HomeMy WebLinkAbout0099 WOOD DUCK ROAD - Health 99 ood Duck Road.
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Marstons Mills P
A 030 040
U.S. Postal ServiceTM j
CERTIFIED MAILTM RECEIPT
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F
�. Barnstable
O�
MAm
mica
BARNSUBMTown of Barnstable
q' ib39. .�0eg`
Regulatory Services 2007
Thomas F. Geiler, Director
Public Health Division
Thomas McKean, Director
C 200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Damon Rose January 9, 2008
99 Wood Duck Road
Marstons Mills,MA. 02648 .
It was a pleasure meeting you at your property. Thank you for removing the construction
debris from the depressed area of your land. Please assure that you continue to work to
remove the debris from your land. Also please remove all tree branches and dead brush
that have been cut down on your property.
You indicated to me that the debris and branches will be removed within a week.
If you should have any questions or need to discuss this matter any further please call me
at 508-862-4640.
Thank you for your tine,
Thomas McKean RS CHO
Director, Public Health
70 own of Barnstable
� - I
Q:Health/orderletters/refuse/274 South.doc
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Town of Barnstable Barn
Regulatory Services caCft
&AMM" M
�$&� Thomas F. Geiler, Director HV
ss;q
Public Health Division 2007
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Damon Rose September 26, 2007
99 Wood Duck Road
Marstons Mills, MA. 02648
NOTICE TO ABATE VIOLATIONS OF TOWN OF BARNSTABLE
REGULATIONS, NUISANCE ARTICLE NO. 1
On September 21, 2007 Donald Desmarais RS received a complaint that there was illegal
dumping at 99 Wood Duck Road. Upon arriving it was observed that there was
construction debris being disposed of over the hill at the rear of the property.
§353-1 Responsibilities of Owner: Construction debris cannot be on the ground.
You are directed to correct the violations by picking up and disposing of debris in a
lawful manner within 10 days of receipt.of this letter.
You may request a hearing before the Board of Health if written petition requesting same
is received within ten (10) days after the date the order is served.
Please be advised that failure to comply with an order could result in a fine of$100.00. Each
day's failure to comply with an order shall constitute a separate violation.
PER ORDER-OF THE BOA D OF HEALTH
can RS
Director, Public Health
Town of Barnstable
Q:Health/orderletters/refuse/274 South.doc
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Town of Barnstable Barnstable
Regulatory Services
L& : 1
MM& . ag Thomas F. Geiler, Director
679.
Public Health Division 2007
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Damon Rose September 26, 2007
99 Wood Duck Road
Marstons Mills, MA. 02648
NOTICE TO ABATE VIOLATIONS OF TOWN OF BARNSTABLE
REGULATIONS, NUISANCE ARTICLE NO. 1 .
On September 21, 2007 Donald Desmarais RS received a complaint that there was illegal
dumping at 99 Wood Duck Road. Upon arriving it was observed that there was
construction debris being disposed of over the hill at the rear of the property.
§353-1 Responsibilities of Owner: Construction debris cannot be on the ground.
You are directed to correct the violations by picking up and disposing of debris in a
lawful manner within 10 days of receipt of this letter.
You may request a hearing before the Board of Health if written petition requesting same
is received within ten -;10) days after the date the order is served.
Please be advised that failure to comply with an order could result in a fine of$100.00. Each
day's failure to comply with an order shall constitute a separate violation.
PER ORD THE BOA D OF HEALTH
can RS
Director, Public Health
Town of Barnstable
Q:Heal th/orderletters/refuse/2e4 South.doc
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COMMONWEALTH OF MASSACHUSETTS
H w EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
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TITLE 5 a
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSES -"ENTSF
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM J ,
PART A
CERTIFICATION
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Property Address: 99 Wood Duck SAD �AAP
Marstons Mills MA 02648 �"ARCE4 :__._a�.0 v
co
Owner's Name: Randy&Karen King
Owner's Address: 16026 Pond Meadow Lane
Bowie MD 20716
Date of Inspection July 2,2004
Name of Inspector: PATRICK M.O'CONNELL
Company Name: SEPTIC INSPECTION SERVICES CO.
Mailing Address: 189 CAM METT ROAD
MARSTONS MILLS MA 02648
Telephone Number: 508-428-1779
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 i
training and experience in the proper function and maintenance of on site sewage disposal systems. I a w�► �FII4J������i
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system ��� •••••••qsS��,
t _XX Passes
,r Conditionally.Passes F TRI K t m=
Needs Further Evaluation by the Local Approving Authority
Fails Q I '
p.••
Inspector's Signature: Date: 7/02/2004 NSPiPi�Q��`
The system inspector shall submit a copy of t is inspection report to the Approving Authority(Board of HealtltIM1111u����
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: Observed 6"standing water in leaching chambers.
****This report only describes conditions at the time of inspection and under the7conditions 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.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 99 Wood Duck Road, Marstons Mills
Owner: Randy& Karen King
Date of Inspection: July 2,2004
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_XX 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 yews 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? of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 99 Wood Duck Road, Marstons Mills
Owner: Randy& Karen King
Date of Inspection: July 2,2004
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 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 I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 99 Wood Duck Road, Marstons Mills
Owner: Randy& Karen King
Date of Inspection: July 2,2004
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 G"below invert or available volume is less than 1/2day flow
_X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_X_ Any portion of the SAS, cesspool or privy is below high ground water elevation.
—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. IThis 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:
y
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
T _ 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.
f
Page 5ofII
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 99 Wood Duck Road, Marstons Mills
Owner: Randy& Karen King
Date of Inspection: July 2,2004
Check if the followinghave been done. You must indicate"yes" r" g:
e yes o no'as to each of the following:b
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 ?
_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 tank 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
I
distance is unacceptable)[310 CMR 15.302(3)(b)]
`I
If
Page 6 of i I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 99 Wood Duck Road,Marstons Mills
Owner: Randy& Karen King
Date of Inspection: July 2,2004
FLOW CONDITIONS
RESIDENTIAL
Number o-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 o-current residents: n/a
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):No
Water meter readings, if available(last 2 years usage(gpd)): 2002—55,000 gal.2003—40,000 gal. = 130 gpd.
Sump pump(yes or no): No
Last date of occupancy: Currently Occupied
COMMERCIALANDUSTRIAL
Type of establishment:
Design flew(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: None
Source of information: -
Was system pumped as part of the inspection(yes or no): No
If yes, volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
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):
Approximate age of all components„date installed(if known)and source of information:
Compliance date: 13/31/99
Were sewage odors detected when arriving at the site(yes or no): No
f
.y
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 99 Wood Duck Road, Marstons Mills
Owner: Randy& Karen King
Date of Inspection: July 2,2004
BUILDING SEWER: X (locate on site plan)
Depth below grade: 6"
Materials of construction:_cast iron _X-40 PVC_other(explain):
Distance Isom private water supply well or suction line: 30'
Comments(on condition of joints, venting,evidence of leakage,etc.):
Under slab.
SEPTIC TANK: XX (locate on site plan)
Depth below grade: 1"
Material of construction:_X_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: 10.5' long x 5.8'wide— 1500 gal.
Sludge depth: 3"
Distance.from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: I"
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: 1 I"
How were dimensions determined: STICK WITH HINGE FLAP.
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 intact and clear, liquid level at bottom of outlet pipe
GREASE TRAP: No (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 fi-om 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: 99 Wood Duck Road, Marstons Mills
Owner: Randy& Karen King
Date of Inspection: July 2,2004
TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan)
Depth below grade:
Material of construction: concrete meta[ 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: 0"
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of
leakage into or out of box,etc.):
Liquid level at bottom of outlet pipe No high stains or solids present
PUMP CHAMBER: No (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comment(note condition of pump chamber,condition of pumps and appurtenances,etc.):
f
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SVSTEM INSPECTION FORM
PART C
SVSTEM INFORMATION(continued)
Property Address: 99 Wood Duck Road, Marstons Mills
Owner: Randy& Karen King
Date of Inspection: July 2,2004
SOIL ABSORPTION SYSTEM (SAS): XX (locate on site plan,excavation not required)
If SAS not located explain why:
Type
_ leashing pits,number:
_X_leaching chambers,number:Two 500 gal. drywells.
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.): Observed 6"standine water in chambers
CESSPOOLS: No (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: No (locate on site plan)
i
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
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: 99 Wood Duck Road,Marstons Mills
Owner: Randy& Karen King
Date of Inspection: July 2,2004
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.
Wood Duck Road
1500 gal tank
Two 500 gal drywells
. I
Page I 1 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 99 Wood Duck Road, Marstons Mills
Owner: Randy& Karen King
Date of Inspection: July 2,2004
SITE EXAM
Slope None
Surface water None
Check cellar Dry
Shallow wells None
Estimated depth to ground water: More than 20 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained fi•om system design plans on record- If checked, date of design plan reviewed:
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)
_X_Accessed USGS database-explain: USGS topo map and town GIS
You must describe how you established the high ground water elevation:
Town groundwater contour map shows groundwater below el.55 and topo map shows property at or
above el. 100.
CO�iMO\'�VEAI.TH OF MASSACHUS ETTS
_ Ia EXECUTIVE OFFICE OF E:�'VIROINMENTAL AFFAIR,
DEPARTMENT OF ENMONMENTALTROTECTION
ONE V'I\TER STREET.BOSTON DLA 0210r 16171 292-550u
TRUDT CO E
Secreta.-"
ARGEO PALL CELLUCCI DAVID B. STPILHS
Governor
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFlCATION
Property Address:.q 9 Wood. Duck Rd.. Name of owner Mar i lu Souza
M stons Mills , MA AddressofOwner: 36 Pam Pr Tennis
Date of Inspection: ._70-9 9
Name of Inspector:(Please Print)Wm, E Robinson Sr .
1 am a DEP approved s err!inspector to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: Wm• E. Robinson Me tic Service
Mai6ngAddress: PO Box 1089, Centerville MA
Telephone Number: a K—R
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address andthat 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 omsite sewage disposal systems. The system:
d/Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspectoi /
s Signaorre: / ) Y Date: a"'
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board.of Health or DEP)within thirty(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 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.
NOTES AND COMMENTS
1
C,J 0
m SEP
�fr IV \°,
8 199g
S� fi � V r ,v
revised 9/2/98 PagclofII
t.: ✓c"ted o,Ren-cird Pane,
r -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A ,
CERTIFICATION Icon hued)
'rop"Address:99 Wood. Duck Rd.. , Marst_ ons Mills
Owner: Marilu„ uza
Dare of Inspection: �_.3 0., 9 9
INSPECTION SUMMARY: Check A, B, C, or.D:
A. SYS PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. S TEM 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.
Indicate y s, 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
Compliance(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 complying septic tank as,
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipes)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled 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
A
revised 9/2/96 Page 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION Icorttinued)
Property Address, A9 Wood. Duck Rd.. , Marstons Mills
Owner: Marilu Souza
¢
Date of Inspection: R^,3.6^9
D. SYSTEM FAILS:
You m t indicate either "Yes" or "No" to each of the following:
I have on that one or more of the following failure conditions exist as described 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 o
Backup of sewage into 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 due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 day flow.
_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped_.
Any portion of the 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 I 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. RGE SYSTEM FAILS:
You m st indicate either "Yes" or "No" to each of the following:
The following criteria apply to large systems in addition to the criteria above:
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 If of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
offi a of the Department for further information.
revised 9/2/98 Page 4ofII
_ _ J
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Prop"Address: 99 Wood. .Duok Rd.. , Marstons. Mills
Owner: Marilu Souza °
Date of Inspection:
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 IN ACCORDANCE WITH 310 CMR 15.303'(1)(b)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 surface water
Cesspool or privy,is within 50 feet of a bordering vegetated wetland or a salt marsh.
r,
2) SYSTEM WILL FAIL UNLESS THE pOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN'`A MAFINER.THA7;PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
=_ _ The system has a septic tank and sill absorption system(SAS)and the SAS is within 100 feet of a surface water supply or
tributary to,a,surf ace.water supply.
The system hes aseptic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS owithin,50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is`isss 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 prese'-de of ammonia nitrogen a►id'nitrate°nitrogen;,ris equal to or less
• than 5 ppm. Method used to determine distance (approximation not valid►` t>i ,a";
3) OTHER
revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Prop"Address:99 Wood. Duck Rd.. , Marstons Mills
Owner: Marilu Souza
Date of Inspection: 3Q^9 cad
Check if the following have been done: You imust indicate either "Yes" or "No" as to each of the following:
Y No
Lesi _ Pumping information was provided by the owner, occupant, or Board of Health.
_ None of the system components have been pumped for at least two weeks an&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.
_ As built plan's have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
✓ _ The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
�✓ _ All system components, excluding the Soil Absorption System, have been located on the site.
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.
The size and location of the Soil Absorption System on the site has been determined based on:
_ Existing information. For example, Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
115.302(3)(b)]
The facility owner (and occupants,if different from owner) were provided with information on the properxnaintenanrw.-0f
SubSurface Disposal Systems.
revised 9/2/98 Pagc5ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
�rop"Address: 99 Wood. Duck Rd.. , Marstons Mills
Owner: Marilu Souza e
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: g.p.d./bedroom.
Number of bedrooms(design):_ Number of bedrooms (actual):_
Total DESIGN flow
Number of current residents:_
Garbage grinder(yes or no):_
Laundry(separate system) (yes or no):_; If yes, separate inspection required
Laundry system inspected (yes or no)
Seasonal use (yes or no):_
Water meter readings, if available (last two year's usage(gpd): 1998 22, 000 gal
Sump Pump (yes or no):_ 1997 52, 000 gal.
Last date of occupancy:
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: qpd ( Based on 15.203)
Basis of design flow
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:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)_
If yes, volume pumped: gallons
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)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed lif known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)_
revised 9/2/98 Page 6(if 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION Icontinued)
'rop"Address: 99 Wood. Duck Rd.. , Marstons Mills
Owner: Mar ilu Souza
Date of Inspection: 3�_ Off+
BUILDI G SEWER:
(Locate n site plan)
Depth be ow grade:_
Material f construction:_cast iron_40 PVC_other lexplain)
Distance rom private water supply well or suction line
Diameter
Comme s: (condition of joints,venting, evidence of leakage,-etc.)
SEPTIC TANK:
(locate on site plan)
Depth below grader
Material of construction:%oncrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal,list age_ Is.age confirmed by Certificate of Compliance— (Yes/No)
Dimensions: 6 16 ,1v9
Sludge depth:('
Distance from top of;sludge to bottom of outlet tee or baffle:Sl
Scum thickness: ,+
Distance from top of scum to top of outlet tee or baffle: C/) '
Distance from bottom of scum to bottom of outlet tee or baffler
How dimensions were determined: ti 7j&C,"
'omments:
(recommendation for pumping, condition of inlet nd outlet tAs or be les, depth of liquid level in relatiyt�to ouget invert, structural integrity,
evidence of leakage, etc.) �lilftt/ `�6-® dA l �+5 l 10/p f Li
MIA
GR SE TRAP:
(locat on site plan)
Depth elow grade:_
Materi of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain)
Dimensi ns:
Scum t ckness:
Distanc from top of scum to top of outlet tee or baffle:
Distanc from bottom of scum to bottom of outlet tee or baffle:
Date o last pumping:
Com ents:
(rec mmendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evi nce of leakage,etc.)
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'ropertyAddress: 99 Wood. Duck Rd.. , Marstons Mills
Owner: Marilu Souza
Date of Inspection:
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or 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
Alarm level: Alarm in working order:Yes_ No_
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) -
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.)
revised 9/2/98 Page 8oftl
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'roperty Address:99 Wood. Duck Rd.. , Marstons Mills
Owner: Mar ilu S ouz
Date of Inspection: T-3Q—
SOIL ABSORPTION SYSTEM(SAS):_✓
(locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number:_
leaching chambers,number:
leaching galleries, number:_
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:_
Alternative system:
Name of Technology:
Comments:
(note condition o,soil, signs of hydraulic ff "lure, level of ponding, damp soil, condition of vegetation, etc.)
�r 16 !L A C
CESSPOOLS:_
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids laver:
)epth of scum layer: 1,
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comm ts:
(note co dition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate o site plan)
Material of construction: Dimensions:
Depth o solids:
Comme ts:
(note c ndition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
revised 9/2/98 Page 9ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
�roperty Address:99 Wood. Duck Rd.. , Marstons Mills
owner: Marilu Souza
Jete of Inspection: p�
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
`a.
i
revised 9/2/98 Page 10of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
rop"Address: 99 Wood. Duck Rd. , Marstons Mills
Owner: Marilu Souza
Date of Inspection:
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site (Abutting property, observation hole, basement sump etc.)
�/
/Determined from local conditions
Checked with local Board of health
_Checked FEMA Maps
Checked pumping records
Checked local excavators, installers '
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
revised 9/2/98 Page 11of11
TOWN OF BARNSTABLE
LOCATION
' SEWAGE #
VII.LAGE_ 1 ASSESSOR'S MAP & LOT °'6
INSTALLER'S NAME&PHONE NO. ,�, j.c �— '�
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) "v-
(size)
NO. OF BEDROOMS ✓T 1�-
BUILDER OR OWNER
PERMITDATE: v (�
COMPLIANCE DATE: � 7
Separation Distance Between the:
i
Maximum Adjusted Groundwater Table to e Bottom of Leaching Facility Feet
Private Water Supply Well and Leac Fac,
on site or within 200 feet of lea ngf acilityty any wells exist
Edge of Wetland and Leaching acility(If any wetlands exist Feet
within 300 feet of leaching facility)
Furnished by Feet
� p4RAP6.
�t
��r J
i TOWN OF BARNSTABLE i
LOCATION 2 SEWAGE # 5'/
VILLAGE y /�� I ASSESSOR'S MAP & LOT 03 04'6
INSTALLER'S NAME&PHONE
/NO. �8
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) 2- (size) /,-L
NO:OF BEDROOMS ✓�
BUILDER OR OWNER �)
PERMITDATE: q�®ig ! COMPLIANCE DATE: :5�'r 0 �
Separation Distance Between the:
Maximum Adjusted Groundwater Table to e Bottom of Leaching Facility Feet
Private Water Supply Welland Leac ' g Facility (If any wells exist
on site or within 200 feet of lea ng facility) Feet
Edge of Wetland and Leaching acility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
t
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s --
�,,.m._
. 3 r . ... �;. $50
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Zippfication for M gpoml *pgtem Congtructiou 3dermit
Application for a Permit to Construct( )Repair(X )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
L io dd so�,Lot�yo. Owner's Name,Address and Tel.No.
�l MoorT. LUCK Rd.. , Marstons M. lls Marilu Souza
Assessor's Map/Parcel (corner)
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Wm. E. Robinson Septic Service
PO Box 1089 , Centerville
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil S and.
Nature of Re irs r Al r bons(Ans er when applicable) new Title-5 septic system.
ank, �ox andw 2 leach .cham ers.
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 Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by is oard of He lth.
Signed Date �TG,
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued a^ a '
o / r
RN J
No. -�.-:R _ Fee /
t THE.COMMONWEALTH OF MASSACHUSETTS Entered in computer:
- Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
ZIpprication for Migoal *patent (Con.5truction J)ermit
Application for a Permit to Construct( )Repair(X )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
ti ddr s Lot o. 118 Mar 11UO U Zame Address d Tel.No.
° oo `�ucl Rd.. , Marstons M.
Assessor's Map/Parcel o_?0J-0Y0(corner)
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
m. E. Robinson' Septic Service
PO Box 1089 , Centerville
Type of Building:
Dwelling - No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of SepticTa W-C Type of S.A.S.
Description of Soil Sand.
,j
Nature of Re irs rA er tions(Ans e when ap icable) new Title-5 septic system.
�'an f ox anf � leaSk chambers. k�
Date last inspected:
Agreement: {{��
The undersigned agrees to ensure the on?ruction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of`Compliance has been issued by his oard of H alth. QQ
Signed Date �v2�- L
Application Approved by Date .-
Application Disapproved for the following reasons
ttA
Permit No. " Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
Souza BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TC�_�EER�,ttiatbthe On-site�ewaj DispgssalrSyste Constructed( )Repaired (X )Upgraded( )
Abandoned( )by WW Kx O b lris On e p Vv
at 99 Wood. Duck Rd.. Marston' Mills has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated 1?"i ;:Pa" 7
E Robinson Su `'�`
Installer Wm+ s„s Designer � .,, /}
The issuance of this e�rtnit sha g t be construed as a guarantee that the s stE - wi 1 func'tiion as desi� ed. U J��
Date �� ( Inspector /U I /
�' --------------------------Fee—CO--
No. 9 THE COMMONWEALTH OF MASSACHUSETTS J
15 '7 PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
&6za
Mi5po5ar *p! tem �tCongtruction permit
Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( )
System located at 99 Wood. Duck Rd. , Marstons Mills
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes 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 t.
Date: '� d^ Approved b
0-3
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
I, William E . Robinson,S,zhereby certify that the application for disposal works
construction permit signed by me dated <3 '-7 , concerning the
property located at 99 Wood Duck Rd. Mar-,t nn M i 1 1 c-- _ M Teets all of the
Mowing criteria:
1 2• e failed system is connected to a residential dwelling only. There are no commercial or business
es associated with the dwelling.
Zoialris classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
e no wetlands within 100 feet of the proposed septic system
sere are no private wells within 150 feet of the proposed septic system
it,/TAere is no increase in flow and/or change in use proposed
Xere are no variances requested or needed.
••/The bottom of the proposed leaching facility will not be located less than five feet above the
maximum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor
method when applicable)
• If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed
leaching facility will not be located less than fourteen(14) feet above the maximum adjusted
groundwater table elevation,
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information)
B) G.W. Elevation T the IvtAX High G.W. Adjustment.
DIFFERENCE.BETWEEN A and B
DATE:
SIGNED :
0 e-
(Sketch proposed plan of system on back).
q:health folder cent
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