) a Encapsulation of Asbestos,453 CMR 6.00 and .� 310 CMR 7.15,and that the information NESM LLP I �o Contained in this notification is true and correct e.Telephone,Number f•Representinq i to the bestof his/her knowledge and belief. o .Address LL �Z h.;City/Town i.Zip Code E anf001ap.doc,.10/02 Asbestos Notification Form•Page 3 of 3 f Commonwealth of Massachusetts —Fcwq H W Title 5 Official Inspection. Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Rosa Lane Property Address Jane Smith Owner Owner's Name information is Marstons Mills MA 02648 February 15 2011 required for Y every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your David B. Mason cursor-do not Name of Inspector use the return key. David B. Mason Company Name r� 4 Glacier path Company Address East Sandwich MA 02537 City/Town State Zip Code 508-833-2177 S1287 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address',and that-the m� 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 maintenanceyoron site sewage disposal systems. I am a DEP approved system inspector pursuant to:Section 15T340 of;, Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails.9 ;; ❑ Needs Further Evaluation by the Local Approving Authoritya ' February 15, 2011 Inspector's Signaturt Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Vv � �I J (Sins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Rosa Lane _ Property Address Jane Smith Owner Owner's Name information is y Marstons Mills MA 02648 February 15 2011 required for , every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Information contained in this report represents the state of the system on February 15, 2011 at 1 PM. This report does not represent the continued operation of the system. Increase in occupancy may casue hydrarulic failure. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the-septic-tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Rosa Lane Property Address Jane Smith Owner Owner's Name information is Marstons Mills MA 02648 -February 15, 2011 required for every page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ .The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or.the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts R Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 70 Rosa Lane Property Address Jane Smith Owner Owner's Name information is Marstons Mills MA 02648 February 15, 2011 required for y every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1h day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Rosa Lane Property Address Jane Smith Owner Owner's Name information is Marstons Mills MA 02648 February 15, 2011 required for y every page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. . For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Rosa Lane Property Address Jane Smith Owner Owner's Name information is Marstons Mills MA 02648 February required for y 15, 2011 every page. City[Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Rosa Lane Property Address Jane Smith Owner Owner's Name information is Marstons Mills MA 02648 Februar 15 2011 required for Y every page. City/Town State Zip Code Date of Inspection D. System Information Description: System passes based on the information observed on February 15, 2011 at 1 PM. This does not guarentee the continued operation of the system. Increase in occupancy may result in hydraulic failure. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d yes 9 ( Y 9 (9p ))� Detail: 2010 62,000 gallons and 2009 54,000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: unknownDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° .� 70 Rosa Lane - Property Address Jane Smith Owner Owner's Name information is y Marstons Mills MA 02648 February 15 2011 required for , every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Board of Health Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ . Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 70 Rosa Lane Property Address Jane Smith Owner Owner's Name information is Marstons Mills MA 02648 February 1.5, 2011 required for y every page. Citylfown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Compliance dated December 5, 2005 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: Not Applicablefeet Comments (on condition of joints, venting, evidence of leakage, etc.): Appears in working order Septic Tank (locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 gallon tank 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: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts F v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 70 Rosa Lane Property Address Jane Smith Owner Owner's Name information is Marstons Mills MA 02648 February 15, 2011 required for y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 42 Scum thickness 2 Distance from top of scum to top of outlet tee or baffle 4 Distance from bottom of scum to bottom of outlet tee or baffle 12 I How were dimensions determined? scour stick I, Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Recommend pumping for maintenance and doing such every 2 years. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: . Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;.H 70 Rosa Lane Property Address Jane Smith Owner Owner's Name information is y Marstons Mills MA 02648 Februar 15 2011 required for , every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ® No Alarm level: Alarm in working order: ❑- Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes IZ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachu setts usetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Rosa Lane �+ Property Address Jane Smith Owner Owner's Name information is Marstons Mills MA 02648 February 15, 2011 required for y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert Level with outlet inverts 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.): No evidence of solids carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of,pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Probed system. No indication of hydraulic failure. t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page_12 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 70 Rosa Lane Property Address Jane Smith Owner Owner's Name information is y Marstons Mills MA 02648 February 15 2011 required for , every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ 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.): 2-500 gallons chambers with 4 feet of stone around. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 i Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,.� 70 Rosa Lane Property Address Jane Smith Owner Owner's Name information is y Marstons Mills MA 02648 -February 15 2011 required for , every page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 I Commonwealth of Massachusetts w Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Rosa Lane Property Address Jane Smith Owner Owner's Name information is Marstons Mills MA 02648 February 15 2011 required for Y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °�M 5 70 Rosa Lane Property Address Jane Smith Owner Owner's Name information is Marstons Mills MA 02648 February 15, 2011 required for y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: November 2005 Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Engineered plan on file ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS.database -explain: You must describe how you established the high ground water elevation: Used engineered plan on file based on test hole data. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Rosa Lane Property Address Jane Smith Owner Owner's Name information is Marstons Mills MA 02648 Februar 15, 2011 required for Y every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 02/15/2011 18:36 5087718012 PAGE 01/01 TOWN OF BA.RNSTABLE . � Q LOCATION :70 z '?,OJ fi SEWAGE#2 VI LAa � ` ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE N0. SEpnc TANK CAPACITY /'�`a 49�4 LEACHLNG FACII.RY:(type) e46 _ (size) /j f NO.OF BEDROOMS V I BUILDER OR OWNER- I PERMITDATE:,-z y COMPLIANCE DATE: /" ! Separation Distance Between the: I Maximum Adjustcd GrnundtvaterTable to thebattom(if Leaching Facility Feet j Private Water Supply Well and Leaching Facility (If any wells exist ✓. Few on site or within 200.feet of Iaaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist i within 300 feet of lcachin facility) Feet ; Furnished byf� c,-- J� /,(2 ' ,� ��LC 0 i i� i A i . r i r ea /1 P ASSESSORS MAP : # TEST HOLELOGS Z° �. PARCEL: /.3 _ N83.�1 . NOTES: ��� Z7• SOIL EVALUATOR: r 4 FLOOD ZONE: i.�------ ------ REFERENCE: �f WITNESS -I�IdT� �i�I,.IC,.A�' 00' �' 1) The installation shall comply with Title V and Town of Barnstable Board of 200- -- p DATE: OLTt -1 3 O :'' PERCOLATION RATS-: ,� Z W", 1 Health Regulations. �g. 0 00 SN o' 2) The installer shall verify the location of utilities, sewer inverts and septic � ARON DEL ,��o Z �i '� g9' D components prior to installation and setting base elevations. � KC-0 _ / , , & SN tk TH- I TH 2 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8 per foot. FNr7 - \MC�µY 0 000 2 apA 54' �" -jKWM 1,0�u1 -bAwip La4M i 4) This planis not to be utilized for property line determination nor any other 0.g. ( N g 2}L purpose other than the proposed system installation. _ • /� Ho�SE z W ,yqw �j�+�r) �u�1c� 5) All septic components must meet Title V specifications. �- $N 1D 3�Z �� t� 3 1' tot 6) Parking shall not be constructed over H10 septic components. �, \ 0 41 6' � 7) The property is bounded by property comers and property lines. LOCATION MAP N } � � � `J � 8) The property owner shall review design considerations to approve of total E design flow and number of bedrooms to be considered for design. Receipt of 3 conc. ° . Ng3 w (f V� � payment for the plan and installation based on the plan shall be deemed p • > C, 1� approval of the design flow by the owner. C • Cr �''y I �' �l� 9 The existing cesspools shall be pumped and filled with material per Title V •" 41 0 ' ! ) g P P P P ii ��' ►� w O abandonment procedures. Those within the proposed SAS shall be removed I f- �' '� along with contaminated it� +� p � :� � � g co tams aced soil and replaced with clean washed sand per Title V 0 SQt�. �� secs. N 59N Z�' O � i_� 10)System components to be 10 feet from water line. Z e�octo' z 11) If a garbage grinder exists it is to be removed and is the responsibility of the fNo Shoe S E P T I C' SYSTEM DES I GN owner to ensure such. C8 9 tro Q #1 ; FLOW ESTIMATE ,1 j ` BED AT IIt7 GAL/DAY/BEDROOM -�7� GAL/DAY 6� 54't g�,5� 1 odes SEPTIC'TANK �T�GAL/DAY x 2 DAYS - GAL - USE /5DOGALLON SEPTIC TANK vehicle tr s___ 8 "iae_� ( e1 L�L+�•?00.. tA)CT �i.(�C�Fif7� f 68.2 SOIL AE SORPT 1 ON SYSTEM P - AR 1,S3'-?a.el,,,a5'T ']7c7� �'I`t'" w Tom! S';DE AREA: Z 5,+-1,7.� )C Z � C ,' F w n czn B`)TTOM AREA: �i,5 y tZ�63)c, ��-1''� _ L.3 � 05- 1 t� - J SEPTIC SYSTEM SECTION ' z fop or rbN olkii yr v l 2?.3 . _)1se� b �w�� vwtX. 3�w1►4�. ' 01 �►5�� ►o'' �'f 2" _1sS"va�43 wkD -tbw� fiAjN$WtL eNs Joy -BOXS"q&9 a„ ICJ PE-�-1500 GAL SEPT I C TANK 53,5 Y, 04 C, 7T 57,4 SITE AND SEWAGE PLAN i FLOCATION : #'7 D K0;5� WQ14 E 4 , PREPARED FOR : r� ESp slc. 96 yo � SCALE: 1 W DAV I D B . MASON,SZS DATE: to Z`1 e FNo DBC ENVIRONMENTAL DESIGNS / G EAST SANDWICH . MA # � �, 9 • .29 DATE HEALTH AGENT ( 508 ) 833- 2 177 I W i A Nfi 7'20 17 yy I I I ail