HomeMy WebLinkAbout0071 STONEY POND CIRCLE - Health 71 STONEY POND CIRCLE
MARSTONS MILLS
A=065-024
Town of Barnstable
Inspectional Services
+ BARNSTABLB.
3 9 �0� Public Health Division
200 Main Street, Hyannis MA 02601
Office: 508-862-4644 Thomas A.McKean,CHO
FAX: 508-790-6304
CERTIFIED MAIL#7015 1730 0001 4987 1715
June 10, 2020
OROURKE, ROBERT F & PATRICIA A
71 STONEY POND CIRCLE
MARSTONS MILLS, MA 02648
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 71 Stoney Pond Circle,Marstons Mills, MA was inspected
on 05/19/2020 by Chad Hathaway, 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:
• The distribution box is rotted.
You are ordered to replace the distribution box within one (1)year 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\71 Stoney Pond Circle Marstons Mills.doc
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Town of Barnstable
, ' ,�� Inspectional Services Department
AjfA�,�A
Public Health Division
200 Main Street, Hyannis MA 02601
Office: 508-862-4644
FAX: 508-790-6304 Thomas A.McKean,CHO
Feb 6, 2007
Rev. 4/26/19
DEADLINES TO REPAIR FAILED SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15.000)
An "x" marked in the ❑ is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA
❑ Discharge or ponding of effluent to the surface of the ground
❑ Pumping more than 4 times during the last year not due to clogged or obstructed
pipe.
❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool
❑ Structurally unsound septic tank or SAS
ONE (1) YEAR DEADLINE CRITERIA
❑ Static liquid level in the distribution box is above the outlet invert due to an
overloaded or clogged SAS or cesspool
❑ A portion of the SAS, cesspool, or privy is below the high groundwater elevation
❑ A portion of the cesspool is located within a Zone 1 to a public well
❑ A portion of the cesspool is located 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
❑ Single Cesspool
o Any "conditionally passed systems" (broken cover, relocation of a pipe, relocation
of a driveway due to H-10 components, etc)
❑ Leaching facility with standing liquid level at or above the invert pipe (per Town
Code §360-20 h)
"0' L4e) d-4ox
Repair deadline: t/ a f
Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc
Commonwealth of Massachusetts
Title 5 Official Inspection Form f ,
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments r
71 Stoney Pond Circle
Property Address c,
ORourke
Owner Owner's Name
information is `?
required for every Marstons Mills Ma 5/19/2020
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. Inspector Information
filling out forms 3
on the computer,
use only the tab Chad hathaway
key to move your Name of Inspector
cursor-do not Hathaway Septic Inspections
use the return Company Name
key.
� Company Address
Forestdale Ma 02644
City/Town State Zip Code
774 274 2581 12866
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ❑ Passes
2. ® Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
5/19/2020
In ector's Sign a Date
The system inspector shall mit a c py of this inspection report to the Approving Authority(Board
of Health or DEP)within days ompleting this inspection. If the system has a design flow of
10,000 gpd or greater, the i ector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: 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.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
71 Stoney Pond Circle
Property Address
ORourke
Owner Owner's Name
information is required for every Marstons Mills Ma 5/19/2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) 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 is not a guaranteeand applies no warrantyof the described septic components in this
report including but not limited to piping structual intergrity of components and life exspectancy of
leaching and described components. This inspection is to describe conditions witnessed at time of
inspection only. Regular tank maintenance and water conservation can prolong life of septic systems
Information on care and do's and don't's can be found at town health dept or mass.gov
2) 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):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
71 Stoney Pond Circle
Property Address
ORourke
Owner Owner's Name
information is required for every Marstons Mills Ma 5/19/2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ 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):
Dbox is rotted out and dirt is flowing into box
❑ 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):
3) 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. -
a. 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:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
71 Stoney Pond Circle
Property Address
ORourke
Owner Owner's Name
information is required for every Marstons Mills Ma 5/19/2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ 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
b. 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.
c. Other:
4) 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
71 Stoney Pond Circle
Property Address
ORourke
Owner Owner's Name
information is required for every Marstons Mills Ma 5/19/2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
❑ ® 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 water supply
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 2000 gpd-
10,000 gpd.
❑ ® 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.
5) 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 CA.
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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
c � Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 Stoney Pond Circle
Property Address
ORourke
Owner Owner's Name
information is required for every Marstons Mills Ma 5/19/2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
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?
® El available
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)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
cam, Commonwealth of Massachusetts
!n ,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
71 Stoney Pond Circle
Property Address
ORourke
Owner Owner's Name
information is required for every Marstons Mills Ma 5/19/2020
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 permited Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Description:
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
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? ❑ Yes ® No
Last date of occupancy: current
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
71 Stoney Pond Circle
Property Address
ORourke
Owner Owner's Name
information is required for every Marstons Mills Ma 5/19/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. 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
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. 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:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
u � 71 Stoney Pond Circle
Property Address
ORourke
Owner Owner's Name
information is required for every Marstons Mills Ma 5/19/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. 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):
Approximate age of all components, date installed (if known)and source of information:
1994
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer,(locate on site plan):
Depth below grade: 1.75'
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 10+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
no signs of poor venting or leaks
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
�d Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
71 Stoney Pond Circle
Property Address
ORourke
Owner Owner's Name
information is required for every Marstons Mills Ma 5/19/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
1'
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
1500 gal H10
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 10'6"5'6"
Sludge depth:
10"
Distance from top of sludge to bottom of outlet tee or baffle
20"
Scum thickness
6"
Distance from top of scum to top of outlet tee or baffle
4"
Distance from bottom of scum to bottom of outlet tee or baffle 12
How were dimensions determined? tape and sludge judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
tees in place tank at working level. recommend pumping tank over due for maintenance
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
w � 71 Stoney Pond Circle
Property Address
ORourke
Owner Owner's Name
information is required for every Marstons Mills Ma 5/19/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. 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
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. 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
t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
1 Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
71 Stoney Pond Circle
Property Address
ORourke
Owner Owner's Name
information is required for every Marstons Mills Ma 5/19/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
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
9. 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.):
Dbox is rotted out and needs replacement
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
gp Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 Stoney Pond Circle
Property Address
ORourke
Owner Owner's Name
information is required for every Marstons Mills Ma 5/19/2020
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
10. 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.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number:
1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
71 Stoney Pond Circle
Property Address
ORourke
Owner Owner's Name
information is required for every Marstons Mills Ma 5/19/2020
page. CityTrown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
6'x6' precast pit camera inspected . water level 1.5' below invert
12. 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
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
cam, Commonwealth of Massachusetts
f p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 Stoney Pond Circle
Property Address
ORourke
Owner Owner's Name
information is required for every Marstons Mills Ma 5/19/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
13. 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.):
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
71 Stoney Pond Circle
Property Address
ORourke
Owner Owner's Name
information is required for every Marstons Mills Ma 5/19/2020
-
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
14. 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
6 J -
gD-- 3 S-
Kl �
0
0
5
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Q
a
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 Stoney Pond Circle
Property Address
ORourke
Owner Owner's Name
information is required for every Marstons Mills Ma 5/19/2020
page. CityTrown State Zip Code Date of Inspection
D. System Information (cont.) .
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 30'feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
town GIS mapping
You must describe how you established the high ground water elevation:
lot el. 80' low in area (little pond)el. 50
t
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
` a
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
71 Stoney Pond Circle
Property Address
ORourke
Owner Owner's Name
information is required for every Marstons Mills Ma 5/19/2020
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank— Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
No. / Fee ?L�
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
ZippliLation for Disposal Opstem ConstCUttlon 3dErmit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location A d Lot Nol/ fj' euvt e W/ wner's Name,Address,and Tel.No.
As o ap cel
Installer's Name,Address,and Tel.No _?C V g S Designer's Name,Address,and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank l ��y Type of S.A.S. ��j
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) Ke
Date last inspected: 2 v O
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the syste eration until a Certificate of
Compliance has been issued by this Board of Health. / P
Sig Date v— o l�D
Application Approved by - Date �®
Application Disapproved by Date
for the following reasons
Permit No. Date Issued ��—l�
Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 1.r�^
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01ppIitation for Misposar *pstem Construction permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
r Location Add s$I Lot No7/ Sf co?4� �,n C;ye'l @Dwwn�er's Name,Address,and Tel.No.
Asse ors ap cel 65 "� /�' or✓ '� A�fc�� t✓ /rT
Installer's Name,Address,and Tel.No.3�09.:C�l 4 Designer's Name,Address,and Tel.No.
PIP/ V' Y'Q SPi•��--� .a.11
Type of Building: `
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
i
Design Flow(min.required) a gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title �c
Size of Septic Tank J -U� Type of S.A.S. �, ' t
Description of Soil ?
s
Nature of Repairs or Alterations(Answer when applicable) C fae 'C_ -�
9
Date last inspected: ��t -Z O
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described otprsite sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the peration until a Certificate of
Compliance has been issued by this Board of Health. (ter
Si d Date �20
Application Approved by Date � C
Application Disapproved by < Date
4 N�
for the following reasons
Permit No. ��� � Date Issued C~"}
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
- Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sew
aje,,Dis'posal system Constructed( ) Repaired( 9XUpgraded( )
Abandoned( )by C)1, 3 y-J Y�-o � -�"' ",,- r A, d ,L,
at�r S+0 n e r rD Ate' e has been constructed in accordance
with the prod ions of Title 5 and the f isposal System Construction Permit No y /7'Qated n (S
Installera�P L+ -P�� -� "s'a Designer
3#bedrooms Approved desigriflowA gpd
The issuance oft is Permit shall not be construed as a guarantee that the system wi)ll functio" as designecd/.
Date 1, o2 0 Inspector
-- /
No." "" ? J Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS
' � J �is�losaY �pstem OnstCUttion �ermit ;
Permission is hereby granted to Construct( ) Repair( - Upgrade( ) Abandon( )
System located at !21 wf���✓L�'C
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 e c {nplete/d within three years of the date of this perm
Date 6
1 Approved by
C)
E�
Ln •. •
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N OFFICIAL
43 Certified Mail Fee
iTj $
Extra Services&Fees(check box;add fee as appropdate)
rq ❑Return Receipt(hardcopy) $
❑Return Receipt(electronic) $ POStRIa
[]Certified Mail Restricted Delivery $ Here
❑Adult Signature Required $. --
❑Adult Signature Restricted Delivery$ /
m -
r`
' TROUT, ROBERT&A N MARIE
a 75 STONEY POND CIRCLE
MARSTONS MILLS, MA 02648
I i
Certified Mail service provides the following benefits:
■A receipt(this portion of the Certified Mail label). for an electronic return receipt,see a retail
■A unique identifier for your mailpiece. associate for assistance.To receive a duplicate
■Electronic verification of delivery or attempted return receipt for no additional fee,present this.
delivery. LISPS(ID-postmarked Certified Mail receipt to the_
■A record of delivery Qncluding the recipients retail associate.
signature)that is retained by the Postal Service— Restricted delivery service,which provides C a
for a specified period. delivery to the addressee specified by name,or
to the addressee's authorized agent.
Important Reminders: Adult signature service,which requires the t
■You may purchase Certified Mail service with signee to be at least 21 years of age(not )
First-Class Mail®,First-Class Package Service®, available at retail).
or Priority Mail®service. Adult signature restricted delivery service,which
•Certified Mail service is notavailabie for requires the signee to be at least 21 years of age.
International mail. and provides delivery to the addressee specifie
■Insurance_coverage is notavallable for purchase by name,or to the addressee's authorized age'
with Certified Mail service.However,the purchase (not available at retail).
of Certified Mail service does not change the ■To ensure that your Certified Mail receipt is
Insurance coverage automatically included with accepted as legal proof of mailing,it should bear a
certain Priority Mail items. USPS postmark.If you would like a postmark on I'
1 ■For an additional fee,and with a proper this Certified Mail receipt,please present your -11
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 Qncluding the recipient's signature). of this label,affix it to the mailpiece,apply
You can request a hardcopy return receipt or an appropriate postage,and deposit the mailpiece. -
electronic version.For hardcopy return receipt,
d complete PS Form 3811,Domestic Return
Receipt attach PS Form 3811 to your mailpiece; IMPORTAN11 Save this receipt for your records.
Ps Form 3800,April.2015(Reverse)PSN 7530-02-000.9047 -
SECTIONSENDER: COMPLETE THIS SECTION COMPLETE THIS ON DELIVERY
■ Complete items 1,2,and 3. A. Signature
■ Print your name and address on the reverse X 0 ent
so that we can return the card to you. Vj7ddressee
■ Attach this card to the back of the mailpiece, B. Received by( ame) C.D e of Delivery
or on the front if space permits. �}h►-7
Yes;ess different from item 1?
.livery address below: ❑No
VROUT'ROBERT&ANN MRIE
i _= 75 STONEY POND CIRCLE i � � j e� iU AMARSTONS MILLS, MA 02648 i
II I�III�I(�I)I�I I IIII II II I I I I�I II IIII II I I I u �clnco ,yp'�'� ❑Priority Mail Express Adult Signature ❑Registered
®
❑ Registered Mail*^^
❑Adult Signature Restricted Delivery ❑Registered Mail Restricted
❑Certified Mall® Delivery
9590 9402 5745 0003 5532 43 ❑certified Mail Restricted Delivery ❑Return Receipt for
❑Collect on Delivery Merchandise
2. I Icicle Number fTransfersrnm tea" r-gin-- —- - r'' " '- very Restricted Delivery ❑Signature Confirmation*'"
{ 7 015 t 7 7 3'10'0 014 4 9 8 7 t 8;4 S6 t 1 t t t t� 4 10 Signature Confirmation
{ _ estricted Delivery Restricted Delivery
over 0)
PS Form 3811,July 2015 PSN 7530-02-000-9053 Domestic Return Receipt
I
I USPS TRACK NG#
A F[ t Glas . ail _
Postage ees Paid
ASP it No: 100
9590 9402 5745 0003 za JuN - - - —:
United States •Sender:Please print your name,address,and ZIP+4®in this box"
Postal Service
n of Barnstable
lth Division
Main Street
Hyannis,MA 02601
I � I
I �
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p a
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Ln
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ca Certified Mail Fee
`Er $
_r Extra Services&Fees(check box,add lee as appropriate)
❑Return Receipt(hardcopy) $
C3 ❑Return Receipt(electronic) $ Postmark
li C3 .❑Certified Mail Restricted Delivery $ Here
O ❑Adult Signature Required $
[]Adult Signature Restricted Delivery$ JJ
p Pect—
M r
rl \
OROURKE, ROBERT F 8r PATRICIAA
rr-1 71 STONEY POND CIRCLE
C MARSTONS MILLS, MA 02648
Certified Mail service provides the following benefits:
a A receipt(this portion of the Certified Mail label). for an electronic return receipt,see a retail
■A unique identifier for your mailpiece. associate for assistance.To receive a duplicate
IN Electronic verification of delivery or attempted return receipt for no additional fee,present this
delivery. USPS®-postmarked Certified Mail receipt to tfie
■A record of delivery pnciuding 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,or
to the addressee's authorized agent
Important Reminders: Adult signature service,which requires the
■You may purchase Certified Mall service with signee to be at least 21 years of age(not
First-Class MOO,First-Class Package Service®, available at retail).
or Priority Mail®service. Adult signature restricted delivery service,which
■Certifufd 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.,
a Insurance coverage is notavailable for purchase by name,or to the addressee's authorized agent';
with.Certified Mail service.However,the purchase (not available at retail).
of Certified Mail service does not change the a To ensure that your Certified Mail receipt is
insurance coverage automatically included with accepted as legal proof of mailing,it should bears 1
certain Priority Mail items. USPS postmark.If you would like a postmark on r1
j ■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 Past Office-for
the following services: postmarking.If you don't need a postmark an 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 mailplece,apply
You can request a hardcopy return receipt or an appropriate postage,and deposit the mailplece.
electronic version.For a hardcopy return receipt,
complete PS Form 3811,Domestic Retum
Receipt;attach PS Form 3811 to your mailpiece; IMPORTARY:Save this receipt for your records.
Ps Form 3800,April 2015(Reverse)PSN 7530-02-000-9047
COMPLETE •
■ Complete items 1,2,and 3. A. Signature
■ Print your name and address on the reverse X E3 Agent
so that we can return the card to you. ❑Addressee
■ Attach this card to the back of the mailpiece, Received by(Printed Namej C. Date of Delivery
or on the front if space permits. k c( - Y,v • t f
ss different from ltem 1? ❑Yes
livery address below: ❑No
I _ `OROURKE, ROBERT F&PAT CIAA
'_. 71 STONEY POND CIRCLE +
M MARSTONS MILLS,MA 02648 i
4. — --- - - - 3:-Servicelype ❑Priority Mail Express@
II I�Iilll leli Ili I IIII III 1111111111 IN 11111111 ❑Adult Signature ❑Registered MailTM
duR Signature Restricted Delivery ❑R�Qistered Mail Restricted
el
9590 9402 5745 0003 5532 36 Certified Mall Restricted Delivery Detur^Receipt for
❑Collect on Delivery erchandise
❑Collect on Delivery Restricted Delivery lignature ConfirmationTM
2,n.,;..;e ni,�mhor/Transfer from_service label} � � � ,- ❑Signature Confirmation
7 015 1730 0 0 01 4988 1715., .: �l Restricted Delivery Restricted Delivery
PS Form 3811,July 2015 PSN 7530-02-000-9053 Domestic Return Receipt
First-Class Mail
Postage&Fees Paid
USPS
i
Permit No.G-10
9590 9402 5745 0003 5532 36
United States •Sender:Please print your name,address,and ZIP+4®in this box"
Postal Service
Town of Barnstable
Health Division
200 Main Street
Hyannis,MA 02601
lip! zHIIl!!jllIj7f}Ilill111ti1I:II)liflll��t'�f�i�lifl'
✓1 TOWN OF 13ARNSTABLE
LOCATION
VILLAGE �/h ASSESSOR'S MAP & LOT �®
INSTALLER'S NAME PHONE NO.
SEPTIC TANK CAPACITY /, im O
r
LEACHING FACILITY:{type) ?/.T— (size) /,
NO. OF BEDROOMS PRIVATE WELL OR PPUB�LIC�WATER
BUILDER 6AR WO NER 6 ,r2a a=,''
DATE PERMIT ISSUED: C?- ---
• DATE COMPLIANCE ISSUED: 24wj 7 Z-
VARIANCE GRANTED: Yes No
67
t �
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No... ...... .. F.Rz 100
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Application is hereby made for a Permit to Construct (A or Repair an Individual Sewage Disposal
Systesp at:
Address
.......xc� V Installer �iw Address
Type of Building Size Lot.... ....Sq. feet
U of Bedrooms............. Expansion Attic Garbage Grinder 6etjj�s\�
------------------------
Z Other Distribution box ( ) Dosing tank ( )
Test Pit No. I....7 minutes per inch Depth of Test Pit....1_7 ........ Depth to ground waterOY��KA
�
-'_-----_'---_------_-'-_--_---_-__-'____.'--___'___--_-_--_'___-'----.--._-____._
Agreement:
The undersigned agrees m install the afore6esoibe6In6ivi6ual Sewage Disposal System io accordance with
�.�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD--OF HEALTH
.......I.O.sAJ---tj.............OF........�.,%? t .:1 ?. .. t ' .- ...............................
Appliration for Disposal Works Ton,strurliun Prrutit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at: f. ( a
Locati Address - or Lot No.
— t- l> ' •..Gil✓ ` ......-7
�?. ._ .......... ...............
er ! Address
a �. _... .�_ ._... Y•-- ..... ------------------------------------------------
Installer Address
Q Type of Building .•, Size Lot.... .....Sq. feet
U Dwelling— o. of Bedrooms - . •----Expansion Attic ( ) Garbage Grinder �CR
Other—Type of Building --__•-----_-•-_-__-____-_- No. of persons____________________________ Showers 6( ) Cafeteria ( )
al Other fixtures ............................... ...
W Design Flow.....................`aif ................gallons per person per day. Total dai}y..fiow------------_ -�......
..........gallons.
C� Septic Tank—Liquid capacity..15E:' allons Length./4-4!.... Width...:j..�"=_�`,___ Diameter________________ Depth .' ....
Disposal Trench—No......... ..... Width.................... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No-----------/------- Diameter.....La Depth below inlet... ........... Total leaching area. Z§.....sq. ft.
Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by........ --- ---••------...-•------................a..................... Date........................................
,.a Test Pit No. I...7dTv:.....minutes per inch Depth of Test Pit----�_.EL....... Depth to ground water6_"''✓___7.L_-
rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 '.........y-•--._ :n...-------•--------X-------•-------------------------•...................._........-------•--..._.....------•-------._...----....--
Description of Soil �J 3..... € p t '4 .......+.:� ter-------------- -----------------------------------------------------------------
U --------•-•----•--------•-------•• -•-- I.`------.. . . .....1.� ......-----•--------------------•-•---------•-----------------------•---•--•----•-------•-•-•--•---"
W
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
-•-•---•----••-----•---------------------------•----..............--...........---••--•-----------•T....__...........---•----•--•-•----•------------•---••---•--••-•-•--•-...........-••---•--•--..._..
Agreement:
1
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Complia ce een >ssu by t oard of health.
Signed �! ............ /. ' '- .. �...-- . _�....
(!!._ ......... .......'----/ r Date ,
Application Approved B � .�:.lr �-- % �� � � ��'...-- .:=:
PP pp Y ------------�..- . ....................... �. .... �..-•t!��'rM'=--"-'- r�'� -- --- ----- -- ......r...I
Application Disapproved for the following reasons: kf----------------------------------------------------------- [J ..............
I..............................................
................ .........................` =----ice`---_-.-....-.--.- .......................----.----............--......... [ _!...G'.. ........................................
Date
Permit No. ! --- Issued .-, 71�%/'�' -�
...... .'! V v ' ....,-�--i,�;;a----�----Date--------<.:✓..........................
THE COMMONWEALTH OF MASSACHUSETTS
......... .T
.
BOARD�O H.EAITTH
l�ffJy l. �....��..
J
r4 . ............
CITErtifirate of C oraptianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
r n
---------------------
.-• -- 1 le.---- ....... -----------------------------------------------------..............
T rI C
has.been installed in accordance with the''provisions of TITLE 5, f 'l�he Sta e vironmental C d as d c•bed in
the application for Disposal Works Construction Permit No. --.. �.:G:.. .... ......... dated --- ---.... f ;0... •�
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE I.VNSTRU AS A GUAR EE THAT THE
SYSTEM WILL FUNCTION$ATISFACTORY.
DATE------------------ - --------.� a.o -... c.. ---------------------_- Inspector ........N........---...............-------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
^�I , POARD OF HEA
.............................t ; F"` i.�ll _�1�a.;!..'. ............
No..... ......I... FEE.... ................
Disposal Works Tonstr ion rruti#
Permission is hereby granted.................... ...........................................................T------- ....................................................
to Construct ( �e(S or Repair (_ an ndividual Sewag Disposal tem,, ,
at No -� / ` `\l- _
et
as shown on the applicati n for isposal Works Construction P i No..�%�r _:------ ,
t�
/ Board of ealt
DATE................ .v�...._.-_F•-.....•--- .................................
FORM 1255 HOBBS & WARREN. INC PUBLISHERS
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FIGURE 6: GROUNDWATER CONTOURS
LEGEND
® OBSERVATION WELL
•--�52---GROUND-WATER CONTOURS ,
--� DIRECTION OF GROUND-WATER FLOW ■
SCALE 1:1320 :
• � II1C.