HomeMy WebLinkAbout0749 WAKEBY ROAD - Health 749 WAKEBY ROAD
Marstons Mills
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LO Tin SEWAGE
VILLAGE Gt S%G A j Mild ASSESSOR'S MAP & LOT c 4 00
INSTALLER'S NAME & PHONE NO.
ASEPTIC TANK CAPACITY
�••//LEACHING FACILITY:(type)' le-A c k P/-I (size),
IDNO. OF BEDROOMS RIVATE WE ' OR PUBLIC WATER
BUILDER OR OWNER d�Wl•eiz 8;9, X /_)d V O-e)J(l .
DATE PERMIT ISSUED: /� 7
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes' No �,
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INSSTA LLER'S NAME A ADDRESS
BUILDER OR OWNER
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DATE PERMIT ISSUED
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DAT E COMPLIANCE ISSUED �' ��
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LO'CATI0N SEWAGE PERMIT NO.
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INST . LtER'S NAIgE & ADDRESS
R U I L D E R OR OWNER ` Au
DATE PERVIT ISSUED g aa � 8
DAT E COMPLIANCE ISSUED ca _ a�3 - BS
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Town of Barnstable Barnstable
Regulatory Services Department
STABM a po
9q � , ' Public Health Division
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Richard V.Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
June 6, 2019
CERTIFIED MAIL 4 7015 1520 0001 2273 3333
Bob Camara
749 Wakeby Road
Marstons Mills, MA 02648
The septic system located at 749 Wakeby Road,Marstons Mills, MA was inspected on
May-17,2016 by Michael DiBuono, a 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 1195 TITLE V (310 CMR 15.00) due to the following
• The distribution box is rotted, collapsing and in need of replacement
You are ordered to replace the septic system within One (1)year of the date you receive
of 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
Q1&eWan,1jR;S., Cho
Agent of the Board of Health
Q:\SEPTIC\Conditionally Passes Ltr\749 Wakeby Rd MM Jun 2016.doc
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XCERTIFIED o RECEIPT
fr1 a. •
Imnly
Im
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m OFFICIAL USE
r�- Certified Mail Fee
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$
nJ F�ctre Services&Fees(check box add fee as appropda[e) H YA
rl El Return Receipt(hardtop» $ to�/
E ❑Return Receipt(electronic) $ p p D� A
E3 ❑Certified Mail Restricted Delivery $ I Pere
0 ❑Adult signature Required $ C D
❑Adult Signature Restricted Del"$
O postage �,� 07
ruLn $ f+ O
Total Postage and Fees 7
Bob Camara /
749 Wakeby Road /
Marstons Mills, MA 02468
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. r associate for assistance.To receive a duplicate
■Electronic verification of delivery or attempted return receipt for no additional fee,present this-
delivery. USPS®-postmarked Certified Mail receipt to the
■A record of delivery(Including the recipients 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 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 notavailable for requires the signee to be at least 21 years of age
international mail. ;;. and provides delivery to the addressee specified
■Insurance coverage is notavailable for purchase by name,or to the addressee's authorized agent,
with Cert'dled 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,
is For an additional fee,and with a proper this Certified Mail receipt,please present your
endorsement on the mailpiece,you may request Certified Mail item at a Post Office'for
the following services: postmarking.If you don't need a postmark on this
t-Return receipt service,which provides a record Certified Mail receipt,detach the barcoded portion
I of delivery(including the recipient's signature). of this label,affix it to the mailpiece,apply
You can request a hardcopy return receipt or an--appropriate postage,and deposit the mailpiece.
( electronic version.For a hardcopy return receipt
_complete PS Form 3811,Domestic Refum.
1 Receipt;attach PS Farm 3811 to your mailpiece; IMPORTANT:Save this receipt for your records.
I
PS Forrn 3300,April 2015(Reverse)PSN 7530.02.000.9047 -
■ Complete items 1,2,and 3. A. Si ature
■ Print your name and address on the reverse ❑Agent
so that we can return the card to you. ❑Addressee
■ Attach this card to the back of the mailpiece, B. d by(Printed Name) C. o e of D livery
or on the front if space permits. z kw
1. Article Addressed to:_ _ _ D. Is delivery address different trom item 1? Yes
job Camara If YES,enter delivery address below: ❑No
1v749 Wakeby Road E
I
Marstons Mills, MA 02468
3.
I�l illl�l l�l lil I l I I(II I l�l I it I II'll II II I I I'll ❑Adult Service S gn turee Restricted D 0 Registered elivery ❑Reg st red Mail Restricted
❑Certified Mail® Delivery
9590 9403 0521 5173 2828 52
❑Certified Mail Restricted Delivery ❑Return Receipt for
❑Collect on Delivery Merchandise
2. Article Number(Transfer from service label) ❑Collect on Delivery Restricted Delivery ❑Signature ConfirmationTM
0 11— sured Mail ❑Signature Confirmation
,7015 15 2 0 ,0001 2 2 7 3:,3 3 3 3 m T ;verred$5 Ojil Restricted Delivery Restricted Delivery
Ps Form 3811,April 2015 PSN 7530-02-000-9053 Domestic Return Receipt
UNITED STATES' eN&.'QdEE First-Class Mail
Postage&Fees Paid
USPS
Permit No.G-10
• Sender: Please print your name, address, and ZIP+4®in this box*
Town of Barnstable
Public Health Division
200 Main Street
Hyannis, MA 02601
USIPS TRACKING#
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Town of Barnstable
• EARNSfAHt.E.
Regulatory Services Department
Public Health Division
200 Main Street, Hyannis MA 02601
Office: 508-862-4644 Richard Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
Feb 6, 2007
Rev. 5/11/16
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
ONE (1)YEAR DEADLINE CRITERIA
❑ Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool
❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation
❑ Any portion of the cesspool within a Zone 1 to a public well
❑ Any portion of a cesspool within 50 feet of a private water supply well with no
acceptable water quality analysis. (This system passes if the water analysis
indicates the well is free from pollution).
TWO (2) YEAR DEADLINE CRITERIA
❑ Single Cesspool
'❑ Any"conditionally passed systems" (broken cover, relocation of a pipe, relocation
of a driveway due to H-1 0-components, etc)
❑ Leaching pit or cesspool with high liquid level, <12"below inlet(per Town Code
§360-9.1)
❑ Leaching facility with standing liquid level at or above.the invert pipe (per Town
Code §360-20 h)
OTHER
+4* x
Repair deadline: Wf CA
Q:\SEPTIC\DEADLINES TO REPAIR AILED SYSTEMS.doc
_ L
Commonwealth of Massachusetts 07
Title 5 Official Inspection Form
Subsurface_Sewage Disposal System Form - Not for Vol untary.Assessments
749 Wakeby rd �
Property Address
Bob Camara "
Owner Owner's Name
information is /
required for every Marstons Mills ✓ Ma 02648 5/17/16 =
page. City/Town State Zip Code. __ Date of.lnspection ® _. .
..
.A
Inspection results must be submitted on this form. Inspection forms may not be altered iany
way. Please see completeness checklist at the end of the form.
Important:When A. General Information cs�#
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Michael DiBuono _
use the return Name of Inspector
key.
DiBuono Sewer and Drain
reb Company Name
8 Johns path
Company Address
R+� S Yarmouth Ma 02664
City/Town State Zip Code
508-364-9587 S103522
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
❑ Passes ® Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
5/19/16 ,
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
�� VS
i }. r
Commonwealth of Massachusetts
u Title 5 Official Inspection For
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w
°M 749 Wakeby rd
Property Address
Bob Camara
Owner "' Owner's Name
information;;is
required f6. every Marstons Mills Ma 02648 5/17/16
page. ``»' City/Town State -Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ 1 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.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will.pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
r
Commonwealth of Massachusetts
Title-5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
749 Wakeby rd
Property Address
Bob Camara
Owner Owner's Name
information is required for every Marstons Mills Ma02648 5/17/16
page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Cramber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired. .
B) System Conditionally Passes (cont.):—
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below):
Distribution box is rotted, colapsing and in need of replacement.
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system wil' pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
A ,
Commonwealth of Massachusetts
W Title 5 Official Inspection F®r
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 749 Wakeby rd
Property Address
Bob Camara
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 5/17/16
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well
❑ The system has a septic tank and SAS and the SAS,is less than'100 feet but 50 feet or
more from a private water supply well**.
n Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
El ® 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 '/z day flow
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
, 749 Wakeby rd
Property Address
Bob Camara
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 5/17/16
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the'above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is.within 200 feet of a tributary to a surface drinking water supply
❑ El the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W . Title 5 Official Inspection For
M
Subsurface Sewage Disposal System Form; - Not for Voluntary Assessments
M . 749 Wakeby rd
Property Address
Bob Camara
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 5/17/16
page. _ City[Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant,.or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been:introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were'all system'components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has.
been'determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if:any.'of the failure criteria related to.Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
1
Commonwealth of Massachusetts
z Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
749 Wakeby rd
Property Address
Bob Camara
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 5/17/16
page. CitylTown State Zip Code Date of Inspection
D. System Information
Description:
System contains a 1,000 gl septic tank. A Dbox and a thousand gl leach pit. Leach pit is in good
shape and stain line indicates level has never been within more than 28" of invert pipe. Liquid level is
just 2" below stain line.
Number of current residents:
1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection El 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)): Well
Detail:
Sump pump? ® Yes ® -No
Last date of occupancy occupied: Date
Commercial/Industrial.Flow Conditions: -
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth.of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° 749 Wakeby rd
Property Address
Bob Camara
Owner Owner's Name
information is Marstons Mills Ma 02648 5/17/16
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
f Pumping Records:
Source of information: 4/8/14
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption.system"
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
- maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe): -
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
1
Commonwealth of Massachusetts
4 Title 5 Official Inspection Forte
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 749 Wakeby rd
Property Address
Bob Camara
Owner Owner's Name
information is Marstons Mills Ma 02648 5/17/16 required for every - '
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
28 Yrs
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
Building Sewer(locate on site plan):
Depth below grade: 2'
feet
Material of construction:
® cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line:' feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
System is-vented at roof line.
Septic Tank (locate on site plan):
Depth below grade: 18"feet
Material of construction:
® concrete, ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1,000 GI
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspec ioh For
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
GSM 749 Wakeby rd
Sye�
Property Address
Bob Camara
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 5/17/16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 24'
_Scum thickness 3„
Distance from top of scum to top of outlet tee cr baffle
42"
Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick
Tape Measure
How were dimensions determined? Ta p
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
No evidence of leakin ,Tees and or baffles in place at time of inspection
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction: =
❑ concrete ❑ metal El fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Foram Not for Voluntary Assessments
749 Wakeby rd
Property Address
Bob Camara
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 5/17/16
page. Cityrrown State Zip Code. Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tees are in place and levels are normal.
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes., ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal Systems Form - Not for Voluntary Assessments
749 Wakeby rd
Property Address
Bob Camara
Owner Owner's Name
information is
required for every Marstons Mills Ma 02648 5/17/16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert Distribution box is rotted, colapsing and in
need of_replacement.
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption Systems (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
749 Wakeby rd
Property Address
Bob Camara
Owner Owner's Name
information is required for every Marstons Mills Ma 02648 5/17/16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
No breakout no ponding
Cesspools (cesspool must be pumped as part of inspection),(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W -Title 5 Official Inspection ®r
Subsurface Sewage Disposal System Fora - Not for Voluntary Assessments
749 Wakeby rd
Property Address
Bob Camara
Owner Owner's Name
information is
required for every Marstons Mills Ma 02648 5/17/16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
' Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
No ponding no breakout
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
I '
Commonwealth of Massachusetts.. .
W Title 5- Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
749 Wakeby rd
Property Address
Bob Camara
Owner Owner's Name
information is required for every Marstons Mills Ma02648 5/17/16
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
l
Commonwealth of Massachusetts
v W Title 5 OfficialInspection r
Subsurface Sewage Disposal System Form - Not for Voluntary.Assessments
�M 749 Wakeby rd
S.eV
Property Address
Bob Camara
Owner Owner's Name
information is
required for every Marstons.Mills Ma 02648 5/17/16
page. Cltyrrown State Zip Code Date of Inspection
®..System Information'(cont.)
Site Exam:
❑ Check Slope
4
❑ Surface water `
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 10+ ft
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USGS Maps indicate ground water well below 10 '
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
r
5/19/2016 Assessing As-Built Cards
ARN
-T I��JTOWN� BARNSTABLE
LOCATION� •�Ep� = — '�S(
_ �,. SEWAGE # �
VILLAGE A( i C,
S r �f �/��� ASSESSOR'S MAP& LOT _lJ
pppp��,
NSTALLER'S NAME& PHONE NO. I SC(,fI SO11,�.
ASEPTIC TANK CAPACITY /
LEACHING FACILITY:(type)_ AOLC.
(�O.OF BEDROOMS RIVATE WE OR PUBLIC WATER
BUILDER OR OWNER e,'�C¢e.11 V,'Kn /.)a'U Cv
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
�r
http://www.townofbarnstable.us/AssessingtHMdisplay.asp?mappar=012007003&seq=1 1/2
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
749 Wakeby rd
Property Address
Bob Camara
Owner
Owner's Name
information is required for every Marstons Mills Ma 02648 5117/16
page. City[Town State Zip Code Date of Inspection
E. Report.Completeness Checklist
❑ Inspection Summary: A, B, C, D, or E checked
❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
❑ System Information — Estimated depth to high groundwater
❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
TOWN OF BARNSTABLE
LOCATION SEWAGE#
VILLAGE �` ZP�PcQ l ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 1-_S 1C ofT kq,
LEACHING FACILITY:(type) -?I (size) dmoo 4 o-�
NO.OF BEDROOMS
OWNER
PERMIT DATE: - — 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 200 feet of leaching facility) Feet
r�I Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY
I
�If
J�
�i
�� P
1�
NO. �Y/ -166 Fee� /_7
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION'- TOWN OF BARNSTABLE, MASSACHUSETTS
9ppfiration for Misposaf *pstrm Construction Permit
Application for a Permit to Construct( ) Repair f) Upgrade( ) Abandon( ) ❑Complete System [individual Components
Location Address or Lot No. t,JaKt,, � Owner's Name,Address,and Tel.No. S-0?-:2 7 el— 89
Assessor'sMap/Pazcel v/� GG/j p�j MatStorS/�li'��5 �� � C�'ccrrr�afa P°' d3c,�c ��yg
Installer's Name,Address,and Tel.No. 64)8_q;t8_ 84A a Designer's Name,Address,and Tel.No.
&rJ(oktt: (Co r,4v ucf eovi ,-=r e- p.v•pow06q Type of 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) AA7 gpd Design flow provided AM— gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) )C
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmen o e not to place the system in operation until a Certificate of
eal .
Compliance has been issued by this Board of H
Si Date
Application Approved by Date ✓`'� /`� �Df�
Application Disapproved Date
for the following reasons
Permit No.Z01,6 A 16 6 Date Issued 6tt117- 6
No. Y/ Fee CFO
r THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
{
application for MisposaY'*pstem Construction Permit
Application for a Permit to Construct( ) Repair e) Upgrade( ) Abandon( ) ❑Complete System [individual Components
Location Address or Lot No. 71{ Lt)U j�tA Zj Owner's Name,Address,and Tel.No. .$`og-2 9 V- 81/3_-�
Assessor'sMap/Parcel O/a 00 p�j �ti6�P5 LaY�S!ui /5 � r{' `GtYYY1trR {�o• oX /oSZ�
' c�
Installer's Name,Address,and Tel.No. 5-VS- Designer's Name,Address,and Tel.No.
i&r�c�(v CvnS�rvc{ �'on ,irc. P•v•�'�ox�oy ��,�}.
Type of Building: )
Dwelling No.of Bedrooms /"ft- Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) A gpd Design flow provided IJ«" gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
f
Date last inspected:
Agreement: i
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 a not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Healt
Si Date (9
Application Approved by Date
Application Disapproved b Date
for the following reasons
Permit No.7 16 — 146 Date Issued ti fi,7117i/6
---------------------------------------------------------------------------------------------------------------------------------------
Q�j THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
i �� Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(x) Upgraded( )
Abandoned( )by &All kttz C " ",
at 9 � (,c,n l�(n�/ � , has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit NoA b"A 0 dated f q
Installer Designer
#bedrooms A Approved design flow A-- gpd
The issuance f thi permit shall not be construed as a guarantee that the system wi functio 'designed.
Date ( � (n �, Inspector �n a C
°j .
---------------------------------------------------------------------------------------------------------------------------------------
No. ;7 /f0 Fee% .7 j a�
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE,MASSACHUSETTS
Disposal *pstem Construction J)Prmit
Permission is hereby granted to Construct( ) Repair(-V) Upgrade( ) Abandon( )
� 9 fA y n ``
System located at C �t i� l '
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
Date Tj ( � I ;(o 1�i Approved by --