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Home My WebLink About0071 ROUTE 149 UNIT #A - Health 71 Route 149 Marstons Mills A = 077 007 __j No. 42101/3 YEL a 50, (ON �®ma 10%0 r druo", or ge __11 roe o, ce f ff w/ 1.)CI^4 cIr AA l � �r -�-�^ �-X",rj (�Vle*v11) TO fLERK No.. �` ... 9ARNSTABLE. MASS. THE COMMONWEALTH OF MASSACHUSETTS '87 AUG io PM i3bAR® OF HEALTH ............... ......._.........------..O F.......................I.....---......---................................................ Appliration for Disposal Works Cfnnstrnrtiun Frrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ... 1...� s -----.- ....- �f.`A.` ................ .................................................................................................. tion-Address or Lot No. ------------------------------- ------------------------------------------- -----......-----------.....-----------------.. Own -•••............................Address Installer Address Q Type of Building Size Lot........................Sq. feet V Dwelling—No. of Bedrooms...................`�i..______ Expansion Attic ( ) Garbage Grinder ( ) ------•. Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures ----------------------------------••••• - W Design Flow.......... U.....................gallons per person per day. Total daily flow----.__...__.------�Q----_............gallons. P4 Septic Tank Disposal Trench—No c..pacityZ6a dthns LengthTotal Lengthidth................Total leaching area_-Depth.._----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........................ W ..........-.................................................................................................................................................. 0 Description of Soil........................................................................................................................................................................ W V ............................. -••-•----••-•......•••••--••-•-•-•----••------••••...........•••••-••-•-••••••••--••••---•-••••-••••••--•-.._......--•••-•••-•••-•---••--•--••------•-••-•••••........ W VNature of Repairs or Alterations—Answer e —ap ica/ble__..._----- --- {� -G� -----....--- f Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of ii i i:;. y g g p y 5 of the State Sanitary Code— The undersigned further agrees not to lace the system in operation until a Certificate of Compliance has ften issued y the h' DC Sign � �^a 0 • ......•••...........••••••..... .............. Date Application Approved By••••-•-••••••. ......•••••••. " ------.. Date Application Disapproved for the following reasons:.............................................................................................................._ •--------------------------------•-•------------------------...---...........-----------...............--•••---•----•--•-•-••••-•--•••••••••---•••••••••••••--••••••••••••--------------=-------------- Date PermitNo....... 7. ----------- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................. .............. .......................................................................................... Appliratiou for Disposal Workii Tonstrurtion Prrmit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: ....Z ZAI.... ------ea-&l f --............... ................................................................................................ 1�ntion-Address or Lot NO. f......................\j...... Anf!.-o....................................... ............................................................................................... 46V.. —owtf Address -----44�X/;�..........*................................... ................................................................................................ Installer Address Type of Building Size Lot.._....311111C--------Sq. feet U .2 Dwelling—No. of Bedrooms..........................................Expansion Attic Garbage Grinder Other—Type of Building .........::................ No. of persons........................_.._ Showers Cafeteria PqOther fixtures ......................... ............................................................................................................................. Design Flow......... .....................gallons per person per day. Total daily flow..............2..20..................gallons. W - ............ 04 Septic Tank—Liquid capacity-6a4l:)gallons Length................ Width........_....... Diameter---------------- Depth_._.._.......... 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 ( ) :zr4- 1-.4 Percolation Test Results Performed by.......................................................................... Date........................................ Test 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..____._............_... P4 ..........................................................................................................................................*...*-------------- 0 Description of Soil........................................................................................................................................................................ .................................................................................................................................................... U .................................................... W Z ....................................................................................................................................................................................................... U Nature of Repairs or Alterations—Answer hhr ap 1,,*c?able. . ... .....-- ... .... .............. ---------t........................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'T T L- E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has een issue by th oa f h#th. Sig ......................... .. ... ... . ... ................................. ............ ................... Date Application Approved By.............. ....... ...... ... .. ------9......... 7. Date Application Disapproved for the following reasons:.............................................................................................................- ........................................................................................................................................................................................................ Date PermitNo.---- ..................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...... .........OF......../-1_'a'-- ................................ fit w1wrtifirate of Tompliaurr THIS I TO CERTIFY, That tl,e Individual Sewage Disposal System constructed or Repaired by--------------- ...........................A?.9L ------------------------------------------------------------------------------------------------------------------------- Installer at 71 1. ........................................................................................... ....................... ... —---------,./- --- ---- has been instilled in accordance with the provisions of TIT 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit *.,\To....6...7--5176e.--�>------ dated--------------- -------------------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE.......................... .......................... Inspector............................ .................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -4.....OF......... 4�!� C.. .................................. Disposal Works Tonotrudivit "prrmit Permission is hereby granted----. ----------------ki-1- -CL------------------------------------------------------------------------------------ Sewagf- tc to Construct or Repair a�nIndividuall __ Disposal System atNo..........77_1.... .............. ................................................................................................ Street ag shown on the application for Disposal Works Construction Permit N ... Dated.......................................... ---------••-----•---•-----•-_.� .1...1-_...-------••--•---•-•-•----•----•---•-3...13........................................................... /DATE........................ ........................... Board of Health FORM 1255 HOBBS & WARREN, INC., PUBLISHERS �A t � j ,rye J � � £Gw/C:$ow✓`� �j, ?.:/. •/. xe �� rry + o. i h $ 't ! 1 '1 '� • \` �' .� [- l.. !f �, �Cf fir...rs� r a i 71 JZ • ,.`�� ,� _ `ram � GZL`V-W 4—;v ez /..i 4104 1 . a No................-....... Fim$..............7.... .. THE COMMONWEALTH OF MASSACHUSETTS —BOARD OF HEALTH o77-00 -7 -- --- ��----------..OF.......... .... Appliratiun for Disposal Works Tonutrurtion Vrrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ,,. -e®----�z-- ..............................2................................................ Location-�ress or Lot No. .......................................................-- ----------- ---------------- ----------------------------------------•---•--------- ...- O t -- Address ---------------------------------- Instalier Address d Type of Building ��nD�Od Size Lot----------------------------Sq. feet V Dwelling—No. of Bedrooms.---• ........Expansion Attic ( ) Garbage Grinder aOther—Type of Building __________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures -------------------------------•--••--------------.....•--•••••.....-•-------•------•-------•---•-•-••-•••••••••---•-•--••-•--••......•-•.........._.. W Design Flow----•-•-•••••---• -•--••---•----•-••••-vgallons per person per day. Total dailyow............................................melon f( WSeptic Tank—Liquid capacity.t __gallons Length.11r....__._... Width... -----•(Diameter______________ _ Depth__&..... x Disposal Trench—No..................... Width.•_. _ .._........ Total Length.......... _. Total leaching area_____----•-•. s ft. X------ q Seepage Pit No._____ '______-- Diameter......1`�'_.-_- Depth below inlet..nT`�. "'.. Total leaching area_A?14.o�tsq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ rZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a 0 Description of Soil.........................................................................................................................-.............................................. x W DESIGNING ENGINE_E_ Iu R NT—ISUPERVISE ----------------- ------------------•--------------------------------------------------------------------------------------------------------•••-- V Nature of Repairs or Alterations—Answer when applicable----------INSTALLATION ANC CERT1FY IN WRITTf G TiE SYSTEM WAS INSTACLED'IN"STRICT Agreement AWORDAN-- _70 R AN --------------------•-------------_-. The undersigned agrees to install the aforedescribed ndiv dual e ag isposaI System/1a cord nce with the provisions of TT'j:j 5 of the State Sanitary Code he dersig e f ther rees n to. c� he tem in operation until a Certificate of Compliance has been iss e�oard f lth. Signed........... ....... ................--•-- .......... ........ ............. ... ...-Zj' Application Approved By..... ......:. �� ig''�67 Date Application Disapproved for the following reasons:-------•-------•-------------------- --------••---• •• -------••-•-•--..............--••••-•-•••-••------. ........................................................................................................................................................................................................ ....... Date Permit No........ i--- ------------- ----- Issued ----- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .........................................OF..........I.............................. ...................------................ %TWrtifirFate of Toutpfiatta THI 0 CERTI �That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by........:..----•- j:� ^ M4 Installer at.-••-•-•-•••I',''��-------•-------....-•-----�-'�� `o�� ------ 7`t�. -•••--...-•--••••----•-•-•-----••----•-•----•......•---•----- has been installed in accordance with the provisions of Ti" r 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No."��?...____._ �'�._. dated------- ......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CPIKSTRUED AS A GEAR TEE TI�IAT VH SYSTEM WILL FUNCTION SATISFACTORY. DATE.................. 0 J � ...-•--•--•................................................... Inspector....-------......�--------•----...-• - -----..._.. .-•--•------------•---•---•--- No.��....: � ,, �'- FEB.........._............. - THE COMMONWEALTH OF MASSACHUSETTS BARD OF HEALTH ....................----------------------OF.................................................. .... Appliratinn for Dhgp sal Works Tooldrnrtiun Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: _1. .<.'v. ......° _T ...!_ `1 ! S �Jr > s-------------------------------=S.. ......................................... f Le5l ocation-Address or Lot No. ..-•-�F--�`-i--�•----=---------------- --Y�:T�__--�--�---._�----•---------- -•----•-----•-----........-•----------------Address...._..---..._.._._..--•-•--------------... Installer Address UType of Building ��v ct Size Lot............................Sq. feet �., Dwelling—No. of Bedrooms....,!;"c TGe`t��. .........Expansion Attic ( ) Garbage Grinder r1lOther—T e of Building No. of persons............................ Showers — Cafeteria aI Other fixtures ...................: W Design Flow............................................gallons per person per day. Total dailyow............................................gallons. 9 Septic Tank—Liquid capacity lP__._.gallons Length.X....._..__.. Width---�__._.. Diameter---------------- Depth_%.57'. �. Disposal Trench—No. .................... Width........ ...._....__... Total Length............ Total leaching area_______-•-_---•_--sq. ft. Seepage Pit No.-----e� "'� ---------- Diameter..... Depth below inlet -. .... Total leaching area.�?!-�'.t.sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ~' Percolation Test Results Performed by................................ ................. Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_.____.______-_----_-__. G%, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ••-•••••••---•--------------•-•---••••------•••-....••••-----•--.....•-•----•-•-•----•------•--•---.....--•-•-•----....----••-•----......•........-•---.----- 0 Description of Soil........................................................................................................................................................................ x V ----••---•••-•••-•-••••••••••••-•-•-•-•--•-••-•-----•--••-••-••--•-•-•--•--------------•-•••-•••--••--------•----•-..._......-••--•---••••••••-•---•••-•••---•-•••-••--•----•...----•-----••-_--•••--••- W UNature of Repairs or Alterations—Answer.when applicable............................................................................................... --------•------------------------------------------•------...--------------------------••...........•--•---•--••-----•------__--•----•••--•••-••••-•_--•-----•-•-•••-••••-••-•••-•••••••------••-....... Agreement: The undersigned agrees to install the aforedescribe ndi djaeag isposal System in ccordance with the provisions of 1Tt ; of the State Sanitary Code The def t1he grees n to lac th s stem in operation until a Certificate of Compliance has been iss e�bo lth. 1. l/Si ned ......... .A lication A roved B ••--•------- --.... .._ �..//.. n�te�----------- Date Application Disapproved for the following reasons___________________________________ ____________ __ ____••_..--_-_•-----------------------•......--....._ ---------------------•-----------------------------••---------------------....------.........-----....-----------------•----------_•--•--_-•-_•_--•-••••-----•--••-_----•-----•-••------•--••----------- �; Date PermitNo...............................-=........................ Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS �„, r•— BOARD OF HEALTH . CIrrtif iratr of T-ampliana Tlj,,.2&.70 CERTIF-Y,.nThat the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by............. h.................. ...-----...... Install .-•- •••--•••-----••••-•---••- has been installed in accordance with the provisions of ml ; LE j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No:��_...... ... dated_...._��__�.1_'�. ............... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS _ „- .. BOARD OF HEALTH w �41...O F............� ............ .... N o FEE........................ i �a 1_ park Tono#rudion permit Permission is hereby granted......_S.__..�1 ............=('.. z: -.. ' to Construct ( } or Repair ( ) an Individual Sewage Disposal System p-. , ..........•••--•_.� ...••-••-•..................•---•••-•---•--•-•--••••-•••••-•-•-••-..•-•-•-•-----. Street { as shown on the application for Disposal Works Construction Permit..-No�-- _� :�� Dated...... •_--•-_- _ .n , , .................................- Board of Health 2 .-.. FORM 1255 HOBBS & WARREN. INC.. PUBLISHER`:. JI .1s-'— HIGH GROUND-WATER LEVEL COMPUTATIO11 Site Location: Mq/N -ST �7" T� � ��,�ixss HiGGs Lot No.— Own er: eG Address: Contractor: Address: Notes: STEP l Measure depth to water table t 1 10 ft_ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 /.� to nearer / _ /zz/87 date STEP 2 . Using Water-Level Range Zone and Index Well Map locate . site and. determine: A) Appropriate ate index well . . . .Z3o . ZontGr , B) ldater-level range Zone . . . . _ . .C_ . . . . STEP 3 Using monthly report"Current Water Resources Conditions" determine current depth to water level for index well _ . _ _ _ d /87 mo yr o ' STEP h Using Table of Water-level jAdjustments for index well STEP 2A , current depth to water level for index well (STEP 3) , and water-level zone (STEP 2B) determine water-level adjustment . . . . . . . . .. .. . . . . . . . . . . . . . . . . . . . . . . . . . . . STEP $ Estinate depth to high water by subtracting the water- level adjustment (STEP 4) •from measured depth to water level at site (STEP 1) . _ I) Figure 3 E _ _ No..........----------•-. - Fps............................. THE COMMONWEALTH OF MASSACHUSETTS OARD OFHEALTH 0-77- 007 vV n/-------OF... 7pp.1�.� GE Appliratiun for Uispao al Turk Tonutrairtion rrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .... ,� -- -------------•---....-----.........------ ation-A re or Lot No. ... ... . ... .................................. ..........-......................................................._......•................-------- Ow n Address a -fir=-: �.......... ............................... Installer Address Type of Building ,� Size Lot............................Sq. feet Dwelling—No. of Bedrooms............. ........................Expansion Attic ( ) Garbage Grinder ( ) a Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures .. W Design Flow............................................gallons per person per day. Total daily flow............................................ WSeptic Tank—Liquid capacity, 4Q_gallons Length__ _..6.... Width..'1e�4.._._ Diameter________________ Deptll_S....f.. x Disposal Trench—No.......I............ Width.�1....... Total Length..�A._....... Total leaching area____40V......sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-___----___---_________- fs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -------------------------•--------•-•---------•-••...••--------....-----..........---••••............__.........-------•--•----••---•------•••--•--•----••... 0 Description of Soil.................................................................................................................................. ................................. x U ---------------•----------•-----•••••••-----•-••--•--•--------------•-------•----•--•-••......---•--•------•••-•-------•----•••••------------•----------•-••-•-------••••--------•......------•---••-•-- W ---------------------------------------------------•- -------------------------•------•---------------------------.....•- M. Nature of Repairs or Alterations—Answer when applicable..._. ESIGiVING ENGlNEEI3-JAU&T- PNSTALLATION q 'ERVTSE T.HE__SV ..............-ND--OERTIFr-.4N.-WRITING..---- Agreement: CC EM WAS INSTALLED IN STIIICT The undersigned agrees to install the aforedescribe In iv du N I%ystem in accordance with ' T�i^ the provisions of r'I ILTLE 5 of the State Sanitary Code T under g further agree no 1 the s stem in operation until a Certificate of Compliance ha It rp 23 O Signed ,,, '`�:....�.... ----•-•-•--•-- Dat Application Approved By-- ---------•-•--------- -----•---- ------------------•----- ........ Date Application Disapproved for the following reasons:..........................................................................•................................. ..........................................--•- --•• .. --------- •---•••-•---------------------------•-•------••------------•------------•---•• -----................ � ate Permit No......................................................... Issued-.................................. � - Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 7—to�.:�'.:...................OF............................................:! 1—.1E...................... Trrtifiratr of Tontph anrr THI,_L. 7_ZO CERTIFY hat the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by------------- - ... .!.`.Q r ---------------- ,^,, f Installer has been installed in accordance with the provisions of TITIE 5 of The State Sanitary Ctt-r desqribed in the application for Disposal Works Construction Permit No...... dated------- _g;0 ............ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... r • ' Now _ 6�r ""�` FEs............ ............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ------- --� .6 .N.........OF.. 0 l Appliratiutt for Ditipmal Work0 Tomitrurtion Vrrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at:' ..«_ .._..... .............. _........... , .......................................... -. ram` cation....:`ds_ ......._...or-Lot_No. ?' � v . -•--- ' - a - ------•Address Ins•aller Address Q Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building __________________••____•••• No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures .............•----------•-•----•--•-•--•-------•------'--•---•-----------•-•----------•------.....--------•---------••-----•-•-----•-••-•----•-•••--•- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. W Septic Tank—Liquid capacityl',aAO..gallons Length_�....6__� Width_ ..4.'�_ Diameter................ Depth.5.:_'._ x Disposal Trench—No...__I............. Width4_5 .......... Total Length..&.A........... Total leaching area___ sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by------•--------------------------•------------•--•......-•••-•---•----•-• Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water_-- _.-___-__________--- 0-4 rz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P1 0 Description of Soil........................................................................................................................................................................ x W ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------•--------------------------------•- U Nature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________ ..•-••-•••••----------••-•-••--••••••••---------•••-----••-•-•-•••••••••-------•......•-----•---•-•••--•-•-•--•-••••••••••••----•••--•.............••-•-•••------•----•••----••-•-••-••••......-----•••. Agreement: The undersigned agrees to install the aforedescribe I ivid i e age Disposal System in accordance with the provisions of 1:.:LE j of the State Sanitary Code T' e unde i d further agree- n_ p c stem in operation until a Certificate of Compliance ha n. . e..be f-heatt r Signed.......... .: ...................... •-- ........ .................... nea........ Date Application Approved By� ------- ----------- ........... -----•--- -••-•-•-•---•- a ..._._ Date Application Disapproved for the following reasons_______________________________________________________________•-----------------•---------------._._...._.._._.. ................................................ ••-•••••••-----•----•---•---•-----•----...--------..._-•-.........----•-•--•-•---••••••--••••...-•-••••••-••-•••-•---•-••--••-------......-•...._..-- �cp Permit No................. -- `-�-•'" --_---_-- Issued.-_-----------��`� �` / Date Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �..�.....u�'! .....................OF.......... SF C. `.............-...._... Trrfifiratr of (1-uotpliaurr THZ, TO CERTIFX„What the Individual Sewage Disposal System constructed ( ) or Repaired ( } by.....................---- --•-------------------•...---......------•---•---•---•--------•-•--•-------•-----•---........._..............--•--_•---- `�,, e� Installer at r..._-'�N............ l Cr I has been installed in accordance with the provisions of TITI j of The Sanitary C� yits described in the application for Disposal Works Construction Permit No..............^7._..`:__.- _� ds.ted_....._..._ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE.............................................................----- Inspector...................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH FEE........................ Dhiposal Morku Cott ion rrntit Permission is hereby granted........... •-'kn�•• ...,. --•-- 1 •••••••••----•••••-•-•••-•-•••••-•••--•-•-•••-••••••.....................•--- to at ��Construnctt ( or Repair, ) an `Individual ewage Disposal System C- _ ..... ....-:-.-I_ ............. ................... street as shown on the application for Disposal Works Construction Permit N ;a Dated__ ' _�3_.�L _ .......... Board of Health DATE------- 3-----�-�------------ FORM 1255 HOBBS & WARREN, INC., PUBLISHERS HIGH GROUNDWATER LEVe COI'1PUTAT I ON .5 /¢ .�9 1zs .ems A/&Zs Lot N o. Site Location: ��^� 7�,�'�-L7 �7Z" `l' - Owner: A�-✓2 S Address: Contractor: Address: Notes: STEP 1 Measure depth to water table to nearest 1/10 ft_ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6/u/87 0 date STEP 2 Using Water-Level Range Zone and Index Well Map locate . site and determine: A) Appropr iate index well . . .�w:Z3o . B) Water-level range zone .�^« C ' - - - - - - - - 3-¢� STEP 3 Using monthly report"Current Water Resources Conditions" determine current depth to ;V.'7 water level for index well . _ . . . 6 /87 mo yr i STEP 4 Using Table of Water-level Adjustments for index well STEP 2A , current depth to water level for index well (STEP 3) , and water-level zone (STEP 2B) determine O, 6 water-level adjustment . . . . . . . . . . . . . . . . i STEP 5 Estinate depth to high water ` by subtracting the water- .. .level adjustment (STEP 4) from measured depth to water /0,9 level at site (STEP 1) I Figure 3 i Commonwealth of Massachusetts Title 5 Official Insp ection Form ®Q� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments / v�� ,M 71 Route 149 .S stem#1 / Property Address Judith Galvin Owner Owner's Name information is Marstons Mills MA 02648 Jul 7, 2014 .required for every y page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your ,. cursor-do not 'David B. Mason use the return Name of Inspector key. David Mason � Company Name 4 Glacier Path Company Address few East Sandwich MA 02537 Citylrown State Zip Code 508-367-1617 S1287 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority `�v� •�/ July 16, 2014 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. d j I 4LO L/V I t5ins-3/13 Title 5 Official Inspection Form:S urfa Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 71 Route 149 System#1 Property Address Judith Galvin Owner Owner's Name information is Marstons Mills MA 02648 Jul 7 2014 required for every y , page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: The observations noted in this report represent the condition of the system only on this date of inspection .and the information contained herein does not guarantee the continued operation of the system. 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•3/13 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 71 Route 149 System#1 Property Address Judith Galvin Owner Owner's Name information is y Marstons Mills MA 02648 Jul 7 2014 required for every , page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts mx Title 5 Official Inspection Form- ; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M ,•'°� 71 Route 149 System#1 Property Address Judith Galvin Owner Owner's Name information is y Marstons Mills MA 02648 Jul 7 2014 required for every , page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Route 149 System#1 Property Address Judith Galvin Owner Owner's Name information is Marstons Mills MA 02648 Jul 7, 2014 required for every y page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public,well. ❑. ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Z 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 F 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 Route 149 System#1 Property Address Judith Galvin Owner Owner's Name information is Marstons Mills MA 02648 Jul 7, 2014 required for every y 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: ® 0 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): 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR*15.203 (for example: 110 gpd x#of bedrooms): 550 t5ins•3/13 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 M 71 Route 149 System#1 Property Address Judith Galvin Owner Owner's Name information is Marstons Mills MA 02648 Jul 7, 2014 required for every y page. Cityrrown . State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Yes Detail 2013; 72,000 gallons and 2012; 39,000 gallons. One meter for the entire property. Sump pump? ❑ Yes ® No Last date of occupancy: Unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 Route 149 System#1 Property Address Judith Galvin Owner Owner's Name information is y Marstons Mills MA 02648 Jul 7 2014 required for every , page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Unknown Date Other(describe below): The existing use has not been utilized in a long period of time. Increase in use of system may result in failure. P ' 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts L r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 71 Route 149 System#1 Property Address Judith Galvin Owner Owner's Name information is y Marstons Mills MA 02648 Jul 7 required for every , 2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Unknown Were sewage odors detected when arriving at the site? El Yes Z No Building Sewer(locate on site plan): Depth below grade: 3 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 3 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Typical Sludge depth: 2" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 71 Route 149 System#1 Property Address Judith Galvin Owner Owner's Name information is Marstons Mills MA 02648 Jul 7, 2014 required for every y 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 44" Scum thickness 1" Distance from top of scum to top'of outlet tee or baffle 3" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Scour Stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Cast covers to grade in driveway. Grease Trap (locate on site plan): Depth below grade: 3 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: 1000 gallon typical Scum thickness 1" 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 32" Date of last pumping: Unknown Date t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ,•''r 71 Route 149 System#1 Property Address Judith Galvin Owner Owner's Name information is Marstons Mills MA 02648 Jul 7, 2014 required for every y page. Cityrrown 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.): Maintanence pumping recommended when system is utilized t Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: 4 Material of construction: ❑ concrete ❑ metal ' ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 Route 149 System#1 Property Address Judith Galvin Owner Owner's Name information is Marstons Mills MA 02648 Jul 7, 2014 required for every y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 71 Route 149 System#1 Property Address Judith Galvin Owner Owner's Name information is Marstons Mills MA 02648 Jul 7, 2014 required for every y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: leaching pits number: 2 ❑ 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.): Indication of staining within foot of pipe. No ponding or damp soil Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Route 149 System#1 Property Address . Judith Galvin Owner Owner's Name information is y Marstons Mills MA 02648 Jul 7 2014 required for every , page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Route 149 System#1 Property Address Judith Galvin Owner Owner's Name information is y Marstons Mills MA 02648 Jul 7 2014 required for every , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a' 71 Route 149 System#1 Property Address Judith Galvin Owner Owner's Name information is y Marstons Mills MA 02648 Jul 7 2014 required for every , page. Cityrrown 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: 18 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Groundwater Contour Map ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Utilized Groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 71 Route 149 System#1 Property Address Judith Galvin Owner Owner's Name information is y Marstons Mills MA 02648 Jul 7 2014 required for every , page. CityrTown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 r ,t A .3.� �rf�j i Commonwealth of Massachusetts Title 5 Official Inspection Form Q� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Route 1491System#2 Property Address Judith Galvin Owner Owner's Name information is required for every Marstons Mills MA 02648 July 7, 2014 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, (yJ} use only the tab jl � 1 Inspector: key to move your cursor-do not David B. Mason use the return key. Name of Inspector David B. Mason r� Company Name 4 Glacier Path �I Company Address East Sandwich MA 02537 City/Town State Zip Code 508-367-1617 S1287 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority July 16 2014 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10;000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 Title 5 Offc al Inspection Form: bsu ce Sewage Disposal System-Page 1 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 Route 149 System#2 Property Address Judith Galvin Owner Owner's Name information is y 7 Marstons Mills MA . 02648 Jul required for every , 2014 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: The observations noted in this report represent the condition of the system only on this date of inspection and the information contained herein does not guarantee the continued operation of the system. 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): I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2.of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 71 Route 149 System#2 Property Address Judith Galvin Owner Owner's Name information is MarstonS Mills required for every MA 02648 July 7, 2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM , 71 Route 149 System#2 Property Address Judith Galvin Owner Owner's Name information is y Marstons Mills MA 02648 Jul 7 2014 required for every , page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup.of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® 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 '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w„ 71 Route 149 System#2 Property Address Judith Galvin Owner Owner's Name information is Marstons Mills MA 02648 Jul 7, 2014 required for every y page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system 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 an question in Section E the system is considered Y q y a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large j 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 L Commonwealth of Massachusetts L Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments G1M i 71 Route 149 System#2 Property Address Judith Galvin Owner Owner's Name information is Marstons Mills MA 02648 Jul 7, 2014 required for every y page. Cityrrown 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): 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 tins•3/13 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 ,M s. 71 Route 149 System#2 Property Address Judith Galvin Owner Owner's Name information is y Marstons Mills MA 02648 Jul 7 2014 ` required for every , page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage Yes 9 ( Y 9 (gpd))� Detail: 2013; 72,000 gallons and 2012; 39,000 gallons. Note; one meter for property Sump pump? ❑ Yes ® No Last date of occupancy: Unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Restaurant/inn 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: See Above t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts w v Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 71 Route 149 System#2 Property Address Judith Galvin Owner Owner's Name information is Marstons Mills MA 02648 Jul 7, 2014 required for every y page. Cityrrown 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 Route 149 System#2 Property Address Judith Galvin Owner Owners Name information is Marstons Mills MA 02648 Jul 7, 2014 required for every y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1987 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Typical i Sludge depth: o„ t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts 7 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM , 71 Route 149 System#2 Property Address Judith Galvin Owner Owner's Name information is Marstons Mills MA 02648 Jul 7, 2014 required for every y 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 47" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 3" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Scour Stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Effluent level with outlet invert. 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 71 Route 149 System#2 Property Address Judith Galvin Owner Owner's Name information is Marstons Mills MA 02648 Jul 7, 2014 required for every y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments G M ,•'°- 71 Route 149 System#2 Property Address Judith Galvin Owner Owner's Name information is y Marstons Mills MA 02648 Jul 7 2014 required for every , page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert effluent level with 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.): 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.): *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: Leaching field without inspection port. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 Route 149 System#2 Property Address Judith Galvin Owner Owner's Name information is Marstons Mills MA 02648 Jul 7 2014 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: Unknown ❑ 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.): dimensions unknown but based on probing it is approxiamatel 25' by 40' Soil probed was not damp Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer ' Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 71 Route 149 System#2 Property Address Judith Galvin Owner Owner's Name information is y Marstons Mills MA 02648 Jul 7 2014 required for every , page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 71 Route 149 System#2 Property Address Judith Galvin Owner Owner's Name information is Marstons Mills MA 02648 Jul 7, 2014 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately C t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 71 Route 149 System#2 Property Address Judith Galvin Owner Owner's Name information is Marstons Mills MA 02648 Jul 7, 2014 required for every y page. Cityrrown 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: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Groundwater Contour Map ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater Contour Map I Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts • = W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M ,•' 71 Route 149 System#2 Property Address Judith Galvin Owner Owner's Name information is y Marstons Mills' MA 02648 Jul 7 2014 required for every , page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 .' f�� ._ 1S � . a�.L�' _.��f�f'o ,�.r —.—,� �I r Commonwealth of Massachusetts ®� Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments / ,M 71 Route 149 System#3 Property Address Judith Galvin Owner Owner's Name information is Marstons Mills_ MA 02648 Jul required for every y 7 2014 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 forms A. General Information on the computer, use only the tab 1. Inspector: I I key to move your cursor-do not David B. Mason use the return Name of Inspector key. David B. Mason VQ Company Name 4 Glacier Path Company Address East Sandwich MA 02537 City/Town State Zip Code 508-367-1617 S1287 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority July 16, 2014 Inspector's Signaffle 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. t5ins•3/13 Title 5 Official Inspectio Subsurface Sewage Disposal System•Page 1 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 71 Route 149 System#3 Property Address Judith Galvin Owner Owner's Name information is Marstons Mills MA 02648 Jul 7, 2014 required for every y page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: The observations noted in this report represent the condition of the system only on this date of inspection and the information contained herein does not guarantee the continued operation of the system. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 71 Route 149 System#3 Property Address Judith Galvin Owner Owner's Name information is Marstons Mills MA 02648 Jul required for every y 7 2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71 Route 149 System#3 Property Address Judith Galvin Owner Owner's Name information is y Marstons Mills MA 02648 Jul 7 2014 required for every , page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® 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 '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 71 Route 149 System#3 Property Address Judith Galvin Owner Owner's Name information is Marstons Mills MA 02648 Jul 7, 2014 required for every y page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massac husetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 71 Route 149 System#3 Property Address Judith Galvin Owner Owner's Name information is y Marstons Mills MA 02648 Jul 7 2014 required for 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): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 i t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 f Commonwealth of Massachusetts H - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 71 Route 149 System#3 Property Address Judith Galvin Owner Owner's Name information is Marstons Mills MA 02648 Jul 7, 2014 required for every y page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d Yes 9 ( Y 9 (gp ))� Detail: 2013; 72,000 gallons and 2012; 39,000 gallons. Note; one meter for property Sump pump? ❑ Yes ® No Last date of occupancy: Unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? Yes El Yes No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 71 Route 149 System#3 Property Address Judith Galvin Owner Owner's Name information is y Marstons Mills MA 02648 Jul 7 2014 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•3/13 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 71 Route 149 System#3 Property Address Judith Galvin Owner Owner's Name information is Marstons Mills MA 02648 Jul 7, 2014 required for every y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Unknown Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments.(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Typical Sludge depth: 0" t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 71 Route 149 System#3 Property Address Judith Galvin Owner Owner's Name information is Marstons Mills MA 02648 Jul 7, 2014 required for every y 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 47" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 311 Distance from bottom of scum to bottom of outlet tee or baffle 16 How were dimensions determined? Scour Stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Effluent level with outlet invert. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 71 Route 149 System#3 Property Address Judith Galvin Owner Owner's Name information is y 7 Marstons Mills MA 02648 Jul required for every , 2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level` Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 71 Route 149 System#3 Property Address Judith Galvin Owner Owner's Name information is y Marstons Mills MA 02648 Jul 7 2014 required for every , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert effluent level with 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.): 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.): * 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: Leach pit below grade. Utilized camera. l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 71 Route 149 System#3 Property Address Judith Galvin Owner Owner's Name information is y Marstons Mills MA 02648 Jul 7 2014 required for every , page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No ponding. No signs of hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 71 Route 149 System#3 Property Address Judith Galvin Owner Owner's Name information is Marstons Mills MA 02648 Jul 7, 2014 required for every y 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.): I l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 71 Route 149 System#3 Property Address Judith Galvin Owner Owner's Name information is Marstons Mills MA 02648 Jul 7, 2014 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Route 149 System#3 Property Address Judith Galvin Owner Owner's Name information is Marstons Mills MA 02648 Jul 7, 2014 required for every y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) l Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 18 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Groundwater Contour Map ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater Contour Map I Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 71 Route 149 System#3 Property Address Judith Galvin Owner Owner's Name information is y Marstons Mills MA 02648 Jul 7 2014 required for every , page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 �1 ?/ �_,��, "--.�.��.....,.__��...�....�.....^_v� 's Ili __ ti �\ 4� �\ ` U �� , 3� �.r �� \� sS` r a Commonwealth of Massachusetts W Title 5 Official Inspection Form ®Q`1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �� °M 71 Route 149 System#4 Property Address Judith Galvin Owner Owner's Name information is y Marstons Mills MA 02648 Jul 7 2014 required for 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 forms A. General Information on the computer, I �L use only the tab 1. Inspector: key to move your I cursor-do not David B. Mason use the return key. Name of Inspector David Mason � Company Name 4 Glacier Path Company Address East Sandwich MA 02537 City/Town State Zip Code 508-367-1617 S1287 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection . was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority - July 16, 2014 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the-future under the same or different conditions of use. H t5ins-3/13 Title 5 Official lin.p. bnrm: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 71 Route 149 System#4 Property Address Judith Galvin Owner Owner's Name information is Marstons Mills MA 02648 Jul required for every y 7 2014 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: The observations noted in this report represent the condition of the system only on this date of inspection and the information contained herein does not guarantee the continued operation of the system. 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): i t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 71 Route 149 System#4 Property Address Judith Galvin Owner Owner's Name information is Marstons Mills MA 02648 Jul 7, 2014 - required for every y page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M ,•''v 71 Route 149 System#4 Property Address Judith Galvin Owner Owner's Name information is Marstons Mills MA 02648 Jul 7 2014 required for every y page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No El 0 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 71 Route 149 System#4 Property Address Judith Galvin Owner Owner's Name information is Jul arstons Mills MA 02648 required for every M y 7 2014 page. Citylrown 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 i`s'within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system'is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M s 71 Route 149 System#4 Property Address Judith Galvin Owner Owner's Name information is y Marstons Mills MA 02648 Jul 7 2014 required for 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? S ❑ 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):. Number of bedrooms(actual): 1 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 110 t5ins-3113 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 71 Route 149 System#4 Property Address Judith Galvin Owner Owner's Name information is Marstons Mills MA 02648 Jul 7, 2014 required for every y page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage Yes 9 ( Y 9 (gpd))� Detail 2013; 72,000 gallons and 2012; 39,000 gallons. Note; one meter for property Sump pump? ❑ Yes ® No Last date of occupancy: Unknown Date Commercial/Industrial Flow Conditions: Type.of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flew(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G M , 71 Route 149 System#4 Property Address Judith Galvin Owner Owner's Name information is y Marstons Mills MA 02648 Jul 7 2014 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-3/13 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 71 Route 149 System#4 Property Address Judith Galvin Owner Owner's Name information is y Marstons Mills MA 02648 Jul 7 2014 required for every , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Unknown Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 71 Route 149 System#4 Property Address Judith Galvin Owner Owner's Name information is y Marstons Mills MA 02648 Jul 7 2014 required for every , page. Cityrrown 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 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, evidence 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5-Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 71 Route 149 System#4 Property Address Judith Galvin Owner Owner's Name information is Marstons Mills MA 02648 Jul 7, 2014 required for every y page. Citylrown 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, El metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 111 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 71 Route 149 System#4 Property Address Judith Galvin Owner Owners Name information is y Marstons Mills MA 02648 Jul 7 2014 required for every , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Route 149 System#4 Property Address Judith Galvin Owner Owner's Name information is required for every Marstons Mills MA 02648 July 7, 2014 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ Teaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ® overflow cesspool number: 1 ❑ innovative/alternative system ' y Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Primary cesspool with overflow cesspool Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 2 with overflow Depth—top of liquid to inlet invert 3' Depth of solids layer 011 Depth of scum layer Oil Dimensions of cesspool 6x6 Materials of construction block Indication of groundwater inflow ❑ Yes ® No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 71 Route 149 System#4 Property Address Judith Galvin Owner Owner's Name information is y Marstons Mills MA 02648 Jul 7 2014 required for every , page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Primary cesspool holding effluent. Overflow cesspool was dry at time of inspection Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 71 Route 149 System#4 Property Address Judith Galvin Owner Owner's Name information is y Marstons Mills MA 02648 Jul 7 2014 required for every , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 71 Route 149 System#4 Property Address Judith Galvin Owner Owner's Name information is y Marstons Mills MA 02648 Jul 7 2014 required for every _ , page. Cityrrown 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: 18' feet Please indicate all methods used to determine the high ground water elevation: . ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local.Board of Health -explain: Groundwater Contour Map ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater Contour Map Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Route 149 System#4 Property Address Judith Galvin Owner Owner's Name information is Marstons Mills MA 02648 Jul 7, 2014 required for every y page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 i to � a3-G �C ®'i.3_�t•+i^a+ rphr.i t r w4r? Yx" a q.• .•. � } wc�;r .rj�,j;;,,�,;..{ a: Fo+ h 1G`F=.y ear- . �s'F.�r�"'r'�4tSa,'�'c�`�,,'"''may��l.,r q"sev"'Y`i`- *..x '�"�'�'�'H kwt �''�+ •� Name: i' �1/1.r4rl ' f ✓" y 1 � please print Name of Food Establishment: f.•✓ ;�i' =� i�"/i �t' Location of Establishment: 14.r" - t // street name and village { Today's Date: 1 i i i i i i i i 1 i OpTHE Town of Barnstable . BARLE , AB , . Board of Health gib 1MASS. 167 Main Street,Hyannis,MA 02601 i CERTIFICATE Of ATTENDANCE Safe Food Handling training OFFICE USE ONLY This certificate of attendance expires two'years after the date of attendance. Verification PERMIT NO TOWN OF BARNSTABLE JANUARY 1, 2000 501 BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 395A and Chapter ill,Section 5of the General Laws,a permit is hereby granted to: WILLIAM G. HENRY D/B/A g INN AT THE'MI.LLS Whose place of business is: 71 COTUIT ROAD MARSTONS MILLS,SMA 02648 Type of business and any restrictions . ' INN HOLDERS ESTABLISHMENT r: 4 3 To operate a food establishment,in the�� TOWN OF BARNSTABLE ` RESTRICTIONS IF ANY: SEATING: ANNUAL: YES SEASONAL: TEMPORARY a N=... .'. . fi F E.E S BOARD OF HEALTH ..: RETAIL FOOD STORE: . Susan G. Rask, R.S.,Chairperson FOOD SERVICE ESTABLISHMENT: $45 00 Ralph A. Murphy,M.D. RESIDENTIAL KITCHEN FOR RETAIL SALE Sumner Kaufman,M.S.P.H. RESIDENTIAL KITCHEN FOR BED+BREAKFAST v 'e a MOBILE FOOD UNIT: PeCmit eXplreS a December 31 2Q - TOBACCO SALES: 000 � . FROZEN DESSERT: Thomas A. McKean, RS, CHO MILK: Director of Public Health CATERER: ------ _ ........._._ t yr PERMIT NO TOWN OF BARNSTABLE JANUARY 1, 2000 501 BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT In accordance with regulations promulgated under authority of Chapter 94, Section 395A and Chapter ill,Section 5 of the General Laws,a permit is hereby granted to: WILLIAM G. HENRY D/B/A: INN AT THE MILLS Whose place of business is: 71 COTUIT ROAD , MARSTONS MILLS, MA 02648 Type of business and any restrictions: INN HOLDERS ESTABLISHMENT To operate a food establishment in the TOWN OF BARNSTABLE RESTRICTIONS IF ANY: SEATING: ANNUAL: YES SEASONAL: TEMPORARY: FEES BOARD OF HEALTH RETAIL FOOD STORE: Susan G. Rask, R.S.,Chairperson FOOD SERVICE ESTABLISHMENT: RESIDENTIAL KITCHEN FOR RETAIL SALE: Ralph A. Murphy, M.D. RESIDENTIAL KITCHEN FOR BED+BREAKFAST: $45.00 Sumner Kaufman, M.S.P.H. MOBILE FOOD UNIT: Permit expires: TOBACCO SALES: December 31, 2000 � FROZEN DESSERT: Thomas A. McKean, RS, CHO MILK: Director of Public Health CATERER: NOT VALID UNLESS ISSUED IN CONJUNCTION WITH A COMMON VICTUALERS LICENSE FEES RETAIL FOOD STORE: FOOD SERVICE ESTABLISHMENT $45.00 RESIDENTIAL KITCHEN FOR RETAIL SALE SEATING: RESIDENTIAL KITCHEN FOR BED+BREAKFAST MOBILE FOOD UNIT: ANNUAL: YES TOBACCO SALES: SEASONAL: CATERER: TEMPORARY: FROZEN DESSERT: . .N MILK: TOWIOF'BARNSTABLE BOA,RDx OF HEALTH PERMIT TO OPERATEA FOOD,,ES "ABLISHMENT < PERMIT NO: 501 ;� o ` " JANUARY 1, 1998 rc' E k yx.'z , r,z z in accordance yln h°regulatonspromulgatedunder authority of,Chapter 94, Section 395A and4 hapter 1 ,7k Sectl'bk— 11he General Laws,a permit is hereby granted to: � 1 x, WILLIAM G. HENRY fib, y w y '� Fyn P"4 '& "C...#�`.L-%: x Seat. D/B/A: INN AT THE MILLS Whose place of business it: .71'�COTUIT ROAD ,AARSTONS MILL4S MA 02648 'Type of business and anyzresitictions: INN,,HOLDERS�ESTABUIS�HMENT� To operate a food establishment imtt>e TOWN OF BA AST/ BLL-; A Permit expires: December 31, 1998 BOARD OF HEALTH Susan G. Rask, R.S., Chairperson Ralph A. Murphy, M.D. RESTRICTIONS IF ANY: Sumner Kaufman, M. .P.H. homas A. McKean, RS,C "^ a Director of Public Health s_ f �tHEI � Town of Barnstable Department of Health, Safety, and Environmental Services 9B" M^�B Public Health Division i639• � ,erFDA 367 Main Street, Hyannis MA 02601 Office: 508-790-6265 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health SEATING J^D ANNUAL SEASONAL ASSESSORS MAP AND PARCEL NO.077 - 00 7 DATE /A, APPLICATION FOR PERMIT TO OPERATE A#&Jy/—y FFOOD ESTABLISHMENT FULL NAME OF APPLICANT 646C-/fl-A l G-• NAME OF FOOD ESTABLISHMENT T/1/0 /67 //�.--'. LIL-11-S ADDRESS OF FOOD ESTABLISHMENT 71 00—,70 NUMBER ® ` TELEPHONE NU .S� o'�'!G TYP F ESTABLISHMENT: V FOOD" SERVICE RETAIL FOOD V BED AND BREAKFAST CONT.BR. RES.KITCHEN MOBILE FOOD TOBACCO SALES FROZEN DESSERT CATERING SOLE OWNER: YES ` NO IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRESS OF ALL PA NERS: IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. STATE OF INCORPORATION ��S (9<11410 S'X,-7 FULL NAME AND HOME ADDRESS OF:" PRESIDENT �jL,L/ �T73-ti AD (9G 770./v3 *I&J-s , ram TREASURER '�T�'/��1 - �-- r /0)c 7005'�/t>S CLERKS VGNAYURE OF APPLICANT RESTRICTIONS: HOME ADDRESS Aix -?®® i7ays S ® d HOME TELEPHONE# y foodest/db/q TOWN OF BARNSTABLE LOCATI 7/ C4�v) )?� /`Y9 SEWAGE # �- VILLAGE !/ ASSESSOR'S MAP & LOT INSTALLER'S NAME &.PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATE BUILDER OR OWNER G G DATE PERMIT ISSUED: S'I7 DATE COLIPLIANCE ISSUED: VARIANCE GRANTED: Yes No Alyl v r � ` FEES RETAIL FOOD STORE: FOOD SERVICE ESTABLISHMENT: $45.00 RESIDENTIAL KITCHEN FOR RETAIL SALE: SEATING: RESIDENTIAL KITCHEN FOR BED+BREAKFAST MOBILE FOOD UNIT: ANNUAL: YES TOBACCO SALES: SEASONAL: CATERER: TEMPORARY: FROZEN DESSERT: �. MILK: STOW OFRIE ARNSTABLE ,BOAIDOF H�EALTi PERMIT TO'OERATE�► FOOD,,ESTABLISH ENT � . , PERMIT NO: 501 , � * JANUARY 1, 1999 'R.'HR \0 In accordance w�ti ;regulatlonspromulga ed'sunder authority of Chapter 94, X ; e :# L Section 395A an Chapter ff S ct1io Nhe General Laws, ;� permit is hereby geanted to: WILLIAM G. HENRY I' D/B/A: INN AT THE MILLS .� _ r� ' sBa, ,11 ."A EE Whose place of business is �71 COTUIT ROAD, AI i►RSTONS Mt UkMA 02648 Mh„ Type of business and anprestridiions: INN Hft OLDER§,ESTABL�ISRI,IVIENT. To operate a food establish�entl iGe TOWNOFARSTABL ��f . v��- Permit expires: December 1,, 1999 J0° r il 40 saw BOARD OF HEALTH Susan G. Rask, R.S., Chairperson Ralph A. Murphy, M.D. RESTRICTIONS IF ANY: Sumner Kaufman, M.S.P Lo Thomas A. McKean, RS, CHO Director of Public Health YOUR MASTER POOL BUILDER POOLS, SPAS, SERVICE & SUPPLIES 955 - • , 1 .1 1 : : 11508-778-2235 IuziettiCcapecod.net Stephen Wrightington THE COMMONWEALTH OF MASSACHUSETTS TOWN OF BARNSTABLE � SWIMMING POOL INSPECTION REPORT i TYPE OF POOL: PUBLIC❑ SEMI-PUBLI SPECIAL PURPOSE❑ POOL VOLUME: GAL. BATHER LOAD NAME OF POOL of ADDRESS OWNER ADDRESS Regulation 105 CMR 435.000 effective date:2/20/98 The items marked below with an"X"indicate the violated provisions. Items marked with a check are satisfactory. _y033.. Bathhouse and sanitary facilities adequate lighting.ventilation:sanitary condition.Adequate enclosure around pool.Gate self-latching 4 ft.above ground. ✓04. Sewage disposal VOS4.Location,structural stability,finish 06 Water circulation&filtration systems.Filter effluent flow meter reading gpm.#of turnovers 06 Suitable automatic equipment for disinfection of pool water. S In �' 1X`(Nt. cx- ' -tr i L 06 CO2 equipment for pH control CO2 cylinders anchored Inaccessible to public Adequate ventilation. 0 Inlets&Outlets-Inlets located to produce uniform circulation.Over rim fill spout 6"above max.water level.Properly shielded&located. 0 Main drain suction outlets covered w/suitable protective covers/grates.Cannot be removed w/o use of tools.Open area does not provide entrapment of fingers,toes, / etc...At least one antivortex drain provided 08 Each system outlet protected against user entrapment by antivortex cover or by other means.Minimum of 2 suction outlets provided for each pump,properly located and plumbed. 0 Suction outlet covers in place,unbroken and secure and cannot be removed except w/use of tools.Close pool immediately if outlet covers missing,broken,loose or can be removed w/o tools until repairs are made. f fM �q'jz - �88 Special purpose pool&wading pools equipped with emergency shut-off pump switch.Accessible and prominently marked. ✓0099 Cross-connections.Potable water supplied through air gap. V 10 Skimming Facilities.50%of recirculation drawn from surface of pool. 2 S "t" 132 Line with floats separates non-swimmer area from deeper water. 2 Water depth markings on deck and walls.Properly spaced.Boundary line on pool floor and walls.Step edges marked with contrasting color. �' 13 Walkways&Decks 4 ft.wide.Safe condition. ✓14 Ladders,steps-one per 75 feet.Not less an 2 ladders. ,XIA-15 Diving equipment in safe condition. 7 Pool supervision provided. CPO w/proper training.On staff or on contract,Documentation provided. t-cl Z/�, 21 Permit issued.Adequate maintenance and testing records.Records initialed by person making tests. 164o re p r,.d-) ( CT 6C4- (3Health Regs.Signs posted Warning signs for special purpose pools. 3 Lifeguard ❑ Qual.SwinunerA If lifeguard:prop crede ials,proper suits and garmgnts worn.Whistle&bullhorn provided. Qual.Swimmer:CPR trained, BOH approved.Limit bather load to 19 �V,eQ C'I� U4'f7 /� �/n a V ' vV�,r`� E24 Safety Equipment.Ring buoys and rescue hook provided. Rescue tube and backboard PPw"/sstrra�aps at pools attended by lifeguard. ' First aid equipment provided. First aid kit complete. 25 Emergency Communication system at the pool and in working order.Emergency communication device in unlocked area and available at all times to staff and the public.Operating instructions and emergency numbers posted. 7,t ;QU- @ 10 , a,_e-,rea�,d�r— _y26 Waste&backwash water disposal properly discharged. No direct connection to sewer system.Separation tank provided for diatomaceous earth filter backwash water. 9 Chemical Standards. Frequency of Testing: POOL SIDE READINGS IN PARTS PER MILLION-ppm Bromine 2.0-6.0 Total chlorine Alkalinity 60-150 Free chlorine 1.0-3.0 Cy anuric Acid 30-50,max 100 Comb.chlorine 0.0-0.2 Water temp. 78-84,spa<104 pH 7.2-7.8 O�Water testing equipment.DPD kit provided for chlorine&bromine.Unbreakable thermometer for special purpose pools.No test strips 1&32 Water Clarity:Can see 6"black disk at bottom of pool.Water clarity maintained.Filtration operating continuously. 2 Special purpose pool drained&cleaned every 14 days minimum fJ _✓33 Thermostatic control provided for each SPP.Thermostatic control only accessible to the pool operator. /OCD-Ia- 34 POOL MUST BE CLOSED UNTIL IT MEETS 105 CMR 435.29 THROUGH 435.31.If the pool is closed by a Health Inspector or other agent of the B.O.H., the pool shall remain closed until the Health Inspector re-opens pool in writing. COMMENTS: `�7�� -- >J -�.Y�S'�G✓� d �` �/ W G SIGNED: SIGNED: DATE: R Board of Health/He th ept.Representative TOWN OF BARNSTABLE 5- S BOARD OF HEALTH G 1 6 ARTICLE 11:MINIMUM STANDARDS FOR HUMAN HABITATION Date Owner rt^" �V` s Tenant Address Z �Y `/ Address Compliance Remarks or Regulation# Yes No Recommendations r 2. Kitchen Facilities ✓ 3�3 3. Bathroom Facilities ✓ /Is, ( �t�<< �rlgv-'s , IV S 4. Water Supply 5. Hot Water Facilities ®lo� 2 10 I -(,✓� a,�,u�+,� 6. Heating Facilities ✓ 7. Lighting and Electrical Facilities 8. Ventilation �L ka� pone 9. Installation and Maintenance of Facilities V 10. Curtailment of Service 11. Space and Use 12. Exits '(414 13. Installation and Maintenance of Structural ✓� Elements 14. Insects and Rodents �,/� V 15. Garbage and Rubbish Storage and Disposal ✓ ,Q' 16. Sewage Disposal Tf 1-1 U": _e�� 17. Temporary Housing ti PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Persons Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here HOBBS&WARREN.INC. L THE COMMONWEALTH OF MASSACHUSETTS TOWN OF BARNSTABLE a� Board of Health Fee: $75.00 Permit To Operate A Swimming Pool In accordance with the provisions of Chapter 111,Section 127A of the General Laws,and Regulations established by the Massachusetts Deparment of Public Health(105 CMR 435.00)permit is hereby issued to WILLIAM G. HENRY/DBA INN AT THE MILLS corporation or individual for the operation of OUTDOOR POOL (Public,Semi-Public,or Special Purpose Pool) at 71 COTUIT ROAD MARSTONS MILLS, MA address Method of water treatment is chlorine-automatically fed Bathing load not to exceed 0 bathers. This permit is valid until December 31,20 00 Susan G. Rask, R.S., Chairman Board Ralph A. Murphy, M.D. of January 1,2000 Sumner Kaufman, M.S.P.H. Health POST CONSPICUOUSLY ( By Thomas A. McKean, RS, CHO, Health Agent THE COMMONWEALTH OF MASSACHUSETTS i TOWN OF BARNSTABLE Fee: Board of Health $75.00 Permit To Operate A Swimming Pool In accordance with the provisions of Chapter 111,Section 127A of the General Laws,and Regulations established by the Massachusetts Deparment of Public Health(105 CMR 435.00)permit is hereby issued to WILLIAM G. HENRY/DBA INN AT THE MILLS corporation or individual for the operation of OUTDOOR POOL (Public,Semi-Public,or Special Purpose Pool) at 71 COTUIT ROAD MARSTONS MILLS, MA address Method of water treatment is chlorine-automatically fed Bathing load not to exceed 0 bathers. This permit is valid until December 31,20 00 Susan G. Rask, R. S., Chairman Board Ralph A. Murphy, M.D. of January 1,2000 Sumner Kaufman, M.S.P.H. Health POST CONSPICUOUSLY ( By Thomas A. McKean, RS, CHO, Health Agent FEES RETAIL FOOD STORE: FOOD SERVICE ESTABLISHMENT $45.00 RESIDENTIAL KITCHEN FOR RETAIL SALE RESIDENTIAL KITCHEN FOR BED+BREAKFAST SEATING: MOBILE FOOD UNIT: ANNUAL: YES TOBACCO SALES: SEASONAL: CATERER: TEMPORARY: FROZEN DESSERT: '. -.. _ MILK: ,, *" TOWN OI" RARNSTABLE., < :BOARDOF,14 E4L TO° . EAT OETSHl IPERMI R D: BSHMENT PERMIT NO: 501 �� JANUARY 1, 1999 I � In accordanceow,h reguiatI ns p omulg a sunder a tho Sty o Chapter 94 Section 396A and'!Chapter 111, �flon, ohe General Laws permit is hereby granted to: WILLIAM G. HENRY r D/B/A: INN AT THE MILLS Whose place of business is � 7' COTUIT ROAD, �1 AJR TONS M�I� S'>xMA 02648 Type of business and anyresicions: INN�HOLDERS/BED 8� BREAKFAST ESTABLI �w7 s ST To operate a food establisHmen %in he T01UN'OF BARIS'fiABL NJ Permit expires: December My999� ; � - 4 BOARD OF HEALTH Susan G. Rask, R.S., Chairperson Ralph A. Murphy, M.D. RESTRICTIONS IF ANY: Sumner Kaufman, M.S.P. . Thomas A. McKean, RS, CHO Director of Public Health 4� oFINErq , Town of Barnstable Department of Health, Safety, and Environmental Services &MW9rABM �� Public Health Division �ED1N0�A P.O. Box 534, Hyannis MA 02601 Office: 508-790-6265 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health SEATING -S—O ANNUAL SEASONAL ASSESSORS MAP AND PARCEL NO. 07`7 DATE /2I 9� APPLICATION FOR PERMIT TO OPERATE A FOOD ESTABLISHMENT FULL NAME OF APPLICANT NAME OF FOOD ESTABLISHMENT INAJ ADDRESS OF FOOD ESTABLISHMENT 71 C.e r u l ! ®V�r l TELEPHONE NUMBER 4,PL?6 7 TYPE AF ESTABLISHMENT: V FOOD SERVICE RETAIL FOOD y BED AND BREAKFAST CONT.BR. RES.KITCHEN MOBILE FOOD TOBACCO SALES FROZEN DESSERT CATERING SOLE OWNER: YES NO IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRESS OF ALL PARWR n IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. STATE OF INCORPORATION FULL NAME AND HOME ADDRESS OF: PRESIDENT -6J16&.i&yV o yc -70 ,Ifr� s/;VNg �,�e,5� Aw TREASURE AaM9 �/2—'-44 -'7-003 o320�3 CLERK i: •4 URE OF APPLICANT RESTRICTIONS: HOME ADDRESS,9p '7O® xneys ems. HOME TELEPHONE# �Ld bY foodest/db/q THE COMMONWEALTH OF MASSACHUSETTS TOWN OF BARNSTABLE Board of Health Fee: $75.00 Permit To Operate A Swimming Pool In accordance with the provisions of Chapter 111,Section 127A of the General Laws,and Regulations established by the Massachusetts Deparment of Public Health( 105 CMR 435.00)permit is hereby issued to WILLIAM G. HENRY/DBA INN AT THE MILLS corporation or individual for the operation of OUTDOOR POOL (Public,Semi-Public,or Special Purpose Pool) at 71 COTUIT ROAD MARSTONS MILLS, MA address Method of water treatment is chlorine-automatically fed Bathing load not to exceed 0 bathers. This permit is valid until December 31, 2001 Susan G. Rask, R.S.,Chairman Board January 1,2001 Ralph A. Murphy, M.D. of Sumner Kaufman, M.S.P.H. Health POST CONSPICUOUSLY By Thomas A. McKean, RS, CHO, Health Agent MRVP # Assessors office (1st Floor) �7 _ ®�� Assessor's Map and Parcel # / Building ar ment (4th Floor) Zoning f��` //� INSPECTION FEE $60.00 RE-INSPECTION FEE $15.00 Request For A Housing Inspection For Certification Under the MAW/c Rental Voucher Program Your NameL /So l+o�C�6y Affiliation (Circle One) Owner Real Estate Agent Tenant Your Address Telephone Number (Day) (Night) Address of Property W re LZnspection is Requested Unit/Apt.# '7r (dMut7 D cr7F 110 d�f��s" ,N� Name of Owner lNtJ Al %l1-4— Rt ti S 7`4ly_.v.7 Address A0, !g0 K -70,0 .44AS70W 41",S Mailing Address (if different) Telephone Number (Day)(W) 414-d o 7 (Night) rPt(t. Will there be any children under the age of six (6) whoxill be occupying the rental unit? (circle one) Yes No r Was the dwelling constructed prior to 1979? Yes No a , MRVP # Assessor's office (1st Floor)Assessor's Map and Parcel # d I—7 /�7 " 007 Building pepar ment (4th Floor) Zoning /r t INSPECTION FEE $60.00 RE-INSPECTION FEE $15.00 Request For A Housing Inspection For Certification Under the / MA Rental Voucher )Program Your Name �c.- /SR I y /G if 0 Lam© f�/ Affiliation (Circle One) Owner Real Estate Agent Tenant Your Address ' Telephone Number (Day) (Night) Address of Property Wh re Inspection isRequested Unit/Apt.# -7/ r"y17 6 ��7"� l q9 ) Aq zs' D us /l.�fi , A4 Name of Owner TAW A-7 TYe 1,11Li s 7_dVS/ Address A0, 40x 7yo , ✓fAXs700.0 41z_�5 , �� 4a�� Mailing Address (if different) Telephone, Number -(Day)$i*) � -a�j�7 (Night) soli=- Will there be any children under the age of six (6) who gill be occupying the rental unit? (circle one) Yes No Was the dwelling constructed prior to 1979? Yes -5,,, No FOR OFFICE USE ONLY: Certification The dwelling, dwelling unit, or rooming unit located at h h a 4(44 A4, //J , Gy Q ,,VA-►S , / J,%/J was inspected on � /3a/99 by Cleti 5t�, fZ• S Health Inspector for the Town of Barnstable and was • found to be in compliance with , the provisions contained within 105 CMR 410.00, State Sanitary Code II: Minimum Standards of Fitness '- for Human Habitation. However, this certification does not include a determination-as to whether this unit contains any lead paint because under-760 CMR 49.02 Massachusetts Rental Voucher Program, a separate' lead paint inspection must be conducted. Inspector's Signature val Date ZZ�O/ / ' ZFORM30 &w HOBBS&WARREN'M THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH CITY/TOWN o DEPARTMENT ADDRESS /�j• 4 1 GSM Sv9 y`0p //j*'' �j,�� Q I� �✓- �� I TELEPHONE Address 7 j�_ f/J- ccupant -' Floor___Apartment No.._—S No.of Occupants / No. of Habitable Rooms Z- No.Sleeping Rooms / No.dwelling or rooming units / No.Stories y Name and address of owner 1'OMILLS T!?- ysT 5-0 � �• (tea C�� ter v Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish fjpcT 1 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: Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N E ui . Repair TYPE: e MA Stacks, Flues,Vents: LAS PLUMBIN : Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: k ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT f'�d Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors I Locks Kitchen ✓ Bathroom a+..Gt ✓ ri ✓ V Pantry Den Living Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten., ,Oil, Elect.: lZ Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink zc�. Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: IyV General Buildin Posted Locks on Doors: 0 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 PENALTIE F PERJUR " INSPECTO TITLE #A G ' DATE 3/367 TIME 5)"CV A.M: A.M. THE NEXT SCHEDULED REINSPECTION P.M. J "'��'�r`► "W -ilF�''�' �,. ) �{ry[ ^' �sL',.{ ('s'�,1- a wY�% 'f '."1 Nt`''A:tf M T ar 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 11, 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 imthis listing. Failure to include shall in no way be construed as a determination that other violations or conditions may .not be found to fa,ll 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. ( ) P PP Y (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. q.,;FORM 30 H&W HOBBSB WARREN'M THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH CITY/TOW N w / a t t'�d S�L DEPARTMENT 1 3 1C ADDRESS �/U y G7M sy0ys0W A� l i•J / 1p b 7 c.I'K N ✓/V' f""n� l TELEPHONE Address 7 / `�i aA loa sj,�.J/fl;�,SOccupant_ Floor Apartment No. 5 No. of Occupants No.of Habitable Rooms 7-- No.Sleeping Rooms No. dwelling or rooming unit No.Stories // Name and address of owner�W '¢-r T&,411jLLS T k`h`j� �J✓� ��ro�w► f ey Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish rjra 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: z ,, C Dampness: Stairs: Lighting: STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys:, Central ❑ Yff�� N Equip. Repair TYPE: F YA Stacks, Flues,Vents: 6AS PLUMBING: Supply Line: / . ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: Q K ❑ 110 11220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen ✓ Bathroom wIti ✓ i ✓ 1i Pantry Den Living Room Bedroom 1 Bedroom 2 W Bedroom 3 Bedroom 4 s .Hot Water Facil. Sup.Ten., asp,Oil, Elect.: z� Stacks, Flues,Vents,Safeties: S Kitchen Facilities Sink (C2 i C' f %( me µ��o ,, ;„ vee Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: �^^ Egress Dual and Obst'n: d C�j✓�y� 5 �114 o .. General Building Posted J v e 6-7-S-i Locks on Doors: 01< , 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` PERJUF�Y � n INSPECTO2 C� � TITLE � � 3I o J A.M. DATE 3 TIME y" • - .` A.M. THE NEXT SCHEDULED REINSPECTION ;- t •l P.M. s 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 This listing is composed of those impair the health, or safety and well-being of a person or persons occupying the premises. s g p 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 11, 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 foun*d 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. (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. s^i .. —r i• - A 1 No. --- -0=--- �D Fee---- -------5-------- BOARD OF HEALTH TOWN OF BARNSTABLE �'= � [itation rye[[ �on�truttion ermit Application is a eby made for a permit to Construct (G7, Alter ( ), or Re it ( )an ind'v' ual Well at: - --- - - oou I - Location — Address 'Assessors Map and Pircel / Owner Address --------------- --------- ------ -------------------------------- -------- ---------- Installer — Driller Add s �~ Type of Building Dwelling --- — -- —-- — Other - Type of Building----------------- No. of Persons—--------------------- Type of Well —��-- — ---- Capacity-------Q�c Purpose of Well-----�-kwf �—_--_—_ — Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until Fe tificateCo pl' ce has been issued by the Board of Health. Signed —- -n— t --- Application Approved By — — -- -- date Application Disapproved for the following rea ns:-------------------- ----- ---------------- ------------ — -- - -------- ----- _-- -- _ date Permit No. -- -�©�3 f01,9- -- Issued V//l_ _ __--_-_-_ date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS T CER I e Indivi al We CDnstructed ( , Altered ( ), or Repaired ( ) by- —� M — J--- �rk/l ----------------— — -- —------ --------- Installer at- -— ------------ -- — ---------- -------- has been installed in accordance with the provisions of the Town of Barnstable Board of Health P 'vate Well Protection Regulation as described in the application for Well Construction Permit No� ated-- - THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE------------ —- -- Inspector-- - — - - - - - ---------- • psi __ No. --- - -- Fee-- =-=---------- rf BOARD OF HEALTH TOWN -OF BARNSTABLE CP�s 2pplicat ion ArVeil Conotruct ion Permit `—Application is hereby made for a permit to Construct ", ter ( ), or Re it ( )an indiv• ual Well at: L ocation Address 'Assessors Map and Pircel Owner — Address 1F0 o'� y�-�-d 50- .t•no�/G� /4-455 Installer — Driller / — — Add Type of Building Dwelling -------- -- ------ Other - Type of Buildings-------------- No. of Persons--------------------__ Type f Well � — ------- Capacity - �'`�----- YP o e T --- - , — Purpose of Well--* - - �— ------ Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a-Ce ificate ofi o ,pli ce has been issued by the Board of Health. Signed 3 — G � "Application Approved By--, a t "A (te PP PP - - date Application Disapproved for the following rea Z ---------------------- ------------ ----------- - — ------------ /--- - ------- date --_ Permit No. -� - — Issued-- �l- ---- - --- j date BOARD OF HEALTH TOWN OF BARNSTABLE f Certificate Of Compliance THIS IS TO CERTIFY, TJhh Indivi luaal Well ��on�struucted (%, Altered(& ), or Repaired ( ) bY-------i/K�`� 1-"fa-1 ---� -f� ��- -'- -- ------------- — --- ---_ -- Installer at- - — --------- has been installed in accordance with the provisions of the Town of Barnstable Board of Health Pp"vate Well Protection Regulation as described in the application for Well Construction Permit No ated-- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE.CONSTRUED AS A GUARANTEE THAT THE.WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE--------- — —- -- Inspector-------- -- - —------- BOARD OF HEALTH TOWN OF BARNSTABLE Yell Construct ion Permit <' [hJ-No . k_ 0�__007 Fee- - Permission is hereby granted L� ✓C -- ------------- to Consttr�uy (�V- lter ( ), or Repair ( ) an I�dividuaal Well at: MNo. — ''-�// -- / /- / St --------- - as shown on the implication f a We Construction Permit No. ��— _ Dated--r djl 1 l/_ ---- -- - / " ------ DATE Board of Health -- /�— M R .n•4' ti ,..� �.,w�sw�es .r�.��y',xu i•;tl, Appucati t': tq 4t �rvperty: l� �i Nqti C • � 1 a t4u4(s w 15(7't dLrd C�OtUkt---" 9VacC Mood fxm t ': 26ojX1 DG(5C flood ion¢: c + I"of ♦ y h FJ CeC'l=t 'tt1Qt t 5 trlort�age mpwtion � Cpajv&-f r oo PAUL T. f u GROVER u 1 r .� KQ 31311 glu dweU,cng ha wm dy., -t-t --fau im a,speaca `r mA =a with can,e*cCwe daft of the dwelling does r,�mnrm -the local ��ning 6y-laws in.¢ ar' at the tune oFcorutruction with. respeet'to }torizpafat dune vsionaT scale: t setback-re or is ew=pr yr , vwlat ton. aDF0rcet1'L tW Date: A_A-a 1 cZtwtt Under M=. Gawratlaws Chaptw40A•Seett'0TV7. File No. oa - (492 PLEASE NOTE: The structures as shown on this plot plan are approximate only. An actual survey is necessary for a precise determination of the building location and encroachments. if any exist, either way across property tines. This plan must not be used for recording purposes or for use in preparing deed descriptions and must not be used for variance or building plan purposes. This plan must not be used to locate property lines. Verification of building locations. property line dimensions, fences or lot configuration can only he accomplished by an accurate instrument survey which may reflect different information than what is shown hereon. Please note that this is "NOT A BOUNDARY SURVEY" and is 'FOR MORTGAGE PURPOSES ONLY". COLONIAL LAND SURVEYING COMPANY, INC. u 269 Hanover Street - Hanover, Mass. 02339 • Phone: 781-826-7186 Fax: 781-826-4823 s t t COMMONWEALTH OF MASSACHUSETTS x EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION Y F 350 MAIN STREET & WEST YARMOUTH,MA 508-775-2800 TITLE,5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A �D CERTIFICATION �� Property Address: 71 ROUTE 149 y o 2 2091 MARSTONS MILLS,MA 02648 MA O-,vner's Name: INN AT THE Mii_,LS OF 13 R' A6LE 0,xner's Address: 71 ROUTE 149 TOWHEALfH t)Ep7- MARSTONS MILLS,MA 0 2648 Date of Inspection APIZIL 9.2001 Name of inspector:(please print) JAMES D. SEA1tS Company Name: A&I3 Canco Mailing Address: 350 Main Street West Yannoudi,MA 02673 Telephone Number: 508-775-2800 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of 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 Inspector's Signature: Date: The system inspector shaisubinita 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 tot he buyer,if applicable,and the approving authority. Notes and Comments NOTE: SYSTEM 2 ON PLAN. REPORT 3 OF 4, SYSTEM FOR INN LEFT SIDE. ****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 1 I � Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 71 ROUTE 149 MARSTONS MILLS,MA 2648 Owner: INN AT THE MILLS Date of Inspection: APRIL 9,2001 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 CUR 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 exfrltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with 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: Title 5 Inspection Form 6/15/2000 2 f Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 71 ROUTE 149 MARSTONS MILLS,MA 02648 Owner: INN AT THE MILLS Date of Inspection: APRIL 9,2001 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 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 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 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 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: Title 5 Inspection Form 6/15/2000 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 71 ROUTE 149 MARSTONS MILLS,MA 02648 Owner: INN AT THE MILLS Date of Inspection: APRIL 9,2001 D. System Failure Criteria applicable to all systems: N/A 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 leaching is less than 6"below invert or available volume is less than%2 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 N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A 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 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: N/A To be considered a large system the system must service 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—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 is 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. Title 5 Inspection Form 6/15/2000 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 71 ROUTE 149 MARSTONS MILLS,MA 02648 Owner: INN AT THE MILLS Date of Inspection: APRIL 9,2001 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 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)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(3xb)] Title 5 Inspection Form 6/15/2000 5 L Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 71 ROUTE 149 MARSTONS MILLS,MA 02648 Owner: INN AT THE MILLS Date of Inspection: APRIL 9,2001 FLOW CONDITIONS RESIDENTIAL Number of Bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no): [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use(yes or no): Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no) Last date of occupancy: COMMERCIALANDUSTRIAL Type of establishment: INN Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): YES,NO FRONT SYSTEM Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: N/A Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: gallons—How was quantity pumped determined? 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 copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 1987 Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 II- OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 71 ROUTE 149 MARSTONS MILLS,MA 2648 Owner: INN AT THE MILLS Date of Inspection: APRIL 9,2001 BUILDING SEWER(locate on site plan): N/A Depth below grade: Materials of construction: Cast iron _ 40 PVC _ other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): X Depth below grade: 30" 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: 1,500 GALLON PRE CAST Sludge depth: 2" Distance from top of sludge to the bottom of outlet tee or baffle: 28" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 12" Distance from bottom of scum to bottom of outlet tee or baffle: 17" How were dimensions determined: ASBUILT AND PLAN Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): TANK AT WORKING LEVEL.INLET TEE,OUTLET BAFFLE.OUTLET COVER 30"BELOW GRADE. TANK SHOULD BE PUMPED. GREASE TRAP(located on site plan) NOTE: NO FRONT SYSTEM Depth below grade: Material of construction: _ concrete metal _ fiberglass _ polyethylenes 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.): Title 5 Inspection Form 6/15/2000 7 L Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 71 ROUTE 149 MARSTONS MILLS,MA 02648 Owner: INN AT THE MILLS Date of Inspection: APRIL 9,2001 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: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.,): D-BOX IS 16"X21",28"BELOW GRADE.ONE LINE IN,FOUR LINES OUT. BOX IS CLEAN AND LEVEL. NO SIGN OF OVERLOADING. 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.): Title 5 Inspection Form 6/15/2000 8 f Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 71 ROUTE 149 MARSTONS MILLS,MA 02648 Owner: INN AT THE MILLS Date of Inspection: APRIL 9,2001 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: leaching galleries,number leaching trenches,number,length X leaching fields,number,dimensions: 25'X32' 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.) PROBED ABOVE AND AROUND FIELD,AREA DRY. NO SIGN OF OVERLOADING OR BACK UP IN BOX. CESSPOOLS: N/A (cesspool must be pumped as part of inspectionX 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,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Title 5 Inspection Form 6/15/2000 9 I Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contumed) Property Address: 71 ROU'I"E 149 MARSTONS MILLS,MA 02648 Owner: INN A'I R IE MILLS Date of Inspection: APRIL 9,2001 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two pennanent reference landmarks or benchmarks. Locate all wells within 100 feet. I_,ocate where public water supply enters the building. N Al PS x0Al Title 5 Inspection Form 6;'15/2000 10 I� Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 71 ROUTE 149 MARSTONS MILLS,MA 02648 Owner: INN AT THE MILLS Date of Inspection: APRIL 9.2001 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to no groundwater 13 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: Observation 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: GROUND WATER TAKEN OFF PLAN AT HEALTH DEPARTMENT. Title 5 Inspection Form 6/15/2000 11 I COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL.AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 350 MAIN STREET WEST YARMOUfII,MA 508-775-2900 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FO PART A RECEIVED CERTIFICATION c� Property Address: 71 ROUTE 149 MAY - 2 2001 MARSTONS MILLS,MA 02648 TOWN OF BARNSTABLE Owner's Name: INN AT TUIE MILLS HEALTH DEPT. Okvuer's Address: 71 ROUTE 149 MARSTONS MILLS,MA 02648 Late of Inspection APRIL 9,2001 Name of Inspector:(please print) JAMES D.SEARS Company Name: A&B Canco Mailing Address: 350 Main Street West Yarmouth,MA 02673 _ Telephone Number: 508-775-2800 CERTIFICATION STATEMENT I certify that I leave 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(31.0 CM 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: The system inspector shf 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 Lie 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 tat he buyer, if applicable,and the approving authority. Notes and Comments NOTE: SYSTEM FOR COTTAGE, REPORT 2 OF 4. ****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 1 r Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 71 ROUTE 149 MARSTONS MILLS,MA 02648 Owner: INN AT THE MILLS Date of Inspection: APRIL 9,2001 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 tank failure is imminent. System will pass inspection if the existing tank is replaced with 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 Healthy' broken pipe(s)are replaced obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 2 Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 71 ROUTE 149 MARSTONS MILLS,MA 02648 Owner: INN AT THE MILLS Date of Inspection: APRIL 9,2001 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 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 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 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 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: Title 5 Inspection Form 6/15/2000 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 71 ROUTE 149 MARSTONS MILLS,MA 02648 Owner: INN AT THE MILLS Date of Inspection: APRIL 9,2001 D. System Failure Criteria applicable to all systems: N/A 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 N/A 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 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: N/A To be considered a large system the system must service 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—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 is 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 CUR 15.304. The system owner should contact the appropriate regional office of the Department. Title 5 Inspection Form 6/15/2000 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 71 ROUTE 149 MARSTONS MILLS,MA 02648 Owner: INN AT THE MILLS Date of Inspection: APRIL 9,2001 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 manholes uncovered,opened,and the interior was inspected for the condition of tees, materials 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)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(3xb)] Title 5 Inspection Form 6/15/2000 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 71 ROUTE 149 MARSTONS MILLS,MA 02648 Owner: INN AT THE MILLS Date of Inspection: APRIL 9,2001 FLOW CONDITIONS RESIDENTIAL Number of Bedrooms(design): 1 Number of bedrooms(actual): 1 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 110 Number of current residents: N/A Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): N/A [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use(yes or no): YES Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no) NO Last date of occupancy: N/A COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CUR 15.203): 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 Source of information: N/A Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system X Cesspool X 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 copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: UNKNOWN Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 71 ROUTE 149 MARSTONS MILLS,MA 2648 Owner: INN AT THE MILLS Date of Inspection: APRIL 9,2001 BUILDING SEWER(locate on site plan): N/A Depth below grade: Materials of construction: Cast iron _ 40 PVC _ other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): N/A Depth below grade: Material of construction: 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: Sludge depth: Distance from top of sludge to the bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom 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,evidence of leakage,etc.): GREASE TRAP(located on site plan) N/A 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.): Title 5 Inspection Form 6/15/2000 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 71 ROUTE 149 MARSTONS MILLS,MA 02648 Owner: INN AT THE MILLS Date of Inspection: APRIL 9,2001 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 resent must be o ened locate on site plan) ( P P )( 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.): Title 5 Inspection Form 6/15/2000 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 71 ROUTE 149 MARSTONS MILLS,MA 02648 Owner: INN AT THE MILLS Date of Inspection: APRI1,9,2001 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: leaching galleries,number leaching trenches,number,length leaching fields,number,dimensions: X overflow cesspool,number: 1 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.) SAS IS ONE BLOCK CESSPOOL.T DEEP,HIGH STAIN LINE AT T UP WALL.COVER 16"BELOW GRADE. NO SIGN OF OVERLOADING. WALLS ARE CLEAN. CESSPOOLS: X (cesspool must be pumped as part of inspectionX locate on site plan) Number and configuration: 1 Depth—top of liquid to inlet invert: 6" Depth of solids layer: 3" Depth of scum layer: 0" Dimensions of cesspool: 6'6" Materials of construction: BLOCK Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): MAIN POOL 18"STEEL COVER AT GRADE. POOL 18"BELOW GRADE.POOL AT WORKING LEVEL.NO INLET OR OUTLET TEES. PRIVY: N/A (locate on site plan) Materials of Construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Title 5 Inspection Form 6/15/2000 9 Page 9 of'] OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 71 ROUTE 149 MARS-TONS MILLS,MA 02648 Owner: [NN A'f THE7MIUS Date of Inspection: APRIL 9,2001 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. Locale where public water supply enters the building. dle fj a O Title 5 Inspection Form 6'15/2000 10 r Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 71 ROUTE 149 MARSTONS MILLS,MA 02648 Owner: INN AT THE MILLS Date of Inspection: APRIL 9,2001 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to no groundwater 13 feet Please indicate(check)all methods used to determine the high ground water elevation: X Obtained from system design plans on record-If checked,date of design plan reviewed: Observation 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: GROUND WATER DEPTH OFF PLAN AT HEALTH DEPARTMENT. Title 5 Inspection Form 6/15/2000 11 t I e COMMONWEALTH OF MASSACHUSETTS _ EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 350 MAIN STREET WEST YARMOUTH,MA 508-775-2800 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 71 ROUTE 149 MARSTONS MILLS,MA 02648 RECEIVED Owner's Name: TNN AT THE M1.L,LS Owner's Address: 71 ROUTE 149 MARSTONS MILLS,MA 20648 MAY - 2 2001 Date of Inspection APRIL 9,2001 TOWN OF 13ARNSTABLE Name of Inspector:(please print) JAMI S D.SEARS HEALTH DEPT. Company Name: A&B Cauco Mailing Address: 350 Main Street West Yarmouth,MA 02673 Telephone Number: 508-775-2800 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at tlus 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 Inspector's Signature: Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. if the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent tot he buyer, if applicable,and the approving authority. Notes and Comments NOTE: SYSTEM 1 ON PLAN,FRONT SYSTEM IN REPORT 4 OF 4 ****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 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 71 ROUTE 149 MARSTONS MILLS,MA 02648 Owner: INN AT THE MILLS Date of Inspection: APRIL 9,2001 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 tank failure is imminent. System will pass inspection if the existing tank is replaced with 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: Title 5 Inspection Form 6/15/2000 2 t � Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 71 ROUTE 149 MARSTONS MILLS,MA 02648 Owner: INN AT THE MILLS Date of Inspection: APRIL 9,2001 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 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 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 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 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: Title 5 Inspection Form 6/15/2000 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 71 ROUTE 149 MARSTONS MILLS,MA 02648 Owner: INN AT THE MILLS Date of Inspection: APRIL 9,2001 D. System Failure Criteria applicable to all systems: N/A 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 pits 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 N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A 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 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: N/A To be considered a large system the system must service 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—IWPA)or a mapped Zone H 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 is 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. Title 5 Inspection Form 6/15/2000 4 f Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 71 ROUTE 149 MARSTONS MILLS,MA 02648 Owner: INN AT THE MILLS Date of Inspection: APRIL 9,2001 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 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)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(3xb)] I Title 5 Inspection Form 6/15/2000 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 71 ROUTE 149 MARSTONS MILLS,MA 02648 Owner: INN AT THE MILLS Date of Inspection: APRIL 9,2001 FLOW CONDITIONS RESIDENTIAL Number of Bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no): [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use(yes or no): Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no) Last date of occupancy: COMMERCIALANDUSTRIAL Type of establishment: INN Design flow(based on 310 CUR 15.203): Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): YES Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: N/A Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: gallons—How was quantity pumped determined? 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 copy of the DEP approval X Other(describe): GREASE TRAP Approximate age of all components,date installed(if known)and source of information: 1987 Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 71 ROUTE 149 MARSTONS MILLS,MA 02648 Owner: INN AT THE MILLS Date of Inspection: APRIL 9,2001 BUILDING SEWER(locate on site plan): N/A Depth below grade: Materials of construction: Cast iron _ 40 PVC _ other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): X Depth below grade: 26" 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: 1,500 GALLON PRE CAST-NOTE:OUTLET COVER UNDER BLACK TOP Sludge depth: N/A Distance from top of sludge to the bottom of outlet tee or baffle: N/A Scum thickness: 1" Distance from top of scum to top of outlet tee or battle: N/A Distance from bottom of scum to bottom of outlet tee or baffle: N/A How were dimensions determined: PLAN AND TAPE Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): TANK AT WORKING LEVEL.TWO INLET TEES,ONE FROM INN,ONE FROM GREASE TRAP. 2' STEEL INLET COVER. OUTLET COVER UNDER BLACK TOP. GREASE TRAP(located on site plan) X Depth below grade: 24" Material of construction: X concrete metal fiberglass _ polyethylene other (explain): Dimensions: 1,000 GALLON PRE CAST Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: N/A Distance from bottom of scum to bottom of outlet tee or baffle: N/A Date of last pumping: N/A Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert;evidence of leakage,etc.): GREASE TRAP AT WORKING LEVEL. T STEEL INLET COVER. OUTLET COVER UNDER BLACK TOP. Title 5 Inspection Form 6/15/2000 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 71 ROUTE 149 MARSTONS MILLS,MA 02648 Owner: INN AT THE MILLS Date of Inspection: APRIL 9,2001 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: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.,): D-BOX IS 14"X22",34"BELOW GRADE. BOX IS CLEAN.ON LINE IN,TWO LINES OUT. 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.): Title 5 Inspection Form 6/15/2000 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 71 ROUTE 149 MARSTONS MILLS,MA 02648 Owner: INN AT THE MILLS Date of Inspection: APRIL 9,2001 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type, X leaching pits,number: 2 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.) TWO 4'PRE CAST PITS.PIT(1)4'BELOW GRADE. 30"TO COVER. 18"CEMENT COVER. PIT(2)4' BELOW GRADE. 34"TO COVER. 18"CEMENT COVER. BOTH PITS 4"WATER,NO HIGH STAIN LINE WALLS ARE CLEAN. CESSPOOLS: N/A (cesspool must be pumped as part of inspectionXIocate 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,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Title 5 Inspection Form 6/15/2000 9 Page 9 of I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contuiued) Property Address: 71 ROUTE 149 Iv1-ARSTONS MILLS,Mtn 02648 Owner: INN hT TI E, MILLS Date of Inspection: APRIL 9,2001 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. F�°� _ 31' 3S 0 p i r0 cro") Title 5 Inspection Form 6/15/2000 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 71 ROUTE 149 MARSTONS MILLS,MA 02648 Owner: INN AT THE MILLS Date of Inspection: APRIL 9,2001 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to no groundwater 13 feet Please indicate(check)all methods used to determine the high ground water elevation: X Obtained from system design plans on record-If checked,date of design plan reviewed: Observation 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: GROUND WATER OFF PLAN AT HEALTH DEPARTMENT. Title 5 Inspection Form 6/15/2000 11 COMMONWEALTH OF MASSACHUSE'TTS x z - EXECUTIVE OFFICE OF ENVIRONMENTAL A- FFAIR.S d DEPARTMENT OF ENVIRONMENTAL PROTECTION Ep 350 MAIN STREET WEST YARMOUTH,MA 508-775-2800 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 71 ROUTE 149 MARSTONS MILLS,MA 02648 RECEIVED Owner's Name: INN AT THE MILLS Owner's Address: 71 ROUTE 149 MAY •MARSTONS MILLS,MA 02648 2 200, Date of Inspection APRIL 9,2001 TOWN OF BARNSTABLE Name of Inspector:(please print) JAMES D.SEARS HEALTH DEPT. Company Name: A&I3 Canco Mailing Address: 350 Main Street West Yarniouth,MA 02673 Telephone Number: 508-775-2800 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function acid maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 1.5.340 of Title 5(310 CM R 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: The system inspector sha Ysubinfit. a copy of this inspection report to the Approving Authority(Board of Health or DEP)witlwn 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 sliall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent tot he buyer,if applicable,and the approving authority. Notes and Comments SYSTEM FOR APARTMENT—REPORT I OF 4 ****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 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 71 ROUTE 149 MARSTONS MILLS,MA 02648 Owner: INN AT THE MILLS Date of Inspection: APRIL9,2001 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 tank failure is imminent. System will pass inspection if the existing tank is replaced with 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: Title 5 Inspection Form 6/15/2000 2 i Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTIN[IED) Property Address: 71 ROUTE 149 MARSTONS MILLS,MA 02648 Owner: INN AT THE MILLS Date of Inspection: APR1L 9,2001 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 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 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 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 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: Title 5 Inspection Form 6/15/2000 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 71 ROUTE 149 MARSTONS MILLS,MA 02648 Owner: INN AT THE MILLS Date of Inspection: APRIL 9,2001 D. System Failure Criteria applicable to all systems: N/A 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 pit is less than 6"below invert or available volume is less than Yz 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 N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A 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 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: N/A To be considered a large system the system must service 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—1WPA)or a mapped Zone H 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 is 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. Title 5 Inspection Form 6/15/2000 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 71 ROUTE 149 MARSTONS MILLS,MA 02648 Owner: INN AT THE MILLS Date of Inspection: APR1L 9,2001 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 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)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(3xb)] Title 5 Inspection Form 6/15/2000 5 r Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 71 ROUTE 149 MARSTONS MILLS,MA 02648 Owner: INN AT THE MILLS Date of Inspection: APRIL 9,2001 FLOW CONDITIONS RESIDENTIAL Number of Bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CUR 15.203(for example: 110 gpd x#of bedrooms: 220 Number of current residents: N/A Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): N/A [if yes separate inspection required] Laundry system inspected(yes or no): N/A Seasonal use(yes or no): YES Water meter readings,if available(last 2 years usage(gpd)): N/A Sump pump(yes or no) NO Last date of occupancy: N/A COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CUR 15.203): 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 Source of information: N/A Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: gallons—How was quantity pumped determined? 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 copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 1986 Were sewage odors detected when arriving at the site(yes or no): NO Tide 5 Inspection Form 6/15/2000 6 i FOR L ASSESSMENTS OFFICIAL INSPECTION FORM—NOT O VOLUNTARY TARY SS SSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 71 ROUTE 149 MARSTONS MILLS,MA 02648 Owner: INN AT THE MILLS Date of Inspection: APRII,9,2001 BUILDING SEWER(locate on site plan): N/A Depth below grade: Materials of construction: Cast iron _ 40 PVC _ other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): X Depth below grade: 2' 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: 1,000 GALLON PRE CAST Sludge depth: 4" Distance from top of sludge to the bottom of outlet tee or baffle: 26" Scum thickness: 4" Distance from top of scum to top of outlet tee or baffle: 12" Distance from bottom of scum to bottom of outlet tee or baffle: 14" How were dimensions determined: ASBUILT AND TAPE Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): TANK AT WORKING LEVEL. INLET TEE,OUTLET BAFFLE.INLET COVER 18"STEEL AT GRADE. TANK SHOULD BE PUMPED. GREASE TRAP(located on site plan) N/A 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.): Title 5 Inspection Form 6/15/2000 7 I Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 71 ROUTE 149 MARSTONS MILLS,MA 02648 Owner: INN AT THE MILLS Date of Inspection: APRIL 9,2001 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.): i DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.,): D-BOX NOTED ON PLAN,LOCATED ON SITE 4'BELOW GRADE. DID NOT OPEN,NO SIGN OF OVERLOADING IN TANK OF PIT.LOCATION OF BOX ON SIDE OF HILL. 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.): Title 5 Inspection Form 6/15/2000 8 I ` Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 71 ROUTE 149 MARSTONS MILLS,MA 02648 Owner: INN AT THE MILLS Date of Inspection: APRIL 9,2001 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type X leaching pits,number: 1 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.) ONE(1)4'Prr.PIT 8'BELOW GRADE. 18"WATER IN PIT.NO HIGH STAIN LINE. COVER 4"BELOW GRADE. NO SIGN OF OVERLOADING CESSPOOLS: N/A (cesspool must be pumped as part of inspectionXIocate 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,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Title 5 Inspection Form 6/15/2000 9 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 71 ROUfE 149 MARSTONS MILLS,MA 02648 Owner: INN AT T11E MILLS Date of Inspection: APRIL 9,2001 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties tout least two pennaneut reference landmarks or benclunarks. Locate all wells witlun 1.00 feet. Locate where public water supply enters the building. �.O �- Jk- 3 O Title 5 Inspection Form�6/15/2000 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 71 ROUTE 149 MARSTONS MILLS,MA 02648 Owner: INN AT THE MILLS Date of Inspection: APRIL 9,2001 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to no groundwater 13 feet Please indicate(check)all methods used to determine the high ground water elevation: X Obtained from system design plans on record-If checked,date of design plan reviewed: Observation 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: GROUND WATER DEPTH OFF PLAN AT HEALTH DEPARTMENT. Title 5 Inspection Form 6/15/2000 11 a oc1HE Town af Barnstable * BAMSrABLF, Department of Health, Safety, and Environmental Services 9� , �� Public Health Division prFD1A°�p P.O. Box 534, Hyannis MA 02601 Office: 508-862-4644 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health SEATING ANNUAL SEASONAL ASSESSORS MAP AND PARCEL NO. ej 7 I•--O:Z DATE 9152 APPLICATION FOR PERMIT TO OPERATE Ap FOOD ESTABLISHMENT FULL NAME OF APPLICANT LQJ [1C. NAME OF FOOD ESTABLISHMENT IY2,c- ��es ADDRESS OF FOOD ESTABLISHMENT I i i - T TELEPHONE NUMBER�M TYr OF ESTABLISHMENT: FOOD SERVICE —�/RETAIL FOOD >� BED AND BREAKFAST CONT.BR. RES.KITCHEN ✓ MOBILE FOOD TOBACCO SALES FROZEN DESSERT CATERING SOLE OWNER: YES NO IF APPLICANT IS A PARTNERSHIP,FULL NAME AND HOME ADDRESS OF ALL PAR ERS: he y -7O o lb�17DAJS 4/U---,9j A6 0,-2-G �(r IF APPLICANT IS A CORPORATION: FEDERAL IDENTIFICATION NO. STATE OF INCORPORATION / S dGIJ-L>g-",'-T 7� FULL NAME AND HOME ADDRESS OF: PRESIDENT tt&Z/ -VLO W"� - TREASURER �� e2� A41Wrrn/5 l�l/�S , /� ��-(�yp CLERK SIGNATURE OF APPLICANT RESTRICTIONS: HOME ADDRESS ®u '?®O HOME TELEPHONE# foodest/db/q . *r.iancY'"•-wr..sv.�t^r�^��*vn:P��.:,t+r�'r. ��-.�,r�v'�,.^�.+,,,.,�... .,.«,�.ti;R„'u•.�..+�..r...• f�n...��.•..,.arr�'* �. ., .�r.. - ,.,- .. - «3,�.'•r�'�..:txn�,y�-�rryr�..r:'- -. .... Name: az, r ' f please print Name of Food Establishment: ;i:l Location of Establishment: '71 ✓r /`a, s . ,f'i /a J,; street name and village Today's Date: I Town of Barnstable Board of Health 9� 1 `0� 167 Main Street,Hyannis,MA 02601 j j CERTIFICATE Of ATTENDANCE Safe Food Handling Training j ------------------------------------------------------------------------------------------------------------------------------ OFFICE USE ONLY This certificate of attendance expires two years after the date of attendance. '" APR 29 1998 verification TOWN OF HEALTH DESTABLE i HEALTH DEPT. i./+ FEES RETAIL FOOD STORE: FOOD SERVICE ESTABLISHMENT $45.00 RESIDENTIAL KITCHEN FOR RETAIL SALE SEATING: RESIDENTIAL KITCHEN FOR BED+BREAKFAST MOBILE FOOD UNIT: ANNUAL: YES _ TOBACCO SALES: SEASONAL: CATERER: TEMPORARY: FROZEN DESSERT: MILK: TOWN'OF.BARNSTAB4E � r BOARDQF HEA g PERMITJQr OPER T A F070ME,STABLISHMENT PERMIT NO: 501 9 JANUARY 1, 1997 x r ;� erg,•., In accordance wlth469ulations promulgated under authoirity of'Chapter 94, Section 395A anc Chapter 111, S,eo>iorr 5"e GeneralaLawsi a-;permit is hereby granted to: WILLIAM G. HENRY S '3 D/B/A: INN AT THE MILLS $ s Whose place of businessggqisy: 7.1POTUIT MILLS;; AAJ){$02648 y= Type of business and any estrjRt ns: IN .a} 'D ILISHMLTT�` ; - f� , To operate a-food establish the TOW Ot-� ►, TABU . Permit expires: December 31 99, MOOBOARD OF HEALTH - Susan.G. Rask,R.S.,Chairperson Brian R.Grady,R.S. RESTRICTIONS IF ANY:. A Ra1ph.A.Murphy, M.D. t 77 w r7 Thomas A:McKean,`R S. 'CHO` - Director of Public Health Ti '^. ,r -v' �..r+•, s.< •1 w w 4',+a t-. .air"e!-'j 4 14r "."a' w.. ,.tro:ira'v<° .T ,y ;L TOWN OF BARNSTABLE BOARD OF HEALTH f ARTICLE 11:MINIMUM STANDARDS FOR HUMAN HABITATION Date ` MIL Owner �' ` LS Tenant lJ Address Address 4 Y fi 2& r 4 Complionce , Remarks or Regulat�ioni#� < Yes No Recommendations i 2. Kitchen Facilities x 1 . 3. Bathroom Facilities V \ N N IV 4. 4ter Supply f�'( '1 ' 6 v ►1v 5. Hoot Water Facilities 6. Heating Facilities /� A / 7. Lighting and Electrical Facilities l9 8. Ventilation ° "t 9. Installation and Maintenance of Facilities V, 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 'ro(A So { 15. Garbage and Rubbish Storage and Disposal 1� r +U f 16. Sewage Disposal �/� \�V(��f Y) /;�"ro 17. Temporary Housing ---- j PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition CD Person(s) Interviewed Inspector C/ If Public Building such as Store or Hotel/Motel specify here HOBB3&WARREN.INC. r 4 oF1NE rti Town of Barnstable Board of Health • BARNSTABLE, y MAC $ 367 Main Street,Hyannis MA 02601 i63q. �0 �AIFD MA'S A CERTIFICATION OF ATTENDANCE Safe Food Handling Training Name: � please print ' Name of Food Establishment: '�'� Today's Date: ---------------------------------------------------------------------------- This certificate of attendance expires two years after the date of attendance. Verficatiox(/ �. FEES RETAIL FOOD STORE: FOOD SERVICE ESTABLISHMENT: RESIDENTIAL KITCHEN FOR RETAIL SALE: SEATING: IA RESIDENTL KITCHEN FOR BED+BREAKFAST: $40.00 MOBILE FOOD UNIT: ANNUAL: YES TEMPORARY FOOD ESTABLISHMENT: SEASONAL: CATERER: TEMPORARY: FROZEN DESSERT: MILK: TOWN OF BARNSTABLE BOARD OF HEALTH PERMIT TO OPERATE A FOOD ESTABLISHMENT PERMIT NO: 454 JANUARY 1, 1996 In accordance with regulations promulgated under.authority of Chapter 94, Section 395A and Chapter 111, Section 5 of the General Laws, a permit is hereby granted to: WILLIAM G.HENRY D/B/A: INN AT THE MILLS, THE Whose place of business is: 71 COTUIT ROAD , MARSTONS MILLS, MA 02648 Type of business and any restrictions: BED AND BREAKFAST ESTABLISHMENT To operate a food establishment in the TOWN OF BARNSTABLE Permit expires: December 31, 1996 . BOARD OF HEALTH Susan G. Rask, R.S., Chairperson Brian R. Grady, R.S. RESTRICTIONS IF ANY: Ralph A. Murphy, M.D. Thomas A. McKean, R.S., CHO Director of Public Health TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date -- ---- Owner ------b '^ '--.----_--____ --- Tenant -- --- Address ---7----rn-Y-r;' ------------------------------- Address ---------------------------------------------------------------------------- Compliance ;i Remarks or Regulation # Yes No Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply I r 5. Hot Water Facilities II / { I 6. Heating Facilities �f 7. Lighting and Electrial Facilities � I 8. Ventilation �• I 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents � I 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal i 17. Temporary Housing PART 11 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition II e j•" �Person(s) Interviewed ------------------- - ------------------------------ Inspector -; ------------------------------------- If Public Building such asr Store or Hotel/Motel specify here __________________________-_-----_____--_____-_-______-_-.-______-__-__--____--_--_-_--_--__ 5 NUMBER FEE THE COMMONWEALTH OF MASSACHUSETTS T014N of B R14STABLE Board of Health of PERMIT TO OPERATE A FOOD ESTABLISHMENT Permit No. 19 JA1iiJANY 1. 1945 In accordance with Regulations promulgated under authority of Chapter 94,Section 305A and Chapter 111, Section 5 of the General Laws a Permit is hereby granted to: PETER ERC'EG D/B/A THE INN AT THE MILLS Whose place of business is 71 COTUIT :ROAD. MAR.ST:INS MILLS Type of business and any restrictions BED AND BREAKFAST To operate a food establishment in TOWN OF BARt1STABLE (City or Town) Permit Expires DSCE14BER 31, 19 95 Copy Board This Copy To Be Retained By Local of Board of Health Health FORM 738 Re,1986 AGENT TOWN OF BARNSTABLE BOARD OF HEALTHr "R - ARTICLE 11:MINIMUM STANDARDS FOR HUMAN HABITATION Date Owner //,A nv► Iy Prr N. Tenant Address ICtX� VY1 Address Compliance Remarks or Regulation# Yes No Recommendations 2. Kitchen Facilities l 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities 6. Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use I�I 12. Exits 13. Installation and Maintenance of Structural Elements l i 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal '`` Y 17. Temporary Housing PART 11 elak 6 A 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition , Person(s)Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here HOBBS♦Ir WARREN,INC. r Thomas F. Geiler { »� TOWN OF BARNSTABLE Licensing Agent .0"a 790-6252 i •ba ❑New Application I f ! M Renewal LICENSE APPLICATION ❑Transfer Print or type only ❑Other........................ (Please bear down hard) V j3 Date ".1.2a.1/.9.4 14 Name of Applicant ...W.?.I1JAM...G.....H2D.ry.................:.........................D/B/A ....I.An...At....The...M1.I.1.S.,.Jrtc.................... FID # ....04-3174910 Corp. Name if Different ......................................................... .......................... Permanent Address of Applicant 11...Q91.01..R.Qay.,.. IdICSt.Q.CtS...M.0.1a,-YA..026.48................................................ LocalAddress of Applicant ............Sdme ........................................................................................................................................... # .....<,.'.......... fType of License ......I.Cut...t-J.o.l.d:exs..........................................................Status: Annual .........X...................Seasonal ............ f I. Name of Manager ..."!0.1.1 0A...5,....Hal ry.............................................................................................................. ..... PermanentAddress .....S Re......................................................................................................................................................................... Local Address Same .................................................................................................................................................................................................... ..........:....................Place of Birth Sdm..................:.............:....... ................................................................................. ! 42$-2967 �. Telephone # of Applicant: Home (.................).....4.�0-.,�6�3.f.............................................Bus (..5II�6)...................................... n . is Telephone # of Manager: Home Same........................................................Bus Sdme j Location of Business ................,��d(Cle................................................................................................................. ............................................ Mail Address if different PA.....B x...zon Idr.5.tons... ................................................................... I Assessor's Map #(s) ...............Q.7.7.................................................................Parcel #(s) .......Q07............................................................ j Any flammable substance or hazardous waste use in business (specify)"..........Q4.5...Reat.................................................. fIf new license - date of proposed opening ..........................................................I...............................................,:...,............................. ! This form must he completed at least twenty-one (21) days prior to the ffective date of license: This applica- tion will not be forwarded to the Licensing Authority for approval until °all necessary inspecticros are com- pleted. Inspections will be carried out during the twenty-one (21).-days p rior to the effective dalb, and if the , premises to be licensed are n•` ;n nertinn the issuance of any license will be delayed pending i reinspection at the convenien ................................... While-Licensing Aulhoriti- Canm1•-Health De panniew Gold-Building Commissioner Pink -Fim De partinent - 1 L. TOP OF FOUNDATION C CONCRETE COVER CONCRETE COVE CONCRETE COVERS Mr �0 ..4, CAST IRON I2"MAX, cC� -•rr MAX. 4 CAST I,'. p� . OR SCHEDULiE 40 • 12 MAX. P.V.C. PIPE OR SCHEDU, 40 4"SCHEDULE 40 PVC.(ONLY) PITCH 1/4-PER. P.V.C. PIPE PIPE - MIN. LEACH DPITCH 1/4"f PITCH 1/4'PER.FT PIT PRECAST -INVERT f/ Z O �J L� J LEACHING l� e F NVERT fr 7t:; a o ` E TX'N/% EL. INVERT w -I / '-- -INVERT • 6.4. , PIT OR r DIST, EL. EQUIV a e INVERT /000 SEPTIC TANK EL. BOX :0, nt �p e' EL..x7. r4 _ M' v �° GAL INVE - ` I INVERT •ww 3/4"TOIV: , t , EL . EL r. Ii �n o�. WASHED K � /-'.�'•� . GAL . INVERT / e w STONE s DIA. �... o �-- DIA. t ` f/. T i , o. • I' GROUNDy WATER TABLE PROFI L.E. OF SEWAGE DISPOSAL SYSTEM NO SCALE r / b "° v WITNESSED BY I SOIL. LOG v / / L0 7- 5 I ��+r r TIME .,:`., ?. . I ./. Z. . . . I .a/G. BOARD OF HEALTH r✓ r DATE. .. . . 4. "�c,.t' r TEST HOLE 1 TEST HOLE 2 ELEV. �DI�14JI�D• EF. 1L!ELL�!. . ENGINEER / I . . ELEV. . . . 1 \ s . DESIGN DATA ' � NUMBER OF BEDROOMS .giTci!�w TOTAL ESTIMATED FLOW . . y�'S . GALLONS/DAY V�`` _ `S t30TTOh1 LEACHING AREA /�-'•S.•� •1. SO.FT. /PIT G.P.A, _ _ yx ^� ��_ I L� SIDE LEACHING AREA �'S3•.9 . SOFT./ P1T/3B9�8 ' r�ic "�, � -� �� GARBAGE DISPOSAL �. .(50 /o AREA INCREASE) r � i -N\ �` 0 TOTAL LEACHING AREA Gfr� SQ.FT PERCOLATION RATE T/«! TLv� MIN/INCH Lj 'J 3", 1 ___1_� L� •, ice„ � a G �r ;y � WATER EN( •-NTFRED LEACHING AREA PER PERCOLATION RATE . . Ia . SQ.FT.I,,. O� L` AA B� tcw NU`MBER� OF LEACHING PITS�.y A .�i7S �c/if�Y \ (a, - � 1 � APPROVED BOARD OF HEALTH -•�` �- �� o' i�� f` l t `� '� SIDE s. . . . . . . . . . . . . . . . . . . . . . . . . . DATE . I V AGENT OR INSPECTOR A// � f r•ce,v� yam- j /z" �� EL TOP OF FOUNDATION \ . CON 7ETE COVERS '4"CAST IRON (PIPE (OR 12 MAX. 4"ORANGEBURG(OR EQUIV.) IEQUIV.)- MIN. 12"MIN. P>ITCH1/4"P'ER.FT. PIPE- MIN.71- I PITCH 1/4"PER.FT. 1 LEACHING FIELD (.S...REQUIRED) 1/g"- I/2" WASHED STONE 1 INVERT Li^ 4 ' ' e EL. ?.•.?. .'. / I INVERT INVERT WASHED g'Ip,{E 1 I SEPTIC TANK i DIST Q ,- 3/a"- I1/2" 'L �' �� • INVERT —� EL BOX -: J ~" ." EL GAL. INVERT-�-� INVERT y EL.�� EL PROFI LE OF Si=WAGE GROUND WATER TABLE SOIL LOG DISPOSAL SYSTEM TYPICAL CROSS SECTION DATA v4-^�E• ?•Y� �-;,y�E /o.o� NO SCALE LEACHING FIELD _ NO SCALE TEST ;-TOLE I TES' HOLE 2 E_Ev. .�-%Q . .. . . ELEV. DESIGN DATA NUMBER OF BEDROOMS ��' 12"MIN. WASHED„ 4,4? Ln•+*, STONE r vP JL ` TOTAL ESTIMATED FLOW . . .~ «. . .. GALLONS/DAY .t 4" 3OTT0M LEACHING AREA R� ez...B.o:� i .• . .. SO-F 1./T RENCH PLASTIC PI iz' SIDE LEACHING AREA '1/rv,c/E E' ��•ae�t.:r � . . . . . . .. . . SQ.FT./TRENCH / � a L 3/4-11/2 S�a!s..o GARBAGE DISPOSAL : . ..(50% AREA INCREASE) WASHED TOTAL LEACHING AREA 40�. . . ... SO.FT. , ' PERCOLATION RATE v 741✓ ti1V PER. NCH S ,.EACHING AREA PER PERCOLATION RATE .B��Y,., SO.FT APPROVED GROUND WATER (ABLE _ — — . . . . . BOARD OF ricdL'H WAT'cR ENCOUNitRED DATE - . . . . . . . . WITNESSED BY . AGENT OR NSPECTOR C'c-�'�sE L, Tug, % ��7 ter ' . L .•v.,ri�v� . 90AR0 'IF HE.:-" - . . . . . . . . . ` "L ENGINEER TONER G F Mqs E=04 s o�' ED')NARb u E. 5 7 KELLEY { Ivo. 2&1Cll �o 1 Ssr�NAL LAND SJ vr�r-rev.✓s e14--le r.. �i /`'i'�, f .SL- LG-�►/s'Z ,. I 33.83 .S) .5.7-&"2`'7 L. ITOP OF FOUNDATION CONCRETE COVER , CONCRETE COVE;ZS CONCRETE COVERS 4"CAST IRONm /r �n"'vr177n7 7nnr 'nrmT �mm�r o •'; OR SCHEDULE 40 4"CAST IR)N 12 MAX. 12'MAX. 12'MAX,MAX i OR SCHEDU -40 4"SCHEDULE 40 PVC (ONLY) u PITCH II/4 PER. P•V.C. PIPE PIPE - MIN. LEACH Q PITCH 1/4"> :R. PITCH 1/4"PER.FT Q �� PIT PRECAST INV!£RT N 2 0 u' -i LEACHING �� _ a e E 1 �.•.C` /, NVERT ! /: ?c, ' caa PIT OR rl�'E/nSE ?T'1��' EL..�.`l SEPTIC TANK EL VEST DIST. EL j= ; EQUIV o (INVERT /000 GAL . INVE T BOX o ,.• :.'�-►- j EL..zrl:r4 GAL . INVERT ��a �� V �� b kh �v : \� ,; EL.. �. . EL-: '7Z // t'% FL E� ww �. �. 3/WASHED i `, uw o \, _ � "j :•; STONE , DIA PROF( LE OF T�ffd � ` � / ; SEWAGE DISPOSAL SYS E , SCALE -j 1 � ' WITNESS , D, Y : �' ti \ SOII LOG f ,• l I L O 7- / r i�•• r, :"' T,�'.t1}/ Z��vn/ .. BOARD OF H LT � I DATE :.t+!�¢ �c�,'. TIME 0 /, ` J�+ ` +` TEST HOLE I TEST HOLE 2 �/Kf�'X�• EEZC ENGINEE I .f?� - ELEV. `' ELEV, AW / DES( N DATA NUMBER OF BEDRO MS 4G!!L^��•�! // \ TOTAL ESTIMATED LO GAL NS DAY t BOTTOM LEACHING ARE /4- Q.F /PI'�� tV7r, SIDE LEACHING A EA I. � ''� :9 Q.FT./ PIT3�9�8 �?� �> '�•w°' /e" �cs- _ l GARBAGE DISPOSAL /. (50b/o AREA IN EASE) TOTAL- LEACHING A EA'. .ty/ SCkFT i a' \� \ �' y'-�:•� �\ .� ! 4*iD ! PERCOLATION RATE k MIN /INCH > b •°'�c et,� LEACHING AREA PER P�RCO� TION RAT /��•� S .FT./a WATER Eh )UNTERED \ fi7.s ,. \ r 3 . . L ��0 NUMBER OF LEACHING QITS `' . APPROVED �, 4 ! r BOARD OF HEALTH o �� a' •_ O elecw DATE. . . . . . . . . `'� 4. AGENT OR INSPECTOR ' t Ott EL TOP OF FOUNDATION COr�RETE COVERS 4„CAST IRON l2"MAX. . Z'7� •....i .ciwi,s,at Cl.�nlr PIPE (OR r � P. EQUIV.)- MIN. 4"0RANGEBURG(OR EQUIV.) 12"MIN. Ir'' PITCH 1/4"PER.FT PI PE- M IN. PITCH 1/4"PER.FT. LEACHING FIELD (`1:..R IRED) 1/8"- 1/2 WASHED E, ' s .� � �'r• I1vv�RT :•! EL .,: .:...'.. INVERT_ INVERT S71ON WASHED i SEPTIC TANK DIST •.. INVERT �', EL " 7:Z1. BOX EL 5. 3/4 - i I/2' EL- �^ GAL. INVERT r 1 i EL 'K-t'" I INVERT ' • PROFI LE OF SEWAGE DISPOSAL GROUND WATER TABLE SOIL LOG L SYSTEM TYPICAL CROSS SECTION TIME io:oU a'' NO SCALE ;' LEACHING FIELD U TEST HOLE I - TES HOLE 2 !� � NO SCALE ELEV. . . . . . . . . . . DESIGN DATA e" ! 12 MIN. ' NUMBER OF BEDROOMS " I. SUNED `14 f TOTAL ESTIMATED FLOW . . . . .`!�? vA jON DAY 1 1 ,PLASTIC PIPE /Z' e,'Z.T.B�v BOT�M LEACHING AREA c'o SQ---�/ NCH 4 u II ! SIDE LEACHING AREA . . .!�a'�!� SQ.Fl./ i CH GARBAGE DISPOSAL `! Y'rx. . .(50% AREA INCR SE) L WASHED r 1 ' STONE -OTAL 'LEACHING AREA 7- L `. �J,. `}`J , /`7/�� PERCOLATION RATE ~•'� �Q- � E. Z� L:,ACHING AREA PER PERCOLa7ioN RATE .-'�=;�. . S _ rr __.. � /�Tj •�Rrz,te ,�,,,! GROUND WATER TABLE . -7- ��'' tz•/r'33cy APPROVED BOARC OF HEALTH Pe 7 e 1� `1 ,v4TEA ENCOUNTERED — — — — WITNESSED BY - AGENT OR INSPECTOR f� vc.oN.�//.%1* BOARD OF HEALTH ENGINEER �'E'iS•. Ls7-ri:} .SL/�{/E-yam . . . . . . . . . . . . . . . . . . . . . --�/'.1 "•1��t�� i� acT,T10NER i I s of Mgssq� I < sT sau F-MIARD ycs i v R.Nn O No. s E. I o� KELLEY No. 26100 ,o ,. � •9 �"� /'! OVAL LAMO