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HomeMy WebLinkAbout0055 HILLTOP DRIVE - Health 55 HILLTOP DRIVE, MARSTONS MILLS A=077-019 J. i� o77 - 619 Commonwealth Of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 2> Property Address Owner Owner's Name M.information is p., required for every a', hS page. City/Town State Zip Code Date of Ins ection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information. filling out forms on the computer, G.J use only the tab key to move your 1. Inspector: cursor-do not Q ✓ use the return l�Y zo /I ,e- key. Name of Inspector rm Company Name /jI0 City/TowLSD -F) State Zip Code �oa?TelephoneNumber License Number B. Certification i certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I an a DEP approved system inspector pursuant to Section '1 5.340 of Title 5 (310 5.000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspector s Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board t of Health or DEP)within 30 days of completing this inspection. If the system 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. t5i6s.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface sewage Oisposai system•Page 1 of 17 1 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M S-) 11111- o e0� Property Address Owner �✓) Owner's Name information is required for every Q rs 0 S /�'/)! -s page. Clty/Town State Zip Code Date of I specti B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System sses: 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.doc-rev.6/16 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M Property Address Owner T- Owner's Name information is / required for every e2YT4A?_C 1411, page. City/I own 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 ❑ I'J ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 CNIR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: El 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System 1Form -Not for Voluntary Assessments b �� l/I•I lI` // Property Address / // �R�///✓ Owner Owner's Name information is /required for every23Nn page. CitylTownDate of I'spectio 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 weli. ❑ 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 ❑ tatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments SS M Property Address Owner ' information is Owner s Name required for every page. City/Town State Zip Code Date of In pectio 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: ❑ L"J Any portion of the SAS, cesspool or privy is below high ground water elevation. El Any portion of cesspool or privy is within 100 feet of a surface water supply or ❑ 5tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ice' ny portion of a cesspool or privy is within 50 feet of a private water supply well. P PP Y ❑ 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.] ❑ 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Fo m -Not for Voluntary Assessments Ht i// Property Address Owner f i'�1 1 Owner's Name information is required for every A airfide page. Cityl I own State Zip �Dao Inspe ion C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes ❑ mping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ❑ as 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 his inspection? Were as built plans of the system obtained and examined? (If they were not available note as N/A) as 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? 0 Was the facility owner(and occupants if different from owner) provided with info rmation on the proper maintenance of subsurface sew �P P age 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): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form /- Not for Voluntaryy Assessments � Property Address VS Owner Owner's Name information is ✓'/� a 6 �� vrequired for every ✓�f ,/ C3 page. City/Town State Zip Code Date of Insp ction D. System Information Description: / /SbO 112 s�� a a Number of current residents: Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes No Laundry system inspected? ❑ Yes P—No— Seasonal use? ❑ Yes N-o Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes No Last date of occupancy: C Date Commercial/Industrial Flow Conditions: Type of Establishment: Y Design flow(based on 310 C M R 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts f Title 5 Official Inspection Form aS Subsurface Sewage Disposal: System/F/orm -Not for Voluntary Assessments Property Address HI 012 Owner Owner's Name information is �r6�OK // /,'l 0)b 7 a C required for every J page. City/Town State Zip Code Date of In pecti n D. System Information (coot.) Last date of occupancy/use: Date Other(describe below): Genera, Information Pumping Records: _ Source of information: (� -elf,. (.� ✓ Was system pumped as part of the inspection? ❑ Yes Vo If yes, volume pumped: gallons How was quantity pumped determined? --- ------- - -- Reason for pumping: Type of Sys . Septic tank, distribution box, soil absorption system LJ 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.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address �/ Owner " ' �� "rf Owner's Name information is / required for every G�/s`�O0 // page. City/Town State Zip Code Date of Ins ection D. System Information (cont.) Approximate age of all components, date installed (if known)and �source Pf information: �1� Were sewage odors detected when arriving at the site? ❑ Yes lil-No Building Sewer(locate on site plan): Depth below grade: feet Material of constructi;r40 : ❑ cast iron PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below e: feet Mated of construction: concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(exp!ain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: C; t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal Syst m Form Not for Voluntary Assessments S5 /�ll-� D� Property Address Owner /l' 0) 4 Owner's Name information is required for every GY�,S ✓JJ page. City/Town State Zip Code Date of Inspe ion D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle it 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 How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition,, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): g y' lees /0 Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Ss Owner Owner's Name d Q information is �� l_�required for every 7'o SArl//j page. City/Town State Zip Code Date of Ins ectio 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 ElNo 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal Syst m Form - Not for Voluntary Assessments M ss ✓��l Property Address D� Owner Owner's Name ` 4 information is n l/ required for every v1 � r%d b(( e a / page. City/Town State Zip Code Date of In pectio D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): /� Depth of liquid level above outlet invert �4�' Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in�working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No" Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): " If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name L information is Q✓S_I NS 1 //�` b�� c�' O� required for every page. City/I-own State Zip Code Date of Inspe tion Do System Information (cont.) Type. 4 3r00 U �`l(�►� C� ���r 1h-�46�7-e a U_x j �J ❑ leaching pits number: ❑ 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.): Zi 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary/Assessments GM JS Owner Property Address information is Owner's Name / X7 required for every page. City/Town State Zip Code Date of Insp tion Do 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form R Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owners 14 T� information is Owner's Name required for every page. City/Town State Zip Code Date of I pecti D. System Information (coat.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate ;Znd-sketch ublic water supply enters the building. Check one of the boxes below: in the area below ❑ drawing attached separately -------------- ��a�✓T - y9 8 - 3 O 4 ,P7�A-6r' I t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal S77M of for Voluntary Assessments Tom' �✓ Property Address J Owner Owner's Name information is required for every �S nJ S page. CitylTown State Zip Code Date of In pection Do System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 0 Estimated depth to high ground water. -- — feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date El Observed site (abutting property/observation hole within 150 feet of SAS) with local Board of Health -explains: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation:0ov fit v`Gvac'GW �v ! ) -t/- — /o,,,v, (.✓F' . tq C-�Le Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System F rm -Not for Voluntary Assessments Hroperty Address Owner Owner's Name Y'I information is required for every y(.Jr j4 page. City/Town State Zip Code Date of I spection E. Report Completeness Checklist Znspection ction Summary:A, B, C, D, or E checked Summary D(System Failure Criteria Applicable to All Systems)completed stem Information —Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 'J t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 f 1 TOWN OF BARNSTABLE 00C' ATION `r�/y/G�To� gf ,:Z SEWAGE# VIL•LAGE,. jf ,*,J,' ?/44ASSESSOR'S MAP&PARCEL -� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type)%G.-6fA- NO.OF BEDROOMS 3 OWNER I-A /✓ PERMIT DATE: /e2/3,/%2_ COMPLIANCE DATE: Separation Distance Between the: ��p Ar-54-Ir�� Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility oa 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) Z Feet FURNISHED BY 'Paz 2w B S � o � �i3Ti�'� oroo 6'AC. e1/w ::r. ��11� �. -> �`ors �r����'/✓ C���4L 6�T� erg C14 TOWN OF BARNSTABLE LOGkTTON 10D I SEWAGE # VILLA GE a,^ L� S T� 144c I/S ' ASSESSOR'S MAP&LOT INSTALLER'S NAAM&PHONE NO. SEPTIC TANK CAPACITY LEACFitNG FACILITY:( ) �� / 7 / `►�' (size) 3 NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPL.IAAiCE DATE: - Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility. F@et -Private Water Supply Welland Leaching Facility (If any swells exist on site or within 200 feet of teaching facility) I Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of teaching f lity) Feet Furnished by 0 (� 6 C 33 ' 1 5' �7 No. O 2- J � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in comp ter: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZippliCation for Mispo8al Opstem ConstCUttion VPrmit Application for a Permit to Construct Repair U rade Abandon( ) ❑Complete System Individual Components PP ( ) P (�Pg ( ) Location Address or Lot No. �`S'/7�lLL/'�opo 49> Z Owner's Name,Address,and Tel.No. Assessor's Map/Parcel '� 9 Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building �'�� No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date / c�- �� Number of sheets Revision Date Title Size of Septic Tank �X/�/'�/ dl— ,",o o® 6/4 yPe of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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. ign Date Application Approved by Date z VVIT Application Disapproved b Date for the following reasons Permit No. O! Z — G 7 Date Issued 2 t No. (�_ ) a __ 4 r N-•t, Fee r THE COMM'QNWEI&LTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2pplication for 30isp' oral *pstrm (construction permit Application for a Permit to Construct( ) Repair(k,Upgrade( ) Abandon( ) ❑Complete System XIndividual Components Location Address or Lot No. s"�/!�/ELh'd� ® Q , Owner's Name,Address,and Tel.No. Assessor's Map/Parcel /9 o#V7 600w `�'� 7 J`./� O` !/`/A101 Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel:No. ��/mil G c�'+�o E'��' 77 s' 0 7v7 �'`'�.d � .�',af✓'�3 6'�/�/� Type of Building: Dwelling No.of Bedrooms -3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building �'C'�f No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 ® gpd Design flow provided I gpd Plan Date 00t-Z Number of sheets Revision Date Title ,.,�� Size of Septic Tank G!`X/✓'�i.✓ � /o 0 o ape of S.A.S. j- Description of Soil Nature of Repairs or Alterations(Answer when applicable) J 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. ign d Date Application Approved by Date 2 Application Disapproved by Date i for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( 10/) Upgraded( ) Abandoned( )by C3r;o'A1;1? E"4oc_ J'�, Dtr✓�-oG J� e�'L, at S$'� �/L �©® ,jj pt has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. P I� �3 dated `2- Installer �/ rn L�Q�'OE Designer 0,4`/1> $ #bedrooms Approved de ' flow �J� gpd r The issuance of this permit sha 1 not b construed as a guarantee that the system will fu ct de 'g ed. Date Inspector 8 .... _ - _.. .. _- 7 _. pp _ ___________ __________ No. D Q (� - J..O.7 Fee / 6 0 , THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Bisposal 6pstera Construction nffmit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at r /G TOf/ 17J sd►,7 , and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construct*on7ust be completed within three years of the date of this permit. Date 2 ) Approved by r Town of Barnstable Regulatory Services Thomas F.Ceiler,Director public Health Division fn r�a Thomas McKean,Director 200 Malin Street, Hyannis,MA 02601 Office: 508- 62-4644 Fax: 508-790-6304 Date: lz 2" Sewage Permit# `' "` 3�',� Assessor's Map/Parcel Installer&Designer Certification Form Designer: �r, l—Dj, Y-� ,7�,. Installer: Address: [ ` 5AtJDW1(4 Address: tr.ZLS On was issued a permit to install a (installer) septic system at ✓v !,(�'ir�� �/�. based on a design drawn by (address) t� L► -11 12& dated �]'Z (designer) -Al certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any compnt of the septic system) but in accordance with State &Local p ''bons. Plan revisionone or certified as-built by designer to follow. Stripout (if rP' --cted and the soils were found satisfactory. ZH OF U4s a DAVIIJ �y �— (Installer's S g nature) MASON 0 9 No.1066 o c� (Design s Signature) 4 PLEASE RETURN TO BARNSTABLE PUBl,.- ��fE OF COMPLIANCE WILL NOT BE ISSUED UN i iL xsc�i tt t rus YORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC FLEALTH DIVISION.THANK YQU. q;\office formsktesipereertification fonn.doc ,ttt= Town of Barnstable P# J 1l9�' Department of Regulatory Services Public Health Division �I NAM 200 Main Street,Hyannis MA 02601 Date r i • Date Scheduled =— Time 'Fee Pd. Soil Suitabi ty.AsSeSsment•f' or Sewage 4is,�osal Performed By: • k5s Witnessed By: LOCATION&GENERAL Location Address S S`l% o INFORMATION Owner'sName,,� O clU��fy��~. Address ���oX —t o o . Assessor's Map/Parcel: 1:::1�� o 9 ��6=J'ZA,j-.6 6f,4 Engineer's Name,,!��U� NEW CONSTRUCTIO R ABt Telephone# 3 6-7 /6 j Land.Use Slopes(%) Surface Stones Distances from: Open Water Bod ' Y _ft Possible Wet Area' r i t R Drinking Water Well ft Drainage Way___ft Property Line K Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes 8c Pere tests,locate wetlands?n proximity to holes) 4 �. r^- + Parent material(geologic) `r Depth to Bedrock Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater Method Used: DETERMINATION FOR SEASONAL HIGH WATER TABLE Depth Observed standing in obs.hole.- Depth to weeping from side of obs.hole: in. Depth to soil mottles: in• Index Well# Reading Date:' Index Well IL In, Groundwater AdJustment F .� AaJ,factor Adj.Groundwater Level_ . Observation PERCOLATION TEST bate Time Hole# ; ime at 91, _ -- Depth of Pere ' Time at 6" Start Pre-soak Time @ Time:(9"-6") End Pre-soak Rate Min./Inch U.^►�' �� ° Site Suitability Assessment: Site Passed Site•Failed: Additional Testing Needed(Y/N) Origfinal: Public Health Division Observation Hole Data To Be:Completed on Back----------- percolation test is to be copducted within 100'of wetland;you must first notify the ` Barnstable Conservation Div> ion,at least one(1) week prior to;beginning, b Q:ISEPTICIPERCFORM.DOC i 3 1 i DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil her Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. o i to c % ravel It DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(inj (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) t 1 DEEP OBSERVATION HOLE LOG Hole#; a Depth from Soil Horizon Soil Texture Soil Color Soil Other ' Surface(in.) t (USDA), (Munsell) Mottling 1(Structure,'Stones,Boulders.\ Consistency, o Grave T 4 • DEEP OBSERVATION HOLE LOG Bole Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA), (Munsell) Mottling (Structure,Stones;Boulders. Consi ten _. i Flood Insurance Rate Map: Above 500 year flood boundary No 1"- . Within 500 year boundary No Yes Within L00 year flood boundary No Yes ��'• r , �itr :t , Depth of Naturally Occurring Pervious Material -1 ► i.j f '". � " Does at least four feet,of naturally occurring perv'q material exist in`all areas observed throughout the Area proposed for the.soil absorption system? %`I a)k k: ? If not,"what is the dept of turally occurring per Tow- If material? Certification 1 I certify that on V (date),I have passed the soil evaluator examination approved by the Department of Enviroi m al ro ion and that the above analysis was performed by me consistent with ' the requi at ,exp e n e p fence described in 310 CMR 15.t017. Signature 2. Date ` Q:\SEPTICIPBRCFORM.DOC Commonwealth of Massachusetts T Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4�M , 55 Hilltop Dr - Property Address OCWEN Owner Owner's Name information is required for Marstons Mills MA 02648 9-30-08 .. every 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. A. General Information 1. Inspector: Shawn Mcelroy 0-7- C ` ` Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 Co City/Town State Zip Code 1-508-495 0905 S13971 c-� Telephone Number License Number t `71 Ga tZ. B. Certification .. CD I certify that I have personally inspected the sewage disposal system at this addre s and tMt the/; information reported below is true, accurate and complete as of the time of the ins ection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340.of Title 5 (310 CMR 15.000).The system: i ® -Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further EvqMation by the Local Approving Authority 9-30-08 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 copieSsent 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. System is in good working order. Recommend pumping now and every 2 yrs for maintenance. t5insp•03/08 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 t Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 55 Hilltop Dr Property Address OCWEN Owner Owner's Name information is required for Marstons Mills MA 02648 9-30-08 every page. City/Town State Zip Code Date of Inspection 4 ' r B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no,or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined,"please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high'static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health):. ❑ broken pipe(s) are replaced ❑ obstruction is removed t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 'I a K N, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 55 Hilltop Dr Property Address OCWEN Owner Owner's Name information is required for Marstons Mills MA 02648 9-30-08 ' every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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: 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. e—.❑= The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Y Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 55 Hilltop Dr Property Address OCWEN Owner Owner's Name inform ation is required for Marstons Mills MA 02648 9-30-08 every page. City/Town State Zip Code Date of Inspection B. Certification cont. C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 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 E ® Liquid depth in cesspool is less than 6"below invert or available volume is less than '/ day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. t5insp-03/08 _ Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 16 { Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Hilltop Dr Property Address OCWEN Owner Owner's Name information is required for Marstons Mills MA 02648 9-30-08 every page. City/Town State Zip Code Date of Inspection I B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ -, ❑ the system is within 200 feet of a tributary to a surface drinking water supply El system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone 11 of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "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. t5insp•03/08 - - - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM ' 55 Hilltop Dr Property Address OCWEN Owner Owner's Name information is required for Marstons Mills MA 02648 9-30-08 every 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? 0 ❑ ' Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp-03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Hilltop Dr Property Address OCWEN Owner Owner's Name information is required for Marstons Mills MA 02648 9-30-08 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 08 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) sr 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 'y Water meter readings, if available: Last date of occupancy/use: Date ' Other(describe): t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 ' Y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form =Not for Voluntary Assessments M 55 Hilltop Dr Property Address OCWEN Owner Owner's Name information is required for Marstons Mills MA 02648 9-30-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: N/A Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under.contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): ' Approximate age of all components, date installed (if-known) and source of information: 1996 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp•03/08 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Hilltop Or Property Address OCWEN Owner Owner's Name information is required for Marstons Mills MA 02648 9-30-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 24 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints,venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): 18" 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: 1500 Gal ' Sludge depth: 12" Distance from top of sludge to bottom of outlet tee or baffle 20 2" Scum thickness Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape t5insp 03/08 - - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary'Assessments 55 Hilltop Dr Property Address OCWEN Owner Owner's Name information is Marstons Mills MA 02648 9-30-08 required for every 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.): Tank is in good condition with all baffles installed. Recommend pumping for solids. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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): t5insp-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 55 Hilltop Dr Property Address OCWEN Owner Owner's Name information is required for Marstons Mills MA 02648 9-30-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) 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.): I Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , M 55 Hilltop Dr Property Address OCWEN Owner Owner's Name information is required for Marstons Mills MA 02648 9-30-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System,(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 3-Infiltrators ❑ 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.): Visual inspection of infiltrators show they are in good condition with no sign of back-up. t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 112 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Hilltop Dr Property Address OCWEN Owner Owner's Name information is required for Marstons Mills MA 02648 9-30-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): t5insp•03/08 . Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts " Title 5 Official Inspection Form Subsurface Sewage Disposall System Form -Not for Voluntary Assessments 55 Hilltop Dr Property Address OCWEN Owner Owner's Name information is Marstons Mills MA 02648 9-30-08 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) ' 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. � a U b E d-O-Y9' Q--D_do. ❑F -F-b 9-F- 33' 6-6- 97' t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 r Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Hilltop Dr Property Address OCWEN Owner Owner's Name information is required for Marstons Mills MA 02648 9-30-08 every 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: 20. feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: Original design plans show no water at 10'. t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 i ,per COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION s` RECEIVED MAY 2 9 2001 TOWN OF BARNSTABLE TITLE 5 HEALTH DEPT. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 55 Hilltop Dr. Marstons Mills Owner's Name: Robert Gonnella Owner's Address: P O Box 772 Osterville MA Date of Inspection: Name of Inspector: (please print) Wi 1 1 i am _ • Robinson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville, MA Telephone Number: (508) 775-8776 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section.15.340 of Title 5(310 CMR 15.000). The system: /Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Z J2 Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of HeaRh,,or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page 1 r Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS ,.SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 55 Hilltop Dr. MargtnnG Mi11g Owner: Date of Inspection: 6 — Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sys m Passes: ave not found an information which indicates that an of the failure criteria described in 310 CMR Ih y y 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 reps' ed.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answ r yes,no or not determined(Y,N,ND)in the for the following_statements.If"not determined"please expla, . The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unso d,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the exis ing tank is replaced with a complying septic tank as approved by the Board of Health. *A etal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance in cating 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 ob cted pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with app oval 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 p s inspection if(with approval of the Board of Health): broken pipe(s)are replaced obsnuction is umoved ND explain: Page 3 of l I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: _ 55 Hilltop Dr. Marstons Mills Owner: Gonnel la Date of Inspection: —6 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 fail' g to protect public health,safety or the environment. 1. yytem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the ystem 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 T- 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 s stem is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more front 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: 3 Page 4 of 11 s OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 55 Hilltop Dr. Mar-stOwner: Gonne la Date of Inspection: ,S—/6 D System Failure Criteria applicable to all systems:. Yo 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 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. 7nYes/No) 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 coliform bacteria and volatile organic compounds indicates that the well isfree 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.] 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 a considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gp Yo must indicate either"yes"or"no"to each of the following: ( e following criteria apply to large systems in addition to the criteria above) .ye 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 . f 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 ignificant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 5.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 55 Hilltop Dr. Marstons Mills Owner: Gnn n A l la Date of Inspection: S-I b 6 "0 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 7 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: Yes ,no 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(3)(b)] 5 Page 6 of l l ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 55 Hilltop Dr. Marstons Mills Owner: Gonne l l a Date of Inspection: 12�—/ 0—0 1 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): -3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):,�L 6 Number of current residents: _ Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):A.o[if yes separate inspection required] Laundry system inspected(yes or no)A/0 Seasonal use:(yes or no): ki o Water meter readings, if available(last 2 years usage(gpd)): 2000 89,W gal. Sump pump(yes or no):/—0 1999 82,000 gal. Last date of occupancy: 6/6-D j C MERCIAL/INDUSTRIAL Type of establishment: Desi n flow(based on 310 CMR 15.203): gpd Basi of design flow(seats/persons/sgft,etc.): Gre a trap present(yes or no):_ Ind trial waste holding tank present(yes or no): No sanitary waste discharged to the Title 5 system(yes or no):_ W er meter readings,if available: L t date of occupancy/use: HER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): o2 If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE F SYSTEM _ eptic 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 o information: l� �r6 46J� �� Were sewage odors detected when arriving at the site(yes or no)./C U 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 55 Hilltop Dr. Marstons Mills Owner: Gonnella Date of Inspection: "-I G-0 t B LDING SEWER(locate on site plan) Dep below grade: Mate 'als of construction:_cast iron _40 PVC_other(explain): Dis ce from private water supply well or suction line: Co ents(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: (locate on site plan) Depth below grade: f Material of construction:_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) a Dimensions: 6 A (o ­�' 1 U Sludge depth: L/ ro L ' ° y Distance from top of sludie to bottom of outlet tee or baffle: Scum thickness: ,7-`I ' o Distance from top of scum to top of outlet tee or baffle: is Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: 0l�- Comments(on pumping recommendations,inlet and outlet tee or baffle.condition,structural integrity,liquid levels as related to outlet invert,evidence of.leakage,etc.): cS a la C S is/Z i j S' LC A ft- / 60 G AL ? Yee G ASE TRAP:_(locate on site plan) Dep below grade: Mate 'al of construction:_concrete_metal_fiberglass polyethylene_other (exp in): " Dim nsions: Scu thickness: Dis nce from top of scum to top of outlet tee or baffle: Di nce from bottom of scum to bottom of outlet tee or baffle: D to of last pumping: mments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels s related to outlet invert,evidence of leakage,etc.): 7 Page 8 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 55 Hilltop Dr. Mars on-, Mi11G Owner: Date of Inspection: - © 1 TI HT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Dep below grade: Mater 1 of construction: concrete metal fiberglass polyethylene other(explain): Dimen 'ons: Capaci gallons Design low: gallons/day Alarm resent(yes or no): Alarm evel: Alarm in working order(yes or no): Date o last pumping: Co ents(condition of alarm and float switches,etc.): DISTRIBUTION BOX: Z(if esent must be o ened)(locate on site plan) P Depth of liquid level above outlet invert: G7 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.): PU P CHAMBER: (locate on site plan) Pu ps in working order(yes or no): Al s in working order(yes or no): C mments(note condition of pump chamber,condition of pumps and appurtenances,etc.): i 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 55 Hilltop Dr. Marstons Mills Owner- Gonnella Date of Inspection: 5•-l o— 6-J SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type—; . eaching pits,number: A( 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.): CES OOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Numbe and configuration: Depth— op of liquid to inlet invert: Depth o solids layer: Depth of1scum layer: Dimensions of cesspool: Material of construction: Indicatiol i of groundwater inflow(yes or no): Commen s(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): t PRIVY (locate on site plan) Matey' Is of construction: Dime sions: Dep of solids: Co ents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): k 9 Page 10 of 11 ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 55 Hilltop top Dr_ MarGtnnc Mill ,-, Owner: GpnnP1 1 a Date of Inspection: 5-1 6—U 3 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. D� i 3.3 4 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 55 Hilltop Dr_ Marstons Mills Owner: Gonnella Date of Inspection: S'!o SITE EXAM Slope Surface water Check cellar Shallow wells x Estimated depth to ground water;1-9 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: /Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Lox- WI a 3 Checked with local excavators,installers-(attach documental on) Accessed USGS database-explain: You must describe how you established the high ground water elevation: d 1.1 1 11 TOWN OF BARNSTABLE LOCATION J !7j�� P' PA CATION SEWAGE # !(CRQ VU',LAGE ASSESSOR'S MAP & LOTS 7�°2.�,(9 INSTALLER'S NAME&PHONE NO. 01f- 2o6nSor1 ' SEPTIC TANK CAPACITY fS00 (c .N LEACHING FACILITY: (type) e-©' Vo1- q&1y1� (size) /Q`Z 5-- Y NO OF BEDROOMS BUILDER OR OWNER`- PERMIT DATE: � COMPLIANCE DATE: y Separation Distance Between the: + Maximum Adjusted Groun water Table and Bottom of Leaching Facility Feet Private Water Supply Well Leaching:Facility (If any wells exist "'vi on site or within 200 feet o eaching facility) `r Feet Edge of Wetland and Leaching cility(If any wetlands exist within 300 felet,of leaching ffaaci y) Feet Furnished by t,� _ G I 9 An r No. Fee50 . 00 s THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pphratton for Wgpool Opgmem Cow6truction Permit Application is hereby made for a Permit to Construct( )or Repair(x )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. A r g o n e Properties 55 Hilltop Dr Marstons Mills P.O. Box 772 Assessor's M Osterville 428-5563 Installer's Name,Address,and Tel' No. Designer's Name,Address and Tel.No. W.E. Robinson Septic Sery P.O. Box 1089 Type of Building: Dwelling No.of Bedrooms 3 Garbage Grinder(no 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 Description of Soil sand Nature of Repairs or Alterations(Answer when applicable) install 1 500 a l tand-box 3 #330 high capcity stonenacked infiltrators. 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 thi Board of Health. n Signed Date �7 Application Approved by Date Application Disapproved for the following reasons Permit No.��� G� Date Issued Fee` Y THE CO MONWEALTH OF MASSACHU ETTS � 'N,j- ' • PUBLIC HEALTH DIVISIOYN � ( N O B&RN,STABL,-- MAS8ACHI�7!9 2p4prication for Mi4ogar Construction Application is hereby made for a Permit to Construct( )or Repair(x)an On-site Sewage Disposal.System at: f . Location Address or Lot No. #A ` Owner's Name,Address and Tel.No. Argone Properties 4 55 Hilltop Dr Marstons Mills P.O. Box 772 Assessor's Map/Parcel ,Osterville 428-5563 Installer's Name,Address,andTef No. �esigner's Name,Address and Tel.No. W.E. Robinson Septic Sery P.O. Box 1089 Type of Building: Dwelling No.of Bedrooms 3 Garbage Grinder(nq 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 I' Description of Soil sand Nature of Repairs or Alterations(Answer when applicable) install 1 ,500 cral tamk d—box & 3 #330 high capcity stonetaacked infiltrators. —r4 Date last inspected: f" i • 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 this Boar of Health. {/1 Signed ' Date �y Application Approved by Date /A- Application Disapproved for the following reasons `f Permit No.9�. /�1 Date Issue Argone Properties THE COMMONWEALTH OF MASSACHUSETTS may' BARNSTABLE, MASSACHUSETTS Certificate of Compliance , THIS IS TO CERTIFY,that the On-site Sewage Dispo�sal System installed( )or repaired/replaced(x)on by Installer tiJ.E. Robinson Septic Sery ; at �� op r ars ons Mills f has been constructed in accordance with the provisions of Title 5 and the for Disposal System Constructi '`Pe t No. dated Date 9,4-0' Inspecto THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE+?THAT THE SYS- TEM WILL FUNCTION SATISFACTORY ————— — ————————— -- ----------- 50.00 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Argone Properties PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migaar *potem Conotruction Vermit Permission is hereby granted to W.E. Robinson Septic Service to construct( )repair(x )an On-site Sewage System located at No.# 55 Hilltop Dr Marstons Mills Street and as described in the above Application for Disposal System Construction Permit. YZ No. Date The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction/must be completed within three years of the date below. Date: !'"'-. � Approved by �'----� Board of Health • a CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I,William E. Robinson, Sr.,hereby certify that the application for disposal works construction permit signed by me dated ci L, ,concerning the property located at 55 Hilltop Drive,Marstons Mills, meets all n of the following criteria: t * There are no wetlands within 300 feet of the proposed septic system. t * There are no private wells within 150 feet of the proposed septic system. * The obseved groundwater table is 14 feet or greater below the bottom of the leaching facility. * There is no increase inflow and/or change in use proposed. * There are no variances requested or needed. SIGNED: / DATE " LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 42 (Attach a sketch plan of the proposed system. Also if the licensed installer proposes a certification plot plan,this plan should be submitted). �s C 1 L-L-L 1 y I l .. J Z:, 348. 659 946 Receipt for Certified Mail 0 No Insurance Coverage Provided ur DWAnS Do not use for International Mail PO sERME (See Reverse) S n . 0) L St 2 ✓ ✓ P.91,.fe 7. 41P Code O C Postage Go M E Certified Fee O LL Special Delivery Fee CO 4. !Fyn t'r'ict'L&,Ly Del1Ve6y Fie �R�t3+'rS'f�eceij5tt Stio'1n�iVig'1 4 to�WYiom&Date Delivered Return Receipt Showing to Whom, Date,and Addressee's Address TOTAL.Postage &Fees Postmark or Date �� 59� STICK POSTAGE STAMPS TO ARTICLE TO COVER FIRST CLASS POSTAGE, CERTIFIED MAIL FEE,AND CHARGES FOR ANY SELECTED OPTIONAL SERVICES(see front). a 1. If you want this receipt postmarked,stick the gummed stub to the right of the return address I� leaving the receipt attached and present the article at a post office service window or hand it to your rural carrier(no extra charge). 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the return rn address of the article,date,detach and retain the receipt,and mail the article. t 3. If you want a return receipt,write the certified mail number and your name and address on a return receipt card,Form 3811,and attach it to the front of the article by means of the gummed m ends if space permits.Otherwise,affix to back of article.Endorse front of article RETURN RECEIPT REQUESTED adjacent to the number. 0 00 4. If you want delivery restricted to the addressee,or to an authorized agent of the addressee, Cl) endorse RESTRICTED DELIVERY on the front of the article. 5. Enter fees for the services requested in the appropriate spaces on the front of this receipt.If ti return receipt is requested,check the applicable blocks in item 1 of Form 3811. d 6. Save this receipt and present it if you make inquiry. 105803.93-13-0218 Town of Barnstable � Department of Health, Safety, and Environmental Services �B"M&M Public Health Division i639 1 367 Main Street, Hyannis MA 02601 Office: 508-790-6265 Thomas A McKean FAX: 508-775-3344 Director of Public Health November 5, 1996 Mr. Robert J. Gonnella P.O. Box F Osterville, MA 02655 NOTICE TO ABATE VIOLATIONS OF 310 CMR: 15.00 THE STATE ENVIRONMENTAL CODE TITLE V• MINIMUM REOUIREMENTS FOR THE SUBSURFACE DISPOSAL OF SANITARY SEWAGE, AND 105 CMR 410.00 STATE SANITARY CODE H - MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION. The property owned by you located at 55 Hilltop Drive, Marstons Mills, listed as Parcel 19 on Assessor's Map 77 was inspected on November 1, 1996 by Jerry Dunning, Health Inspector for the Town of Barnstable, because of a complaint. The following violation of 310 CMR 15.00, the State Environmental Code, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage and 105 CMR 410.00 State Sanitary Code II- Minimum Standards of Fitness for Human Habitation was observed: REGULATION 310 CMR 15.02 (207)AND 105 CMR 410.300: Overflowing sewage onto the ground. This violation is a serious public health hazard. 1) You are directed to hire a licensed septage hauler to pump the overflowing cesspool within twenty-four(24) hours of receipt of this letter. 2) You are also directed to keep the on-site sewage disposal system pumped as many times as necessary to keep from overflowing onto the ground. 3) You are further directed to contact and hire a licensed Disposal Works Installer within seven (7) days of receipt of this letter in order to repair this system or connect to town sewer. You may request a hearing before the Board of Health if written petition requesting same is received within seven O days s after the date the order is served. Non-compliance could result in a fine of up to $500.00. Each day's failure to comply with an order shall constitute a separate violation. y F HE BOARD OF HEALTH as A. McKean Director of Public Health ] PAR ] Real Estate System - General Property Inquiry] Help [ ] Parcel Id: 077 019- - Account No: 39906 Parent : Location: 55 HILLTOP DR Neighborhood: 12DC Fire Dist : CO Devel Lot : 11 Lot Size : . 23 Acres Current Own: GONNELLA, ROBERT J State Class : 101 PO BOX F No. Bldgs : 1 Area: 1200 Year Added: OSTERVILLE MA 2655 Deed Date : 120186 Reference : 5464/021 January 1st : GONNELLA, ROBERT J Deed MMDD: 1286 Deed Ref : 5464/021 Comments : Values : Land: 18600 Buildings : 68800 Extra Features : Road System: 55 Index: 719 (HILLTOP DRIVE ) Frntg: 90 Index: ( ) Frntg: Control Info: Last Auto Upd: 050695 Status : C Last TACS Update : 021491 Land Reviewed By: Date : 0000 Bldgs Reviewed By: Date : 0000 Tax Title : Account : Taken: Account Status : Hold Status : Cancel [ ] Press XMT for more data Next screen [PAR ] Action [ ] Owners Name [ ] Road Index [ ] Road Name [ ] Parcel Number [077] [020] [ ] [ ] [ ] Y NOTICE TO ABATE VIOLATIONS OF 310 CMR: 15.00 THE STATE ENVIRONMENTAL CODE TITLE V: MINIMUM REQUIREMENTS FOR THE SUBSURFACE DISPOSAL OF SANITARY SEWAGE AND 105 CMR 410.00 STATE SANITARY CODE II - MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION. The property owned by you located at 'wry Il r 1�r✓ , listed as Parcels /9 on Assessor's Map 077, was inspected on /1 L _ 1, , 199 , by'; .e �, CJ E, w�,'nr G , Health Inspector for the Town of Barnstable "because of a complaint. The following violations of 310 CMR 15.00, the State Environmental Code, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage and 105 CMR 410.00 State Sanitary Code II - Minimum Standards of Fitness for Human Habitation were observed: REGULATION 310 CMR 15.02 (207) AND 105 CMR 410.300: Overflowing sewage onto the ground. This violation is a serious public health hazard. 1) You are directed to hire a licensed septage hauler to pump the overflowing cesspool within twenty-four (24) hours of receipt of this letter. 2) You , are also directed to keep the on-site sewage disposal system pumped as many times as necessary to keep from overflowing onto the ground. 3) You are further directed to contact and hire a licensed Disposal Works Installer within seven (7) days of receipt of this letter in order to repair the system. You may request a hearing before the Board of Health if written petition requesting same is received within seven (7) days after the date the order is served. Non-compliance could result in a fine of up to $500.00. Each day's failure to comply with an order shall constitute a separate violation. run onnMa or, wun 80AAo or RMALWO Thomas A. McKean Director of Public Health ASSESSORS MAP 77 NOTES: TEST HOLE LOGS PARCEL : 19 l� 67- FLOOD ZONE: 71 I ��t�''ry�� �� s SOIL EVALUATOR : AV 1) The installation shall comply with Title V and 'Town of Board of WITNESS : W health Regulations. REFERENCE ' 2) The installer shall verily the location of utilities, sewer inverts and septic 2 ? _.T � DATE ��" � O RATE: components prior to installation and setting; base elevations. �i '�'t�'�t. �'` ,� � � PERCOLATION 10 RAT � M��W� 1 CL w� �w 1 ,� . 3) All gravity septic piping to be 4 inch Sch 401'VC at 1/8"per loot. 'I'l e first. 46AA \,9 114\ / ",ILI d.AAA Rf two feet out of the d-box to the leaching shall be level. TH- I TH-2 4) This plan is not to be utilized for property like determination nor any other Zowtf purpose other than the proposed system installation. t� � 5) All septic components must meet Title V specifications. 6) Parking shall not be constructed over TII0 septic components. 7) The property is bounded by property corners and property Lines. LOCATION MAP L (} ti 8) The property owner shall review design considerations to approve of total �' r design flow and number of bedrooms to be considered for design. Receipt 1 of payment for the plan and installation based on the plan shall be deemed approval of the design flow by the owner. T� I , 9) The existing leaching or cesspools shall be pumped and filled with material �I ? per Title V abandonment procedures. Those within the proposed SAS shall be removed along with contaniinated soil and replaced with clean sand per 60 (�- Title V specs. 10 'S stem components to be 10 feet from water line. Sewer lines crossing the ,w l; water line shall be sleeved with 4 inch SCI140 PVC with ends grouted if applicable. The proposed SAS is being installed below the water service pp P p g S E P T I C SYSTEM DESIGN line. The line is to be sleeved as alorementloned and maintained in place. 11) If a garbage grinder exists it is to be removed and is the responsibility of the owner to ensure such. ` r k1D F LOW ESTIMATE 12)'The installer is to take caution in excavation around the gas line if such - exists. tp BEDROOMS AT �I� GAL/DAY/BEDROOiA -rGAL/DAY 13)The installer shalL verify,the location, quantity and elevation of the sewer rr Mt o �'' lines exiting the dwelling prior to the installation. M ; CJ SEPTIC TANK 14)This plan is representative only that a system can fit on a property meeting o �� Title V requirements. +'; 1 (( GAL/DAY x 2 DAYS LLD GAL USE ( GALLON SEPTIC TANK (a Cp � _ SOIL ABSORPTION SYSTEM � ,��H p� DAVID _— B. Tq 2-X (G,��+2'�5' X e J a _ v SIDE AREA: � r BOTTOM AREA: PTIC SYSTEMSECTION ----- -- 09 0 wVIC0 l I cy' A �-7 IV I ,�� ;� " err C .. /'� ' _ 2a /COG GAL tL) 6 7 Al SEPTIC TAtJ C �1 �t _ t Q SITE AND SEWAGE PLAN 1 PREPARED FOR : IVa\ s ! P gkW o , SCALE: I r- DAV I D B . MASON �`7 DATE: 1 3 Z DBC ENVIRONMEN�rAL DESIGNS (:AST SANDWICH MA DATE HEALTH AGENT ( 508 ) 833- 2 177 Z f "i—Tr