HomeMy WebLinkAbout0950 SANTUIT-NEWTOWN ROAD - Health 0 Santuit- Newtown
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•
027-014, Marstons Mills
,l
Date
To Whom It May Concern:
I, , voluntarily grant permission to the Town
(Occupants name)
of Barnstable Board of Health (Agent or Health Inspector) to inspect my dwelling unit
located at S — Vc C in accordance
(House#, [Apt\Unit#if applicable],street,village)
with the Town of Barnstable Code (Chapters 59 and 170) and the State Sanitary Code
(105 CMR 410.000) on%1/P>SLi 11-/5--/I AT /d qM . I hereby authorize and name
Date of inspection)
6;V s- 11 l V to be my tenant representative for the
(Occupant representative)
purpose of this inspection.
is an adult person
PmP p C ( C
(Occupant representative)
designated and duly authorized to act on my behalf and will be accompanying the Town
of Barnstable Board of Health for the inspection, granting access to any and all locations
(including bedrooms, bathrooms, closets, etc.,) allowing the use of photographs and
answering questions. This authorization is only valid for the inspection date specified
above, and must be renewed for any future inspection(s.)
Occupants Si e \ Date
j�a -- 0-
Occupants Representative Signature \ Date
Q:\Rental Ordinance\inspection permission 2.doc
-'A TOWN OF BARNSTABLE
BOARD OF HEALTH
ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION
Date / — 17 ( Time: in Out
Owner f Tenant
Address i O .fi � Address
Compliance Remarks or
Regulation# Yes NO Recommendations
2. Kitchen Facilities
3. Bathroom Facilities
4. Water Supply �D
5. Hot Water Facilities
6. Heating Facilities '
7. Lighting and Electrical Facilities
8. Ventilation Amroved:
9. Installation and Maintenance of Facilities Celt::'j -�
10. Curtailment of Service
11. Space and Use
12. Exits
13. Installation and Maintenance of Structural
Elements
14. Insects and Rodents
15. Garbage and Rubbish Storage and Disposal n
16. Sewage Disposal _ �✓��
17.Temporary Housing D� �
18. Driveway Width
19. Number o.Tenants Observed
PART II
37. Placarding of Condemned Dwelling;
Removal of Occupants; Demolition /
Number of Bedrooms Number of Vehicles Allowed (max)
Number of Persons Allowed (max)
Person(s) Interviewed Inspector
If Public Building such as Store or Hotel/Motel specify here
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
950 Newtown Road (second house)
M Property Address
Barbara Goudin
Owner Owner's Name
information is
required for every Marstons Mills ✓ Ma 02648 1-27-16
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered m any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information ` 2 filling out forms 39.7
on the compuutt er,
use only the tab 1. Inspector:
key to move your
cursor-do not Brett Hickey
use the return Name of Inspector
key.
B&B Excavation
„y-41 Company Name
14 Teaberry Lane
Company Address
Sandwich Ma. 02644
City/Town State Zip Code
(508)477-0653 S113747
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
1-27-16
41nspectorr'se C- ' 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 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
�o ej Vs
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
950 Newtown Road (second house)
Property Address
Barbara Goudin
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 1-27-16
page. CityfTown 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:
This inspection was done on the second house at 950 Newtown Road. The system was in working
order per BOH regulations. System has a cesspool acting as a tank and a leachpit.
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
950 Newtown Road (second house)
Property Address
Barbara Goudin
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 1-27-16
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
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 950 Newtown Road (second house)
Property Address
Barbara Goudin
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 1-27-16
page. Citylrown 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
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
950 Newtown Road (second house)
Property Address
Barbara Goudin
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 1-27-16
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 11 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
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 950 Newtown Road (second house)
Property Address
Barbara Goudin
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 1-27-16
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): No plans
sign Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): NA
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 950 Newtown Road (second house)
Property Address
Barbara Goudin
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 1-27-16
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
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d see below
9 ( Y 9 (gP ))�
Detail:
"*WELL WATER"
Sump pump? ❑ Yes ® No
Last date of occupancy: NOV 2015
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
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° M 950 Newtown Road (second house)
Property Address
Barbara Goudin
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 1-27-16
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: Pumper Driver
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 750gallons
How was quantity pumped determined? measured
Reason for pumping: Maintenance
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):
Cesspool and leach pit
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
950 Newtown Road (second house)
Property Address
Barbara Goudin
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 1-27-16
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: 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.):
At time of inspection building sewer appeared to be in good working order with no sign of leakage.
Septic Tank (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ® other(explain)
Septic tank is a cesspool acting as a tank in series with a leachpit. Cesspool is made of block and is
6'x8'
If tank is metal„ list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1000 gallon 6'x8'
Sludge depth:
4"
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 950 Newtown Road (second house)
Property Address
Barbara Goudin
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 1-27-16
page. Cityfrown 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 3
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? measured
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Cesspool was structurally sound and in working order. Cesspool was pumped after inspection
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
950 Newtown Road (second house)
Property Address
Barbara Goudin
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 1-27-16
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 ❑ 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-3113 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 950 Newtown Road (second house)
Property Address
Barbara Goudin
Owner Owner's Name
information is Marstons Mills Ma 02648 1-27-16
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
M 950 Newtown Road (second house)
Property Address
Barbara Goudin
Owner Owner's Name
information is required for Every Marstons Mills Ma 02648 1-27-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number:
1 6'x6'
❑ 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.):
At time of inspection leaching appears to be in working order with no sign of hydraulic failure. Pit was
dry with no sign of high staining.
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
wM 950 Newtown Road (second house)
Property Address
Barbara Goudin
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 1-27-16
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.):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y 0 950 Newtown Road second house
Property Address
Barbara Goudin
Owner Owner's Name
information-is
required
revery
MarstonS Mills
required foi•:eve Ma 02648 1-27-16
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
Al-28'
A2-44'
51.24'5"
MAIN HOUSE 82.53'
DRIVEWAY HOUSE B
NEWTOWN 1
RD
SHED
A
GARAGE
COTTAGE
DRIVEW Y
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
N F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 950 Newtown Road (second house)
Property Address
Barbara Goudin
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 1-27-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: No Gw 10'
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:
perk test results from near by lot at same elevation
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Perk results
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
950 Newtown Road (second house)
Property Address
Barbara Goudin
Owner Owner's Name
information is Marstons Mills Ma 02648 1-27-16
required for every
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
E Inspection Summary: A, B, C, D, or E checked
E Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
E System Information— Estimated depth to high groundwater
E 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
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c,M 950 Newtown Road (main house)
Property Address
Barbara Gourdin
Owner Owner's Name
information is required for every Marstons Mills ✓ Ma 02648 1-27-16
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:
key to move your
cursor-do nct Brett Hickey
use the return, Name of Inspector
key.
B&B Excavation
Q Company Name
14 Teaberry Lane
Company Address
Sandwich Ma. 02644
City/Town State Zip Code
(508)477-0653 S113747
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 Fu her Evaluatio y the Local Approving Authority
1-27-16
Inspector's SJ&Fature 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 Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
�O ffd VS
Commonwealth of Massachusetts
,F Title 5 Official Inspection Form
1. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
950 Newtown Road (main house)
Property Address
Barbara Gourdin
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 1-27-16
page. CityFrown 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:
This inspection was done at the main house located at 950 Newtown Road. The system was in
working order and was pumped after inspection for maintenance.
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
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° M 950 Newtown Road (main house)
Property Address
Barbara Gourdin
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 1-27-16
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 FIND (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
950 Newtown Road (main house)
Property Address
Barbara Gourdin
Owner Owner's Name
information is Marstons Mills Ma 02648 1-27-16
required for every
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 Form:Subsurface Sewage Disposal System•Page 4 of 17
I
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 950 Newtown Road (main house)
Property Address
Barbara Gourdin
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 1-27-16
page. Cityfrown 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 Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 950 Newtown Road (main house)
Property Address
Barbara Gourdin
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 1-27-16
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): No pans sign Number of bedrooms (actual): 5
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): NA
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
950 Newtown Road (main house)
Property Address
Barbara Gourdin
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 1-27-16
page. Citylrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
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 d see below
9 ( Y 9 (9p ))�
Detail:
2015-29,0009allons 2014- 12,000gallons
Sump pump? ❑ Yes ® No
Last date of occupancy: current
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:
l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
950 Newtown Road (main house)
Property Address
Barbara Gourdin
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 1-27-16
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: pumper driver
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1250
gallons
How was quantity pumped determined? Tank size
Reason for pumping: Maintenance
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
i
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 950 Newtown Road (main house)
Property Address
Barbara Gourdin
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 1-27-16
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:
>25 years
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: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
At time of inspection building sewer appeared to be in good working order with no sign of leakage.
Septic Tank(locate on site plan):
2'
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: 1250 gallon
Sludge depth:
12"
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
950 Newtown Road (main house)
Property Address
Barbara Gourdin
Owner Owner's Name
information is required for everyMarstons Mills Ma 02648 1-27-16
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
24"
Scum thickness 1
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
15"
How were dimensions determined? measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
At time of inspection septic tank appeared to be in working order, baffles present with no sign of back-
up. Liquid level equal with outlet invert. Tank was pumped after inspection for maintenance.
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
l5ins•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 950 Newtown Road (main house)
Property Address
Barbara Gourdin
Owner Owner's Name
information is
required for every Marstons Mills Ma 02648 1-27-16
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
950 Newtown Road (main house)
Property Address
Barbara Gourdin
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 1-27-16
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 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.):
At time of inspection d-box appears to be in working order with no sign of 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:
l5ins•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
°M 950 Newtown Road (main house)
Property Address
Barbara Gourdin
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 1-27-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number:
1 6'x6'
❑ 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.):
At time of inspection leaching appears to be in working order with no sign of hydraulic failure. Pit was
half full at time of inspection.
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 950 Newtown Road (main house)
Property Address
Barbara Gourdin
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 1-27-16
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
ti 950 Newtown Road (main house)
Property Address
Barbara Gourdin i
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 1-27-16
:
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
r ❑ drawing attached separately
NEWTOWN RD
DRIVEWAY
8
FAIN HOUSE
Al-16'
A2-21'6"
A3.42'
A4.64'7"
B1.13'
132-20'
83-34'
84-57'5"
t5ins-3113 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
CGgM , 950 Newtown Road (main house)
Property Address
Barbara Gourdin
Owner Owner's Name
information is
required for every Marstons Mills Ma 02648 1-27-16
page. CitylTown 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: No Gw 10'
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:
Near by perk done at same elevation with no GW found at 10'
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Perk from near by lot
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
IL
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
950 Newtown Road (main house)
Property Address
Barbara Gourdin
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 1-27-16
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
No.. ...... Fss....5s..................
THE COMMONWEALTH OF MASSACHUSETTS 'y
BOAR® OF HEALTH
..... 07.4�`^'..............OF...........
� ---•------------------------------------
Appliraft n for Disposal Works Tonstrudiun thrmit
Application s ade for�a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Systemat: .. .. ....! '.. . . ....---•------- .. ........... :�"........ . -- ---------..........................
:fib
- L, on:Address - t 0
... °...:.:. ............ ........................ ..... ......---
W i Addr -_
a ..... ................................•----------------------•................-• --.. ...... --•--- .._.. .........
M Installer Address
U T e of Building Size Lot.,f�.......Sq. feet
Dwelling No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers
a YP g ---------------------------- P ( )•-- Cafeteria.( )
Otherfixtures -----------------------••------•--•-------------•-----••------------•--••••--•--•------....-•••-•--•••-.._.....••--• --•••-
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid*capacity............gallons Length................ Width................ Diameter---------------- Depth................
xDisposal 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 ( )
7 Percolation Test Results Performed by..............
..................................... Date...........>............................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
r Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
x -----------I----•--------••------------------- ...........................................................................................................
0
Descriptionof Soil ---------- ---•--•--•---••------•-------------------------•-••---------------•--------•---•---------------------------
x
c, ••••-•••--•-...-------•...•---•-.......•---------•-•••••••••--.....•••••---•--------------•••••---------•••------------------•-----••-•••------------•...•••--------.....------------•--••--------------
UW --••---••-••-------------------•••-•----•-------------------..................................................---• ----------------- ..........
Natu of R airs iA erations Answer when appl; ble.:_<.-'-_-_- -- 1=�' -' - -�J--G � ._..---•---.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITlE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been isslied7by !he bo rd f ealth.
Signed ................................
.....:: ------. -•......_----•--•...------•--•.--•-
Date
Application Approved BY ,...,,.. 1)'....._ ................... -------`...... -----------
Date
Application Disapproved for the following reasons---------------------------------•-------------------------------•---------------•••...----. ..-------•••••-•---
......................................................------...--•........------•--•---•----•............__....._.......----•------••---------•-----•---•----------••----••--•-------------•.....--•---
Date
PermitNo......................................................... Issued.....................................................
Date
No.. /7 .-. ,3 i Fms..... _ ..._
THE COMMONWEALTH OF MASSACHUSETTS '^
BOARD OF HEALTH
Applirtttion for Disposal Works Tonstrnrtiun rumit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at*
r - r^ _
. . ._.. - - ... .....--• -----•-------•--••--•.............
C� r m`•. L n- ddress o; t
...................... . ----------- ...................
w - ........................................................... ...----a--. � � .. r.........
a Installer� Address
UT e of Buildin�, Size Lot..,�/��:�e.........Sq. feet
Dwelling—No. of Bedrooms..............................•...._.___._._Expansion Attic ( ) Garbage Grinder ( )
'4 Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtures -----------------------------------------•-•--
w Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter____--_-.._---_- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by...........=.............................................................. Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.......:................
GL, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
7 -- .........-•-•.
O Description of Soil. .:..........•---•--••---------------------------------------------------------------------------•------•-----
x
W �-•-••-•-•-•-----------------•-------•-------•---•••-••-••-•••-••-•--•••----•••----•••••-•-------••-. •-•--• -- --- ---- -- - -----------
UNa of Re air eations�Answer when appl' -ble �
... .... .:�.�:• --- -- .....................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITI-E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been.iss ed by WbDord. if th.
Signed ..._
, � r Date
Application Approved By...... ---- ------.. ..............=- .........T_ 'X/...--------
Date
Application Disapproved for the following reasons:..............................................................................................................
----------------------------------------------------------------------------------------------------------••...............-•-•••---••-•...............................................................
Date
PermitNo......................................................... Issued.........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH
....... ,,.............OF........ ..............................
. �rrti�irtttr of f�unt��ittnr�e �,
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by - .:......�. . .....•--------------------------------------------------------------------------------------------------------------------------------
at.
has been installed in accordance with the provisions of TIT 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.__.4'PZ __-___z-3>........., 'dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............................................ -----••--•---•------ Inspector..---......... - -1- ------------------...............-----.........--
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........ ............OF......:-"=% ' � ......................................
No...z- � FEE.....
Disposal Works lTonotrnrtittn .ermit
Permission is hereby gran te '._...��'........... !c :...............................
to Construct I ) or Repair ( ) an Individual Seewa e Disposal System
Street
as shown on the application for Disposal Works Construction Pe it No..................... Dated..........................................
�•�!' ` ----------------------•-••-----.---•----
of Health
DATE............. '° -- ...........................................
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
AsBuilt Page 1 of 2
i
XILOr. AT10 SE.W G PERMIT NO.
VILIAGE
INS'T,.,A,L ER' NAM - i ADDRESS
t
e 01'L'D E R OR OWNER
A
DATE PERM tSS'U'E..
DATE, pI:P`L1AN:CE I.SS
CO 'UED '
V
I
http://issgl2/intranet/propdata/prebuilt.aspx?mappar=027014&seq=3 8/30/2017
i
' 0 2,7- ol�
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
SAN+uI'I- r'*
950 Newtown Road (cottage) W
Property Address
Barbara Gourdin
Owner Owner's Name ~
information is
required for every Marstons Mills ✓ Ma 02648 1-27-16 '
page. City/Town State Zip Code Date of Inspection
W
M+
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 l#
on the computer, /
use only the tab 1. Inspector:
key to move your
cursor-do not Brett Hickey
use the return Name of Inspector
key.
B&B Excavation _
ray Company Name
14 Teaberry Lane
Company Address
Sandwich Ma. 02644
City(Town State Zip Code
(508)477-0653 S113747
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
A
-6
_ 1-27-16
Inspector's Wture ' 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 Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�^M 950 Newtown Road (cottage)
Property Address
Barbara Gourdin
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 1-27-16
page. Cityfrown 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:
This inspection was done at the cottage located at 950 Newtown Rd. System was in working order
and pumped after inspection for maintenance.
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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
f
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 950 Newtown Road (cottage)
Property Address
Barbara Gourdin
Owner Owner's Name
information is
required for every Marstons Mills Ma 02648 1-27-16
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
<L\, Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 950 Newtown Road (cottage)
Property Address
Barbara Gourdin
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 1-27-16
page. CityFrown 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
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
950 Newtown Road (cottage)
Property Address
Barbara Gourdin
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 1-27-16
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
I
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
950 Newtown Road (cottage)
Property Address
Barbara Gourdin
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 1-27-16
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): No glands sign Number of bedrooms(actual): 1
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): NA
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
P 9 P Y 9
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 950 Newtown Road (cottage)
Property Address
Barbara Gourdin
Owner Owner's Name
information is required fo-every Marstons Mills Ma 02648 1-27-16
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
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)): see below
Detail:
well water" no laundry in cottage
Sump pump? ❑ Yes ® No
Last date of occupancy: current
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
i�
I -
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
950 Newtown Road (cottage)
Property Address
Barbara Gourdin
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 1-27-16
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: pumped truck driver
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1000
gallons
How was quantity pumped determined? Tank size
Reason for pumping: Maintenance after inspection
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):
Tank and pit
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
S Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 950 Newtown Road (cottage)
Property Address
Barbara Gourdin
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 1-27-16
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 due to lack of records
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1'6"
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.):
At time of inspection building sewer appeared to be in good working order with no sign of leakage.
Septic Tank(locate on site plan):
6"
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: 1000 gallon
Sludge depth: 91,
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 950 Newtown Road (cottage)
Property Address
Barbara Gourdin
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 1-27-16
page. Cityffown 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
27"
Scum thickness
4"
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
12"
How were dimensions determined? measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
At time of inspection septic tank appeared to be in working order,baffles present with no sign of back-
up.Liquid level equal with outlet invert. Tank was pumped after inspection for maintenance.
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
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
W 950 Newtown Road (cottage)
Property Address
Barbara Gourdin
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 1-27-16
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 950 Newtown Road (cottage)
Property Address
Barbara Gourdin
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 1-27-16
page. Cityrrown State Zip Code Date of inspection
D. System Information (cost.)
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-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
°M 950 Newtown Road (cottage)
Property Address
Barbara Gourdin
Owner Owner's Name
information is
required for,every Marstons Mills Ma 02648 1-27-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1 6'x6'
❑ leaching chambers number:
❑ leaching galleries number:
a
❑ 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.):
At time of inspection leaching appears to be in working order with no sign of hydraulic failure. Pit had
1' of standing water with a stain line 2'from bottom. SAS is >100. from well
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
950 Newtown Road (cottage)
Property Address
Barbara Gourdin
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 1-27-16
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.):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
. Commonwealth of Massachusetts
4 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
950 Newtown Road (cottage)
Property Address
Barbara Gourdin
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 1-27-16
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
Al-13'
#2 A2.19'8"
A3.28'8"
81.1815*1 Q
e2.23'8" A e
83.31'
COTTAGE
i
DRIVEWAY
MAIN HOUSE
GARAGE
i
NEWTOWN ROAD
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°wM 950 Newtown Road (cottage)
Property Address
Barbara Gourdin
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 1-27-16
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: No Gw 10'
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:
Taken from perk at lot at same elevation
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Perk for near by lot at same elevation
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
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 950 Newtown Road (cottage)
Property Address
Barbara Gourdin
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 1-27-16
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
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LOCATION � JT SEWAGE. PERMIT NO.
VILLAGE
INSTALL R'SSNAME i ADDRESS
-
all& R OR OWNER
DATE _ PER WrlT IS f U E DO
DATE COMPLIANCE ISSUED
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......... ......... ....................OF.................................................wo......................................
. ppliration for Dhipoottl Work.5 Tonotrurtion 11rptit ,
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System a ,ttG1? A&L_::.... ....
ocation d ess / or Lot No. VV
....__ �__.r .. _"__ i " •' _ ' ---'.... .......... ..............^____""_'_^___.... _ ..._ ....................F...--
,Qw r ress � � �
W '.....�..J . .................................... .......
.- .f .{.�
a Installer Address
Type
of wilding Size Lot_,V e/' : ---Sq. feet
� Dwelling�No, of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
pa Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures .....•••••••...............................•-
W Design Flow............................................gallons per person per day. Total daily flow.............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
a Percolation Test Results Performed by.......................................................................... Date__?.`'�f-
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Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
(z, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Ix
0 Description of Soil....,_ :_._ .... e ..__--.__'...........................
x •• .......................•--_.___....------....
V .........................................................................................................'•-•----------------_._.----.___.•-•---_____.___......_
W
-• ___________ __ __._
U Nature of epairs o Alterati%n An er w*k��
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--------------- 1� `�G�� ��=
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of LITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the
�boardd if heealth. e�
S, d �'�r.. ..%..!�L-•--••......•................. 1.• _e...........
ApplicationApproved By.G. ........ --- -••-•-•..... .........•--•-..._....--•-•-..................____.-----•'-' / ----
Date
Application Disapprove r t following reasons:...............................................................................................................
............................................................................................................................................_...................................................... ...
Date
G� o>
PermitNo.............•-------___.._...--'-'-------------........ Issued.... ...1 .........-
Date
No.l ... Fmc..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O,F ..HEALTH
::OF_
,���lirtt# ��T:..fur 3�i,�:�o,�tt1 ork,� C�on,��rnr#ion rani#
Application is hereby made for a Permit t"o Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: -•- - - - ------• - - -- --
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. -.....---------- - --•----•-----------
i ocation d es, 4V or Lot No.
s ss
W ------- . . ...... .... .......... -- .............. �
Ow re
a Installer Address
U /,�
Type of uilding Size Lot. ....90 49.0 Sq. feet
Dwelling/ No. of Bedrooms.....................................:......Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No, of persons............................ Showers ( ) — Cafeteria ( )
P4Other fixtures -----------------------------------------------------------•--•-----•-•••......
W Design Flow............................................gallons per person per day. Total daily flow.............................7..............gallons.
Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
W Disposal Trench—No..................... Width.....................Total Length.................... Total leaching area.....................sq. ft.
Seepage Pit No---------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
~" Percolation Test Results Performed b .................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Gz., Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
---------- • ---------------------- --•-•-----•----------••-••-•----••-•---..............................................................
ODescription of Soil----.� .....`�...: -•------ ------ - ----------------------------------------------------•--------------------...---••-----••---•---•----.
x
W •-•--•-----------------.=---------•--------•-•-•-----•......--••••----•-•--- •••••-•--•----•-•--•--------••--•------ --•- ---••- -- -
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U Nature of epairs o Alteration An er when applicab ._.... ______-__. .------ --------- -------------—......
_____......_
--------- •------ . --•--•----•---••-•---•••-----------•------•-•-••----•.......................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of i�,MLL 5 of the State Sanitary Code— The:undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by he bard f health.
..__.. '... •-- •----••-•-••-•------•--......_ 1=_ .....-.._
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Si
Application Approved By. : ... __ ........................... /'-- ---D--
at
Application Disapprove or t f ollowing reasons:------•--------•------------------------------------------------------------•------------. •---••-•----=•-----
-•....--•-•--•----•--------•------••--•---•----•--•-•----••---•-••---••-.....-•--------••....--•••-......--•--•-•:.................•-•---......-••-----••--•••-----••-----•--••------•--...----•-•-•••--
4
Permit No......................................................... Issued..---- -• Date
---��-----��.... ------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...................OF.......................
Trrtif iratr of Toutphattri
Z THI S ;CERTIFY, That the Individual Sewage Disposal',System constructed ( ) or Repaired
by.. ••--- ..
...
�- •-••••---•Installer
X' at..... =`iod --.!`'r[j ......................•..................-..................................................................0 ... •-----•-------•--
- has been installed in accordance with the provisions-of TIT F ` of The State Sanitary o. as cr}i�bed in the
application for Disposal Works Construction Permit No____________ __ ;".�.............. dated_ -. ._r . ... ...,.._........._........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
-.� DATE.................................................�..�.� ............. Inspector....................-•--•-1.......................................................
"'fi I
THE COMMONWEALTH OF MASSACHUSETTS
�5
BOARD OF HEALTH
N .......✓ ..._ OF....................... r i FEE/"0--•-...........
i fro �t1 All IM nrtion rrntif
Permission is hereby anted --
to Construct ( ) a Indi al .wage Disposal System
at No.
-- -• •. ...........�.............................Skreet-------...................
as shown on the application for Disposal Works Construction Permit No.. Dated=: .............
Board of Health
DATE............................................. _....-----�•�•---------•---••-- �-
FORM 1255 A. M. SULKIN, INC., BOSTON
AsBuilt Page 1 of 2
LOCATION � �� � SFWAGE PERMIT NO.
VILIAGE
INSTALL III'S NAME i ADDRESS
K•�
R OR OWNER
DATE PERMIT IS UED
DATE COMPLIANCE ISSUED
N
http://issgl2/intranet/propdata/prebuilt.aspx?mappar=027014&seq=1 8/30/2017
AsBuilt Page 1 of 2
(76
LO.CA SEWAGE PERMIT N0•
V'IELAGE
1NSTA L ER''S' A i ADDR.ES"S
U
B-VIVY" OR OWNER
f
DATE. PERMIT ISSUED f
DATE COMPLIAN=C,E 'ISSUED
j.
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http://issgl2/intranet/propdata/prebuilt.aspx?mappar=027014&seq=2 8/30/2017
TOWN OF BARNSTABLE
BOARD OF HEALTH
ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION
Date o - 1 5- f I Time: In Out
Owner Tenant Arum
Address �] S Address $v I T 5 w�- _
Complian,pe Remarks or
Regulation# Yes NO Recommendations
2. Kitchen Facilities AMrovet _
3. Bathroom Facilities '"44
4. Water Supply �0
5. Hot Water Facilities R
6. Heating Facilities
7. Lighting and Electrical Facilities
8. Ventilation
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
15. Garbage and Rubbish Storage and Disposal
16. Sewage Disposal
17. Temporary Housing -
18. Driveway Width
19. Number of Tenants Observed
PART II
37. Placarding of Condemned Dwelling;
Removal of Occupants; Demolition
Number of Bedrooms Number of Vehicles Allowed (max) ,V
Number of Persons Allowed (max)
Person(s) Interviewed Inspector
If Public Building such as Store or Hotel/Motel specify here
COMPLETEoN COMPLETE THIS SECTIONON DELIVERY
■ Complete items 1,2,and 3.Also complete A. Signature
item 4 if Restricted Delivery is desired. L ❑Agent
■ Print your name and address on the reverse ❑Addressee
so that we can return the card to you. B. Receive y(Printed afire) C. Date If D Iivery r
■ Attach this card to the back of the mailpiece, O r
or on the front if space permits.
D. Is delivery address different from item 1? Yes
1. Article Addressed to: If YES,enter delivery address below: ❑No
Barbara Gourdin
950 Santuit-Newtown
Marstons Mills,MA 02648 3. Sery a Type
{ ertified Mail® ❑Priority Mail Express-
! ❑Registered ❑Return Receipt for Merchandise
❑ Insured Mail ❑Collect on Delivery
4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number 7D14 12DD DDD1 'D358 ' 352D 'TO 1
(transfer from service label
PS Form 3811,July 2013 Domestic Return Receipt
UNITED STATES POSTAL SERVICE First-Class Mail
Postage&Fees Paid
LISPS
Permit No.G-10
C • Sender: Please print your name, address, and ZIP+4®in this box*
I
I ;
:Hya:nnis,
Barnstable
* ;avision
I Street
MA 02601 it
I
1tf?fii :I:?�j :lj:?itjie ttii?ii•� t t!'?3 liitil? ! Pil:11
e
Certified Mail#7014 1200 0001 0358 3520
�oFT Tati Town of Barnstable
r +
Regulatory Services
* BARNSCABLE +
v MAss Richard Scali, Director
Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
October 8, 2015
Barbara Gourdin
950 Santuit-Newtown
Marstons Mills, MA 02648
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY
CODE II—MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION.
The property owned by you located at 950 Santuit-Newtown Road (First Floor), Marstons
Mills, MA was inspected on October 8, 2015 by Timothy B. O'Connell, R.S., Health
Inspector for the Town of Barnstable. This inspection was conducted on the basis of a
complaint received at Town of Barnstable Health Division.
The following violations of the State Sanitary Code were observed:
105 CMR 410.500 — Owner's Responsibility to Maintain Structural Elements.
Observed mold-like growth iri the basement on the sheetrock walls. Also observed damp
rugs and damage to ceilings in bathroom and main area of basement from previous water
leak.
You are directed to correct the violations listed above within thirty (30) days of your
receipt of this notice by removing mold-like growth using best industry practices; by
removing any sources (damp rugs/damp sheet rock) of chronic dampness causing
the mold like substance in the basement; by repairing all ceilings and walls.
You may request a hearing before the Board of Health if written petition requesting same
is received within ten (10) days after the date the order is served. Non-compliance will
result in a fine of$100.00 per violation. Each day's failure to comply with an order shall
constitute a separate violation. Should you have any questions regarding the above
violations, please contact the Town Health Division and ask to speak with the inspector
who erformed the inspection.
�2 ER OF E BOARD OF HEALTH
homas— . McKean, R.S., CHO
Director of Public Health
Town of Barnstable
QAOrder letterMousing violations\Rental ordinance\950 santuitnewtown 10-9-15,doe
Citizen Web Request Page 1 of 3
2"�G
Logged In As: Citizen Request Management Wednesday,October 7 2015
�N 70N\occ,nneit
Route to Users Search Reauests Create Requests
Request Information
Request ID: 54253 Created: 10/2/2015 9:03:35 AM
Status: Assigned To Staff Assigned To: O'Connell,Timothy
Health Office
Anonymous: No Request Category: Chapter II : Housing Substandard edit
Routine work: No Estimate: No edit
Date scheduled: edit
Estimated 10/19/2015 Change Estimated Seg October 2015 Nov
Completion Completion Date:
Date: Sun Mon Tue Wed Thu Fri Sat
27 28 29 30 1 2 1 3
4 5 6 7 8 9. 10
11 12 13 14 15 16 17
118 19 20 21 22 23 24
25 26 27 28 29 30 31
1 2 3 4 5 6 7
Created By: Sousa, Vanessa Priority: Medium edit
Health Office
Citation Numbers: edit
Requestor Information
Requestor
Request Parcel Number Ma0-2--7---'Block: 014 t Lot: 000
http://issgl2/internalwrs/WRequest.aspx?ID=54253 10/7/2015
Citizen Web Request Page 2 of 3
Tenant reporting black/green
mold in basement. Describes black
mold on rug, ceiling with mold (below
her apartment), mold 2-3 inches high
at wall. Says mold is growing 3-4
inches each week. It is a finished
basement where she stores boxes
with her belongings. Says there was a
pipe leak morning of her rental
inspection. Tenant had to remove
everything in basement(her boxes
are now under tarps outside).
Landlord did have a plumber go out
to fix issue. Currently there is no fan Email:
or dehumidifier in basement(there
was previously). Tried communicating
with landlord about mold issue, but
nothing has been done.She lost most
of her belongings due to situation.
Edit Reouestor Information
Track Request Progress
Request Work History: Internal Note History: .
System entry on 10/2/2015 9:03:35 AM:
Assigned to O'Connell,Timothy
Enter work progress: Enter internal note:
(Viewed by everybody) (Viewed internally only)
F-
-
�ry
ti :
Y
Spell Check i Spell Check
http://issgl2/intemalwrs/WRequest.aspx?ID=54253 10/7/2015
.,�
4
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/ _____r
r
10/9/2015 Health Master Deettaiil
✓ > i' e `1?`y, yir ra L.,+i` ,a -�+ i� _ .¢ .a•eH �V .5 � -
w`
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Logged In As: TOWN\health Health Master Detail Friday, October 2015
Application Center Parcel Lookup Selection Items
Parcel Septic Perc Well I Fuel Tank
Parcel: 027-014 Location: 950 SANTUIT-NEWTOWN ROAD, MARSTONS MILLS Owner: GOURDIN, BARBARA C
1 .................. _..... ......... .....-._..._... .. _ —
Business name: Business phone:
i
Rental property: D Deed restricted: O Number of bedrooms
Contaminant released: ❑ Fuel storage tank permit:
Save Parcel-Changes 1 Return to Lookup
Parcel Info Parcel ID: 027-014 Developer lot:LOT 3
Location:950 SANTUIT-NEWTOWN ROAD Primary frontage: 170
Secondary road: Secondary frontage:
Village:MARSTONS MILLS Fire district:C-O-MM
Town sewer exists at this address: No Road index: 1425
a: '~
Asbuilt Septic Scan: 027014_1 Interactive map: sa�y+ �1k
WP (Wellhead Protection Overlay
Town zone of contribution:District) State zone of contribution:IN
Owner Info owner: GOURDIN, BARBARA C Co-owner:
Streeti:950 SANTUIT-NEWTOWN ROAD Street2:
city:MARSTONS MILLS State:MA zip: 02648
Country:
Deed date:6/11/2009 Deed reference:23791/245
Land Info Acres: 1.82 use: Multi Hses MDL-01 zoning:RF Neighborhood: 0105
Topography:Level Road:Paved
Utilities:Gas Location:
Construction Info Building No Year Built Gross Arealsving Area Bedrooms Bathrooms
1 1920 3004 2024 5 Bedrooms2 Full-1 Half
1971 1812 1152 3 Bedrooms Full-0 Half
3 1970 498 336 1 Bedroom 1 Full-0 Half
Buildings value:$285,800.00 Extra features: $46,200.00 Land value: $133,700.00
C
http://issq 12/i ntranet'healthM aster/H ealthM asterDetai l.aspx?ID=027014 1/1
t J
RAC' EDWAR S HOME IMPROVEMENT
-'0 Constance,aye.
.Wes!)`armouih. ;1•lfl i1267
(508)989-1595 .
Rayedwarclsl7?c``r gmniL com
September 16,2015
Rob Douglas
Sanitut Newtown rrb
Marston Mt71s�MA
Tlre7allow�iagls ao esthuste to ampatr waterdamaye to basement ols"tal
Arouse located at above addsiess.IfestJmate is acceptable,ceaftaet with
paym,exit teawrs WMAre-puovJdeAL
Descalptfan ofwomk-
!,Remove AffoAdsov trfm~v4sa ire and replpoe wA*new
Remove a/f a lstibg sheebock to an off the Mwrhelgbt.of48 inches and replace
wit li new.Remorse and iep rce damaged COMBO sheebwck and replace wak new.
Tape,compound and sand aff seemiL
X Remove of etdtting doors and Jambs and replace with new.
4.Remove all fixtures from bathroom and replace with new.
5 Remove extstrmg fibwft from bathroom and replace with new tile: Tile
bathroom waft to a he/ght of48 inches.Grout tries as required,
6.Pbfine and paint of suilaces In basement area
MateHels fst-
"sheetrock-3 sheets
1/2ffsheetrock-16sheets
5%"x 9M6"x 16'speedbase-7p/eces
f%'drywa//screws-5f
90 minute durabond-2 bags
Joint cvrnpoend-3$al bucket
2 Vwx 9/f6'x 96"co/omaf casing-f0 pieces
32'x 78"prehang 6 panel molded door-2
28"x 78"prehung S pajf molded door-f
32'x 78"probung 9 No exterior door-f
Yeffx 12"x W prfiued phw-3
32"x32'shower stal/-f
Glacier bay shower valve-f
Gfacfer bay 24'vanf[y wftsrcet-f
Olaclerbayround bowl toffet-f
Tfe mastic-3 gal bucket
Tile thin set mortar-20Arbag
Tile grout-10#bag
41wx 4f°linen white wall Mfrs-50 s*A:
12"x f2"f)ow trio -SO s,g&,AL(Nome Depot baeia$ZOO/sq N)
white primer-50af bucket
White eggsbelf latex wag pahtt-Seal
white semAgloss blm part-f gat can
Materials price. $2,620
Labor price $2,700
Total materials aad labor $5,320
Dampater flee $ 300
Total to compiste)'ob 6ZO
Barbara Gourdin
950 Santuit Newtown Road
Marstons Mills,MA 02648
Mr. Jeffrey Bristol
950 Sanhut-Newtown Road
Unit 1
Marston Mills,MA 02648
WRITTEN NOTICE TO REMOVE PROPERTY AND DEBRIS
Mr. Bristol,
Your personal property in and around the unit you rent must be removed from the:
■ basement to allow for the important repairs
■ area behind the building to stem health hazard
■ stairs leading up to Unit II
Records indicate you are in receipt of the"Notice to Quit"(10/05/2015)for failure to
pay rent. The week before,you came by,supposedly to pay your delinquent rent. You did not;
ieverrheless,'during that meeting;,you"'were-advised'that your personal-property you stored in the
basement apartment had to be completely cleared so demolition and construction to repair flood
damage could begin. The contractor ordered a dumpster to accommodate the debris his work
yvo`uld:gerierate:'He stated he could not proceed because your considerable property remain in
the space to tie repaired. He also advised that delaying demolition will result in further damage.
Despite having had use of the larger-than-auto-sized shed on my property,you removed
some of your belongings to the outside rear of the unit which,after weeks uncovered,have begun
to rot presenting an unsightly health hazard.
As per order of the Health Department of the Town of Barnstable,the necessary repairs
must be begun by November 8,2015.Thus,I and the contractor need access to the basement,
free and clear of your personal property.Respond in writing to advise you have complied prior to
that date, so the work can begin as needed and ordered.
w
Barbara Gourdin.Oetoler 28,2015 a.
ct:'Atiorney Adam Dupuy;Tim O'Connell,Health Inspector;Town Of Barnstable ";
Z3/
�� fA, ` AT 10 SEWIA GL PERMIT NO.
V1LLAGE
t
INSTAL E Ill NAM i ADDRESS
i
BUILDER , OR OWNER
A
DATE PERMIT ISSUE4-
1-"�l �
DATE COMPLIANCE ISSUED
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V LLAGE
AYL� At
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DATE PERMIT ISSUED
9
DAT E COMPLIANCE ISSUED,
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.r TOWN OF BARNSTABLE
BOARD OF HEALTH
ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION
Date - �5 Time: In Out
Owner Tenant
Address 1 5 Lx~ r Address 5 0 -
K41e� r 041,1� WLJ
Complian,pe Remarks or
Regulation# Yes NO Recommendations
2. Kitchen Facilities
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
12. Exits
13. Installation and Maintenance of Structural
Elements
14. Insects and Rodents
15. Garbage and Rubbish Storage and Disposal
16. Sewage Disposal IM2
17. Temporary Housing
18. Driveway Width t b/L
19. Number of Tenants Observed
PART II
37. Placarding of Condemned Dwelling;
Removal of Occupants; Demolition
Number of Bedrooms , Number of Vehicles Allowed (max)
Number of Persons Allowed (max) 2---
Person(s) Interviewed Inspector
If Public Building such as Store or Hotel/Motel specify here