HomeMy WebLinkAbout0096 TANBARK ROAD - Health 96 Tanbark Road
t Mars- tons Mills P
A = _100 023001
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Hazardous Materials Inventory Sheet Checklist
Date
Physical Street Address-Check database to ensure it exists
Working Phone Number
L—Actual Amounts-(le.gas being used to fuel machines,thinner to
clean brushes all count as hazardous materials)
f:Z—Storage Information-location of storage,how long is storage for?
If none,note that.
___4,.,,,Qi&posal Information-where and who?If none,note that.
_4 —Applicant Signature-understand what is listed and noted
Staff Initial-any questions,know who to ask
Vehicle Washing/Rinsing? -provide a vehicle washing policy and
explain it-note that it was given
�/iiCttach the Business Certificate with your sign off and comments
"The inventory form should explain what the business consists of and the procedures
they are doing. Notes need to be left to explain what you discussed with them.
200
YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town which
you must do by M.G.L.-it does not give you permission to ope.rate.) Business Certificates are available at the Town Clerk's Office, 1� FL.[367
Main Street, Hyannis, MA.02601 [Town Hall)
ane�mmx oxapi{9w;Flgy l lO f
GATE•o co/
Fill in pioasa:
Vi'.41nA�"Ei��mnnei a .-..•. , i .
v APPLIGANT•S YOUR NAME: L�,.1�p i�f f\n A 1 lV S
BUSINESS YOUR HOME ADDRESS:_ 4 otti)Oosr k
TELEPHONE # Home Telephone Number
NAME OF NEW BUSINE55 C C-I�ct�n r
TYPE OF BUSINESS: V S C r 1S THIS A HOME OCCUPATION? YES N
Have you been given approval from the building djvisioo'? YE5 NO
ADDRESS"OF BUSINESS
(>t ' MAP/PARCEL NUMBER_ 100- Q�5-() j/
When starting a new business there are several things you must do in order.to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you
[n' ay need.. You MUST GO corer of Y
Rd. &Main Street). to make sure you have the appropriate permits and licenses.required to legally operaOte your business to this town.armouth
1. BUILDING CO IONER'S OFFIC
This indivi ual ee ed- ny permit requirements that pertain to,this type of business.
,.., MUST COMPLY IN►'�.
` Authprize Si H HOMF- OCCUPATION
** RULES AND riLtOUI AT'r'".,!5.; FAIL R ATI�N
COMMENTS: COMPLY MAY RESU U E TO
2. BOARD OF HEALTH
This individual h en infor e o he per it re Uirements that pertain to this type of business.
ut orized Sig ature*
COMMENTS: . MUSTCpM a
SMA
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature.*
COMMENTS:
N#
TOWN OF BARNSTABLE Date:�c/
TOXIC AND HAZARDOU MATERIALS ON-SITE INVENTORY
NAME OF BUSINESS: C* 8
BUSINESS LOCATION: ' INVENTORY
9h At
MAILING ADDRESS: TOTAL AMOUNT:
TELEPHONE NUMBER: �" 6
CONTACT PERSON:
EMERGENCY CONTACT TELEPHONE UMBER: - 3 _ S MSDS ON SITE?
TYPE OF BUSINESS: k
,
INFORMATION/RECOMMENDATIONS: Fire District:
Waste Transportation: V Last shipment of haz o stat
%"WZL9
Name of Hauler: Destination.
Waste Product: -k� '80 LQI Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health and the Public Health Division have determined that the following products exhibit toxic
or hazardous characteristics and must be registered regardless of volume.
Observed/Maximum Observed/Maximum
`o Antifreeze (for gasoline or coolant systems) 10 _ Misc. Corrosive
NEW USED 0 Cesspool cleaners
Automatic transmission fluid y Disinfectants
Engine and radiator flushes Road Salts (Halite)
Hydraulic fluid (including brake fluid) ® Refrigerants
Motor Oils Pesticides
NEW USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers)
Diesel Fuel, kerosene, #2 heating oil NEW USED
Misc. petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil NEW USED
Degreasers for engines and metal Printing ink
0 Degreasers for driveways & garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Misc. Combustible
0 Car wash detergents ki Leather dyes
Car waxes and polishes O Fertilizers
ID Asphalt & roofing tar 0 PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (inc. carbon tetrachloride)
NEW USED Any other products with "poison" labels
0 Paint &varnish removers, deglossers (including chloroform, formaldehyde,
Misc. Flammables hydrochloric acid, other acids)
Floor &furniture strippers Other products not listed which you feel
Metal polishes may be toxic or hazardous (please list):
3 Laundry soil & stain removers
(including bleach)
0 Spot removers & cleaning fluids
(dry cleaners)
c� Other cleaning solvents
Bug and tar removers
Windshield wash
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS
Hazardous Materials Inventory Sheet Checklist
1 d ate
ysicai Street Address-Check database to ensure it exists
�orking Phone Number
Actual Amounts-(le.gas being used to fuel machines,thinner to
clean brushes all count as hazardous materials)
JGStorage Information-location of storage,how long Is storage for?
If none,note that.
,,::'Disposal information-where and who?If none,note that.
l,,C::�Applicant Signature-understand what is listed and noted
Staff Initial-any questions,know who to ask
Q —Vehicle Washing/Rinsing? -provide a vehicle washing policy and
explain it-note that it was given
Attach the Business Certificate with your sign off and comments
"The inventory form should explain what the business consists of and the procedures
they are doing. Notes need to be left to explain what you discussed with them.
YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which
you must do by M.G.L.-it does not give you permission to ope.rate.) Business Certificates are available at the Town Clerk's Office, 1"° FL., 367
Main Street, Hyannis, MA.02601 [Town Hall)
fine:+,mnx:etl[WA 9u NS'!',F.. GATE: V / 1 0
Fill in please:
Y;::say r,•.r::fi;,,....... �, ;m 1
APPLIGANT'S YOUR NAME:M ft 4L CAI A q12-T 1 N 1
YOUR HOME ADDRESS;c% v��nq,rk Q�
a" •'+ '� II'�' ice. NC4R.�S'IZ�NS 1711t,L
i -
bldit TELEPHONE # Home Telephone Number
NAME OF NEW BU5'INE55 M 02iv -(1 Ntr TYPE OF BI7SINESS' y �}'T 11J �
1S THIS A HOME OCCUPATION? k. YES NO
Have you been given approval,from the buildin _'division? YES' NO
ADDRESS OF BUSINESS °I(P 'F o.ti 1,c7.r V-Q 46 MAP/PARCEL NUMBER `00-OA_i3-0
When starting a new business there are several things you must do in order-to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you Inay need'. You MUST GO TO 200 Main St. — (corner of Yarmouth
Rd. &Main Street). to make sure you have the appropriate permits and licenses required to legally operate your business in this town.
1. BUILDING CO SS NER'S OFFICE
This individ al ha e n infot
- y permit requirements-that pertain to,this type of business. MUST COMPLY WITH HOME OCCUPATION
RULES AND REGULATIONS. FAILURE TO
A hprized Si re** COMPLY MAY RESULT IN FINES.
COMMENTS:
2..BOARD OF HEALTH
This individual h f r of the mit requirements that pertain to this type of business.
Authorized Si a ure** KWCOWYWRHAlL
COMMENTS: .
tg
3: CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business. Z ( IQ�Z
Authorized Signature.*
Lh . I I � '
COMMENTS: .!1 1l;t :).
4
Date:QC /(I / o�
TOWN OF BARNSTABLE
TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY
NAME OF BUSINESS: MOLE V A-10T I N�
BUSINESS LOCATION: q,(P 4t,,v\b0.r k moA-t INVENTORY
MAILING ADDRESS: S_fO ouvyk0\,r k "fio b TOTAL AMOUNT:
TELEPHONE NUMBER: 10 i— L410 '-:K 62
CONTACT PERSON: Wic_9I n
EMERGENCY CONTACT TELEPHONE NUMBER: Dltl - 2-3Q- MSDS ON SITE?
TYPE OF BUSINESS: 1bpIn1-r i nic,.
INFORMATION/RECOMMENDATIONS: Fire District:
Waste Transportation: StAF Last shipment of hazardous waste:
Name of Hauler,• Destination: bows�OMLL -V)r0h0CY- S4o,A,, ,
Waste Product:-t!!Z1he_r Ly"4) hoIh4 r�Xhs Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health and the Public Health Division have determined that the following products exhibit toxic
or hazardous characteristics and must be registered regardless of volume.
Observed/Maximum Observed/Maximum
Antifreeze (for gasoline or coolant systems) Misc. Corrosive
NEW USED Cesspool cleaners
Automatic transmission fluid 0 Disinfectants
Engine and radiator flushes D Road Salts (Halite)
Hydraulic fluid (including brake fluid) p Refrigerants
Motor Oils Pesticides
NEW USED O (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers)
Diesel Fuel, kerosene, #2 heating oil NEW USED
Misc. petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil NEW USED
Degreasers for engines and metal Printing ink
9 Degreasers for driveways & garages Wood preservatives (creosote)
\VCaulk/Grout Swimm
ing pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Misc. Combustible
Car wash detergents Leather dyes
Car waxes and polishes �0 Fertilizers
Asphalt & roofing tar PCB's
�- Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
3 Lacquer thinners (inc. carbon tetrachloride)
NEW USED Any other products with "poison" labels
Paint &varnish removers, deglossers .(including chloroform, formaldehyde,
d, Misc. Flammables hydrochloric acid, other acids)
Floor & furniture strippers Other products not listed which you feel
Metal polishes may be toxic or hazardous (please list):
0 Laundry soil & stain removers
(including bleach)
Spot removers &cleaning fluids
O (dry cleaners)
Other cleaning solvents
�. Bug and tar removers
Windshield wash
WHITE COPY-HEALTH DEPARTMENT I CANARY COPY-BUSINESS
COMMONWEALTH OF MASSACHUSETTS
z W EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: #96 Tanbark Road
Marstons Mills,MA
Owner's Name: Steven Albanese C=
Owner's Address: #96 Tanbark Road =
Marstons Mills,MA a,i,
cr+
Date of Inspection: 05/25/05 C)
Name of Inspector: (please print) Mr.Carmen E. Shay ra
Company Name: CAPEWIDE ENTERPRISES,LLC
Mailing Address: P.O.Box 763 rya rn
Centerville,MA 0632
Telephone Number: (508)-428-4028
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper functiodand 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:
OF 414 0
XX Passes y
Conditionally Passes g CARMEN
Needs Further EEreporrIt
lti b the Local Approving Auth SHAY y
Fails o
CF9TlF��pQ
Inspector's Signature: Date: 5/25/05 Fs INSP��
The system inspector shall submit a copy of this inspectioApproving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
3' Liquid observed in Leach Pit.
****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.
K
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: #96 Tanbark Road
Marstons Mills,MA
Owner: Steven Albanese
Date of Inspection: 05/25/05
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:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health, will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with 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.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: #96 Tanbark Road
Marstons Mills,MA
Owner: Steven Albanese
Date of Inspection: 05/25/05
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 CNVIR 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
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 coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: #96 Tanbark Road
Marstons Mills,MA
Owner: Steven Albanese
Date of Inspection: 05/25/05
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
XX Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
XX Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
XX Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
XX Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow
XX Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
XX Any portion of the SAS,cesspool or privy is below high ground water elevation.
XX Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
XX Any portion of a cesspool or privy is within a Zone 1 of a public well.
XX Any portion of a cesspool or privy is within 50 feet of a private water supply well.
XX Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this forma
NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system 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.
T ., 1 1 r .,,.,..,.- 4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: #96 Tanbark Road
Marstons Mills,MA
Owner: Steven Albanese
Date of Inspection: 05/25/05
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
XX Pumping information was provided by the owner,occupant,or Board of Health
XX Were any of the system components pumped out in the previous two weeks
XX _ Has the system received normal flows in the previous two week period`?
XX Have large volumes of water been introduced to the system recently or as part of this inspection?
N/A Were as built plans of the system obtained and examined?(If they were not available note as N/A)
XX _ Was the facility or dwelling inspected for signs of sewage back up ?
XX Was the site inspected for signs of break out
XX _ Were all system components,excluding the SAS, located on site'?
XX _ 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 ?
XX _ 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:
Yes no
XX _ Existing information. For example,a plan at the Board of Health.
XX _ 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(3)(b)]
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: #96 Tanbark Road
Marstons Mills,MA
Owner: Steven Albanese
Date of Inspection: 05/25/05
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: Unk.
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no):_
Seasonal use: (yes or no): Yes
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: None Available
Was system pumped as part of the inspection(yes or no):
If yes, volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
XX Septic tank,distribution box, soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank _Attach a copy of the DEP approval
I
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
January 1989-ori2inal,- per Owner&BOH Records
Were sewage odors detected when arriving at the site(yes or no): No
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: #96 Tanbark Road
Marstons Mills,MA
Owner: Steven Albanese
Date of Inspection: 05/25/05
BUILDING SEWER(locate on site plan)
Depth below grade: 18"
Materials of construction:_cast iron _40 PVC XX other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints, venting,evidence of leakage,etc.):
SEPTIC TANK: XX (locate on site plan)
Depth below grade: 24" to Top of Tank
Material of construction: XX concrete_metal_fiberglass_polyethylene
—other(explain)
If tank is metal list age:_ is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: 5' deep x 51wide by 8' lone (1,000 gallons)
Sludge depth: 4.0'
Distance from top of sludge to bottom of outlet tee or baffle: 2'
Scum thickness: '/4 inch scum laver noted
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: 17"
How were dimensions determined: Measured
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
IC Structural integrity of tank was ok. No evidence of cracks, leaks, or water infiltration/exfiltration. 4" PVC Tee present at
inlet end. Outlet baffle present and in good condition. Liquid level equal with outlet invert.
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: #96 Tanbark Road
Marstons Mills,MA
Owner: Steven Albanese
Date of Inspection: 05/25/05
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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: XX (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.): D-Box Present—one outlet,no evidence of significant carryover.
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Page 9 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: #96 Tanbark Road
Marstons Mills,MA
Owner: Steven Albanese
Date of Inspection: 05/25/05
SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required)
If SAS not located explain why:
Type
XX leaching pits,number: 1
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number, dimensions:_
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.): No evidence of hydraulic failure of septic tank or of leach either leach pit. 3' Liquid observed in
leach pit. Cover located and removed as part of inspection. No Riser present. Top of leach pit is 42" below
ground.
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 or no):
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.):
9
Page 10 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: #96 Tanbark Road
Marstons Mills,MA
Owner: Steven Albanese
Date of Inspection: 05/25/05
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
Swing Ties•
Tanbark Road
A- Tank In—23.5'
B- Tank In—30'
A-Tank Out—21.5'
B -Tank Out—35.5'
Water Line A—D-Box—29.5'
B—D-Box—41.25'
A—Leach Pit —39.5'
B—Leach Pit —46.5'
Exist House
A B
Deck
10 0 Septic Tank
(1000 Gal.)
D-Box
Leach Pit
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: #96 Tanbark Road
Marstons Mills,MA
Owner: Steven Albanese
Date of Inspection: 05/25/05
SITE EXAM
Slope
Surface water /2 mile+/-
Check cellar -Yes
Shallow wells—None
Estimated depth to ground water 25' feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record- If checked,date of design plan reviewed:
XX 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)
XX Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Checked with Ouadrangle of USGS Map.
Per USGS MAP PLATE 2:
Elev.of Ground=Elev.-75
Elev.Of Groundwater=Elev.-25 Feet
Elev.Of Bottom of Leach Pit 10 Feet below grade or Elev.65
Therefore: 65-25=40 feet separation between Bottom of Leach Pit and Groundwater.
Groundwater Adjustment using Index Well SDW-253(Zone C): 4.8 feet
Adjusted Groundwater Separation=65'—29.8=35.2 feet between bottom of pit and adi. groundwater
Grade=Elev. 75 feet
Pit#1
Septic Tank
Bottom of Pit=Elev.=65 feet
Adj. Groundwater=Elev.29.8
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
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DEPARTMENT OF ENVIRONMENTAL PROTECTION
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TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM FORM
PART A
CERTIFICATION
Property Address: 96 TANBARK RD MARSTONS MILLS, MA 02648 006 °��Q)
Owner's Name: TRACY WILLIS i L 3 S C7
Owner's Address: C/O REALTY EXEC. 1582 RT 132 HYANNIS MA
Date of Inspection: 3/21/02 RECEIVED
Name of Inspector: (please print) JOHN GRACI MAR 2 8 2002
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O. BOX 2119 TEATICKET, MA. 02536 TOWN OF BARNSTABLE
HEALTH DEPT.
Telephone Number: 508-564-6813 FAX 508-564-7270
CERTIFICATION STATEMENT
certify that I have personally inspected the sewage disposal system at this address and that the information reported below is
true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and
experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system .
inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
X Passes
Conditionally Passes
_ Needs Furthe aluation by the Local Approving Authority
_ Fails
Inspector's Signature: ! / Date: 3/21/02
The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the
inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be
sent to the system owner and copies sent to the buyer, if applicable,and the approving authority.
-Notes and Comments
' SYSTEM PASSES TITLE V INSPECTION. SYSTEM SHOWS NO SIGNS OF FAILURE. RECOMMEND PUMPING
NOW AND THEN EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.
y ****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.
Page 2 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 96 TANBARK RD MARSTONS MILLS,MA 02648
Owner: TRACY WILLIS
Date of Inspection: 3/21/02
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310
CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
SYSTEM PASSES TITLE V INSPECTION.SYSTEM SHOWS NO SIGNS OF FAILURE. RECOMMEND
PUMPING NOW AND THEN EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.
B. System Conditionally Passes:
_ One or more system components as described in the"Conditional Pass"section reed to be replaced or repaired. The system,
upon completion of the replacement or repair,as approved by the Board of Health,w:11 pass.
Answer yes, no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain.
n/a 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.
ND explain: n/a
n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed
pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of
Health):
_ broken pipe(s)are replaced
_ obstruction is removed
_ distribution box is leveled or replaced
ND explain: n/a
n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
_broken pipe(s)are replaced
_obstruction is removed
ND explain: n/a
Page 3 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 96 TANBARK RD MARSTONS MILLS, MA 02648
Owner: TRACY WILLIS
Date of Inspection: 3/21/02
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
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 I 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 n/a
**This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and
volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy
of the analysis must be attached to this form.
3. Other:
n/a
Page 4 of
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 96 TANBARK RD MARSTONS MILLS, MA 02648
Owner: TRACY WILLIS
Date of Inspection: 3/21/02
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all-inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_ X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped nLa.
_ X Any portion of the SAS,cesspool or privy is below high ground water el:vation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. (This system passes if the well water analysis,performed at a DEP
certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this forma .
_ — (Yes/No)The system fails..I have determined that one or more of the above failure criteria exist as described in 310
CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no".to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
X.the system is within 400 feet of a surface drinking water supply
'X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—I W'PA)or a mapped
Zone 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
des" in Section D,above the large system has liiiled. The owner or operator orally large system considered a signilicnlll threat -
„:.
under Section E or failed under Section D shall upgrade the system in accordance.with310 CMR 15.304.The system owner
should contact the appropriate regional office of the Department.
Page 5 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 96 TANBARK RD MARSTONS MILLS, MA 02648
Owner: TRACY WILLIS
Date of Inspection: 3/21/02
Check if the following have been done. You must indicate "yes"or"no" as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks.?
X Has the system received normal flows in the previous two week period
X Have large volumes of water been introduced to the system recently or as part of this inspection '?
_ X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X Was the facility or dwelling inspected for signs of sewage back up?
s
X _ Was the site inspected for signs of break out
X _ Were all system components,excluding the SAS, located on site?
X _ Were the septic tank manholes uncovered,opened,and the interior of the ink inspected for the condition of the
baffles or tees, material of construction, dimensions,depth of liquid,depth of sludge and depth of scum ?
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance
of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes no
X _ Existing information. For example, a plan at the Board of Health.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable) [310 CM 15.302(3)(b)]
' , r
Page 6 of
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 96 TANBARK RD MARSTONS MILLS,MA 02648
Owner: TRACY WILLIS
Date of Inspection: 3/21/02
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 2
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system (yes or no): NO [if yes separate inspection required]
Laundry system inspected (yes or no): NO
Seasonal use: (yes or no): NO
Water meter readings, if available(last 2 years usage(gpd)):•n�a 760()
Sump pump(yes or no): NO 2-00 l— �3r 00D
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the Title 5 system (yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information: n/a
Was system pumped as part of the inspection(yes or no): NO
If yes, volume pumped: n/agallons-- How was quantity pumped determined? n%a
Reason for pumping: n/a
TYPE OF SYSTEM
X Septic tank, distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from
system owner)
_Tight tank Attach a copy of the DEP approval
Other(describe): n/a ,
Approximate age of all components,date installed(if known)and source of information:
1989 13Y (OWNER
Were sewage odors detected when arriving at the site(yes or no): NO
r,
Page 7 of
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 96 TANBARK RD MARSTONS MILLS,MA 02648
Owner: TRACY WILLIS
Date of Inspection: 3/21/02
BUILDING SEWER(locate on site plan)
Depth below grade: 22"
Materials of construction:_cast iron X40 PVC_other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints, venting, evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade: 16"
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 1000G L 8' 6" H 5' 7'• W 4' 10""
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 32"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 16"
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.)`.
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL
LIFE.
GREASE TRAP: _(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage, etc.):
n/a
Page 8 of
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 96 TANBARK RD MARSTONS MILLS, MA 02648
Owner: TRACY WILLIS
Date of Inspection: 3/21/02
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locafie on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX: X(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
Comments(note if box is level and distribution to outlets equal,any evidence of.solids carryover,any evidence of leakage into
or out of box,etc.):
D-BOX 1S STRUCTURALLY SOUND.
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Continents(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
u
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNT
ARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C `
SYSTEM INFORMATION(continued)
Property Address: 96 TANBARK RD MARSTONS MILLS, MA 02648
Owner: TRACY WILLIS
Date of Inspection: 3/21/02
SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
1000 GAL 6' X 6' leaching pits, number: 1
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a Ileaching fields, number: n/a
„/a overflow cesspool, number: n/a
n/a innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
LEACH PIT IS FUNCTIONING PROPERLY AND SHOWS NO SIGNS OF FAILURE. RECOMMEND RAISING
COVER. BOTTOM IS AT 10'. THERE WAS Y OF LIQUID IN IT AT TIME OF INSPECTION.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert:n/a
Depth of solids layer: n/a
1 Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
.Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
i n/a
l
PRIVY: (locate on site plan)
k Materials of construction: n/a
Dimensions: n/a..
Depth of solids:n/a
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
h
Page 10 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PAIN C
SYSTEM INFORMATION(continued)
Property Address: 96 TANBARK RD MARSTONS MILLS,MA 02648
Owner: TRACY WILLIS
Date of Inspection: 3/21/62
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.
Locate all wells within 100 feet. Locate where public water supply enters the building.
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Page I I of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSM ENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 96 TANBARK RD MARSTONS MILLS, MA 02648
Owner: TRACY WILLIS
Date of Inspection: 3/21/02
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 12+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record- If checked, date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
NO Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
HAND AUGER- 12+FT.
ia� ti
k
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Dept. of Environmental Protection
One winter Street,Boston,Ma. 02108 Jolui Grad
D.E.P. Title V Septic Inspector
P.O. Box 2119
Teaticket, MA 02536
WILLIAM F.WELD (5 - 6813
Governor
ARGEO PAUL CELLUCCI
Lt.Governor
s Odt 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR e
�O PART A
�
CERTIFICATION is Property Address: 96 Tanba arstons Mills Address of Owner: y 9 1
Date of Inspection: 5113198 (If different)
Name of Inspector: John Graci Stewart Schulman Ve
I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) �f
Company Name,Address and Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
x Passes This Inspection Is based on criteria dented In Title V
Conditional) Pa ses code 310CMIR16303.My findings are or how the system Is
performing at the time of the Inspection.My inspection does
Needs Fur er valuation By the Local Approving Authority not Imply anywarranty or guarantee ofthe longevity ofths
Fells septic system and any of Its components useful life.
Inspector's Signature: Date: wiwos
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B,C,or
A] SYSTEM.PASSES:
x ,I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
,,,COMMENTS:
'. B],SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system,upon completion
of the replacement or repair,passes inspection.
Indicate yes,no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined",explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
:Co7hpliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or
"the septic tank,whether or not metal, is cracked, structurally unsound,shows substantial infiltration or exfiltration, or tank
failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04127197)€. -
f. ,
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 9 Telephone(617)292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 95 Tanbark Marstans Mills
Owner: Stewart Schulman
Date of Inspection:5rt31g8
— Sewage backup or.hreakout.or hiah.static water level observed.in.the distribution box is due to a broken.
or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if
(with approval of the Board of Health). Describe observations:
broken pipe(s) P s are replaced
obstruction is removed
distribution box is leveled or replaced
—The system required pumping more than four times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
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 the public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
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.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
— The system has aseptic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
— The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well.
— The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
— The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method usedto determine distance (approximation not valid)
3)Other
D] SYSTEM FAILS:
You must Indicate either"Yes"or"No"as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in
310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be
contacted to determine what will be necessary to correct the failure.
Yes ' No
— Backup of sewage in facility or system component due to an overloaded or clogged SAS or
cesspool.
— Discharge or ponding of effluent to the surface of the ground or surface waters dtie to an overloaded or clogged
cesspool.
— SAS is in hydraulic failure.
(revised 04I17)87)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued) .
Property Address: 90 Tanbark Marstans Mills
Owner: Stewart Schulman
Date of Inspection:5113199
D]SYSTEM FAILS(continued)
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 1/2 day flow.
Required pumping more than 4 limes in the last year NOT due to clogged or obstructed pipe(s).
Numbers of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for
coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revleed 0421)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 90 Tanbark Marstons Mors
Owner: Stewart Schulman
Date of Inspection:51113r9s .
Check if the following have been done:YOU must indicate either"Yes"or"No"as to each of the following:
_c_ — Pumping information was requested of the owner,occupant,and Board of Health.
x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal
— flow rates during that period. Large volumes of water have not been Introduced Into the system recently or as part of this
inspection.
x As built plans have been obtained and examined. Note if they are not available with N/A.
x — The facility or dwelling was inspected for signs of sewage back-up.
x — The system does not receive non-sanitary or industrial waste flow.
x — The site was inspected for signs of breakout.
x All system components, excluding the Soil Absorption System, have been located on the site.
x The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected
for condition of baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge,depth of scum.
x The size and location of the Soil Absorption System on the site has been determined based on
— — The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of
Sub-Surface Disposal Systens.
x Existing information. Ex. Plan at B.O.H.
x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is
— — unacceptable)(15.302(3)(b)]
t
(revised 0627)87I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 95 Tanbark Marstons Mills
Owner: Stewart Schulman
Date of Inspection:5119198
FLOW CONDITIONS
RESIDENTIAL: d/bedroom for S.A.S.
Design flow: 330 g•p
Number of bedrooms: a
Number of current residents: 5
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings,if available:(last two(2)year usage(gpd):
rda
Sump Pump(yes or no): No
Last date of occupancy: nla
COMMERCIAL/INDUSTRIAL:
Type of establishment: nla
Design flow:0 gallons/day
Grease trap present:(yes or no) No
Industrial Waste Holding Tank present:(yes or no) No
Non-sanitary waste discharged to the Title 5 system:(yes or no) No
Water meter readings,if available: we
Last date of occupancy: We
OTHER:(Describe) Ma
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System has never been pumped
System pumped as part of inspection:(yes or no)No
If yes,volume pumped:n gallons
Reason for pumping: We
TYPE OF SYSTEM
x Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) ( if yes,attach previous inspection records,if any)
I/A Technology etc.Copy of up to date contract?
Other:
APPROXIMATE AGE of all components,date Installed(If known)and source Information:
1990
Sewage odors detected when arriving at the site:(yes or no) No
(revised 04r2l)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 90 Tanbark Marstons Mills
Owner: Stewart Schulman
Date of Inspection:5113199
SEPTIC TANK: x
(locate on site plan)
Depth below grade: 2'
Material of construction:x con create metal FRP Polyethylene—other(explain)
If tank is metal, list age we . Is age confirmed by Certificate of Compliance No (Yes/No)
Dimensions: LOW-He7"w410^
Sludge depth:is'
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:t'
Distance from top of scum to top of outlet tee or baffle:6"
Distance form bottom of scum to bottom of outlet tee or baffle:6"
How dimensions were determined: measured
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
Septic tank and all components ere structurally sound and functioning properly.Recommend pumping now,then every two years.
GREASE TRAP:
(locate on site plan)
Depth below grade: rda
Material of construction: concrete metal FRP Polyethylene_other(explain}
Dimensions: We
Scum thickness:We
Distance from top of scum to top of outlet tee or baffle:rda
Distance from bottom of scum to bottom of outlet tee or baffle: nia
Date of last pumping,
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.)
rya
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 27
Material of construction:_cast iron x 40 PVC_other(explain)
Distance from private water supply well or suction line"
Diameter: 4°
rd�mments: (conditions of joints,venting,evidence of leakage, etc.)
(revised 0427)97)
r r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: BB Tanbark MarstonsMills
Owner: Stewart Schulman
Date of inspection:5119rgg
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: Na
Material of construction:_concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: nre
Capacity: rda gallons
Design flow: rde allons/day
Alarm level:_nta Alarm in working order?_Yes_No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
rda
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: rda
Comments:
(note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.)
rda
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)No
Alarms in working order(yes or no)Yes
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
rda
(refted 04127197),
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 96 Tanbark Marstons Mills
Owner: Stewart Schulman
Date of Inspection:5/13199
SOIL ABSORPTION SYSTEM(SAS):x
(locate on site plan,If possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
rda
Type:
leaching pits,number: one 1000 gallon leach pit
leaching chambers, number:rda
leaching galleries,number: nla
leaching trenches, number,length: rda
leaching fields,number,dimensions:We
overflow cesspool,number:nia
Alternate system: nla Name of Technology:_ria
Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
Leach pit and all componente are structurally sound and functioning properly.system must get pumped.
CESSPOOLS:
(locate on site plan)
Number and configuration: Wa
Depth-top of liquid to inlet invert: rda
Depth of solids layer: rda
Depth of scum layer: nla
Dimensions of cesspool: nla
Materials of construction: Iva
Indication of groundwater: rda
inflow(cesspool must be pumped as part of inspection)
rda
r,Comments:(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
rda
PRIVY:
(locate on site plan)
Materials of construction: nla Dimensions: ^la
Depth of solids: nla
Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
rda
(revised 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
90 Tanbark Marston Mills
Stewart Schulman
5113198
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references, landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
0ec�c
LUJ
0 0 .
At
L�°
c
p
(rnvlwd0l)2TMT) Paya ! of to
h
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
96 Tanbark Marstans Mills
Stewart Schulman
5113199
Depth of groundwater 12,
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from design plans on record.
Observation of Site(Abutting property,observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of Health
Check FEMA Maps
Check pumping records
Check local excavators, installers
x Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
USGS maps and chard
t ,
r
S
(nviaedOMTST) page 10 of 19
OWN OF BARN TABLE
.OtC ATION � SEWAGE #
V,LA,SE� ASSESSOR'S MAP
INSTALLER'S NAME&PHONE NO.SEPTIC TANK CAPACITY `0
LEACHING FACILITY: (type) 01,T (size) (O
NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE,DATE:
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 2.00 feet of leaching facility) Feet
Edge of Wetland.and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by - CV& CA
°DI
AA j
� cAc
�1 �
46
u 1 6
�+ * TOWN OF BARNSTABLE
LOCATION 9 SEWAGE # 9 32
VILLAGE ASSESSOR'S MAP & LOT 100 a3 0 11
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY I rQQQ QO, f)
LEACHING FACILITY: (types) �\T (size) ( i X G a l.10�
NO.OF BEDROOMS 3
BUILDER OR OWNER
PERMITDATE: � COMPLIANCE DATE: lSt)k-.
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility. 3`S a Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) 1VA Feet'
Edge.of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of 1 hing facility) ' r Feet
Furnished by
ra
A B
�cx3e 3C
Our
. . . ��k o � �g a�•s �oe�s
TABLE
TOWN OF BARNS
ATI �`ly � � SEWAGE `
VILLAGE �j'('�{�Ir•�� �6�� ASSESSOR'S MAP & LOT__Zj��
INSTALLER'S NAME & PHA NE NO,
SEPTIC TANK CAPACITY 160 6'�tl,
LEACHING FACILITY:(t9Pe) (size)
NO. OF BEDROOMS _PRIVATE WELL O PUBLIC WATE
BUILDER OR OWNER 6',yeeIJ Rel¢t l
e .
DATE PERMIT ISSUED:
DATE COUPLIANC.r ISSUED:
VARIANCE GRANTED: Yes No
�� � ,.. \� s§.. l
-. ^..
. 7
. `t
`Ly {
�q �' �� .
��
, .
�u
_...�.
�
Foic �
THE COMMONWEALTH orMmasAoxussrrs
U����� U��� '�U�
����^�" ^�� � "��"^�� " " "
^.� �� � �� (y��
__---�"����.�----'��F--���------___-_--_____._______
�
Appliramwu ��� �� �.°��� �� � Wo�ws To* sturtmou» ��r��ft
Application is hereby made for u Permit to Construct or Repair ( ) an Individual Sewage Disposal
System
x
-'j 01---��I----�p°/���K---'fl*'''��- �f/o��ro^� �� x((.................................. .�� �'��»� ��»
--------------------------'----' -------------- -----------------r---------------------------'---'owner �
�� �n ��0^/ Aaa�" �
-- .......................................................................... -------------------------------------------------
z"st"le, Address
.14 Type of Building
Size Lot �q ...................Sq. feet
Dwelling—No. of Bedrooms-------��........................Expansion Attic (`�). Garbage Grinder (M)
Other—Typeof Building ............................ No. ofperuouo---_--------' Showers ( ) -- Cafeteria ( )
04 (]tb�r fixtures --------_..__----_.---__-----_-------- .. .--..
5 5
Design Flo=c------.����--.-.-- �ul000pc, peroouperday. Totddu�yflow--.-���f�.......................gallons.
04 Septic Tank—Liquid cupucity.�����-_gallons I.eogt6'-----' VVidtb.---_-' Diaou�rc-.-.--- Depth-----'-
DisposalTrcuch--No. _--------' VVidxh-----_--' IotuLougt6----..--_- Totubeacbiogurea--------------------sq. fr.
Seepage Pit No--------------------- Diao`etcr-_----- Depth below inlct-.---_---- Iotu leaching area..................ag. ft.
Z Other Distribution box ( ) Dosing tank
'- Percolation Tcut Results Performedn�d by ' ���- �- f�����- _ Dut�---'4 --' __-----.+ /"� 3Teo Pit No. ]-. �-'minutes per�cb Depth of Test Pit ':.......... ^
Depth �o ground �x��r-.��!*,�-_.�
PL, Test Pit No. 2................minutes per inch Depth of Test Pic---.----- Depth toground water........................
9 ------------------------....................................................................................................................................
0 � r�
D cfSoi-�������'--'5����--=i+--'�����-'------------_---_-----------------_---------------..
---------------`---------------`-------------------------`-----------------`'----------`---`-----
------------'_---'------__-'-_-------_''-__-------_.--'-__--'---'-_------_.___-_.
U NutnreofRepair» orAltezutions--Aoxwcrwbeoupplicuhle.------.._------_--_-_---------------.--_.
'-----'--'-------''----'--'''----''---------'--------'------------'--''--'-----'-'-------
Agrccnzeot:
The undersigned agrees to install the zforedescribed Individual Sewage Disposal System in accordance with
the provisions ofITIlE 5 of the State Sanitary Cmde— The mi si ui further agrees not to place the system in
operation until a Certificate of Compliance ha en iss bAt e board of health.
�
v ....en
---'---
��� / ~ 9��
z�ypl�a�oo Approved By............. -��=,- ---------------- -----',�.c'.�����.�'^---
"=°
Application Disapproved for the following reasons:................................................................................................................
� ---------------'------_---.'-------------------'----_------------------.--.-------_-.---.���-------
PermitNo. .......................................................
]
No................-....... Fss............................_
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
.................... ------------..OF..................................................................
Appliration for Disposal Works Totulrnrtiun Pumit
Application is hereby made for a Permit to Construct (V ) or Repair ( ) an Individual Sewage Disposal
System at: -->
a. /J i f q f I,,wo f$4 it K /.+,)r f °n A s t�.�s � z�c S
................_........--...................................................-................. ----•....._............--•--_....-
Lo ion.Address y� Lot No.
..._�............. .................�13........ ...._.._..................._..._ ---/--•• )..-/lfd...........fU ---- C_Iu.?.`I-•Wa"--t--C --.---------_------••-•-•--
W J J \ GC 1 ?. n r Address
Installer Address
Type of Building Size Lot.. :_ --------Sq. feet
Dwelling—No. of Bedrooms............... ........................Expansion Attic (V Garbage Grinder ov)
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures .................:...............
W Design Flow..............5.. gallons per person per day. Total daily flow........_...................................gallons.
1:4 Septic Tank—Liquid capacitylI �U gallons Length................ Width................ Diameter---------------- Depth................
Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft,
Seepage Pit No..................... Diameter--------------------- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'"' Percolation Test Results Performed by(FvlJ t c 1) a_1 (&-- -----s�n ............... Date_.`',.I......-_---___--------_. -
4 Test Pit No. 1...��-_.__minutes per inch D�epth of Test Pit..r_"�_.� .__. Depth to ground water.._�_"�`"`�_._.___.
GT, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-___•______-____-_---__.
9 ---•-••--•-•-•-•-------------------•••--••..................................................................................................................
D Description of Soil..: r N!�..... &' .....?c_411<.c-3------------------
U ---------------------------------------------------••---------------------------------------••--------•-•-------------------------------•---------------•------------------------------•-•-•••----••----
W
VNature-of Repairs or Alterations—Answer when applicable...............................................................................................
----------------------------•----------------------------------•--------------------..........---------------------------------------------------------•- ..............................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
f'1 T r'1<
the provisions of i 1 i!E 5 of the State Sanitary Code—The undersigned furti:er agrees not to place the system in
operation until a Certificate of Compliance h byhealth.
{ Date
Application Approved By---•--••-••......-•---•----••......-•--•-........•--
D ate
Application Disapproved for the following reasons:----•---•••-•----•-------••••••••••••-•••••-•-•-•••••-•••--•-••---•-•-•----•-•••••••......•-•--•--•.............
-••---•--•-•----•------•---•••••-••-•---•-•-•-•••...--------•-•--••••--•-••--•-•--•--•-••-•-•------•••--••••--•-•--•----••---•--•--•---•---------••-••••----------•----•-•••--••----•-•-•••-•--...------
Date
PermitNo......................................................... Issued------------•--•----------------------------•-----------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
!?W. ................OF..... 1_1r.ni. ..r 13 (. ....................... .... ...............
w-Errtif iratr of Toutpliattrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ('LT ) or Repaired ( )
------------•------•---•----------------------------------------------------------------------
Installer
...............................................7t ! r"->IV 5 4 rz it v 41) � ,-y I /* s Pr c't S
at ................................ ........4-•-----------
has been installed in accordance with the provisions of TITIE j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No......................................... da.ted--------------------------......................
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............................. .. ..- .. ....................... a Inspector................... .)i....................................................
THE COMMONWEALTH OF MASSACHUSETTS
,. BOARDS OF HEALTH
No......................... FEE................... ..
Disposal Works Tnntrur#ion rrnti#
Permission i •hereby granted----JL .'?-.,e cZ t• ... ....
to Construct ( or Repair ( ) an Individual Sewage Disposal System
at No..... ¢........ </ •--•.••--••f� ra
;v/5, .40 o '�t 44.70t, s Z'; ( .3
.............................................. ............................ --•-- -------•--••-••••••.......................••.............--
Street a' !'
as shown on the application for Disposal Works Constructro Permit No...._.-a_.._�-_ D t d.. '7�.-.:_ :_I
Board of Ma
th
DATE--------------------- 1-- J-Y----------•--------•-•-•--••-•----•--•---•
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
BobtMAIt;:S
SHEET 7A OF 7
■►1■►r r BABr�1 wAB
•a T+ I ® ® oESICN cALwuTwNs® amsol orBAMAQ momma IMT SOTAL a1116ATp PLOW
- 641111 n. r sx•r1B PLR
IOGAOM YAP �� ra w1a 1/r 111 rt sm 1A ti n. UIL,J ■ Ofnie LMYOt xGiADm ���
w■01■W �� ]TE
u�w16 JAKAA SK uIMMOM �lLw11L AKA JAOAI./E.►.�OMUAa1Y(O�OTVam S rmmL) 600aA u sIK 1tAeY10 evac T 800 .u1 1sox MOM:
1. ALL 10yYAmBls NO 1011WAS1.2 MALL 0090011 TO&L&L
MIX B AM TAR 10101 OF ■A■IeTAaF BIAO AM
BtaAATleoos FOB 11[su.!...' Or.=f000 QALLON SEr•lIC TANK 1 r I r I r 1 s ALL cowls To IAMTMY.swLL a O10YOIT To
woo 1r or FBBlIm MrL
>s A YMTB usm to 111■a OOtlOIt 10 wAa
_SEPTIC SYSTEM PR E F 1 1O I ` 9WL A01Y Y K 11MAXm 0 wAM
. ♦ ALL OSPs1o1TB a 1BI MMTMY IMM HALL KOAMa[
NOW w 0■m[ _BOTTOM OF TEST HOLE ar"IIBTA1101140 11-tO LOAOnB yloal TM[Y ARE UIIOaI OR
W"Bm 10 17.Or 9MM OR PAMM WA& 0-10 W00010
LEACHM PIT ►6ALL K Y IMOIX 01 1rwY1 torr.or BRIM OR
A 0001010111AL A110 VOMCAL 00 OM IQ a W.Bae1�a j
B 10MINa FMA t101a100B•JUA=1B FlM/730-10
LOT ELEVATIONS LEGEND:
N0.
FAIL SOT aAMA1011 m -
�EV. 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 1417 142 143 144 145 146 147 148 149 �TAWc
aI011110m B0X O
LOCATI 1 1 PFAMY LGOYIO PIT p
r.O.FOtJND,
A 73•s 1s.f 71•0 �A 700 910 0•9 7Ls 741E Ifs 7i0 77.e 70.0 bo.0 M•s b7 0Ls Mo fld Oo• LIL 7� 1f
- o 61.e f o 744E 1f.6 7fo 74.• i { FOOZA04al001 la (!I
14.s 74,7 7•a 71.0 74.0 70.0 764E liy�.f 70.0 740 72.0 7C•o 71.5 71/. W0 A AM OW O�INWAI 11PIT0111a1lt1
B 11B.9 Nf N•o 64J 64•1 00.0 61! 740 1t.0 70.e 730 74•f 76'•o 7+4 711; 77.5 76d 70.1 104 7s.f - 7b.0 76f 751* 70.E 4 i t
f }•Y 7i.� 714E �3 1t.e 7f.f s4 1f.5 741 7s.41 rrt.1 ?7,4 IG4 W.4 064 l•s! N.o 7b0 B
C 7b.1 too .s 60•7 60.4 "0 i21 1i4d 7Ls 7L1 7t.7 7s.1 74•s 7l.7 ri•1 71 77.1 7r. 77.° 11.6 'N.L - 77.7 711 14 70 rLb 7f.IP 71,1 70--
7 - 11.7 74 s 74Y 7f.s 4! 7A& miF 7.1-1171.1 644 WS 61016,01 '1r•7 C
D 70.0 H•o Ys.s 614 30.4 p,f 6,40 7L• 71•9 7i.f 77
'ILS ".o 70.5 740 0 .0 74.0 "IV 77 i !
{ 7Lo - 71.5 77 7f.• 0 71•I �i.� 91.1 710•0 lo.0 7Gf 7bo 7s4 ago 7{.4' �754 n,4 71.4 !b. 4,91 V&.o yfo Ls.f 7K3 D
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-- 1 12 8 1 INITIAL ISSUE WcT
NO. OATS I DESCRIPTION BY
PERC TEST 1 PERC TEST 2 PERC TEST 3 PERC TEST 4 PERC TEST s D SEPTIC SYSTEM DESIGN
LOT 116 LOT 123 LOT 131 LOT 140 LOT 146n.Zt MARSTONS MILLS WOODLANDS
OAB�.Z1Bt Y . AL- Yaa�. eL■� cop-wuA ae �y IN
w.0■PLF.n.O DAY) w mom w w OMnI w oma w w B HARNSTAHLE, MASSACHUSETTS
wONDage W1..1 .e. ��. Bookom voom aWOODLANDS ASSOCIATES REALTY TRUST
eB0m1.■10 B/esss Boom wimm woolsimo
wtwa BB0 wAr e!♦m
B w1W 40• JOB No. 133E/arm
B0 loft
SCALE: 1- a,
r BAa r q1 11111111101 11111 Billion
�r a VA
OAR OF IOL TTB 2Mft_ OAR ar f011 TttT�LaJ'_w 011E w sm RRu BB i N
.11101112010 BY t1®BY 111Ka{!m BY M Epsom n 1C;� ME Q sm 7IIT ma'm
_ �o
Pa10aAT10M BAN 31_Yll./MOI PaIOaAT011 RAT& <1 rLAKH POOaA101 MR SLYaA1a1 ra1001A10M MR_U_-LA1a1 Pa03A10m~MR <A rLA M .v f
PERCOLATION SOIL TESTS LIM, SI WGB A TACNett MOCAS BIC
sly mom® B w t1>elona
Bee 1nRr 1[.ui 5TIM CIXTR V= ILA t711a12
Y l
+ MN iAUMM e. SHEET 7 OF 7
I
MARSTONS MILLS j
LOT 130
»ee w
aauR to
LOT 129
aw
LOCATION MAP
11 �.. Lot b ,
401
Opp // 7l 5 \a l wr LOT 12� �
R �d OT}02
Ga1V Mane s ,
dr" LOT J1 '
LOT t4sw3W LOT 124
" � I�I i /�•�'� a AA` �` `
LOT 106
� �: I /..11 ��►. 9 LOT 123
1, r'- r
KA ll m s
I /� Q I 74• Ta " LM/7�s6 '
LOT
3 i y/ b1f
i I
LOT
149
LOT 136 'All 1P•%d111.111"or
i }�
i
!� / �,�� LOT 122
`� it �• - LOT 134 9Lr i� j
z S&M Airl 135 '. \ j LOT 121
I �1 Wrap a
LOT 107 OT x Z' / l ) I .. '¢ ~ h•6 j fS! y10 w ' 1 I ' < 0-4
1 e
%ipT 147, �oo
sere= ; •r\ , LOT 119 .• $
LOT 141.�1�.'' < s4•S ►� ri.
\� JL30 4 1 o I i.l �' 'LOT,1 4� -%'' t C "Q SOT}� \ �+
-r1 1• o>� I�I. �(�. '�Y Wae s �i 1)Ptee W >bd `' LOT 120 e
>.11' ' , LOT 117
xsr )• 1 ,Qt. N �\ •`,tkA ' !� WUYn43`� ` �.� < *4 `�1
'LO 1 '' Rh Y I�.I ~ tt ,�� ``'� X1o71�5
LI �� fit• ���'' lam ed ��'��' 4a to ' l� I.3E! fl1U'.BT 7A or-'? �1C 5o L- V(sS mob
1/ LOT 115 1a• .+ �' oLQTwJ -Msr. REoK�.
LOT 146 i76t>a x45 �L'�� th'.� ! a < IyA $ .. �e a.—o sltisT 7A of 7 FOPL %M&WrW'
LO7 106 „atp.- _� `e1 Y < 15'4 moll 1.I
LOT 11 � `
l\ 'md t ' r
LOT 116
Wee 1A.�
,�� I�I � < �9.0 4• tl �
c� ���'��' ',e• Y^ LOT 111 LOT
LOT,114 -
I.I Y +4eoe>A p• 4`i "� a,� 11 #Iaeo 4. esr+nwld
�tiA ICI 3 11 28 88 FINAL &MG. AND SEPTIC LOCATIONS PAL
BUILDING LOCATION PLAN
1 10 2 INITIAL ELK
If4 0 e. NO. DATE DESCRIPTI 9Y
` seta �t s4�
,•�� ,dl- 1:1 BUILDING LOCATION PLAN
II MARSTONS MILLS WOODLANDS
LOT 110 ■
\� LOT 109 tl.M Q I BARNSTABL.E, MASS CHUSETTS
�\ WOODLANDS ASSOCIATES US
SCALE: 1- a 50` JDe NO. 1338/Jae-to
so 0 e Wo �• �- 1
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{mm mcm AAM u I �
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