HomeMy WebLinkAbout0035 STALLION WAY - Health 35 STALLION WAY
Marstons Mills
- - - - - - A = 174 - 001
} TOWN OF BARNSTABLE
LOCATION SEWAGE# cold-6'7
VILLAGE / , rP`(itf-tA SSESSOR'S MAP&PARCEL J7L^00/ -031
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY l�l � 1 �u� � �- i.¢!�►l� '�/a
LEACHING FACILITY:(type) /,, (size) /a7 C,`
NO.OF BEDROOMS
OWNER V!:tniz-A-to
PERMIT DATE: �'��. t�— COMPLIANCE DATE: ,O v't
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY
00
�- Tas
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: V
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01ppliLation for Misposal 6pstrin Construction j3prutlt
Application for a Permit to Construct( ) Repair(6 Upgrade( ) Abandon( ) ❑Complete System Individual Components
Location Address or Lot No. ���� Ln�,, 1 Owner's Name,Address,and Tel.No.e.j�_.�70_5-f 99
Assessor's Map/Parcel /�y I vU �GtrS{7� ~"V' 'm aly\ 1 �� ab,
av J
Installer's Name,Address,and Tel.No. Gog -S/,�L$- 0,;X G Desi ner Name,Address,and Tel.YNoo.. .y
l9J7A i c
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other . Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title nn
Size of Septic Tank 1566 —1 C� Type of S.A.S._ %S{Yn�(�X� 21 k
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) an�� 21�i�t e.v kn nk mod' nQ1d)— 14(()
C 4—AL4rl oi � P X%5+"' f
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environment o and not to place the system in operation until a Certificate of
Compliance has been issued by this Board
Signe Date L�7
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. Date Issued g' DL&P W
a4t
No. "'� t� r�_ CGC} Fee " c�
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 1/r
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
2pplitation for Misposal 6pstem (Construction Permit
Application for a Permit to Construct Repair(�) Upgrade Abandon( ) ❑Complete System ®Individual Components
Location Address or Lot No. 1,0Owner's Name,Address,and Tel.No. , ,,Y
ei Assessor'sMap/Parcel i 1t C ,
M_ ,� tJn.t 4 Ri
Installer's Name,Address,and Tel.No.GO9u - tja�. <y,;L6r, Designer's Name,Address,and Tel.No.
/tl/,4 —, 1_ P::,6x
`"if.+-;'r. ;, .^!A e /�1s i i `t,�.�f A'l(/I Y^rs�-:.irr• i�.�e/IC kM Il` C.�c�G.1 :.\ (t
Type of Building?
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures -
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date M
Title
Size of Septic Tank}1 Type of S.A.S. 0.1.1'1:. 4
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) Q_,dj1n.. o t ,r,� c . , trA �n�r r ,._,, �_L� () 4.r } {(rff
R1�-�,`J• � �.
Date last inspected: #
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal systeffiri
« a
accordance with the provisions of Title 5 of the Environmental-C"ode and not to place the system in operation until a Certificate of
Compliance has been issued by this Board yof,Health.,
Signed _ .. ...,�._ Date
Application Approved by `'An .... Date f
Application Disapproved by Date
for the following reasons
Permit No. l '" cx Date Issued i #
THE COMMONWEALTH OF MASSACHUSETTS
'y BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(4,Y) Upgraded( )
Abandoned( )by
at has been constructed in accordance
with the provisions of Title 5�and the for Disposal System Construction Permit No.e901 -z , (dated 7S )�
Installer f�.� {a f�aTt t t.'�,�r, T�a rir�e,� . r�L Designer i Gx r,f + } .=> � C3 L r tt
u
#bedrooms Approved design flow gpd
The issuance of this permit shall not be cjon�s�^trued as a guarantee that the system wiy 11 function as signed.
Date l ft Inspector
- ---- --------------------------- -- -
No. rfD Fee •�"
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal 6pstem Construction 213ermit
Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( )
z
.System located at
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
Date `fed Approved by I'll—
r ♦ ;
Commonwealth of Massachusetts
r; Title 5 Official Inspection Form
^� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
U R VN
_
Property Address
�S64//t kj
Owner Owner's Name g information is �� �� A ,[j
required for every �'__[[
page. Ciryfrown State Zip Code Date of I pection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system,including ties to
at least two per anent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate
where p water supply enters the building.Check one of the boxes below:
hand-sketch in the area below
❑ drawing attached separately
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;_ms.cbc•rev,Ei 16 - T:^e 5 Cli=I Inspection Fo•rrn Subsurface Sewage Disposal system•Pogo 5 of 17
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Town of Barnstable Barn
Regulatory Services Department j14n9d0C j
rexrtsrnstE
.e 3a
3 Public Health Division.� •
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Richard V.Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL#7015 1730 0001 4990 0249
July 10,2018
SULLIVAN, CHARLES O
35 STALLION WAY
MARSTONS MILLS, MA 02648
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5
The septic system located at 35 Stallion Way,Marstons Mills,MA was inspected on
06/29/2018 by Mark Polselli,certified Title V Septic Inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system"Conditionally Passes"
under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: '
• Septic tank is leaking. Septic tank is underneath the deck. Septic tank must
be repaired or replaced, and must be accessible for pumping.
You are ordered to repair or replace the septic system within two (2)years from the date
you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
Thomas McKean, R.S., CHO
Agent of the Board of Health
Q:\SEPTIC\Title V Inspection Report Letters Mailing\Conditionally Passes Letters\35 Stallion Way Marstons Mills.doc
a
THE r
'Town of Barnstable
i AwNCTIAT V, !
-�, 16 ,�� Regulatory Services Department
Public Health Division
200 Main Street,Hyannis MA-02601
0$ca; 508-862-4644 Richard Scab,MCCtQr
FAX' 508-790-004 nomas A McKcaq CEO
Feb 6,2007
Rev. 5111116
DEADLINES T.O*REPAIR FA.ILED.SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15.000) _
'An`�e'marked in the❑is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA
❑Discharge or ponding of effluent to the surface of the ground
❑Pumping more than 4 times during the last year not due to clogged or obstructed
Pipe- :.
o Backup of sewage into the house due to as overloaded or clogged SAS or cesspool
ONE(1)YEAR DEADLINE CRITERIA
❑Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool
❑Any portion of the SAS, cesspool,or privy below high groundwater elevation
❑Any portion of the cesspool within a Zone 1 to a public well
❑Any portion of a cesspool within 50 feet of a private water supply well with no
acceptable water quality analysis.(This system passes if the water analysis
indicates the well is free from pollution).
TWO(2)YEAR DEADLINE CRITERIA
q Sirlgl.e'Cesspool
(1 !Any"conditionally passed systems"(broken cover,relocation of a pipe,relocation
of a driveway due to H-10 components, etc)
o Leaching pit or cesspool with high liquid level,<12"below inlet(per Town Code
§360-9.1)
❑Leaching facility with standing liquid level at or above the invert pipe (per Town.
Code §360-20 h)
OTHER
Repair deadline:
Q'\SEPTICIDEADLINES TO REPAIR FAILED SYSTEMS.doc
00/-o38
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i
A Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4;.
Property Address
ti or'l 5
Owner Owner's Name /� /��
information is a s / - Oa�p�e Gi a
required for every
page. City/Town State Zip Code Date of KispectioK "a
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 3
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your -
cursor-do not a/ l 0 1
use the return �-
Name of Inspect
key.
Company Name PO /o> / Age
Company Address �!
,ate �G.S��o►(M
CitylTowrS,PF\ J9O ` / AY,n State O j - Zip Code
Telephont/e Number 'J /i (� License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information repotted 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
- 4, /Z9.
Inspector Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system 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.
i
t5ins.doc•rev.6116 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address
Sti �ltra�
Owner Owner's Name
information is AV' ,r� s
required for every
page. City/Town State Zip Code Date of Inspec on
B. Certification (cost.)
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:
-T�n 164 Sher -tv
S uvtCGr dDe�l✓
B) ; e onditionally 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):
a Oh l v,� o� (H l✓
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address
h —
Owner Owner's Name
information is O 1 .� n,
required for every — . � r n
page. City/Town State Zip Code Date of Insp ction
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(cunt.):
❑ 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.doc•rev.6116 i Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
I
I
<3
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
3S S4�mo 61 (.,/a
Property Address
Owner Owner's Name
information is Allf A� cold� �o
required for every
page. Cityrrown State Zip Code Date o nspecti n
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
t5lns.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
MW Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address I
Owner Owner's Name
information is %4,40,,ts ' !A/z
required for every
page. City/Town State Zip Code Date of Ilikpection
B. Certification (cont.)
Yes No
❑ Required pumping more than 4 times in the last year NOT due to clogged or
structed pipe(s). Number of times pumped:
❑ Any portion of the SAS,cesspool or privy is below high ground water elevation.
ElAny 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.
❑ E y portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ Ly' An portion of a cesspool or privy is less than 100 feet but greater than 50 feet
Y P P P vY
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.]
❑ he system is a cesspool serving a facility with a design flow of 2000gpd-
10 OOOgpd.
❑ gK 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.
I
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
i
,f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
3s f4411toIII, W�
Property Address
u ll�r�
Owner Owner's Name /^
information is Q I✓0.43 it. s a�6
required for every
page. City/Town State Zip Code Date of Irlspectionf
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
❑ [W ere any of the system components pumped out in the previous two weeks?
❑ as 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: / l
Number of bedrooms(design): ----- Number of bedrooms(actual): ! 'K
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
/Orl A
Property Address SC4
Owner / 1Q c
information is Owner's Name G✓ Hs // al r.!T"� v
required for every
page. City/Town State Zip Code Date o1✓nspect' n
D. System Inf rmation
Description / ��� �-,.��10y /W v"
—lot
d
Number of current residents:
I
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)):
Detail:
Sump pump? 5E] Yes No
Last date of occupancy: Da
yr
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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
i
I
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
h Q
Property Address Mom
y
Owner Owner's Name
information is AV 6 a
required for every 9 X-9
page. Cityrrown State Zip Code Date of Ingpectiorr
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes No
If yes,volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of S em:
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.doc-rev.6116 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
R Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
3S12=1l
Property Address
Owner Ava ki .-e-
Owner's Name
information is Ir
required for every — —
page. City/Town State Zip Code Date of In ection
D. System Information (cont.)
Approximate age of all MY
ts,date installs (if mown)and source of information:
0,0
Were sewage odors detected when arriving at the site? ❑ Yes o
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 /O /
Comments (on condition of joints,venting,evidence of leakage,etc.):
Septic Tank(locate on site plan):
Depth below grade: feet
Mate con ria struction:
concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
t5ins.doc•rev.6/16 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
3S m r,✓G
Property Address SSR�
u ll�vG
Owner Owner's Name
information is �� AWS
S
required for every
page. City/Town State Zip Code Date of I spection
D. System Information (cont.)
Septic Tank(cont.) S0
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle ��c
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
T
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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Si
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address
Owner Owner's Name G�J T�Mf , • �ry� �� /^ /� —
information is
required for every ——
page. City/Town State Zip Code Date of specti
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.):
I
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:, -- -.-_
gallonn s p er 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.):
i
l
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
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t5ins.doc-rev.6116 Title 5 official Inspection Fonn:Subsurface Sewage Disposal System•Page 11 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewa a Disposal System Form-Not for Voluntary Assessments
Property Address
Owner Owners Name �j
information is Gf es f14 1,14
• —"6`/8 6 ,. V
required for every
page. Cityrrown State Zip Code Date of I spection
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.):
Se r s
it00 �a�
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.doc-rev.6116 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
doil, L✓a
Property Address - c
Owner Owner's NamA/0-r5)1y--r1f1r
information is
required for every
page. City/Town State Zip Code Date finspecAon
D. System Information (cont.) 6 y / d c-// �� SY" o"te
Type: 612
(�
leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number,dimensions:
❑ overflow cesspool number. --- - - - -
❑ innovative/altemative system
Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of
vegetation,etc.):
h rS tdOi 4— A 4' Xxx,--
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
15ins.doc•rev.6/15 I Tille 5 Officiai inspection Fonn:Subsurface Sewage Disposal System•Page 13 of 17
C
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�S S4 il,Oh
Property Address TC.
Owner Owner's Name
information is
required for every
page. City/Town State Zip Code Date o nspect'
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.doc•rev.6/16 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
Property Address
Owner Owner's Name
information is S 194 f� � —q O Q
required for every Ctr/ '� � �fJ
page. City/Town State Zip Code Date of I pection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two per anent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where p water supply enters the building. Check one of the boxes below:
hand-sketch in the area below
❑ drawing attached separately
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Gam,!/fah
Se�rc
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143-13 G.)- -31
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t5ins.doc•rev.6/16 ! Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not Not for Voluntary A��ssessments
[�
Property Address S
Owner Owner's Name s . // //
information is !`/ b 1�
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked,date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
Checked i h local Board of Health-expl 'n:
At.,H s L�sf t /Ll�►r�s
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must es a how you established the high ground water elevation:
must e
IS levrecl o2S"+ g6cft 0&4c .
o Hoe,, i � /S lOGv,--
�/a'rf0✓I Q✓� G �S' vC
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc•rev.6/16 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
Property Address
Owner Owner's Name ' �q
information is S 1 /� �/P�iq-r 1. �
required for every
page. City/Town State Zip Code Date of Iripection
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
t5lns.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
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o0 F F I C I A L ,,U,-GE
0— Certified Mail Fee
Q. $ a
Extra Services&Fees(check box,add fee as appropriatel.. a' C.
❑Return Receipt(hardcopY) $ '
r ❑Retum Receipt(electronic) $ -` postmark
C3 ❑Certified Mail Restricted Delivery $III ere Q Adult Signature Required $
❑Adult Signature Restricted Delivery$ �f.y
p Postage \ •p�� t
rn $
I- Total Postage
'r-q $ SULLIVAN, CHARLES O
`" sent To 35 STALLION WAY _
MARSTONS MILLS, MA 02648
Ciry State,Zll
Certified Mail service provides the following benefits:
•A receipt(this portion of the Certified Mail labeQ. for an electronic return receipt,see a retail
■A unique identifier for your mallpiece. associate for assistance.To receive a duplicate
■Electronic verification of delivery or attempted return receipt for no additional fee,present this
delivery. USPS®-postmarked Certified Mail receipt to the
■A record'of delivery(including the recipient's retail associate.
signature)that is retained by the Postal Service- Restricted delivery service,which provides
for a specified period. delivery to the addressee specified by name,orb
to the addressee's authorized agent.
Important Reminders: Adult signature service,which requires the
■You may purchase Certified Mail service with signee to be at least 21 years of age(not
First-Class Mail®,First-Class Package Services, available at retail).
or Priority Mail®service. Adult signature restricted delivery service,which"
•Certified Mail service is notavailable for requires the signee to be at least 21 years of age
international mail. and provides delivery to the addressee specified
•Insurance coverage is notavailable for purchase by name,or to the addressee's authorized agent
witlYCertified Mail service.However,the purchase (not available at retaiq.
of Certified Mail service does not change the
g ■To ensure that your Certified Mail receipt is
insurance coverage automatically included with accepted as legal proof of mailing,it should bear a
certain Priority Mail items. USPS postmark.If you would like a postmark on
•For an additional fee,and with a proper this Certified Mail receipt,please present your
endorsement on the mailpiece,you may request Certified Mail item at a Post Office'for
the following services: postmarking.If you don't need a postmark on this
-Return receipt service,which provides a record Certified Mail receipt,detach the barcoded portion
of delivery(including the recipient's signature). of this label,affix it to the mallpiece,apply
You can request a hardcopy return receipt or an appropriate postage,and deposit the mailpiece.
electronic version.For a hardcopy return receipt,
complete PS Forth 3811,Domestic Return
Receipt attach PS Form 3811 to your mailpiece; IMPORYAIM Save this receipt for your records.
PS Form SSOO,April 2015(Reverse)PSN 7530-02-0004047
�ENDER.�- COMPLETE THIS SECTION- COMPLETE THIS SECTION ON DELIVERY,
■ Complete items 1,2,and 3. A. Signet
■ Print your name and address on the reverse ent�jj TCg
so that We can return the.card to you. <p4 43addressee
■ Attach this card to the back of the mailpiece, B• ceived by,.finte Na e) C. Dqie of D li
or on the front if space permits. i
I` 1. D. Is delivery address different from item,l ❑Yes
1 If YES,enter delivery addr-s below:;i!p No
SULLIVAN, CHARLES O
ti
35 STALLION WAY O
MARSTONS MILLS, MA 02648E
II�'I�IIII�III�II�IIIIII�'II'II'IIIIIIII'I�II ❑AduRSg Signature �O`PReeol ice Typ
�a�pMssa
Adult Signature Restricted Delivery 0 Registered Mail Restricted
9590 9402 4116 8092 9357 25 Certified Mail® Delivery
Certified Mail Restricted Delivery Return Receipt for
❑Collect on'Delivery Merchandise
2--Articl,n.Nrimher LTransfer from service label)_- ❑Collect on Delivery Restricted Delivery ❑Signature Confirmation rm
}i I;f i�. - ' p.Signatur�p�rmaU n
7d1`5` 1730 0001` 4990 0249° °- RestrictedpLliV r�l�if
a>�Fre�w
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[,PS Form 3811,July 2015 PSN 7530-02-000-9053 Domestic Return Receipt
First-Class Mail
Postage&Fees Paid
USPS
Permit No.G-10
9590 9402 4116 8092 9357 25
United States •Sender:Please print vour_name__address_andzip+d® fhi—k,...--._
Postal Service
d'""° 4 Town of Barnstable
' Health Division j
200 Main Street
j Hyannis,MA 02601
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IrlI011 Milli1111111liuVIIIIIIjillJIli
G , TOWN OF BARNSTABLE
LfDCATION L o4 132 5 I&OLm, w SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT I7� 6®I�3
INSTALLER'S NAME & PHONE NO. 77 l-lol(o
SEPTIC TANK CAPACITY yOC) gay US
LEACHING FACILITY:(type) L2,/tLU (size) 0
NO. OF BEDROOMS PRIVATE WELL O PUBLIC WATER
BUILDER OR OWNER y-,y5l4 co, -7-71
DATE PERMIT ISSUED:
DATE COLIPLIANCE ISSUED: Ll - to . �
VARIANCE GRANTED: Yes No��
SS
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THE COMMONWEALTH OF MASSACHUSETTS
'BOARD OF HEALTH
1q 011 .......... 1......of..........
�,� 5.7� ..
Appl ration for Di-opuattl Warks Tomitrnr#inn Vrrutit
Application is hereby made for a Permit to Construct Q4 or Repair ( ) an Individual Sewage Disposal
System at: 3 /,�
................--....__............................................... ....?�r ... .. ......��.. ..--- ...................
................_.._._. ._..._..Lo tion-Addres A . .[�!�`1 ` .or/ o. .......�...-.
• , cam ,.— G�L / c
_ / t // Address
............
--(�r� .5 !�1 •------- .---•-. f i,� a q mac.................
Installer Address
Type of Building Size Lot../—_ -..7.....Sq. feet
., Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aN Other—T e of Building No. of persons............................ Showers
YP g ---------------••----------- P ( ) — Cafeteria ( )
Other fixtures -------------------------------------
Design Flow...................f._r.o_._._._....gallons per 1 per,daX. Total da'y flow......._... .��. ._........_...gallons
W //
WSeptic Tank—Liquid capacity-f�=i llons Length....�._�_. Width..`'_�.�O.. Diameter................ Depth..-IF r
x Disposal Trench—No. .................... Width.................... Total Length..................... Total leaching area....................sq. ft.
3 Seepage Pit No........I-.--.-.---- Diameter.......//..... Depth below inlet.............. Total leaching area(........sq. ft.
Z Other Distribution box ) Dosing tank� )
~" Percolation Test Result Performed by y-------------------- Date---r.� .........
lf�Test Pit No. 1�. minutes per inch Depth of Test Pit..... Depth to ground water..__ ��-
Lr. Test Pit No. 2..._.a.........minutes per inch Depth of Test Pit.................... Depth to ground water........................
..................•-•----•---•--..........---........----•---.----........
Descriptionof Soil.....! .....................•----•-•-•--.........-----•----------•------:.._-•-------..........................---.......-----...........---
U .....-----•-----•-•............. • -----•----••----------------------......------•-----------------...---•-----------------------•--•-•--------...------........... --..........----•---•-•-.
UW ................................... -----•----------------•--•••------------------------------------•---•---------------......----------------..........---------------........---•••----•-----.....
Nature of Repairs or Alterations—Answer when applicable...............................................................................................
-------------•------------------.....-----------....-------•--------•-.........-•---...........................--------------------------------•-••----•-----•---••••.................................
Agreement: ,
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of 4ITL_ 5 of the State Sanitary Code— The undersigned further-agrees not to place the system in
operation until a Certificate of Compliance has been�ssu by the board of health. _
Signed.
Date
Application Approved BY ... . .. . ..............
---------------- ............. =143.m .
Date
Application Disapproved for the following reasons:.....................................................................•--------..............--..._........... ..
...........•-•------•-.......•--•--•----•---.....--••...............•---....-•-•---•--.........---................------•-------•--------------....•....-----------...................................�
Permit No........
ate
— Issued.- ................ ........
Date
r '
Fins ........_.
THE COMMONWEALTH OF MASSACHUSETTS t
! l . - '-'BOARD OF HEALTH
i -T696 )A.]-------OF......... � ' <t� 1
Appliratiun for Dhgpviial Hijarkii Tonatrurtiun Prrmit
Application is hereby made for a Permit to Construct ( V or Repair ( ) an Individual. Sewage Disposal
System at: / _,., 2y ��t
................__....--•-•-....._ �t�.-�- --- •-- .. ......................... ...........----- t....- ----- .................
a , '7/0 ............
..-..—.•-
••••.........Lo atio Address r Addre
............. ....... Owei
---------------------- '------f .....__ ....
�r ..................
Installer Address /
Type of Building Size Lot../..� ...7......Sq. feet
.. Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
a`a Other—Type T e of Building No. of persons ......................... Showers
„� yp g ---------------------------- p ( ) — Cafeteria
Other fixtures ............................. .._..._ T •--• ........._._..
W Design Flow.........................�...........gallons per person per/day. Total daily flow.......................!;;2............._gallons.,
WSeptic Tank—Liquid capacity.h2a) allons Length._..e�._ __ Width:.'1 ._ Diameter................ Depth5_....4-
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area._..................sq. ft.
3 - Seepage Pit No........ .......... Diameter......./,, ?..... Depth below inlet...... ........ Total leaching areaQ.. ...sq. ft.
Z Other Distribution box (V Dosing tank
Percolation Test Results p. Performed by.._...._C... ... TJl1!! ._.�........................ Date...�.���U��7
Test Pit No. l_...._._.-.......minutes per inch Depth of Test Pit_-- Depth to ground water�.?� ...
fZ. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...
--------
.,...
....___.
a .......................... w
O Description of Soil.....- -1'. .71.7...........-•-----•..................•-----••--------------•---------•--------•.....------•-•-•--•-•-•......----••......•.
_ _----•••--•--•-----------• --------- -•--•-......--•-------------------•.........---•----•-------••----•••-•---•--•--......-- ----•--•--•--••-••......•---••- ........................................
---..._•------••--........_..._.•---• 'Fi
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
_ -----------------------
•----------------
•--------
•-------
•----------
---------------------
-------------------------------------------
---.-------
•------------
.-.......
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code — The undersigned further agrees not to place the system in
operation until a,Certificate of Compliance has been issued by the board of health.
Signed....-----..: ...`--' ............................................ .... ... .. ... 1_.
1/ 0 Date
Application Approved By-------- .. ---........ .... :.5�.' :3.:'1l-.
Date
Application Disapproved for the following reasons:..............•--...................-----------.....-•--•----.....---•---•----••-------•--..................
---•-•...............•--..........--•-------•---••-••---•-•--.._..............---••.......-•--------.......---•--•--------•••••-•-....------•-•---------••-------•---...--•-•-......-Date...---•-•-•-
Permit No....... —
� ....a•••-••---------•----... Issued..-•----------•-----Date ............................
Date t
TS
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
CIrrtif iratle of Toutplittnre
THI IS TO CERTIFY,.That the Individual Sewage Disposal System constructed O"or Repaired O
,5-
- .......v r.< ,-----•---•...........................•----------------...-----------------------------------•------------------------••-•--•••-•...__....
Installer n�
at._.......! - " -- ram r !/ I 1 -A .I1 +7?.I11� ........................
has been installed in accordance with the provisions of"-Tl!'L�. 5 of T e State Sanitary Code as described in the
application for Disposal Works Construction Permit No......., ...../. ...... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...................... ..................................................0 Inspector.... :_...a,i------------------------
T_ ll
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF 9i HEALTHf .......OF.....I ,t_�-r'✓�YtL ! � /l)
NO................ �� FEE---Y.. r7.......
Disposal Varks Tonstrurtion frrutit
Permission is hereby granted................ ..�. ._ `: Ufa_...... .:.._......
to Construct or Repair ,( ) an Individual a-Arage Disposal System
at No.................... ........ /''!f> i ..._..........
- •------•-----•--• ------ ... ........................_.....-•----
Street� �
as shown on the application for Disposal Works Construction Permit No�::��Dated..........................................
{� ............................. ---F - - -----------------------•----------...........
DATE. ---`/� / Board of Health
;:;--------------- -----.......
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