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HomeMy WebLinkAbout0056 HEAD OF THE POND LANE - Health 56 HEAD OF THE POND LANE h'7 .L L L S i \ Commonmfealth of Masss:acihuse Title l0 Official Inspection Form -" Subsurface'sewage Disposal.System Form-Not for Voluntary Asse ments IOU ' 56 Head of the Pond Fed. Marslon„Mills, MA 02648 Property Address P+.7 Hyun Suh 13 Riverview Ave. Q Owner Owners Name —— -- — information is Ardsley NY 10502 �, 4/19/2017 required for every —._—_ _— _ page. CityfTown State Zip Code �""'' Date of Inspection Inspection rirsults must be sl.lbraitted on this form. Inspection forms may not be altered in any way.Please see com,pletene::s c:heciclist at the end of the form. Important:When A. General lir�f®rrtlaiti!lDn-- > - filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Paul Martin _ use the return Name of Inspector key. Cape Cod Septic Services -- Company flame 350 Main St i Company Address v e IF= W.Yarmuuth MA 02673 Cityrrown State Zip Code 508-775-282 f; _ S15016 Telephone Number License Number B. Certification ---- I certify that I have personally irlsp.rted the sewage disposal system at this address and that the information repotted below is t*ue, accurate and complete as of the time of the inspection. The inspection was performed based on my trnining and experience in the proper function and maintenance of on site sewage disposal systems. I awr a DEEP approved system inspector pursuant to Section 16.340 of Title 5(310 t.'MIR 15.000).The!sy:;t.em: ® Passes C] Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority - 4/21/2017 Inspecto Signature Date The systern 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 c:Df 10,000 gK;cl or greater, the inspector and the system owner shall submit the report to the appropriate rep iional office of the DER The original should be sent to the system owner and copies sent to the buys, is applicable, and the approving authority. '*This reptlrt l;9nly describe:-j ct,x%,ditions at the time of inspection and under the conditions of use at that throe,1rhis inspection c[mm not address how the system will perform in the future under the same-or different corisditi,clns,of use. t5ins•3/13 Title 5(Official Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 17 Commomeaiat:h of MassacNmset is Title la Official [Inspection For Subsurface oiewsige Disposal!System Form-Not for Voluntary Assessments 56 Head of the Plond Rd. Marston Mills, MA 02648 Property Address; Hyun Suh 43 Riverview Ave. Owner Owner's Name information is Ardsley _ _ _ NY_ 10502 4/19/2017 required for every � page. Cityrrown state Zip Code ^ Date of Inspection B. Ceitof6�caldon (cont.) _ Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System f'as:a= ® I have not found any inlorn cation which indicates that any of the failure criteria described in 310 MAR 15.303 or 41310 CMR 15.304 exist.Any failure criteria not evaluated are indicated velour. Comments: S sy tem irk working conditiar% B) System Conditionally Payscut ❑ One or m,ore 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 Boar<I of Health, will)pass. Check tho box for"yes", "m:."or'not determined"(Y, N, ND)for the following statements. If"not determined1," please explain.. The septic;tank is metal ant:;over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substanti;ri 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 pa::;s irosp:ection if it is structurally sound, not leaking and if a Certificate of Complianl.e indicating that liie'*,ank is less than 20 years old is available. ❑. Y E, N ❑ ND(Explain below): t5ins•3f13 Title 5 Offiaal Insp ection Form:SubsuAaca Sewage Disposal System•Page 2 of 17 Cornmonw.,eafth of Massichusetts --- Title , 0. fic ll [Inspection Form Subsurface Uwage Disposal System Form-Not for Voluntary Assessments 56 Head of the Pond Pd. Marsh°>ns Mills, MA 02648 Property Address: --- Hyun Suh 43 Riverview Ave. Owner Owner's Name ----- ---- information is Ardsley NY 10502 4/19/2017 required for every — page. Cityrrowm - -------- State Zip Code Date of Inspection B. Cerfifica` ion (cont.) _ ❑ Pump Chamber pump,,;4e nns not operational. System will pass with Board of Health approval if pumps/alarms are repa'Ted. B) Systern Conditionally Passes(cont.): ❑ Observation of sewage bac;'(U p or break out or high static water level in the distribution box due to brokers or obstructed pipes)or due to a broken, settled or uneven distribution box. System will pass inspection if(with =apl.:froval of Board of Health): ❑ broken pipe(s),:ire replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is r,:�movecj ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box:is tuveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required purnping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspect iorr 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) Etirth(w l::oraluation is P;equired by the Board of Health: Conditions exist which v:,quire further evaluation by the Board of Health in order to determine if the systern is failing to public health, safety or the environment. 1. Sir-stem will pass urdesa Soard of Health determines in accordance with 310 CA R I&W.I(1)(b)that the syi�steno is not functioning in a manner which will protect public health, safety and the environment: ❑ Casspcol or privy is within 50 feet of a surface water ❑ Cesspool or privy i� within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 3 of 17 Commonvireatith of Masnachusetts Title 5' Ot icia] [Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 56 Head of the Fond Rd. Marstons Mills, MA 02648 Property Address Hyun Suh 1•3 Riverview Ave. Owner Owner's Name --- ---- --- information is Ardsley NY 10502 4/19/2017 required for every —__- _— page. Citylrown State Zip Code Date of Inspection Bo Cerfli licatiol. (cont.} 2. Systiern will fail unless the Board of Health (and Public Water Supplier,if any) determines that the s ystvm is functioning in a manner that protects the publlic health, safety and environnit:;nt: ❑ The systern has a! ept�c tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface viater supply or tributary to a surface water supply. ❑ The systern has a ;,eptic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a ;epdr tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The:Tystem has a sep�,.:'c tank and SAS and the SAS is less than 100 feet but 50 feet or more;from a p mate waiter supply well*". Method used to determine;distance: '*This system passes if this well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates, bsE nt and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less then 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached`b this form. 3. Other: D) System Failuire Ct•iteria Applicable to All Systems: You must indicato"Yes' or`'No"to each of the following for all inspections: Yes No ❑ L� 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 21 due tc,an overloaded or clogged SAS or cesspool ❑ SIX] Static:liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® L� Liquid depth in cesspool is less than 6"below invert or available volume is less than 1,2 clay flow t5ins•3/13 Title 6 Ofidal Inspection Form.Subsurface Sewage Disposal System.Page 4 of 17 Commonwealth of Massachuseds Title 5 Officica"] Inspection Form Subsurface 3a.virage Disposal System Form-Not for Voluntary Assessments 56 Head of the Pond Rd. Marstons N10s, MA 02648 PrOperty Address Hyun Suh 4.3 Riverview Ave. Owner Owner's Name informaticin is required for every Ardsley NY 10502 4/19/2017 page. Cftyfrown State Zip Code Date of Inspection B. Certification (cont.) Yes 040 ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: D K 1,731 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. .ED aEJ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Any portk*in of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portia n 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 systc,,m passes if the well water analysis, performed at a DEP certified labov==.itos,O,,for fecal colliform bacteria indicates absent and the presence of animcmia nitrogen and nitrate nitrogen is equal to or less than 5 pprn, prov[ded that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] The s� 0 N ystern is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. E] F, The s stem falls. I have determined that one or more of the above failure criteri,i exist as described in 310 CMR 15.303,therefore the system fails. The systern owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large SyMeinz: 'To be considetroad a large system the system must serve a facility with a design flow W 10,000 gpd to '15,000 gpd. For large systems, you musl'.-indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ El the systern is within 400 feet of a surface drinking water supply the sy!;terTi is within 200 feet of a tributary to a surface drinking water supply ❑ E I the sy::;tern is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IIAPPA)or a mapped Zone 11 of a public water supply well If you have answered "yes"-1-0 any question in Section E the system is considered a significant threat, or answered 'yes" iiii Section D above the large system has failed. The owner or operator of any large system considereda significant lbreat tinder Section E or failed under Section D shall upgrade the system in acoordane,e with 110 CMR 15.304. The system owner should contact the appropriate regional offlcx;of the; Depailmeni.. t5ins-3/13 rifle 5 Official lrqxvdon Form:Subsurface Sewage Disposal System-Page 5 of 17 ;\ Commonwealth ,cif Mas-:ac:huseft --� Title 5 Officical [Inspection For Subsurface Sewage Disposal S°ysteln Form-Not for Voluntary Assessments F, 56 Head of the fond Rd. Mar-si-ons Mills, MA 02648 �M Property Address Hyun Suh �_3_Riverv_cew Ave. Owner owner's Name information is required for every Ardsle _NY 10502 4/19/2017 --_� page. CityfTown Y_-- State Zip Code Date of Inspection C. Checklist Check if the followinghave been done. You must indicate"yes"or"no"as to each of the following: Y 9 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? ❑ U Has the syste.rn received normal flows in the previous two week period? Have larger volumes of water been introduced to the system recently or as part of ❑ �r� this inspe:tion? z Ej Were as b°.tilt plans of the system obtained and examined? (If they were not available note:as N/A) ® ❑ Was the f Gility or dwelling inspected for signs of sewage back up? ® [.] Was the;sits inspected for signs of break out? ® EI Were sill system components, excluding the SAS, located on site? ® [] Were i he:peptic tank manholes uncovered, opened, and the interior of the tank inspected or the condition of the baffles or tees, material of construction, dimen ion;, depth of liquid, depth of sludge and depth of scum? ® G] Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The si':re arld location of the Soil Absorption System(SAS)on the site has been(iete::rmined based on: ® [� Existing ir&ortnation. For example, a plan at the Board of Health. ❑ Detern iined in the field (if any of the failure criteria related to Part C is at issue appro.ximiaaon of distance is unacceptable)[310 CMR 15.302(5)] D. System Infor°matic,n - Residential Flow Condiitir:?aas: Number of badro rns (design): 4, — Number of bedrooms(actual): 4 DESIGN flow based on 31 is CIvIR 15.203(for example: 110 gpd x of bedrooms): 110x4= 440gpd t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 6 of V Commonywrwilth of Masuachusetts Title 50 Offpichal] IInspection Form Subsurface Saks age Disposgil System Form-Not for Voluntary Assessments 56 Head of the Pond Rd. Marston-i;Mills, MA 02648 Property Address Hyun Suh 1.3 Riverview Ave. Owner Owner's Name information is required for every Ardsley NY 10502 4/19/2017 page. City/Town State Zip Code Date of Inspection D. System Informathm Description: Number of current residen'i5: 0 Does residence have a gafbag�,--grinder? Ej Yes ED No Is laundry on a separate sti.wage system?(Include laundry system inspection El Yes 0 No information in this report.) Laundry systern inspected'? Yes [I No Seasonal use? 0 Yes El No Water meter readings, if available(last 2 years usage(gpd)): 2015=3gpd 2016=47gpd Detail: Sump pump? 0 Yes 0 No Last date of orx�urxancy: Unknown Date Commer(-.ialfli,T,dt,j,.,.ttriaI Flcw(�'ordffions: Type of EstabH-:'Phrnent: Design flow(bsised on 3,10 CWR 15.203): Gallons per day(gpd) Basis of design ficxv(seatsplpersoris/sq.ft., etc.): Grease trap przisent*7 El Yes M No Industrial iArsste,ho,ding tarak pr(.-:sent? D Yes n No Non-sanifary waste discharqe6 to the Title 5 system? El Yes n No Water meter TC.'adirigs, if availa;je: t5ins-3/13 Title 5 official inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwoalth (0 Massiachusetts a] Inspection Form TitletS 011 Id 1 Subsuilace Sewage'I'Disposail SV-atem Form-Not for Voluntary Assessments 56 Head of the Flond Rd. Mars,towi Mills, MA 02648 Property Address Hyun Suh 43 Ri-verview Ave, Owner Owners Name inform requir ation is required for every Ardsley NY 10502 4/19/2017 page. Cityrrown State Zip Code Date of Inspection D. Systwrn lin-k%rmati-cm (cont.) Last date of oc-c-upancy/uso: Date Other(dascdil)e bolow): General Informat6on Purnping Recomlla: Source;of information: BOH 2016 Was system pumped as pi:rt cat the inspection? E3 Yes ED No If Yes, VOIUIT19 purriped: gallons How was cluanity purnrx)d deti,rmined? Reason for pumping: Type of Sys;tern: S;eptic taril;, distribution box, soil absorption system ❑ Single cosspool El Owerflow cossmol ❑ FAVY El Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative0d1te-unative technology.Attach a copy of the current operation and ry;@,intenanl ,;e contract(to be obtained from system owner)and a copy of latest in.&Pection of the UA system by system operator under contract ❑ Tight tank.Afta,-h a copy of the DEP approval. El Other(dvscxib�i): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonyvea lth (-A:N at.,,s ei.-,�jsetls Title 5 01iffIcial Inspection Form Subsurface Sewage Disposal Sysleini Form-Not for Voluntary Assessments r yr 56 Head of the Pond Rd. Mar ai ans Mills, MA 02648 Prop"Address -- --- -------- - Hyun Suh _43 Riverview Ave. Owner Owner's Name ------------- -- ----- requir ..__._-. atian is Ardsley NY 10502 4/19/2017 required for every --_--._.----- . -------__-_— —�- page. City/Town _ _ _ State Zip Code Date of Inspection D. System Ilrilrarmaitian (•xnt.) Approximate age of all coiriporients, date installed(if known)and source of information: 1982 Per RC►Hl rec;crrds Were sewage c1dors detectE�d when arriving at the site? ❑ Yes ® No Building Sevva.:r(iocate on site plan): Depth below 9 rad : 48' feet Material of c;r:lr stru(lion: ❑cast in)n ❑ other(explain): +10' Distance fTorn cnriwate waiRw supl)ly well or suction line: feet Comments(on j,,oriditicn of Joints, venting, evidence of leakage, etc.): Line checked with sewer csione;<1 and was found to be clean, properly pitched with no sign of root intrusion. Septic Tank on site. plan).- `Depth below gi actin 36"!: feet Material of construcFion: ®concrete F-1 metal ❑fiberglass ❑polyethylene ❑other(explain) If Wnk is metal, ist age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000Gal 1„ Sludge de.,pth: t5ins••3113 Title 5 Official Impaction Forth:Subsurface Sewage Disposal System•Page 9 of 17 COMMOnwe"al";r{u a it 6��a��ia�fitl� e Title 1) Of f isi,IM Inspection Form Subsurface•Sew ago Dispo�, ,a w S)ll tem Form-Not for Voluntary Assessments M 56 Head of the Pond Ind. Mars ons Mills, MA 02648 Property Address-- - y- -- --- — Hyun Suh 43 Rilr-inview Ayie. Owner Owner's Name------ ------._._--- information is Ardsle NY 10502 4/19/2017 req�lired'rc�revery �----------.._.-_.__ ------_---- page Cityrrown State 'Lip Code Date of Inspection D. SyStelln 1"T01.Mat1X41 (cont.) Septic Tank(coat.) Distance fro:rn trap of slu,;gr-to b,;)ttorn of outlet tee or baffle Scum thickne..;:, 0" Distance frorn top of scum i:o tor of outlet tee or baffle Distance frorn 1--i(tom of scum to bottom of outlet tee or baffle How were dimersic>ns dr;tel;Tnirr.c?? Estimated Comment,, (car, furnping reclonIdMendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as;ro!i ,ted to outle,':invert, evidence of leakage, etc.): 1000Gal h-10 tank in good condition. Back end of tank on edge of paved driveway. PVC tees in place and clear. at normal r,.peratin level. Covers 4"below grade. Grease Trap on sitr• pla i): Depth below feet Material of construction: ❑concrete ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to tcp of(outlet tee or baffle — Distance fron-1 b o:l orn of ;cuIn to bottom of outlet tee or baffle Date of last purnping: Date t5ins-3113 TNe 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 10 of 17 j�\ COMMOnv'realftl of Mat-Isacitlialetts. Title ,"' Off"ca, Inspection Form Subsurface 39mfvq(,,,Dispor;al System Form-Not for Voluntary Assessments 56 Head of the Pond Rd. Maralons Mills, MA 02648 Property Address Hyun Suh '�3 Riw-:Xiew Omer Owner's Name infonnation i's required Ibir every Ardsley NY 10502 4/19/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont) Comments(on pumping rer.,omnnendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as ral;:Aed to ot.itlet invert, evidence of leakage, etc.): ............. Tight or Mogd',�,',rifjTank(�'.ank rilUst,be pumped at time of inspection) (locate on site plan): Depth below grade: Material of comeAruction: El concrete ❑ m0al El fiberglass El polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: 0 Yes El No Alarm level.- ------ Alarm in working order. 0 Yes El No Date of last pun,iping: Date Comments(Coridi¢ion of al;---;mnsnd float switches, etc.): Attach copy of current purnping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official In Form:Subsurface Sewage Disposal System-Page 11 of 17 commonvietlICIE1 of Mw--.i's-aCfiUSGttS Title 5 C)'ficii,sil inspection Form Subsurface Seivag ce,, Disposgil SIrintom Form-Not for Voluntary Assessments 56 Head of the Pond Rd. W. Mills, MA 02648 Property Add,ress Hyun Suh 43 Ave. Owner Owner's Name information is required for every Ardsley NY 10502 4/19/2017 page. City/Town State Zip Code Date of Inspection D. Systeirn haformatic)rji (cont.) DistrilmUou Hox(if pre::;ant must be opened)(locate on site plan): Depth of liquid it.-!vel above outlet invert 0" Comments(ni);.(! if box is Rivet and distribution to outlets equal, any evidence of solids carryover, any evidence of 1e':,-kFc.je into or out of box, etc.): DB-3 with 'I Err: in and 11 lxii o,,.,t it good condition. Box is clean and level with some solids carryover. _No sign of ovedoaqjq it 1tyqraufic failure. Cover is @ grade. Pump CliarnLt,r(locate Dn site, plan): Pumps in wcridr( order: ❑ Yes ❑ No* Alarms in w(;rk;riy order.- ❑ Yes ❑ No* Comments(noi.e,condition of pump chamber, condition of pumps and appurtenances, etc.): If pump".3 Ore.13!Tns are,ricit in \vorking order, system is a conditional pass. toil Msoirpido.,:rp, 1,5,ystein (SA a) (locate,on site plan, excavation not required): .If SAS not located, explain why.. t5ins•3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonviriml ra of Mvimuni-tuse ft [Irnspection Form Title' !'S (Cli MsQi Subsurfw:e'Seiwqxe OispazAil Sip term Form-Not for Voluntary Assessments 56 Head of the Pond Rd. Marstons Wls, MA 02648 Property Address Hyun Suh_43 'Rtivs��i/iew Ave. Owner Owners Name --- information is required for every NY 10502 4/19/2017 page. City/Town State Zip Code Date of Inspection D. System hil'armcatilcm (cont.) Type: 23 1 c-) c,h i n o o i t! number: 1-6X6 Fj kAching conmi'Mms number: E-1 leaching cjNieri:-s number: ❑ ie.7ching tr"--�riches number, length: ❑ leaching-ikBlds number, dimensions: number ❑ irmcvativ4J@Iem"iative system j )a/riame of teohnology: Comments of rx'.41, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, 1-6x6 pit with Flit found dry at time of inspection with stain about 1'. No sign of overloading or tailurs. Cov, r ls (!grade. Cesspools be pumped as part of inspection)(locate on site plan): Number and con':Iguration, Depth trap of 1ic.jjdd to iale-1 invort Depth of f3o,'ids,1E-,,yar Depth of scum layer bim�n-sions,Of t,*;�::;spo,al Materials of c.on!i.truction Indication of inflovi Ej Yes Fj No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonv:teR1--r*'t1 of'MF..,-,vi-achusefts Title 15, C -Ifflict'hf.-ild Inspection Form Subsurface Sowid DiWsail Sy$,tem Form-Not for Voluntary Assessments 56 Head of the Porld Rd. Mlarstom;Mills, MA 02648 Property Adrjres,s Hyun Suh --43 Riv,;Irview A,,(:c:!. Owner Owner's Name information is required for every Ardsley —------ NY 10502 4/19/2017 page. Cityfrown State Zip Code Date of Inspection D. Syste!Lml, lirl"ormsitic)n (cont.) Comn ienty l,n,,---t(.:!condit�ix-1 of signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (Io,ate ori site plan): Materials of con.e.aruction: Dimensions Depth of ef.)Iid,, Commenti;(no'i;;condition afsoil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Smrage Disposal System•Page 14 of 17 commonum"Calth of Wiss3eil"Seus Title 5 Officlal !Inspection Form Subsurfwr- e D L-po!,,-,,fl .131�stcm Form-Not for Voluntary Assessments 56 Head of the Pond Rd. h4a-r!3lons Mills, MA 02648 Property Address Hyun Suh 43 Riverview Ave. Owner Owner's Narre information is A required for every rdsley NY 10502 4/19/2017 page. City/Town State Zip Code Date of Inspection D. Systern lirtfiwrnialic)n (cont) Sketch Of 13),aviaqet Disri�t;;nl Sy stem: Provide a view of the sewage disposal system, including ties to at least tkv<) perryi-anent n'.,ift;r(ance landmarks or benchmarks. Locate all wells within 100 feet. Locate where public wate4r supj,�.fy nntens the building. Check one of the boxes below: El hand-sketi-i in the are; below drawing attachad s(,-.!paretE,1y 15ins 3113 Idle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Corr menivealtag of Masse-4c.,li'wsetts Iffmck-, 11 Inspection Form C Title C) "J'r q�v [is 'a Subsurface"'rm,F D" pos .1 Sys tem Form-Not for Voluntary Assessments 56 Head cf thr.! Poncl Rd. Mamstons Mills, MA 02648 Property Addre,,�,,, Hyun Su 43 Rivefviavv Owner Owner's Nai ne information is required for every Ardsley_......... NY 10502 4/19/2017 page. City/Town State Zip Code Date of Inspection D. Systemii Iri.formabitxi (cont.) Site Exam: Sl,jrfa%e water Shallow wells EstimAted dep i tn- high gFOUnd water: +15' feet Pleaso ri-.,11 rrtetf�orjs us(,.ad to determine the high ground water elevation: Obt;.i.ined frorn system design plans on record If rhecked, dal of design plan reviewed: 1/12/1982 Date ❑ 1-.,,°erved sitar 1(vbU-Lti[,'1g property/observation hole within 150 feet of SAS) ❑ C1,,ecked wish Ioc,;l Board of Health -explain: with local excavators, installers-(attach documentation) ❑ Ac.issed d-,:itabase-explain: You must df.,.Sf�ribe how you established the high grou I nd water elevation: Per p1c,..'in onfilo.at.130H. 13c,'iltorn cri'leach pit elv. 77 with pond elv. 54. 23'groundwater separation. .......... Before fifliriy thb3 Inspe;(Mon Repork, please see Repoil Completeness Checklist on next page. t5ins-3/13 Title 5 official Impaction Form:Subsurface Sewage Disposal System-Page 16 of 17 COMMOnva"811i"il of Mass'achusetft --apection Form Title 15� (Y11,6114,a] lit SubsurTae* Sowa�jz,Dispose 3yAem Form-Not for Voluntary Assessments 56 Head of th,,,�Pond Rd. W r!Jtcns Mills, MA 02648 Property Address Hyun Suh_ 43 Wt�Brvievy Ave. Owner Owner's Name_ information is required for every Ardsley NY 10502 4/19/2017 page. Cityfrown state Zip Code Date of Inspection E. Repoll C'thecklist Surrirnar)- i., B, D, or E checked 1n:.-;pec1:i,Dn Sumr,,i@f-4- C, (,Systern Failure Criteria Applicable to All Systems)completed Systurn Mformatiori—E,.stiniated depth to high groundwater Sketcl of �1aystern either drawn on page 15 or attached in separate file t5ins-3/13 TitI6 5 Officiall Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 dd TOWN OF BAyyRNSrARIE LC�..r'1�011_._-y A a A/ Yid SEWAGE tr'ih L.LLO ._.__.e! ".t fi•115 ASSESSORS MAP&LUT LEika Yei (type) �iUJiT.Lif1R1:fi�.CI�TfTAI��;_,..c''�f��!� eG.l� C1 ; vaP imcn Il�ima�c Tk:�rot�m tine: rira°sur CcolmdwaterTAletadmomofLeadnn6FacMty Few Privt9b.ll xr4:l:iuNtdy Wolf md UadzimgFooft(If any weIIs exist cat si s;m w lk;'e�U ,ba of lei facWq) Feet FdF;e ri'i :rntd a td Lvid iag Fkility(if any viedan&exist xvel r zH rat ru:n(yf k.a4N4 farHteY) Feet R , J .R c i t 27 d r t F oo r-o 6 Kevin J. Medeiros Plumbing&Heating,Inc. Invoice 63 Kerry Drive Marston Mills,MA 02648 Date Invoice# 4/18/2017 1699 Bill To Hyun Suh 43 Riverview Ave Ardsley,NY 10502 Terms Job Location Due on receipt 56 Head of Pond-The Cape Quantity Item Description Price Each Amount Plumbing Work:Remove disposal-Repair drainage piping 1 DW Tail Piece DW Tail Piece 17.86 17.86 1 Basket Strainer Basket Strainer SS 36.88 36.88T 1 Flawed Tailpiece Flaked Tailpiece 12.73 12.73 2 1.1/2"ST 90 1 1/2;ST 90 9.93 19.86 1 1 1/2"Desahco"` ` `1 11T'Desanco 12.99 12.99 ''4 Labor Labor 98.00 392.00 Thank..you•for your business. Subtotal $492.32 A service charge of 2%per month or 24%annually will be charges to accounts 30 days or more past due. Purchaser agrees to pay all costs of collection,including attorneys fees. Sales Tax (6.25%) $2.31 Contractor shall have choice of venue Total $494.63 Fax# ` 26 508 420-3615 508 420-55 ;,. t , i t AFFIDAVIT OF PRIOR HOMEOWNER RE: 56 HEAD OF POND LANE Then personally appeared TINA ERBAFINA who did depose and say as follows: 1. I am a resident of 32 Old Framingham Road, Unit 26, Sudbury, Massachusetts. 2. In the year 1982 my husband and I purchased property known as 56 Head of Pond Lane in Marstons Mills (Barnstable) Massachusetts. 3. In 1982 my husband and I had a house built upon the said property which contains four bedrooms, two on the first floor and two on the second floor. 4. Between the time of the construction of our Marstons Mills home and our sale of it to Veronica and Luis Viada in 1990, we continually used the property as a four-bedroom home. We also sold it to the Viadas with the understanding that it was a four-bedroom home. 5. The building sketch (Exhibit A) is an accurate depiction of the layout of the four- bedroom home we built. 6. Any paperwork that suggests that our property in Marstons Mills was anything other than a four-bedroom home is mistaken. Signed under the pains and penalties of perjury this l day of November, 2015. Tina Erbafina COMMONWEALTH OF MASSACHUSETTS November /L/ 2015 Then personally appeared Tina Erbafina who acknowledged the foregoing to be her free act and deed before me, Notary Public My commission spires: 03�//�q�%(� n ANA C.F®LGAR POkC amorweafiofWssachusft �6 wwsb Bon Mamb 11,2016 2 i ,'.! OTT , Aw • r I 1 t l f f! , : �,—.'--••-�-•�-.p�•w.,.....�..y...{..� ".1 r..T -•t---�-. - J-w>..el_,p,n.o......�>�1.q.wr,,,-,,.,.hw,,.T.!.1 .4, .P, t r + �• F ♦•--a �-..j-.�y.1 � ...,).,1 � I .� ' ,,.,,.�,,,e„�sa..,.. ..ter•— 0-+. _Sy_s. S .Y-+--r..... ! -p:..d....:. ,� .^^-t '...s i ' r i � � I s i f off- VOW ! r : 41I � E 3 rv.:'•v •. 1 wMit 01 A AM 1 Lill. r I War , yy f f +1 i ' �,,, o f ,,. a , 1 t a A ff t - tr Uy • i i s ! I � .; I j. I A Van , QUA ; t 1 .ry j �' 1 iY S.. I , Tan ] lip ( , t It .�1./`.i ' 1—Y i ; t ' _, 1 i LL SKIRT Q. t ! � 1 Own K I Brow } t ' • I /� { ' 1. I lly ' F-- -•._? i• .,-...,w.,,A�.._...�.s.�_.. r� 'h"Fj� � " �,�,ter-�•--4I ' �•-� �..',...,. r i 5 t I' 1 , 0 —'` 1_ t 1 l I i f 1 r ,.s..., 1 'i' 1•, , D S ? ,.5...:...,..i..t.,.t...�,.Z.,�,. 1 s 1 h rl �-.� i 1 I• i .t ..... 1 .� too?, 1 1 i 1 y I i j cnily VISA I I t r i . } tt .i. 1.5 ` ! I c j1dWWWA 1: 10 MOM � , i ! Ir '� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 56 Head of the Pond Rd. Property Address Veronica Viada Owner Owner's Nameinform r on is required for every ad required for Marston Mills Ma 02648 6/26/2014 , page. City/Town State Zip Code Date of lrgx to ; 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, Dated 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 sae 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): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 110x4= 440GPD t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17 No.(:;10I _ ���/L� Fee A%) THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: � Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppl LAtion for Mispo8AY *pstrm Construction i3ermit Application for a Permit to Construct( ) Repair(X) Upgrade( ) b ( ) El Complete System ❑Individual Components Location Address or Lot No.-SW /S1411 o7'* fie wner's Name,Address,and Tel N�J. -Iors�rs __,ew. Ir i/�iB.yi'C4 fii'crcC�L Assessor's Map/Parcel 0 ^ /O 77- 7335 Installer's Name,Address, nd Tel.No. 4--er f .�'�Q''f�� Designer's Name,Address,and Tel.No. ul' y1a ©69— 1 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 'f 3 O gpd Design flow provided 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) Gu 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 Certificate of Compliance has been issued by this Board of Health. Si ed Date '7101111 K Application Approved by Date Application Disapproved by Date for the following reasons 1 5' 0 q Date Issued - s No. `� �-/ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes f ltlfication for 33isposal *, pstrm Construction Permit Application for a Permit to Construct( ) Repair()() Upgrade( ) b {and¢p( ) ❑Complete System ❑Individual Components Location Address or Lot No.s"6 //­/ of t4e 14'e wner's Name,Address,and Tel.Np. � Assessor's Map/Parcel — /O ' v s ciwre 77'V-7?2-7 3 S Installer's Name,Address,,and Tel.No. ci/ �r�or�i� Designer's Name,Address,and Tel.No. �Gc/ sT 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 r` x Design Flow(min.required) i gpd Design flow provided ;' gpd r Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil s j Nature of Repairs or Alterations(Answer when applicable) �w Sri p_sd Date last inspected: Agreement: �. r The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the-prqvisions of Title 5"df the Environmentai°.Code and not to place thesystem in operation until a Certificate of Compliance has been issue�by this Board`of Health. Si ed Date 7_/Xox�/ Application Approved by Date �. Application Disapproved by Date for the following reasons ' Permit No. 9 01 y � � r� Date Issued —2 /0 2 M ----------- ------------------------------------------ - ----------------------------------------------------------------------- TH E COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(6) Upgraded( ) Abandoned( )by at S-F ra y�' �L,��o s�„r� dc� has been constructed in accordance ) ) with the provisions of Title 5 and the for Disposal System Construction Permit No�/<< a 4ated 7 Installer Designer #bedrooms Approved design,.flow / gpd The issuance of this permit sshhal'not /b�e construedf / j as a guarantee that the system will /ffanctiioonj�as designed. / piq 0 Date / IS /�1 ! I L Inspector ll�il � "r la !! I k " V rrl� }(, �1 / r1�- t No. i-01 Z-1 -D- ' Fee /Q THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS jMisposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair(^ Upgrade( ) Abandon( ) System located at 3—d" �P'v c>>'' f.G� ��� i'e.� ��/cs�� o�'s ✓�i l'r-S r and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her dutty.to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must b completed within three years of the date of this permit. �d Date Approved b ���+�,>> f���X' oil � �i��`r��.�i mac."J-/' - aa,;,, Commonwealth of Massachusetts -I�le'ljolv u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 56 Head of the Pond Rd. Property Address Veronica Viada Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/26/2014 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, (U�( use on!.y the tab 1. Inspector: key to move your cursor-do not Paul Martin _ use the return Name of Inspector key. Neighborhood Waste Water _ rae Company Name 350 Main St Company Address _W.Yarmouth _ MA 02673 City/Town State Zip Code 508-775-2820 S15016 _ Telephone Number License Number r B. Certification I certify that I have personally inspected the sewage disposal system at this addres3,and that'tfTe information reported below is true, accurate and complete as of the time of the inspection. ThEMnspeL4on was performed based on my training and experience in the proper function and maintenance of on s sewage disposal systems. I am a DEP approved system inspector pursuant to ction 1SA40 ON Title 5 (310 CMR 15.000). The system: ray ❑ Passes Z Conditionally Passes ❑ Fails o i ❑ Needs Further Evaluation by the Local Approving Authority 6/2_7/2014 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. tIms•3/13 Title 5 Official Inspectio rm: bsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments „M 40 56 Head of the Pond Rd. Property Address Veronica Viada Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/26/2014 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: ❑ 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. 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 56 Head of the Pond Rd. Property Address Veronica Viada Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/26/2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (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): H-10 DB-3 box in driveway is rotted and walls are gone. Box needs to be replaced. ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 56 Head of the Pond Rd. Property Address Veronica Viada Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/26/2014 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". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts I w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9M 56 Head of the Pond Rd. Property Address Veronica Viada Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/26/2014 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 ❑ ❑ 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 56 Head of the Pond Rd. Property Address Veronica Viada Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/26/2014 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): 4 — DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 110x3=330GPD t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 56 Head of the Pond Rd. _ Property Address Veronica Viada Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/26/2014 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2012=87gpd g ( y g (gp ))' 2013=30gpd Detail: Sump pump? ❑ Yes ® No Last date of occupancy: CurrentDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(9Pd) 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 56 Head of the Pond Rd. Property Address Veronica Viada Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/26/2014 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: BOH pumped 2011 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 56 Head of the Pond Rd. Property Address Veronica Viada Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/26/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 32 years per plan on file at BOH. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 3'8° Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: +10'feet Comments (on condition of joints, venting, evidence of leakage, etc.): Line inspected with sewer camera and was found to be clean, properly pitched with no sign of root intrusion. Septic Tank (locate on site plan): 3' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: — years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal _ Sludge depth: 4 t5ins-3/13 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 56 Head of the Pond Rd. Property Address Veronica Viada Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/26/2014 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 29" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 0" — Distance from bottom of scum to bottom of outlet tee or baffle 0 11 How were dimensions determined? Sludge Judge/Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1000 Gal H-10 septic tank in good condition. Tees in place. 1/3 of tank is under corner of paved driveway with no access to outlet cover. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 56 Head of the Pond Rd. Property Address Veronica Viada Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/26/2014 page. City/Town 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.): 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 56 Head of the Pond Rd. Property Address Veronica Viada Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/26/2014 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 0 11 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.): Box is in poor condition. Walls are gone and not holding water. Box needs to be replaced. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): " If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 56 Head of the Pond Rd. Property Address Veronica Viada Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/26/2014 page. Cityrrown 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.): 1-6x6 Leach pit was found to be clean and dry during inspection. No staining or indication of hydraulic failure. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 56 Head of the Pond Rd. Property Address Veronica Viada Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/26/2014 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.): 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 56 Head of the Pond Rd. Property Address Veronica Viada Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/26/2014 page. City/Town 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Hecl.-J PO/7d- Property Address Ve.ror7 iC-a. 1 1 OJe, Owner Owners Name information is !�I r,,f)+i Oq ' s r/ C76// required for every I I dam_ page. Cityfrown State Zip Code Date of Inspecti n 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 Ci vt � v v 1-7 o t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 56 Head of the Pond Rd. iM Property Address Veronica Viada Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/26/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 23 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: 1/12/1982 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: Per plan on file at BOH. Bottom of Leach pit elv.77 with pond elv. 54. 23' groundwater separation. 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 56 Head of the Pond Rd. Property Address Veronica Viada Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/26/2014 page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked E Inspection Summary D (System Failure Criteria Applicable to All Systems)completed E System Information— Estimated depth to high groundwater E 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 AsBuilt Page 1 of 2 TOWN OF BARNSTABLE LOCATION SC t � pow SEWAGE# �. VILLAGE M • 4-'. + s pASSESSOR'S MAP&LOT ME INSTALLER'S NA &PHONE NO. Z_w SEPTIC TANK CAPACITY LEACHING FACILITY: (type) T (size) NO,OF BEDROOMS _ BUILDER OR OWNER / ; PERMIT DATE: �I/7 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by T i l(i (�✓+t S /dI��QS' J_ A A. 17/ 3b' 33' yy ' http://issgl2/intranet/propdata/prebuilt.aspx?mappar=030102&seq=1 4/10/2017 .gyp ram, Town of Barnstable *Permit Expires 6 months from Issue date aKRNSrABM Regulatory Services . Fee � Thomas F.Geiler,Director A Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 w EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Impript Map/parcel Number 0 30 f 0 ,:2— Property Address Residential Value of work 3,-7-9,0 Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address ��`� Y',, zi a, S 6 A/,e -ca ion-d1 Contractor's Name /l L,, Telephone Number r�CJ g—t{ ^A o_Q p. Home Improvement Contractor License#(if applicable) a,5 3 Construction Supervisor's License#(if applicable) Oworkman's Compensation Insurance m1 � Check one: ❑ I am a sole proprietor ❑ I am the Homeowner JUN 2 2 200 JR I have Worker's Compensation Insurance Insurance Company Name CUD TOWN of SARNSTAB LE Workman's Comp.Policy#_ �{Ll L l R ' Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: ro Owne ust sign weer Letter of Permission. Home ense is required. SIGNAT RE: Q:Forms:expmtrg Revise071405 TROY WILLIAMS SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection (508) 760-1819 40 Old Bass River Road South Dennis,MA 02660 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM AE Address of property (, �� u o f o �, a /�1 a` S N s /l/1, Owner's name& v; Vc ro +l � c� c. Mailing address a � s �, �� �� ram . S + Date of Inspection PART A Fp .� CHECKLIST S 199�. ti Check if the following have been done: ,* Pumping information was requested of the owner, occupant and Board of None of the system components have been pumped for at least two weeks 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. VAs built plans 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 site was inspected for signs of breakout. _ ' All system components, excluding the SAS, have been located on the site. V"The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of bales or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. Page 1 of 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential number of bedrooms S number of current residents V0 garbage grinder, yes or no E s laundry connected to system, yes or no �-5 seasonal use, yes or no If nonresidential, calculated flow: 9 y = 9T a a y a►/,H , 93 = 77� o � oy4 ►►o� � Water meter readings, if available: 6c c-a'e; J �a +,�,� Last date of occupancy �e . GENERAL INFORMATION Pumping records and source of information: L G-S 7 -eo fJ t d /O /c/ .� d t✓ i H 4, sue. -c --, a &' A S I N t / Al° System pumped as part of inspection, yes or no If yes, volume pumped 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) Other(explain) Approximate age of all components. Date installed, if known. Source of information: u-< - .,4 I /f obi Sewage odors detected when arriving at the site, yes or no Page 2 of 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: V/ �� (locate on site plan) depth below grade: 1 Sr material of construction: concrete metal FRP other(explain) dimensions: .5" 'x 9 X 6 ' I " sludge depth a,L, distance from top of sludge to bottom of outlet tee or baffle ,nroKF scum thickness Tdistance from top of scum to top of outlet tee or baffle distance from bottom of scum to bottom of outlet tee or baffle 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,recommendations for repairs,etc.) A--G s 7OJ4 r� �b �� 4 v� J✓ K/ Y A , /O✓ eR.c✓. [r`�4.i1�'�y- W -, S 6A41 �� J G T � � LN d f r a t, f o 7` /Ge. A-0k Ll✓ .�TJ/tJ Ci?✓law �.�.YH G�9� _ Oy T'I .r7 u J t rh- ►-,-F 0..� S N O / �� h t T to J DISTRIBUTION BOX: (locate on site plan) 1 w,� 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, recommenda't1/ion for repairs,etc) L L !s) 0. S 1<1 /�'� ok'/ 1- 0 /- •C r 2`) IO r t I• CC L27 A 1 C "4 f✓ �2U 7 ivy St1�7Zc— �. k 4 "^�I .C h c.c../ p t.J°C.u.�J�'� L. /J✓ Ir/:,`> J n N i s S o- ¢G r y Ul✓c LJ o✓/�'.�g o✓cl•�✓ c.6.c/ W k/-.-✓ (tug /s ��. 7~trKh u»d /cok-c 4fp :f PUMP &44& (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber,condition of pumps and appurtenances, recommendations for maintenance or repairs,etc.) Page 3 of 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,if poss.;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: leaching pits and number �X6 ' L L 3' S� leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,recommendations for maintenance or repairs,etc.) L / c-t/,, ll -! ✓o L /� �f �(O //S CESSPOOLS (locate on site plan) : 1S/1� 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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, recommendations for maintenance or repairs,etc.) PRIVY: Al 9 (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, recommendations for maintenance or repairs,etc.) Page 4 of 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' R . 5% OF 1` )-7 3° too L Xb 't cam L p •4- �v DEPTH TO GROUNDWATER w depth to groundwater "` adjusted high groundwater level method of determination or approximation: / 1 +-J W A 4-C✓ L S.�- i rh a 7 c JA A 7 J c. rh i YI , nn .►I., Page 5 of 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no or not determined(Y,N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) P Backup of sewage into facility? A Discharge or ponding of effluent to the surface of the ground or surface waters? _// Static liquid level in the distribution box above outlet invert? A1119 Liquid depth in cesspool<6"below invert or available volume< 1/2 day flow? Al Required pumping 4 times or more in the last year? Number of times pumped Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration?tank failure imminent? Is any portion of the SAS, cesspool or privy: below the high groundwater elevation? within 50 feet of a surface water? within 100 feet of a surface water supply or tributary to a surface water supply? within a Zone I of a public well? Vwithin 50 feet of a bordering vegetated wetland or salt marsh(cesspools and privies only, not the SAS)? within 50 feet of a private water supply well? N 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. Page 6 of 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector: Troy Williams Company Name: TROY WILLIAMS SEPTIC INSPECTIONS Company Address: 40 Old Bass River Road, South Dennis, MA 02660 Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. the inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and maintenance of on-site sewage disposal systems. Check one: �I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15.303. Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15.303. The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector's Signature ,,, /� ez�L,,,,� Date Original to system owner Copies to : Buyer(if applicable) Approving authority PROPERTY ADDRESS: Aav-S -7L-` 5 Page 7 of 7 .. _. .... _..._..:...._ .. 77 _ f CoT � 2 ?Z 77 Sewage Permit .No.. Location: += _ &CAP D F 2 j F LaND LAIyC �3 Village: AN-1-.r Installer's Name & Address , V. G• ryG• Builder's Name & Address :OUR Me- SNAML A'1.4• Date''Permit Issued Z Date Compliance Issued L 1- 49 A/k AMP to too HEAa oA'. Ik PeNP 44A*VE TOWN OF BARNSTABLE LOCATION .SC 4s- i4L Pon SEWAGE # VILLAGE M • S ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 0 SEPTIC TANK CAPACITY C>(Z�U cT i LEACHING FACILITY: (type) (size) fJ X 6 NO.OF BEDROOMS BUILDER OR OWNER V r/ ; PERMIT DATE: �/(7 l/K a) COMPLIANCE DATE: /Za ;t Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet.of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by CrJ, 1 i ✓', s 1310S i A/ , Lr M 4. 0 �� � Z 7 ? Sewage Permit No. Location: A669 6 f E Rowe LANE Op Village: I o AM G aArP, _Meffl 4' AM-M/157 /L 4- Installer's Name & Address ffFiE/P�I�"'• l HRHM TAl rb Builder's Name & Address MA, Date Permit Issued 1 qZ Date Compliance Issued � 1-- La Nl� TDB IP —_ IW NovSE� VAGO Awl H�'R=�' FJ/� TJE e�OND# SANE _ Fps...........a.S........ THE COMMONVVEALTH OF MASSACHUSETTS BOARD OF HEALTH OF............................................. ApplirFa#ilan for Dhip ii al Workfi Tonstrn.rtinn ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ...... ... r.a__...._.. .► �� --------------------- ----- :.........-------------=- -------._....--------- Location Address r Lot No. Owner Ad�daress ------------���2' -1 _�.2 :. / sli1_ ----------------------•------------- 1 Installer Ad res8 s Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms__..2........................._ _Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons........._.................. Showers ( ) — Cafeteria ( ) Q' Other fixtures ----------------------------------- -_____._�,_______________________ ______ w Design Flow....... _ ....�__ .._____gallons per person per day. Total daily flow____�_c3...........................gallons. WSeptic Tank—Liquid capacity/,__gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No_____________________ Width........_........... Total Length.................... Total leaching area.........._---------sq. ft. Seepage Pit No_________ _________ Diameter____ P..____.__ Depth below inlet____............ Total leaching area_____ 5Lsq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ a Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -----------------------------------------------------....................................................................................................... 0 Description of SoiL0_-fix-ice_____ w --------------- ------ UNature of,:Repairs or Alterations—Answer when applicable---------...................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITIE 5 of the State Sanitary Code—The undersigned further agrees not:to place the system in operation until a Certificate of Compliance has be i s S Uig d by the board health. • Signed.------ ---- _ ....f°...4-----v-_--------••----------•----------------- Date, Application Approved By.1___4- 2_ .X1..--- .------•--------------•--- --•Leoe' Date Application Disapproved for the following reasons---------------•-•-•---•-•-•---------•----•----------------•---•----............................................ ---------------------------------------------------------•-••---------------------------------•-------------•-•-•-----•-•-------•---••-----.._•..-------••-•••------------....-•---- ------•------- Date PermitNo.......................................................-- Issued_..................- ................................ Date {� F77 NO.. Fims..........................._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r'• ................... ...--...---....O F..........................._.--...........---••-----.....----------.....................•- Appfiration for U44pooal Works Tonatrurtion thrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at. L� VS .f S [ Location Address l P� t No ......................b ..+1 l3 Q _�! i j :........................0........- ._ � `• !o" ,/ + Owner a -! ..... moress - - - ---------------•- . .............................. Installer Adess d feet Type of Building Size Lot...........................S q. Dwelling—No. of Bedrooms._ :...................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ..-_____-_-_•______________ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures --------------- - W Design Flow.......job. _......._._.gallons per person per day. Total daily flow.... �.__.•..................gallons. WSeptic Tank—Liquid capacity6t04---gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.......-...-.-._... Total leaching area............_......sq. ft. Seepage Pit No.........l---------- Diameter..../P......... Depth below inlet--- ............ Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by........-••••••••------•••.......................•-•----•----•--•--•--... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ...........................----- . ---•--•-----. •------••--•-- O Description of " _..� - .e. ...V I'll ................... _._ W UNature of Repairs or Alterations—Answer when applicable._.__........................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT1,;=. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beev issuftd by tpoebd 4 health. Signed.---•4.•-•-- !f-------------- ---------------------•--•-•-------•--------- ................................ ' ` 2 .....r Dat , Application Approved By- .- :. s._... .................. D�-�......---- Application Disapproved for the following reasons:.....................-------------•----•-•-•-•---••--•-•-----•-----------------------•--••----•-------........_ ----•-.........-•---•---•----------------•---------•---•------------•--.......------•----------------•••.--•-••......._...-••-----••--------•-•-•---------•-----•-•------•--••------------••----•-----•- Date PermitNo-------------------------------------------------------- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS t BOARD OF HEALTH ..........................................OF...................................................................................... T rtif iratr of Tanutpliatto THIS IS TO CERTIFY,That the In vidual Sewage Disposal System constructed ( ) or Repaired ( ) by------------•------- -a/- !rC:'-.... . � � . -...1...... -----•----------•........ .:........................................... ......... ------- kstall `, at................ l o� ;r- L�.J-414�3i 4 r�? f1 l4! ................................ .r has been installed in accordance with the provisions of TILUZ 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No..... :":._>. ............... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM 1lAlIL6 FUNCTION iSFA�TORY. DATE....................................... .. ...11.4 ........... Inspector...-------i�---•----------............................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �} OF............................................•---..................................... No. ..... FEE..: ................ orkao o#rrt' n rrntit Permission as hereby granted---------�---�!I�= --I4............. ---•-----------------------------•-------..........................._ to Construct ( ) or Repair ) ap Individual Se,, e D�' sal yY�tem, at No.• a-1` l4!. .Ci....... �F`f-.._._ ' r__f ' -•----------------------------------- Street as shown on the application for Disposal Works Construction Permit No Dated ...................................... . / $tea d of Health DATE............... . FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ZHU MURES NPR RESIDENTIAL CONSTRUCTION 15 INDEPENDENCE WAY CUSTOM HOMES DENNIS VILLAGE MASSACHUSETTS 02638 617 - 385-8762 February 24, 1982 Tina. Erbaftna 48 Anthony- Urcle NewtonvVile, MA 02.160 We agree not to occupy the house until town water 1-& hooked up.. 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