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HomeMy WebLinkAbout0929 SANTUIT-NEWTOWN ROAD - Health 929 S antu-Lt-Newtown iarstons Mills r A = 027 - 040 --- 1 k .f 0 r\ r + I i i i Fee/5� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pplicatlon for Misposal Opstem Construction Permit Application for a Permit to Consfruc`t( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ndividual Components Location Address or Lot No.49r14 Sr v • Owner's Name,Address,and Tel.No. Assessor's Map/Parcel CA— O �Or-Pe►h Installer's Name,Address,and Tel.No. Designer's Nam ,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan. Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Boar alth. Signe �_� Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. r 1 Date Issued ) Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2ppYication for Misposal *pstrm' Construction Permit - n ual Components for a Permit to CConsruct Repair( ) Upgrade Abandon ❑Complete System id Location Address or Lot No. ,qVT Sn v tv,r P e�- tgww Owner's Name,Address,and Tel.No. �MhptSCar� M Assessor's Map/Parcelyu F, ,% ; Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. er �`•tu ..�-... Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd .+.-.i, _. •._. . :.ge'-..t,.... .srto-.:`,sr. Plan Date -Number of sheets' Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil ++ Nature of Repairs or Alterations(Answer when applicable) } .� �4 e e� � , .�•t► i/t-�'C,.J ear�. TC�...,,. 1c.. � � �. �'p�r 4.5� � D 1 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board-bof Health. Signed!—`• _ \ v.. DateS- ( Application Approved by Date t 5 Application Disapproved by Date for the following reasons r r 6� Permit'No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS ` BARNSTABLE,MASSACHUSETTS ''neJ (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( ) `Abandoned( )by �A c \tr.)Le Dom - °•at �,��} cam.;i vs'f)N r►w T ow f`?_ Chas been constructed in accordance / rr with the provisions of Title 5 and the for Dispfsal System Construction Permit NAYS— t i dated 4 b 5 Installer C, \ewtl Y r to r l Sq— Designer Bedrooms Approved design flow �-" gpd . The issuance of this permit shall not be construed as a guarantee that the system will function as des,i ned. Date �� �!✓/� Inspector - -- ------------------------------ No. p``! 1 Fee /,50 �1 THE COMMONWEALTH OF MASSACHUSETTS r PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS - Misposal *pstent onstruttion Permit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at r" and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this p'•ermi Date L� C� Approved by N't I 314 7x S I i � 4 T � I { t 92� <,S"an,f�u i-4- -f(f P�,�e�,,,r+ �G��►'s'd�n� .�:�'�$; .�'"'�fs��`' f IKE Town of Barnstable Barnstable brtyvi . Regulatory Services Department A IARNSfAB14 I 9� " . ,� Public Health Division A 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A-McKean,CHO CERTIFIED MAIL# 7015 1730 0001 4987 6995 February 6, 2018—Revised Year Date ORTENZI,MARY P 318 N CENTRAL ST EAST BRIDGEWATER, MA 02333 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 The septic system located at 929 Santuit Newtown Road,Marstons Mills, MA was inspected on 1/22/2018 by Sean M. Jones, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Conditionally Passes" under the guidelines of 1995 TITLE V (310 CMR 15,00) due to the following: • Will need to install a pipe between septic tank and leaching. You are ordered to repair or replace the septic system within two (2)years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. 4PERER OF BOARD OF HEALTH Thomas cKean,R.S., CH0 Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mail ing\Conditional ly Passes Letters\929 Santuit Newtown Road Marstons Mills Revised YEAR date.doc 1 iioLn h ir I� OFFICIAL U—S- E 117 Certified Mail Fee $ _ o Extra Services&Fees(check box,add fee as appropriate) ❑Return Receipt(hardcop» $ n 0 ❑Return Receipt(electronic) $ 1-3 []Certified Mail Restricted Delivery $ '•yp � Here p []Adult Signature Required $ ❑Adult Signature Restricted Delivery$ O Postage'_ u I`- $ ra Total Po $ ,.ORTENZI, MARY P � Sent TOK� 318 N CENTRAL ST C3 �� e�ei EAST BRIDGEWATER, MA 02333 i Ciry-Sfax � Certified Mail service provides the following benefits: ■A receipt(this portion of the Certified Mail label). for an electronic return receipt,see a retail ■A unique identifier for your mailpiece. associate for assistance.To receive a duplicate ■Electronic verification of delivery or attempted return receipt for no additional fee,present this delivery. USPS®-postmarked Certified Mail receipt to the ■A record of delivery(including the recipient's retail associate. 2 signature)that is retained by the Postal Service- Restricted delivery service,which provides r for a specified period. delivery to the addressee specified by name,or to the addressee's authorized agent Important Reminders: Adult signature service,which requires the ..T ■You may purchase Certified Mail service with C. Y P signee to be at least 21 years of age(not First-Class Mail®,First-Class Package Service®, available at retaiq. --C or Priority WHO service. Adult signature restricted delivery service,which ■Certified Mail service is notavailable for requires the signee to be at least 21 years of age international mail. and provides delivery to the addressee specified ■Insurance coverage Is not available for purchase by name,or to the addressee's authorized agent with Certified Mail service.However,the purchase (not available at retail). CJ of Certified Mail service does not change the ■To ensure that your Certified Mail receipt is insurance coverage automatically included with accepted as legal proof of mailing,it should bear a certain Priority Mail items. USPS postmark.If you would like a postmark on ■For an additional fee,and with a proper this Certified Mail receipt,please present your endorsement on the mailpiece,you may request Certified Mail item at a Post Office'for the following services: postmarking.If you don't need a postmark on this -Return receipt service,which provides a record Certified Mail receipt,detach the barcoded portion of delivery(including the recipient's signature). of this label,affix it to the mailpiece,apply You can request a hardcopy return receipt or an appropriate postage,and deposit the mailpiece. electronic version.For a hardcopy return receipt, J. complete PS Form 3811,Domestic Return Receig attach PS Form 3811 to your mailpiece; IMPORTANT:Save this recefpt for your records. Ps Form 3800,APHI 2015(Reverse)PSN 7530-02-000.9047 ■ Complete items 1,2,and 3. 78c97eivedby ,,��,,'�{{�� -/ s Print your name and address on the reverse G �� ( Agent so that we can return the card to you. �j Addressee ■ Attach this card to the back of the mailpiece, ted Name) C. Date f jel�ery or on the front if space permits. J UI q 6 t D. Is delivery address different from item 1? ❑Yes If YES,enter delivery address below: p No 40RTENZI, MARY P 318 N'CENTRAL ST EA " BRIDGEWATER, MA 02333 II I IIIIII(III III i II II I III IIIII I II II I II II II III 3. Service Type ❑Priority Mail Express® ❑Adult Signature ❑Registered MaIIT"' ❑�4duit Signature Restricted Delivery ❑Registered Mail Restricted rtified Mail® qtlurn ivery 9590 9402 1933 6123 1781 25 El Certified Mail Restricted Delivery Receipt for ❑Collect on Delivery mhandise 2. Article Number(Transfer from service/atie0 _ ❑Collect on Delivery Restricted Delivery ❑Signature Confirmationm all ❑Signature Confirmation 7 015 17 3 0 0001 4 9 8 7 6995 ;1 Restricted Delivery Restricted Delivery PS Form 3811,July 2015 PSN 7530-02-000-9053 Domestic Return Receipt USPS TRACKING# First-Class Mail Postage&Fees Paid USPS . Permit No.G-10 9590 9402 1933 6123 1781 25 I United States •Sender:Please print your name,address,and ZIP+4®in this box• Postal Service --— �1 Town of Barnstable . I Health Division 200 Main Street Hyannis,MA 02601 Ln CO 3 cE) CertHied Mail Fee d Er Extra Services&Fees(check box,add fee as appropdate) ❑Return Receipt(hardcopy) $ in 0 ❑Return Receipt(electronic) $ �" Postmark J 0 ❑Certified Mail Restricted Delivery $ �A He- 0 ❑Adult Signature Required ❑Adult Signature Restricted Delivery$ ✓�� LZI Postage --- — -- ——- m $ Total Postage ) $ ORTENZI, MARY P Sent To 318 N CENTRAL ST o SiieeiandApt:C EAST BRIDGEWATER, MA 02333'-------"' - t~ __ ___ _ City,State,ZIPi ' }fir Certified Mail service provides the following benefits: •A receipt(this portion of the Certified Mail Isbell. for an electronic return receipt,see a retail •A unique identifier for your mailpiece. associate for assistance.To receive a duplicate •Electronic verification of delivery or attempted return receipt for no additional fee,present this. delivery. USPS®-postmarked Certified Mail receipt to the •A record of delivery(including the recipient's retail associate. LP _ signature)that is retained by the Postal Service- Restricted delivery service,which provides L for a specified period. delivery to the addressee specified by name,or to the addressee's authorized agent. i Important Reminders: Adult signature service,which requires the •You may purchase Certified Mail service with signee to be at least 21 years of age(not _y First-Class Mails,First-Class Package Services, available at retail). or Priority Mail®service. Adult signature restricted delivery service,which •Certified Mail service is notavailable for requires the signee to be at least 21 years of age international mail. and provides delivery to the addressee specified •Insurance coverage is notavailable for purchase by name,or to the addressee's authorized agent with Certified Mail service.However,the purchase (not available at retail). of Certified Mail service does not change the •To ensure that your Certified Mail receipt is insurance coverage automatically included with accepted as legal proof of mailing,R should bear a,. certain Priority Mail items. USPS postmark.If you would like a postmark on-, ■For an additional fee,and with.a proper this Certified Mail receipt,please present your endorsement on the mailpiece,you may request Certified Mail item at a Post Office'for ,T the following services: I postmarking.If you don't need a postmark on this -Return receipt service,which provides a record. Certified Mail receipt,detach the barcoded portion of delivery(including the recipient's signature), of this label,affix it to the mailpiece,apply - You can request a hardeopy return receipt or an appropriate postage,and deposit the mailpiece.- , electronic version.For a hardcopy return receipt, complete PS Form 3811,Domestic Retum Receipt attach PS Form 3811 to your mailpiece; IMPORTW.Save this receipt for your records. Ps Form 3800,April 2015(Reverse)PSN 7530-02-000-8047 SENDER'do !Sk6�1014 N Complete items 1,2,and 3. A. 7S' ature ■ Print.your'riame and address on the reverse X `Agent so that we can return the card to you. �'� G� ❑Adiinessee B. ceived by(Pri ted Name) C. to of ery N Attach this card to the back of the mailpiece, , or on the front if space permits. U _ 'i. D. is delivery address different from Kern 1 ❑Y If YES,enter delivery address below: p No ° ORTENZI, MARY P 4' 318 N CENTRAL ST EAST BRIDGEWATER, MA 02333 I II IIIIII IIII III I II II II I I I IIIII I II II III I III 3. Service Type ❑Priority Mail Express® ❑Adult Signature ❑Registered MaiIT"' � ❑AduR Signature Restricted Delivery ❑Registered Mail Restricted W 9590 9402 1933 6123 1785 52 ❑Certified Mail Restricted Delivery Ietu Receipt for ❑Collect on Delivery Merchandise 2-_Article_NUmber(Tran3fer from service label) ❑Collect on Delivery Restricted Delivery ❑Signature Confirmationm i I _ i_ ❑Signature Restricted Delivery lion 7 015 i 17 3 0,10 0 0:-1;,4 9 6 7 L8 6°S , l I ;p Restricted Delivery PS Form 3811,July 2015 PSN 7530-02-000-9053 Domestic Return Receipt 1 USPS TRACKING# I L 9590 9402 1933 6123 1785 52 United States •Sender:Please print your name,address,and ZIP+4®in this box* Postal Service Town of Barnstable Health Division I 200 Main Street I , Hyannis,MA 02601 s�is{i{s{{i{ilr{.�'{11`11�{I{1�I:Ij"1�1i11'�ltllsi'f�1i1�{sllrs.{rl Town of Barnstable Barnstable SAMeftC Regulatory Services Department j BAANBTTABIA + 16 on p Public Health Division A1�RM m 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7015 1730 0001 4987 6865 February 6, 2017 ORTENZI, MARY P 318 N CENTRAL ST EAST BRIDGEWATER, MA 02333 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 The septic system located at 929 Santuit Newtown Road,Marstons Mills,MA was inspected on 1/22/2018 by Scan M. Jones, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Will need to install a pipe between septic tank and leaching. You are ordered to repair or replace the septic system within two (2)years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF E BOARD OF HEALTH C, mas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mail ing\Conditionally Passes Letters\929 Santuit Newtown Road Marstons Mills.doc Town of Barnstable XAM Regulatory Services Department Public Health Division 200 Main Street,Hyannis MA-02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A McKean,CHO Feb 6, 2007 Rev. 5111116 DEADLINES TO'REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15,000) _ An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑Discharge or ponding of effluent to the surface of the ground w . ❑Pumping more than 4 times during the last year not due to clogged or obstructed pipe. :. ❑Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1)YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2)YEAR DEADLINE CRITERIA q Single Cess-pool- P(Any"conditionally passed systems" (broken cover,relocation of a pipe,relocation of a driveway due to H-10 components, etc) ❑Leaching pit or cesspool with high liquid level, <12"below inlet(per Town Code §360-9.1) ❑Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER Repair deadline: WSEPTIMDEADLINES TO REPAIR FAILYD SYSTEMS.doc Commonwealth of Massachusetts 627 'Ova v W Title 5 Official Inspection Form 71 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 929 Santuit Newtown Road Property Address !' Mary Ortenzi Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/22/2018 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 <S� /a Sa3 filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Titi'e V Septic Inspection r� Company Name 74 Beldan Ln. Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmail.com SI4522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 16.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 1/22/2018 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 F 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 Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 �v VS Commonwealth of Massachusetts r Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 929 Santuit Newtown Road Property Address Mary Ortenzi Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/22/2018 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: 13) 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 s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 929 Santuit Newtown Road Property Address Mary Ortenzi Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/22/2018 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): Pipe between septic tank and leach pit was found collapsed and needs to be replaced. ❑ 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 M Sve a 929 Santuit Newtown Road Property Address Mary Ortenzi Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/22/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® 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 Forth:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 929 Santuit Newtown Road Property Address Mary Ortenzi Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/22/2018 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. ❑ ® 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form x Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 929 Santuit Newtown Road Property Address Mary Ortenzi Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/22/2018 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): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd 15ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 r N Commonwealth of Massachusetts W W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 929 Santuit Newtown Road Property Address Mary Ortenzi Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/22/2018 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)): f Detail: Sump pump? ❑ Yes ® No Last date of occupancy: vacant 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 929 Santuit Newtown Road Property Address Mary Ortenzi Owner Owner's Name information is Marstons Mills Ma 02648 1/22/2018 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(descrbe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, 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 929 Santuit Newtown Road Property Address Mary Ortenzi Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/22/2018 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: original system installed 1972 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): Depth below grade: 1 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 gallons Sludge depth: 6" 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 929 Santuit Newtown Road Property Address Mary Ortenzi Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/22/2018 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 3" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? opened covers, took measurements Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): tank needs to be pumped now for maintenance and again every 2 years after. Water level was even with outlet invert, tank was structurally sound and not leaking. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 929 Santuit Newtown Road Property Address Mary Ortenzi Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/22/2018 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 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,•�'°° 929 Santuit Newtown Road Property Address Mary Ortenzi Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/22/2018 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 N/A 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•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 929 Santuit Newtown Road Property Address Mary Ortenzi Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/22/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1x1000 ❑ 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.): s.a.s. consists of 1 1000 gallon leach pit. Pit was dry at time of inspection with 1' standing water with stain line 2' higher. Cover is 6" below grade. 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•3113 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 929 Santuit Newtown Road Property Address Mary Ortenzi Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/22/2018 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 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 929 Santuit Newtown Road Property Address Mary Ortenzi Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/22/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately t p Z o i v4( 2 ) 61 Ilb AZ 22''° 3 e) 132 2f'fo A3 53 i33 b2 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M '< 929 Santuit Newtown Road Property Address Mary Ortenzi Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/22/2018 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: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Groundwater elevation was determined by accessing Town of Barnstable 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 l r Commonwealth of Massachusetts N r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 929 Santuit Newtown Road Property Address Mary Ortenzi Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/22/2018 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 oa ►� _ ago Town of Barnstable ,%I Health Inspector oFtHF tp� 4� C✓U Office Hours do Regulatory Services 8:30—9:30 Thomas F.Geiler,Director �:00—2:00 w &UMSTABLE. MARS 1639. Public Health Division��,n, A�0 / Th nas M Keari Director 2D0 Main Street,Hyannis,MA 02601 v At R \ Office: 508=862-4644- Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT — SEPTIC QUESTIONNAIRE 1. General Information: ( 4 , Size of Property: — T ' Address: t'ii/1/ Map Parcel 7 b �40 Name, (n iA�2 Phone 2a. How many bedrooms exist at your property now? __ 2b. Are you planning to add any bedrooms? ff-0 If yes, how many? 2c. How many bedrooms total are proposed at this property(including the amnesty unit)?\,S— 2d. Please include a copy of the floor plans for the entire property- showing the existing rooms in the home plus the proposed amnesty apartment and/or addition.. Please label each room clearly on the plans. 3. Is the dwelling connected to public sewer? YEAS or NO - <k If the dwelling is connected to"public sewer,skip questions#4 through#9 below.. 4. Location of dwelling is INSIDE or OUTSIDE a Zone of Contribution to public supply wells? 5. Is the dwelling connected to an ONSITE WELL or to PUBLIC WATER CD M 6. Is a disposal works construction permit on file? YES or NO 6a. If yes,how many bedrooms were approved according to this permit? Bedrooms. 7. Were any building permits obtained for construction of additional bedrooms? YES or NO 8. Is there an engineered septic system plan on file at the Health Division? YES or NO 9. Has the septic system been inspected by a DEP certified inspector within the last two years? . YES or NO -----=------------------------=------------------------------------------------------------------------------------- FOR OFFICE USE ONLY l The Public Health Division has no objection to bedrooms at this property. Special Conditions: Signed: Date: Q;/health/wpfiles/amnestyapp iL c k Ur \1 1 ei 00 cc 0 :� y - 1 LOT LOT 1 48 0 34� 0 7"t L. C. PL.lrl% 340 oo � o . �O O or RES. ZONE.- 11RF" This PLOT PLAN Plan is For FLOOD ZONE "C" Bank Use Only TOWN: _MARSTONS MILLS___________ REGISTRY OWNER: RICHARD_& MARY P _ORTEVZI__________ DEED REF: _ 61394 _71109 _____BUYER- ---------------------- --------- -------------------- DATE: _ 7�23f98 _ ________________ PLAN REF: _34846_B � C SCALE: 1"= 50 FT. I HEREBY CERTIFY TOIV/A===-___—_—_______— ��tN Oi yANKEE SURVEY — THAT THE BUILDING SHOWN ON THIS PLAN IS LOCATED 'ON THE GROUND AS ���,.-. PAUL `y�, CONSULTANTS SHOWN AND THAT ITS POSITION DOES CONFORM A � 40B (SUITE 1) TO THE ZONING LAW SETBACK REQUIREMENTS OF THE u MMTHE4V y No•02M � INDUSTRY ROAD TOWN OF, ___BARIUSTEIBLE _______AND THAT � IT DOES_ NOT _ LIE WITHIN THE SPECIAL FLOOD HAZARD /STfP� MARSTONS MILLS, MA. 02648 AREA AS SHOWN ON THE H.U.D. MAP DATED1985 TEL: 428-0055 Co nit -Panel 250001 0015 C FAX 420-5553 & Ire __ _____ THIS PLAN NOT MADE FROM AN INSTRUMENT 24389 PA L MERITHEW, PLS SURVEY, NOT TO BE USED FOR FENCES ETC.