The URL can be used to link to this page

Home My WebLink About0061 HILLTOP DRIVE - Health 61 HILLTOP DRIVE MARSTONS MILLS -- T A = 077 018 --- - f Commonwealth of Massachusetts _ -=- 7 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 61 Hilltop Drive _Property Address _- Jason Souza Owner Owner's Name information is required for every Marstons Mills V/ Ma 02648 1/21/2021 page. Cityrrown 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. Inspector Information on the computer, use only the tab Raymond Dumas key to move your Name of Inspector cursor-do not Dumas Landscape Const. Inc. use the return key. Company Name r-0. 564 Old Stage Rd. Company Address Centerville, Ma. 02632 &I_yrrmw_n State Zip Code 508-509-0210 S1437 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. 0 Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation,by the Local Approving Authority 4. El Fails 1/12/2021 Inspector's Si nature 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 has a design flow of 101000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DER The original form should be sent to the system owner andcopies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc-rev.7126/2018 Title 5 Official inspection Form:Subsurface Sewage Disposal system-page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 61 Hilltop Drive Property Address Jason Souza Owner Owner's Name information is required for every Marstons Mills Ma 02648 page. CityrFown 1/21/2021 State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: 2) 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): t5insp.doc-rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 61 Hilltop Drive Property Address Jason Souza Owner Owner's Name information is required for every Marstons Mills Ma 0264$ page. City(rown 1/21/202,1 State Zip Code Date of Inspection C. Inspection Summary (Cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber,pumps/alarms not operational. System will pass with Board of Health approval if Pumps/alarms are repaired. ❑ 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): ❑ 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 pipes)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) 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. a. System will pass unless Board of Health determines in accordance with 310 CMR 16.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 61 Hilltop Drive Property Address Cason Souza Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/21/2021 page. City/Town State Zi Code te of P Da Inspection C. Inspection Summary (cunt.} ❑ 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 b. 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. c. Other: 4) 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 t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 16 Commonwealth of Massachusetts P Title 5 official Inspection Form 1Ib Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 61 Hilltop Drive Property Address Jason Souza Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/21/2021 page. Ciiir own State Zip Code Date of Inspection C. Inspection Summary (Cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y 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 water supply 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 2000 gpd- j ❑ ® 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 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. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section CA. 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 1.5insp.doc-rev.7/26Y2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of IS Commonwealth of Massachusetts 0 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 61 Hilltop Drive Property Address Jason Souza Owner Owner's Name information is required forevery Marstons Mills Ma 02648 1/21/2021 page. City/Town State Zi Code Date of Inspe P ction C. Inspection Summary (cunt.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat-, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for af/inspections: 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)] t5insp.doc•rev.7n6f2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 61 Hilltop Drive Properly Address Jason Souza Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/21/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: 1000 gallon septic tank, D-Box and 2 500 gallon leaching chambers as per permit on file dated 11/7/2000 Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: 2020 33000 gallons, 2019 23000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: Occupied now Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sews Disp osal posal System•Page 7 of 18 Commonwealth of Massachusetts (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 61 Hilltop Drive Properly Address Jason Souza Owner Owner's Name information is required for every Marstons Mills Ma 02648 page. city/Town 1/21/2021 State Zip Code Date of inspection D. System Information (cont.) 2. Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No ' If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: 2010 &2015 as per Barnstable Sewage Plant Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 61 Hilltop Drive Property Address Jason Souza Owner Owner's Name information is required for every Marstons Mills Ma 02648 page. cityrrown 1/21/2021 State Zip Code Date of Inspection D. System Information (cont.) 4. 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: 1982 1000 gallon Septic tank, upgrade D-Box and 2-500 gallon chambers Nov 2000 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ®cast iron 2140 PVC ❑other(explain): Distance from private water supply well or suction line: approx 24 ft. feet Comments(on condition of joints, venting, evidence of leakage, etc.): good t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 9 of 18 Commonwealth of Massachusetts �. F Title 5 Official Inspection Form ( w Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I U 61 Hilltop Drive Property Address Jason Souza Owner information is Owner's Name required for every Marstons Mills Ma 02648 page. cnyrrown 1/21/2021 State Zip Code — Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 2 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 gallon Sludge depth: 10" Distance from top of sludge to bottom of outlet tee or baffle 15" Scum thickness 401 Distance from top of scum to top of outlet tee or baffle 6f1 Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? removed cover dip tank with stick Comments(on pumping recommendations, inlet and outlet.tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping is recommended at this time, last um 2015 t57nap.doc•rev.7/2&2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of to Commonwealth of Massachusetts f: (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 61 Hilltop Drive Property Address Jason Souza Owner owner's Name information is required for every Marstons Mills Ma 02648 1/21/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. 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.): 8. 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 t5rnsp doc•rev.7/262018 Title 5 Official Inspection Forth:Subsurface Sewn Disp osal posal System•Page 11 of 18 • Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 61 Hilltop Drive Property Address Jason Souza Owner Name information is owner's required for every Marstons Mills Ma 02648 page. City/Town 1/21/2021 State Zip Code Date of Inspection D. System Information (cunt.) 8. Tight or Holding Tank(cunt.) 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 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert at level Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-Box level and does show some carryover, recommend pumping the septic tank t5insp.doc•rev.7P262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts 6 P Title 5 Official Inspection Form to Subsurface Sewage Disposal System Form -'Not for Voluntary Assessments �i 61 Hilltop Drive Properly Address Jason Souza Owner information is Owner's Name required for every Marston s Mills Ma 02648 page. City/Town 1/21/2021 State Zip-Code Date of Inspection D. System Information (cont.) 10. 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: camera from d-box to chamber, water 18"below invert Type: ❑ leaching pits number: ® leaching chambers number: 2-500 gallon ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Pre cast t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 • Commonwealth of Massachusetts • �. P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �a 61 illtop Drive Property Address Jason Souza Owner information is Owner's Name required for every Marstons Mills Ma 02648 page. City/Town 1/21/2021 State Zip-Code Date of inspection D. System Information (coot.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, vegetation, etc.): condition of all good 12. 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): t5insp.doc-rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts 0 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ®/tl� 61 Hilltop Drive Property Address Jason Souza Owner Name information is Owner's required for every Marstons Mills Ma 02648 page. City/Town State ZipCode 1/21/2021 Date of Inspection D. System Information (cunt.) 13. 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.doc-rev.R2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts (P Title 5 official Inspection Form It Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 61 Hilltop Drive Property Address Jason Souza Owner Owner's Name information is required for every, Marstons Mills Ma 02648 page. Ciiir own 1/21/2021 State Zip Code Date of Inspection D. System Information (cunt.) 14. 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 t5insp.doc-rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 61 Hilltop Drive Property Address _ Jason Souza Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/21/2021 page. City/Town State Zip Code Date of Inspection D. System Information (Cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 12 ft+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: No water at 12' hand auger 5 ft below bottom of leach area Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments F� .. 61 Hilltop Drive Property Address Jason Souza Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/21/2021 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 _TOWN OF BARNSTABLE LOCATION_:1.1 l l,{l a D c�/ SE WACE# 6 6 VILLAGE 12 r iQJ1f : ASSESSOR'S MAP&LOT �—o j1 INSTALLER'S NAME&PHONE NO. 6 ! v SEPTIC TANK CAPACTTY_JOB) LEACHING FACM=:(type) NO.OF BEDROOMS— BUILDER OR OWNER _ )O -4�i�-O PERMITDATE:_k 7 -s COMPLIANCE DATE:/Z= 1—&--,6 Separation Distance Between the: Maximum Adjusted Groundwater Tabl/theB n of Leaching FacilityFeet Private Water Supply Well and LeachIf any wells exist on site or within 200 feu of leachi Feet Edge of Wedand and Leaching Facilitands exist within 300 feet of leaching facility) Feet Furnished by �t 1 I �7 ff i 3 � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in cotnQuter_ ~ PUBLIC HEALTH DIVISION-TOWN OF BARNSTABLE.MASSACHUSETTS Yes application for Miopoga[ Spgtem Con'qtruction J)erm,t Application for a Permit to Construct( )Repair(C ) Upgrade( )Abandon(t'O�'DD Address or L.ot No. ) C Complete System ❑Individual Components �ltop Drive 1 a"�'sN� szodTeLNo. Assessor's a ► Marstons John Saladino 0-77—Ol Mills i Installer's Name,Adder and Tel.No. Will. E. Robinson Septic Ser, i Designer's Name,Address and Tel.No. L P O Box 1089, Centerville ! -__ Type of Building; Dwelling No.of Bedrooms Lot Site Other Type of Building � No 4f Persons _--_� ft. Garbage Grinder( j Other Fixtures Showers( ) Cafeteria( ) Design Flow — Plan Date gallons per day. Calculated daily flow Title' Number of sheets M gallons. _ ------�__Revision Date Size of Septic Tank _ Description of Soli Type of S.A.S. -------------- Natare of-Repairs erAltentions(Answer when applicable) T _ of a D boxes 2 concret Date last inspected: �—�__----_—'---1�— Agr+eementt 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 cafe of Compliance has been issued by this oar to place the system in operation until a Cenifi- Health. , Signed Application Approved by Date Application Disapproved for the following reaso < �---- Date Permit No. -- ———— —— _ .-- ._ —.— Date Issued THE COMMONWEALTH OF MASSACHUSETTS z — .aladino BARNSTABLE,MASSACHUSETTS <_ � certificate of compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Construct by ed( )Repaired(X )Upgraded( j Abandoned( :j at withtheprovWonsofT1de5.and tbeforDis has been constructed in accordance Installer�7' . k:. Robinson Sr posal,SystemConsuuctionPennitNo.7,VZ —f�� dated The issuance:ofthis es, peimit h ! t e constnied as aguarantee that the systiuti w ll fupctioq as destgfled. Date r f Inspector_— r y ry��i r6.'%- ? r r . Nw' d'"dE✓`>9f'rt ———— ----------------- 077-t?/.t7 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE.MASSACHUSE7TS 6"teM 4°OnItruction permit Permission is hereby granted to Construct( }Repair System located at ( )Upgrade{ )Abandon( ) and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following focal provisions or special conditions. Provided:Construction must be completed withi ' n three years of the date of this. Date :. �/" 7, �OrTtS. Permit. �,.�,��r Approved- '.� 1� TOWN OF BARNSTABLE LOCATION t2 SEWAGE # 6-0-8'`' VILLAGE ASSESSOR'S MAP& LOT �D INSTALLER'S NAME&PHONE NO. . 3 6A./ `' 7 V? SEPTIC TANK CAPACITY ,® LEACHING FACILITY: (type) ��`��- �--L (size) NO.OF BEDROOMS BUILDER'OR OWNER PERMITDATE: t-cfYJ COMPLIANCE DATE:/`— Separation Distance Between the: Maximum Adjusted Groundwater Tabl/cility) m of Leaching Facility Feet Private Water Supply Welland Leach (If any wells exist on site or within 200 feet of leachi Feet Edge of Wetland and Leaching Facililands exist within 300 feet of leaching facility) Feet Furnished by ` I Commonwealth of Massachusetts 077- 01 8 - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 61 Hilltop Dr { Property Address I) VAUGHAN, JILIAN A& MORTON, JEFFREY L N Owner Owner's Name information is CIL) required for every Marstons Mills Ma 02648 2/28/18 3=, page. City/Town State Zip Code Date of Inspection i;:� k...L jwrL 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 '5# /a¢j(A on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain ,By Company Name 35 Content Ln Company Address Cotuit MA 02635 City/Town State Zip Code 508-364-9587 S113522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the oval Approving Authority 3/5/1 8 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System--yPage 1 of 1'7/C Commonwealth of Massachusetts Title 5 Official Inspection Form h Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 61 Hilltop Dr Property Address VAUGHAN, JILIAN A& MORTON, JEFFREY L Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/28/18 page. Citylrown 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: System contains a 1000 gallon septic tank. As well as a concrete distribution box and 2 500 Gallon leaching chambers 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 . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 61 Hilltop Dr Property Address VAUGHAN, JILIAN A& MORTON, JEFFREY L Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/28/18 page. CityrFown 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): ❑ 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 FIND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 61 Hilltop Dr Property Address VAUGHAN, JILIAN A& MORTON, JEFFREY L Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/28/18 page. Cityrrown 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 %day flow t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 61 Hilltop Dr Property Address VAUGHAN, JILIAN A& MORTON, JEFFREY L Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/28/18 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•3/13 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 M 61 Hilltop Dr Property Address VAUGHAN, JILIAN A& MORTON, JEFFREY L Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/28/18 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 61 Hilltop Dr Property Address VAUGHAN, JILIAN A& MORTON, JEFFREY L Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/28/18 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 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 178 GPD 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form y Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 61 Hilltop Dr Property Address VAUGHAN, JILIAN A& MORTON, JEFFREY L Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/28/18 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: Not provided Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for um in : P P 9 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 Forth:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 61 Hilltop Dr Property Address VAUGHAN, JILIAN A& MORTON, JEFFREY L Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/28/18 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: 11/7/00 Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: 2.5 feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): System is vented at the roof line Septic Tank (locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 61 Hilltop Dr Property Address VAUGHAN, JILIAN A& MORTON, JEFFREY L Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/28/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System form - Not for Voluntary Assessments wM 61 Hilltop Dr Property Address VAUGHAN, JILIAN A& MORTON, JEFFREY L Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/28/18 page. Citylrown 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •''y 61 Hilltop Dr Property Address VAUGHAN, JILIAN A& MORTON, JEFFREY L Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/28/18 page. Citylrown 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 level and at normal level 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•3/13 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 , ' 61 Hilltop Dr Property Address VAUGHAN, JILIAN A& MORTON, JEFFREY L Owner Owner's Name information is required for every Marstons Mills Ma 02648 2128/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No ponding no break out 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 61 Hilltop Dr Property Address VAUGHAN, JILIAN A& MORTON, JEFFREY L Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/28/18 page. Cityrrown 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 61 Hilltop Dr Property Address VAUGHAN, JILIAN A& MORTON, JEFFREY L Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/28/18 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 F. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M , 61 Hilltop Dr Property Address VAUGHAN, JILIAN A& MORTON, JEFFREY L Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/28/18 page. Cityrrown 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 + Ftfeet 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: 11/7/00 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: Test hole data on plan 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 61 Hilltop Dr Property Address VAUGHAN, JILIAN A& MORTON, JEFFREY L Owner Owner's Name information is required for every Marstons Mills Ma 02648 2/28/18 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ❑ System Information—Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 / L6�� n//� /? /~ Commonwealth Of Massachusetts : / / - �^^ ~0~^��U �� Official U Inspection �� / Title 8�� 0�� 0°M�� 0��U�U *m �wU Knn~� � N— ' n �~ x n ��* n�rxn ��xnnn Subsurface Sewage Disposal.System Form Not for Voluntary Assessments ��. 61 Hill-To Dr —+ Property Address Tha/euaAdamnons »w»o' Owner's Name information is required for every MaretonoPWiUs � Ma 02648 9/24/15 page. City/Town State Zip Code . Date o,Inspection Inspection results must be submitted on this form. Inspection forms may not be,altered in any way. Please see completeness checklist ot the end of the form. . Important:When A. ��6��U U0�m��'K�� mxno out forms ^ ^' General Information ' /�/� mmemm�e� w'-� /«y^� use only the tab 1 Inspector: ' key m move your cvom, do not N1iohae| Di8uono use the return key. Name o(Inspector DiBuuno Sewer and Drain ��`��`��`�� Company Name 8Johns path ��----------------- Company Address GYarmouth MA 02664 _--__—__--_- cur7nwn State Zip Code 508'364'9587 S|13522 Telephone Number License Number B. Certification | certify that | 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 (31OCNlR15.00O). The system: M Passes Fl Conditionally Passes Fl Fails � Fl Needs Further Evaluation by the Local Approving Authority � v;sw S ��ure � --�- --'------------�—'' l� e--�--'-----'----------��—��---'--- The system inspector shall submit e 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 ho the appropriate regional office oftheOBRThoorigino| shou|dbesenthothoxyuhommwner and copies sent to the buyer, if applicable, and the approving authority. ""T his . at that time. This inspection does not address how the system will perform in the future under ` the same or different conditions ofuse. �n� � / 0 �" -`nx m�5om"wm*""°"~��u�^="o°°�°o�p�"��p "`"*,r i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ; r 61 Hill Top Dr --- ------- ------- ------- -- — ---- ...----- - Property Address Theresa Adamsons _ Owner — ------------=—_--- ------------------------------ ----------------- Owner's Name information is required for every Marstons Mills Ma 02648 _ 9/24/15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) i 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 i in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system contains a 1000 gallon tank as well as a concrete Distribution box. All tees and baffles are in place. The Distribution box is level and at normal level. The leaching is made up of several leaching chambers and at time of inspection levels appeared to never have been at abnormal levels. 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): t ins•3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title �� ~��| U ^��~�� Inspection ��N�U�� | " ~"~~ ~� Official mnn~.��n��vw Form Subsurface Sewage Disposal System Funn ' Not for Voluntary Assessments 61 Hill Tor) O Property Address ThoneoaAdomuunn Owner Owner's Name � ��---------------�-----------'-------��----�---------- informationio rec red for every N1arstonsMiUo Ma 02648 0/24/15 page. City/Town State Zip Code Date ofInspection B. Certification (cont.) [l Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (contj: D 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 o broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ' �l broken pipe(n) are replaced El Y El N F1 ND (Explain below): El obstruction is removed El Y El N El NO (Explain below): El distribution box is leveled orreplaced 0 Y Ej N El ND (Explain below): -------'---------------- ------ ------ L� Thesystemnequiredpumpingmorethun4dmenayeorduetobrokonorobotruotedpipe(s). The system will pass inspection if(with approval of the Board nfHea|th): ' [] broken pipe(e) are replaced 0 Y 0 N El ND (Explain below): [] obstruction isremoved El Y Ej N [l NO (Explain be|ow): ___ -___ / || ' C) Further Evaluation is Required by the Bound 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 hea|th, safety or the environment. ' 1. System will pass unless Board of Health determines in accordance with 31OCNlR 15.303(1)(b) that the system is not functioning in o manner which will protect public health, safety and the environment: i El Cesspool or privy is within 5O feet nfa surface water � El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5i=-3113 Title o Official Inspection Form Subsurface Sewage Disposal System-Page;w`r | »p� Commonwealth mfMassachusetts ~�~^��U�� ~��'^��^�� U D��~��~�� R°R�� Title �� 'U � ��*��K Inspection �—��onox Subsurface Sewage Disposal System Form ' Not for Voluntary Assessments 61 Hill Top D Property Address Theresa Adamsons OwnerName � infonnauoni's � required for every MarntonxPWiUs Ma �02648 9C24/15 ^ _ page. cm[/own state Zip Code Date«rInspection � B. Certification (cont,) '2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system io functioning ina manner that protects the public health, safety-and environment: LJ The ayoUam has e septic tank and soil absorption system (SAS) and the SAS is within 1OU feet ofa surface water supply or tributary toa surface water supply. El The system has a septic tank and SAS and the SAS is within a Zone 1 of public water supply. LJ The oyaham has o septic tank and SAS and the SAS is within 50 feet ufa private water supply well. LJ 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 weU°° Method used to determine distance: This system if the U water analysis, performed at a DEP certified laboratory, colifor.m 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 �l �� Backup nf sewage into �ci|hyorsys�m component due hoovedoadedor �~ �� dogged SAS or cesspool Discharge or ponding of effluent tn the surface of the ground or surface waters -- �� due toan overloaded or clogged SAS orcesspool 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 5^ be|ovvinvo�or available volume is |oys �� than '12 day flow Is*"-ma no.,nmu°/m"=*""p°m.o"bs"x="newag°o/°~sa/srmm-Page 4m`r � Commonwealth of Massachusetts F.: Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 61 Hill Top Dr Property Address Theresa Owner Owner's Name information is required for every [Norstons Mills Ma 02648 9/24/15 � page. City/Town mate Zip Code Date mmsneu vn �------- � B. Certification (cont.) Yea No �� Required pumping more than 4dmeain the last year NOT due ho �oggedor �� ~ obstructed pipe(s). Number oftimes pumped: El M Any portion of the SA3, cesspool or privy is below high ground water elevation. �l �� Any po�ionof cesspool orpr�yiswbhin1OO feet ofa surface water supply or �� ~ tributary toa surface water supply. El E Any portion of cesspool or privy is within a Zone 1 of public well. Any portion of cesspool or privy is within 50 feet of private water supply well. El E 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 DEP certified ' |aboratory, for fecal oo|ifornn boutn,io indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or, |eom than 5 ppno^ , provided that no other failure uritnria are triggered. A copy of the analysis and chain of custody must be qMoohod to this form.] �� The system is a cesspool serving facility with a design flow of20O8gpd' / �� 10.000gpd Fl �� The system fails. | have determined that one or more of the above failure -- -- criteria exist aodescribed in 310CK8R 16.303 therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. i E) Large Systems: To be considered a large system the system must serve a facility with o design flow of 10.000 gpd to 15.000 gpd. ' For large oyahomo, you must indicate either"yes" or"no" to each of the foUowing, in addition to the ` | questions in Section D � . Yea No El El the system ia within 40U feet ofu surface drinking water supply the system jowithin 200 feet of tributary to o surface drinking water supply El �� the system is located in o nitrogen sensitive area (Interim Wellhead Protection �— �� Area — |VVPA) Or mapped Zone || of public water supply well If you have answered "yes" to any queVdon in Section E the system is considered a significant thnaat, or answered ^ycs^ in Section Oabove 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 CN1R 15.304. The system owner should contact the appropriate regional office of the Department. ' � m° -a^o Title,Official Inspection Form:Subsurface Sewage Disposal System-pag°ow,r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .0 61 I Property Address Address Theresa Adamsons Owner ----------— Owner's Name information is required for every Marstons Mills ---- - Ma 02648 ___ 9/24/15 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 cff 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): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 6 of 17 Commonwealth of Massachusetts R)= - Title 5 Official Ins ecti-®n Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 61 Hill Top Dr Property Address --- ----- ---- Theresa Adamsons Owner Owner's Name ---------------------- - information is required for every Marstons Mills-- _ — _ Ma_ 02648 9/24/15 _ page. City/Town State Zip Code Date of Inspection D. System Information Description: The system contains a 1000 gallon tank as well as a concrete Distribution box. All tees and baffles are in place. The Distribution box is level and at normal level. The leaching is made up of several leaching chambers and at time of,inspection levels appeared_to never have been at abnormal levels. 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 ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available last 2 ears usage 174 GPD 9 ( y 9 (9pd)) ------ Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): ---------------------------------------._.-___- _._.. Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): --- --------- --------------------------------__ Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts �u _ = Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y; 61 Hill Top Dr — - Property Address Theresa Ada_msons Owner Owner's Name -- -- -- ---- -- ---------- - information is required for every Marstons Mills - — --- Ma 02648 9/24/15 page. City/Town --_ — State Zip Code Date of Inspection I D. System Information (cont.) Last date of-occupancy/use: Date Other (describe below): General Information Pumping Records: Source of information: 6/19/15 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts - T Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 61 Hill Top Dr Property Address Theresa Adamsons OwnerOwner's Name ------------------------------- -------------------- -----------------__---------- information is Marstons Mills Ma 02648 9/24/15 required for every _ _.. _...___ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: New leaching installed in 2000 Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: 18 — - --------------...----------------- feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): — -- - —— - Distance from private water supply well or suction line: -- --- - -- feet Comments (on condition of joints, venting, evidence of leakage, etc.): System is vented throught the roof. Septic Tank (locate on site plan): 1 ft Depth below grade: feet ---- ----- --- ---- Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) 1000 gallon_ 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: - --------- Isms•3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 61 Hill Top Dr —--------- —--------- —--------- Property Address Theresa Adamsons Owner Owner's Name information is Marstons Mills Ma 02648 9/24/15 required for every 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 " Scum thickness 3 , " Distance from top of scum to top of outlet tee or baffle 42 Distance from bottom of scum.to bottom of outlet tee or baffle VSludge stick Tape Measure 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.).. No evidence of.leakinq,Tees-and or baffles in place at time of inspection. ........... ------------- ----------------- -------- —------- Grease Trap (locate on site plan): Depth below grade: NA feet Material of construction: El concrete El metal [I fiberglass El 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 15ins-3113 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 bra 61 Hill Top Property Address Theresa Adamsons Owner Owner's Name information is required for every Marstons Mills Ma 02648 9/24/15 page. State Zip Code Date of InspectionD. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tees_are in place and levels are normal. ------—----- —------ Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan).. Depth below grade: Material of construction: 0 concrete El metal El fiberglass ❑ polyethylene El other (explain): Dimensions: Capacity: ---------- gallons Design Flow: gallons per day Alarm present: 0 Yes ❑ No Alarm.level: Alarm in working order: El Yes F No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): —------------- ....... Attach copy of current pumping contract (required). Is copy attached? El Yes F No [Sins-3/13 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 61 Hill Top Dr ------......-------------- -_--------- ---------- ....... --------------- Property Address Theresa Ada msons Owner Owner's Name information is required for every Marstons Mills Ma 02648 9/24/15 page. City/TDwn __ State Zip Code Date of Ins'pection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert At normal level------ 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.): Distribution Box is level and at normal level with no signs of carry over or decay. —---------- Pump Chamber (locate on site plan): Pumps in working order: El Yes R No* Alarms in working order: EJ Yes El 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: (5ins-3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ti� 0 61 Hill Top Dr ----------------------- roperty Address ----Theresa Adamsons Adamsons Owner Owner's Name ------------------ ------- --------------- information is required for every Marstons Mills Ma 02648 9/24/15 page. &Ty_down -"—__-- - State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: -------------------- ® leaching chambers number: 2 ❑ leaching galleries number: ----------_ ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: -- --- ----------- ❑ innovative/alternative system Type/name of technology: --_.....- - ---------- - ---- --- - Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No signs of carry over and no signs 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 15ins•3113 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts == r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 61 Hill Top Dr Property Address ------_---- ----- ------- Theresa Adamsons Owner -- ----- ---- -------- ---— ---------------------- ...-Owner's Name information is required for every Marstons Mills — _ Ma _ _02648 9/24/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): No signs of ponding or hydraulic failure. 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.): 15ins•3113 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 61 Hill Top Dr Property Address - - Theresa A_damsons Owner Owner's Name - —---------- —----------- ------ — ----------ion is reequiredquired for every -- Marstons Mills Ma 02648 9/24/15 - ---------- --- - --- ------ -- --------- --- ------ --------- 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. I (Sins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 �sseSS imu As-BLII]t C-111-CIS Pa I o12 TOWN 01"BARINSTABLE. LOCATION-_'/Z Hit'[ lo 41_1) SEWAGE H G ,�6 _6Ca VILLAGE ASSESSOR'S MAP&LOT INSTAI.LER'S NAME&PHONE NO. SEPTIC TANK CAPACFFY Z0 e�_e2 LEACHING FACILITY:(typc))-, C "9't a 4 C. (size)-Z;)- NO.01:BEDROOMS BUILDER OR OWNER PERMIT DATF: L,/—2 ---t, —COMPLIANCE DATF:d�:_�_— Separation Distance Between die: tviaxiiiltiinAdjusic-dGroijriiJwaicrTable,,),I,,ilI o,�jcf Leaching Facility Fcct [each Private Waicr Supply Well and ngF ,liry any WC115 CAJ51 a on silt or wiOun 200 fat of leaching cil"y) Edge of Wctland and Leaching , E Facie (If any wetlands exist withiu 30)fcci of leaclung facility) FCC[ FLu-ni5l)Cd by "IV Q/17/20 15 Commonwealth of Massachusetts - = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments, 61 Hill Top Dr Property Address Theresa Adamsons Owner —--- —------ -------- ---------------Owner's Name information is required for every Marstons Mills _ Ma 02648 9/24/15 page. Cit Town Sta-t—e-- —Z—ip C-o—de----- — Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10+ ft feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 11/7/00 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain.- El Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Test hole data on plan dated 11/7/00 indicates NGE at 10+ft _ Before filing this Inspection Report, please see Report Completeness Checklist on next page. (Sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts ��- Title 5 Official Inspection Form �r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments \� 61 Hill Top Dr Property Addr--ess --------------.._.. ----------- ---- - -------- ------------ ------- ----..- - - _ Theresa Adamsons _ Owner Owner's Name -- -- --.—_ information is ------ required for every Marstons Mills -- _- - - Ma 02648 9/24/1 page. 5 City/Town ---._---- -------- State_ Zip Code Date of Inspection E. Report Completeness Chec—klist - ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information - Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file (Sins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE /LOCATION `� �a � 1�� SEWAGE I N r # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY A 6--0 LEACHING FACILITY: (type. 2- �' �• (size) NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: �l`7 —t-t--y COMPLIANCE DATE://— Separation Distance Between the: Maximum Adjusted Groundwater Table to the B om of Leaching Facility Feet Private Water Supply Well and Leaching F ility (If any.wells exist Feet on site or within 200 feet of leaching cility) Edge of Wetland and Leaching Facili If any wetlands exist Feet within 300 feet of leaching facility) Furnished by i i rN i Town of Barnstable Regulatory Services 'ME TOwti Thomas F. Geiler, Director • Public Health Division w BAMSrast.E. » 9. � Thomas McKean, Director 367 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 September 25,2000 John R. Saladino 61 Hilltop Drive Marstons Mills, MA 02646 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.00, STATE SANITARY CODE H, MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE RENTAL ORDINANCE,ARTICLE 51 The property owned by you located at 61 Hilltop Drive, Marstons Mills, was inspected on September 21, 2000 by Glen Harrington, R.S. Health Inspector for the Town of Barnstable, because of a complaint. The following violations of 105 CMR 410.00, State Sanitary Code H, Minimum Standards-,of,Fitness for-Human Habitation were observed: 410:253 Thelight.at;south entrance.to:lower floor was inoperable due to electrical problem. 410.300: Paragraph on septic replacement. 410.351: The electrical outlet in children's bedroom was observed to be loose. 410.351: The thermostat control was observed not to be secured to wall with exposed wires. 410.351: The rear outdoor light switchplate was observed to be cracked. 410.481: Dwelling was not posted with owners name, address, and telephone number. 410.500: The kitchen counter top was not secured to cabinets. 410.500 f ;?' f '.,;nets observed not to be secured to ymll. 410.551:• Six windows were observed to be missing screens. saladino/wp/q/ls r' You are directed to correct the above listed violations within thirty (30) days of receipt of this notice. You may request a hearing if written petition requesting same is received by the Board of Health within seven (7) days after the date order is received. However, these violations must be corrected regardless-of any request for a hearing. Please be advised that failure to comply with an order could result in a fine of not more than $500. Each separate day's failure to comply with an order shall constitute a separate violation. PER ORDER OF HE BOARD OF HEALTH Thomas A. McKean Director of Public Health saladino/wp/q/ls i E T UR " To 0 ToM at wow* 1 i U.—PsTac « REASON,CE D .Y l ? J E p SEP21'00R��rtad026Q1,� ef dAYere')fRi*pm* Y@W}}W ✓ I� ��,.,",�y`. 1 �rM�,�.-.- Nair..� BnsuffiCt 1,drfs; PEA �6�38443 o`s No such _num6� Pdo such office i m stele f f Do not"email in this envelope APRIL WHITE 6I '?ILL"OP i'?J" ` MARSTONS ILL r.!o'Zx, +a r'~.a�:.;:«.Q 1:1„11,,it►i1111;1,t1,1toift,r1,i{„1:1„l,,i toil 11 3 M.cT"' .�`..`�+t,.�� .�..�.�•,,..,tom<mw.s�.:. ��li J '""«ncvc�..Ai°•..r.:wuwa�auaUm"' y i it 11 ill Jill i i I I I lllllil I II 1 11 III i Ii 11 i i P�oFIKEj � Town of Barnstable H 0� Y Department of Health, Safety, and Environmental Services BARNSTABLE, 9Q MASS. 1639. Public Health Division -D �0 AlfDMA�A P.O. Box 534, Hyannis MA 02601 Office: 508-790-6265 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health 61 IA1/h1a RECORD OF VERBAL COMMUNICATION 5!x14 c A L- Cf CA-k i�, . ��c �a G�1 Ste-(aC ✓� G'C' 04r'1�eC�due 40 -(tea v,j 6�(ov-W, sI., S 0'-'�/ G,�, Co Lt_�d dtct.�, ► ,a r��cs ou�d2 �wv verbcomm.doc THE 1p�y Town of Barnstable BARNSTABLE Department of Health, Safety, and Environmental Services MASS. 1639. Public Health Division �0 ATfDMAIa P.O. Box 534, Hyannis MA 02601 Office: 508-790-6265 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health RECORD OF VERBAL COMMUNICATION IT caa d ,��% GvG�,�e Lac a ite�,. d 6 MC/414 ,0r,e w 14 ev- ( Sa. V Y-l� ow I , O ea,.�e V at-A.v(* K-6 C"'� 9'A4.1gQod o, A-L- graL- a4., ( G l-o 9 o t i-� 04 � /� 3 P!,t¢.yt vl &'QA"t-f av�J)� a f 4.P aj/GW lj c . ✓cti. 4 �v• / Gyj d�� d2/"F avI Fri 9jZZ J2� J' .i'�ry�O� / 1.a., C&J C" di ow L�Zf-o 3 2- verbcomm.doc Z 273 502 642 US Postal Service Receipt for Certified Mail No Insurance Coverage Provided. Do not use for Internation Mail ee reverse ;Sea t Nu Post Office,State,&ZIP Code Postage $ Certified Fee Special Delivery Fee Restricted Delivery Fee c3� Return Receipt Showing to Whom&Date Delivered Q Return Receipt Showing to Whom, Q Date,&Addressee's Address a TOTAL Postage&Fees $ EPostmark or Date 0 L U) a Stick postage stamps to article to cover First-Class postage,certified mail fee,and charges for any selected optional services(See front). 1. If you want this receipt postmarked,stick the gummed stub to the right of the return address leaving the receipt attached, and present the article at a post office service window or hand it to your rural carrier(no extra charge). 1 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the Q) return address of the article,date,detach,and retain the receipt,and mail the article. uO 3. If you want a return receipt,write the certified mail number and your name and address rn on a return receipt card,Form 3811,and attach it to the front of the article by means of the gummed ends if space permits. Otherwise,affix to back of article. Endorse front of article Q. RETURN RECEIPT REQUESTED adjacent to the number. Q 4. It you want delivery restricted to the addressee, or to an authorized agent of the O O addressee,endorse RESTRICTED DELIVERY on the front of the article. e 0 5. Enter fees for the services requested in the appropriate spaces on the front of this E receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. Los" 6. Save this receipt and present it if you make an inquiry. 102595-99-M-0079 a Town of Barnstable Regulatory Services °FTHE l° Thomas F. Geiler, Director • Public Health Division w BARNSTABLE, 9� 6,9. � Thomas McKean, Director ArFD^10�A 367 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 September 25,2000 John R. Saladino 61 Hilltop Drive Marstons Mills, MA 02646 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.00, STATE SANITARY CODE H, MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE RENTAL ORDINANCE, ARTICLE 51 The property owned by you located at 61 Hilltop Drive, Marstons Mills, was inspected on September 21, 2000 by Glen Harrington, R.S. Health Inspector for the Town of Barnstable, because of a complaint. The following violations of 105 CMR 410.00, State Sanitary Code H, Minimum Standards of Fitness for Human Habitation were observed: 410.253: The light at south entrance to lower floor was inoperable due to electrical problem. 410.300: Paragraph on septic replacement. 410.351: The electrical outlet in children's bedroom was observed to be loose. 410.351: The thermostat control was observed not to be secured to wall with exposed wires. 410.351: The rear outdoor light switchplate was observed to be cracked. 410.481: Dwelling was not posted with owners name, address, and telephone number. 410.500: The kitchen counter top was not secured to cabinets. 410.500: Wall .-,binets were observed not to be secured to wall. 410.551: Six windows were observed to be missing screens. saladino/wp/q/ls i You are directed to correct the above listed violations within thirty (30) days of receipt of this notice. You may request a hearing if written petition requesting same is received by the Board of Health within seven (7) days after the date order is received. However, these violations must be corrected regardless of any request for a hearing. Please be advised that failure to comply with an order could result in a fine of not more than $500. Each separate day's failure to comply with an order shall constitute a separate violation. PER ORDER OF HE BOARD OF HEALTH Thomas A. McKean Director of Public Health saladino/wp/q/ls FORM30 Caw HOBBSB WARREN TM THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH CITY/TOWN g DEPARTMENT ^M ADDRESS TELEPHONE 7 Address i L� ( IQ D�� M�'''� _//"Accupant Floor Apartment No. No.-of Occupants No.of Habitable Rooms_- No.Sleeping Rooms '7- No.dwelling or rooming units—/ No.Stories_ /• 49- Name and address of owner o + Sc �I p�v%A7, 1 d �t �� Svor/� '7 I-6 gC'S Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: A/V S- f, we f) vb 6&k / L3-_3 ❑ B ❑ F ❑ M Doors,Windows: U / Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Li htin : STRUCTURE INT. Hall,Stairway: 4c1 L,.,. Lvv, _ H,n t",Vcf CA k1 /o so Obst'n.: fit,( t!, "+ 1�u-ur/ Hall, Floor,Wall, Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: - au, ov46- - jn ki cts 6 Iz-lavU 1c, L l 411cl3 S-� Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Ve ts: PLUMBING: Supply Line: -, , ❑ MS ❑ ST ❑ P Waste Line: ;0- taco #2 W/ 60 H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: 114-3 e TS/ ❑ 110 ❑ 220 Fusing,Grnd.: CA✓01-e -�v fet ct.,� dv C�/-a // AMP: Gen.Cond. Distrib. Box: ftn ;4co, 1314, (4-et j o-c_L.� '//c7 3J'/ Gen. Basement Wiring: T vii,.o�jP DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks OK Kitchen Bathroom Pantry Den Living Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas, Oil, ec . Stacks, Flues,Vents, afeties: Kitchen Facilities Sink _ Stove -0(k Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: 0 k Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: ` Egress Dual and Obst'n: Ok General Buildin Posted v%( LLo+ os 64,P-W tea" if i Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR. (See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES RJU (� INSPECTOR a TITLE DATE TIME z' �� THE NEXT SCHEDULED REINSPECTION /�� d P.M. llt3:"«.. ,..« pKHi:rk"'''YW�;1,did?A4`� iR triit� ;`df4 aiF j+/F"w:r j7�;1 9c4f'w'�kw , :r�'p".'+F `r+C'•';F4;�', .Px7 �`r 4 �V'., 1'' 'i" '"°N+ MR?a."r,p:�"� 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter II, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B) and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254.' (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600;410.601 or 410.602 which results in any accumulation of gar- rubbish filth or other causes of sickness which may provide a food source or harborage gar- bage, Y e for rodents, insects or other pests p 9 or otherwise contribute to accidents or to the creation or spread of disease. (J) .The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any'defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. P An other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750 A through O shall be deemed to be a con- dition Y ( ) 9 ( ) dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. y �FTHE Tp� , STAB Town of Barnstable 9 ass. � Board of Health lED MA'S s 367 Main Street,Hyannis MA 02601 Office: 508-790-6265 Susan G.Rask,R.S. FAX: 508-790-6304 Ralph A.Murphy,M.D. Brian R.Grady,R.S. 2 r. 3,2000 6 t (-j;'( I4'�o bv'-"t 2 p -1 iM o�J4o-.L1 /0 f/S, NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.00,STATE SANITARY CODE II, MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE RENTAL ORDINANCE,ARTICLE 51 61 (4-1 t,�,1� ��./4a,,)h-I V,71) � The property owned by you located at ,was inspected on 9 1Z 2000 by Glen Harrington,R.S. Health Inspector for the Town of Barnstable,because of a complaint. The following violations of 105 CMR 410.00,State Sanitary Code II,Minimum Standards of Fitness for Human Habitation were observed: t 0 S nti 12 Lt to . "Z 5-3 f 6v WV'' 300 (f 0 z(e uA—a& L{ v . 3 S I 7"t-� fec -,2c:2 o v+(mil- i`v, G� ('4t✓�.� Qeo(�.uv1,• wo 1 4�01 erv�� ---o (ae loos-e- L' 40to e Se Cc, ee� Pe �e a,. W d I s t s w d�-�- r r�. tea v f�I .eel 04) (.Lk G v c—e✓Ut-0( , Cati,,.-,IaAL 4,lp V,,,pLJ )ro4 w.zd1 do C.af�<<.a+S , &0tL are dir d to ec at n of .48 with' my-f )ho of r t o i c You are,*8 directed to correct the wfiiHftg above listed violations within seven(7)days of receipt of this notice. ��c9 Soo .` Ca.(A tie 4-3 �Vk'-R 0(1 1,0 4- P f ecv>-ecl lid y 10. SS-- S i K C,J L In 4-' .v1 In-L. C)61 e-✓P{O/ 010 .6 e W►%1.f!i7 j .�'G Q �7 f. You may request a hearing if written petition requesting same is received by the Board of Health within seven (7)days after the date order is received. However,these violations must be corrected regardless of any request for a hearing. Please be advised that failure to comply with an order could result in a fine of not more than$500. Each separate day's failure to comply with an order shall constitute a separate violation. Renting the above property with uncorrected violations is a violation of the State Sanitary Code and the Town of Barnstable Rental Ordinance,Article 51,section 6-2. PER ORDER OF THE BOARD OF HEALTH Thomas A.McKean Director of Public Health Enclosure: Copy of Inspection Report C C, r V G L Vv�5 V('e,%,- D r Ga Health Complaints 19-Sep-00 Time: Date: 9/19/00 Complaint Number: 2560 Referred To: GLEN HARRINGTON Taken By: LS Complaint Type: CHAPTER II HOUSING Article X Detail: Business Name: Number: 61 Street: HILLTOP DRIVE 0 g Village: MARSTONS MILLS Assessors Map_Parcel: Complaint Description: THE SEPTIC TANK WAS PUMPED A MONTH AGO AND IS OVERFLOWING INTO THE LEACHING PIT. IT NEEDS TO BE PUMPED AGAIN. THE OWNER FILLED THE LEACHING PIT WITH WOOD CHIPS. THE WATER ALSO GOT SHUT OFF FOR NON--� �"�°` PAYMENT BY THE OWNER. THE w ELECTRICAL BOX IS HANGING OFF THE QA,,-11 ,,,-F) WALL WITH ALL THE WIRES EXPOSED. SHE HAS TWO CHILDREN THAT CAN REACH IT. Actions Taken/Results: Investigation Date: Investigation Time: (,✓� `�'� .Zr3r� q - z ( - ZonO Z�- 1 � l/ 1 LOCATION �' SEWAGE PERMIT NO. VILLAGE . I N S T A LLER'S NAME i ADDRESS i� . Ca LA BU'TF 0 U I L D E R OR OWNER DATE PERMMIT ISSUED DATE COMPLIANCE ISSUED `3 '8` FRgaT -rowa HBO .......... .............. �Fi�dsMap Fafcel 077018 din Ov�mer 077018 e V p 1+1 000398 ire 0000000 d,,c@ ; /t y/ sr rhno 12DC Reuel`%t LOT 10 � �%,�`"� �� 9 °s�1��e 33 urr Ow SALADINO,JOHN R Stfss� 101 y 00 s /61 HILLTOP DR MARSTONS MILLS ' MA 02647 w r. a 00-0000-000 _ e y 120191 efe a ce j 7440 258 £u Jnua s SALADINO JOHN R De dv MYY: 0291 x t}ee of 7440/258 aloe s r� 000023400 Btu �n�y a 000069600 ,,, z Fea#ues 0000000000 #0 61 HILLTOP DRIVE d 0719 fir„ 0079 Ga ` " VW S cal de 0000 �i g` 0000 I M e • ��/ / , / • � � /I /�� i i �s� • � ;hw CCJ � S��a�t vet �I rt��(Q -T u j -o k�v �a vk U*Jay —TQ wk� s ca.Ja c v1 Vv c--vd loe - VL� ( RECEIVED AP P r 5 2000 TOWN OF BARNSTAbLE HEALTH DEPT. /'o; d e) lv� 4c; 67 E7 �Vl,ye ( ` wj1 0,- � LD�fit a z�ti o�P V- � VN VA �a,vV� vi tL ✓ W� PO� rtVtN t � CO11MO:\-%N7 ALTH OF MASSACHliSETTS EXECUTIVE OFFICE OF E 'vIRO\MENTAL AFFAIRS DEPARTMENT OF FxmONMENTAL'PROTECTIOh O\E R'INTER STREE". BOSTON DLA 0210c t617i 292-55(w TRUDYCOXE Secretan ARGEO PALL CELLUCCI DAVID B STR'--H.S Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 61 Hill Top Dr Name of owner John S a lad.ino N�[a`� Oris JJS Address of Owner: Date of Inspection: 3 O` Name of Inspector:(Please Print)Wm. E . Rob ins on Sr. I am a DEP approved systerq inspector rsuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: Wm. E . Robinson Septic Service. Mailing Address: PO Box 10d9, Centerville . MA Telephone Number: 7 7 K— 7 7 0 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: asses Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fa�ils� Inspector's Signature: !✓y IL/� Date:,` The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to tfre system owner and copies sent to the buyer, if applicable, and the approving authority.' NOTES AND COMMENTS ✓U� Q-11 \ revised 9/2/9E Page Iof11 H _ �� .!n!ed on Reca•drd Pane. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) opeKy Address: 61 Hill Top Dr . , Marstons Mills Jwner: John Salad.ino Date of Inspection: P� 3 INSPECTION SUMMARY: CheckOA- 8, C, or D: A. SYS PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. S TEM CONDITIONALLY PASSES: ne or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon ompletion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yet, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined', explain why not. I The septic tank is metal, unless the owner or operator has provided the system inspector.with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or } the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if Iwith approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM € PART A CERTIFICATION(continued) Prop"Address: 61 Hill Top Dr. , Marstons Mills Owner: John Saladino . ° Date of Inspection: 3—G/ C. �RTIHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) S1(4STEM1 WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE M ACCORDANCE WITH 310 CR 15.303.(11(b)THAT THE SYSTEM IS WOT FUNCTIONING IN A MANNER WHICH W11-1-PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) STEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS NCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revise: 9/,2/98 PaRc3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ` PART A CERTIFICATION (continued) PropertyAd&ess: 61 Hill Top Dr. , Marstons Mills Owner: John Salayydino Date of Inspection: D. SYSTEM FAILS: You mu indicate either "Yes" or "No" to each of the following: I eve determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this d ermination is identified below. The Board of Health should be contacted to determine what will be necessary to correct.the failure. Yes No Backup of sewage into facility-or system component due to an overloaded or-clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available_volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s)• Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARG SYSTEM FAILS: You must i dicate either "Yes" or "No" to each of the following: T e following criteria apply to large systems in addition to the criteria above: he system serves a facitity with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public ealth and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The o ner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Pagr4ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART B CHECKLIST Property Address: 61 Hill Top Dr. , Marstons Mills Owner: John Saladino Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes/ es No it Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks 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. _✓ _ As 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 system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. _✓ _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: Existing information. For example, Plan at B.O.H. _✓ _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) 115.302(3)(b)) �- _ The facility owner (and occupants,if different from owner) were provided with information on the propermaintana— f SubSurface Disposal Systems. revised 9/2/98 Page 5of11 s z SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 'roperty Address: 61 Hill Top Dr . , Marstons Mills Owner: John Salad.ino Date of Inspection: 3— 0--C� FLOW CONDITIONS RESIDENTIAL: Design flow: ( O g.p.d./bedroom. Number of bedrooms (design):-3— Number of bedrooms factual):-3 Total DESIGN flow— Number of current residents:— Garbage grinder lyes or no):_.A—p Laundry(separate system) (yes or no)YL0; If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no):41 0 Water meter readings, if available (last two year's usage(gpd): 1999 73, 000 gal Sump Pump (yes or no):d�V 1998 53 , 000gal. Last date of occupancy: COMIOI RCIAL/INDUSTRIAL: Type of tablishment: Design flo : apd ( Based on 15.203) Basis of de ign flow Grease trap present: (yes or no)_ Industrial ante Holding Tank present: (yes or no)_ Non-sanit y waste discharged to the Title 5 system: (yes or no)_ Water m er readings, if available: Last d of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of info r at ion: System pumped as part of inspection: (yes or no)-A, D If yes, volume pumped: gallons Reason for pumping: TYPE SYSTEM ✓ Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) lif yes, attach previous inspection records;if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed lif known)and source of information: Sewage odors detected when arriving at the site: (yes or no) /L e) revised 9/2/9E Page 6ofII ✓ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'ropertyAddre s: 61 Hill Top Dr . , Marstons Mills Owner: Jol'n Salad.ino Date of Inspection: 3 ,1 BUILD G SEWER: (Locate n site plan) Depth be ow grade:_ Material f construction:_cast iron_40 PVC_ other(explain) Distance from private water supply well or suction line Diamet Comm nts: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK:_ (locate on site plan) l Depth below grade: Material of construction:Vconcrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal, list age_ Is.age confirmed by Certificate of Compliance_(Yes/No) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffler Scum thickness:' _ Distance from top of scum to top of outlet tee or baffle: 3 Distance from bottom of scum to bottom of outlet tee or baffle:_ How dimensions were determined: comments: (recommendation for pumping>, condition of inlet and outlet tees or baffles dept f`liquid)evel in I tion to outlet i vert,rstructural integrity, evidence of leak ge, etc.) l ty�� t~ tJ l �A 4 �� Y. //!ice �✓r{—1 �6rscJ, <S A ' SE TRAP: (Iota a on site plan) Dept below grade:_ Mate:al of construction:_concrete_metal_Fiberglass _Polyethylene_otherlexplain) Dimensions: Scumkhickness: Dista4e 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: Co ments: ^(r ommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, 'I.evi ence of leakage, etc.) 9 Yev�sPd. 9/2/98' Pagc7ofil t T' 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) -rop"Address: 61 Hill Top Dr . , Marstons Mills Owrw: John Saladino Date of Inspection: HT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) Iloc to on site plan) Dept below grade:_ Mate al of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimen ions: Capac y: gallons Desig flow: gallons/day Alar present A m level: Alarm in working order: Yes_ No_ Dat of previous pumping: Co ments: (co dition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert:_ Comments: (note if level and distribution is equal, eviden of solids carryover, evidence of leakage into or out of box, etc.) PUMP CH MBER:_ (locate on ite plan) Pumps in orking order: (Yes or No) Alarms in orking order(Yes or No) Comment (note con ition of pump chamber, condition of pumps and appurtenances,etc.) reviser 9/2/98 Page 8ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) top"Address: 61 Hill Top Dr . , Marstons Mills a Owner: John Salad.ino Date of Inspection: 3—L` cp-e- SOIL ABSORPTION SYSTEM(SAS):v/ (locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number: leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydr is failure, level of ponding, damp soil, condi ' n of v getatipn, etc.) CES OOLS:_ (locate n site plan) Number a d configuration: Depth-top of liquid to inlet invert: Depth of sol(Ids layer: )epth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note conditi)of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on ite plan) Materials o construction: Dimensions: Depth of s lids: ! Comment (note con ition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) 4 revises 9/2//7C Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'rop"Address: 61 Hill Top Dr. , Marstons Mills )wrw: John Salad.ino Jate of Inspection: 3--2 AO-ZA-e - SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) �L ( .sg � /p s s revised 9/2/98 Prkc 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION lcoetinued) ,openyAddress: 61 Hill Top Dr. , Marstons Mills Owner: John Saladino Date of Inspection: NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater�_-sFeet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) revised 9/2/98 Page norlt No.-'d lD(4(O Fee $S Q THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pplication for Migaar *pgtem Cow6truction Permit Application for a Permit to Construct( )Repair(X )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's'Map/Ir Atop Drive, Marstons John Saladino 0'77-0/1- Mills Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Ser. P O Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms_ 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil S and- Nature of Repairs or Alterations(Answer when applicable) T i i-1 A—rs leach system c on s i s t i n g of a D—box and 2 concrete chambers with stone all around 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 this Boarddf Health. Signed 71 Date ^� Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued 11-7- No.Z'd / t0 66 , - Fee d THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLEs MASSACHUSETTS 01pprication for ;0i9;po!6af *p! tem Construction Permit Application for a Permit to Construct( )Repair(X )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's'Map/Praio ltop Drive, Marstons John Saladino 0"77-0/ Mills Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Ser. P O Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms_ 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Sued. Nature of Repairs,or Alterations(Answer when applicable) i-1 e-S 1 eaCK SYSTEM non s lsa tn,g of a D—box and 2 concrete chambers with stone all around, t Date last inspected: y - 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 oar Health. Signed «'��/° Date Application Approved by Date��— !-' ?..01'?1 Application Disapproved for the following reaso s Permit No. 'l�oh Date Issued 7-OY-0 ------- ------------------- '----------- t THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Saladino (tertificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired(X )Upgraded( ) Abandoned( )by Wm- E.- Rabi ngnn Septic gerviCx� at 61 Hilltop Dr_ , Marstons MT11 s has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 70'IW ' j;6 dated l/—i 7— 2&2) . Installer Wm. E. Robinson Sr. Designer a The issuance of this permit 1hilAptibe construed as a guarantee that the systcY will functio as dest,ed. Date Inspector t�1�-0 ----------------------------- No. ZC/v" - 0 7 7-0/.%P' THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSETTS Saladino liepogal *pgtem Construction Permit Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( ) System located at—61 Hill top Drive,ye, th arg t®,ns Nil 1 s and as described,in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. e Date: A— Approved b utr99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTI>H'[CATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) I, W i l l iain E. Bob ins on,S Rweby certify that the application for disposal works construction permit signed by me dated /6 -7— &--e,-, , concerning the property located at 61 H i 11 tnp n r M a r G t nn s lit i 11 s meets all of the following criteria: • The ed system is connected to a residential dwelling only. There are no commercial or business uses iated with the dwelling. The '1 is classified as CLASS i and the percolation rate is less than or equal to:5 minutes per inch. There re no wetlands within 100 feet of the proposed septic system — There- c:no privata wells within 150 feet of the proposed_septic system There s no increase in flaw and/or change in use proposed • There are no variances requested or needed. • The ttom of the proposed leaching facility will ngt he located less than five feet above the ma mum adjusted groundwater table elevation: [Adjust the groundwater table using the Frimptor od when applicable) • If a S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed 1 ching facility will not be located less than fourteen(14)feet above the maeimum adjusted roundwater table elevation. Please complete the followisr. A) Top of Ground Surf tce Elevation(using GIS information) B) G.W.Elevation +the MAX High G.W_ Adjustment .---- / DIFFERENCE BETWEEN A and B / SIGNED X L DATE: C�'-' [Sketch proposed plan of system on back[. y:heahh folder cn r .:Y�" .. .,,.' a •.. "• ... • ..,! #.r ii... '):Ia a 'i ,*., .. 'xi.. - C0\L%10.X%%Z3L.TH OF M"SACHi:SETTS £ _ EIMCL-MTE OFFICE OF EN-MO\'AMN-TAL, AYF.AJR.-; 'DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE RZ\TER STREZ7.ROS O\MA 0210i 1617.1'292.5.i1kf TRI DT COL Secret&-. ARGEO PALL CELLI CCi D4t.D B STF-Yc Governor Cam:atss:one- SUBSURFACE SEWAGE DISPOSAL SYST6N ri1SPECTION FORM PART'A CERT1FV-ATM Prop"Address:.61 Hilltop Drive Naetaetoanw John Saladino M a r s t o n s Mills Address of Owear: Date of Mspection: N.me o+fnspenor:Imams PMO WM. E. Robinson Sr. I sm a DEP approved a eery inspector m Saetiort 15.340 Of TWO 5 9310 CUR 15.000) camp.nyf.,: Wm. E. Robinson a tic Service Ma3ingAddress: PO Box 0 9 Centerville . MA Telephone Number: CERTIFICATION STATEMENT I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and-experience in the proper function and maintenance of on-site sewage disposal systems. The system: _ Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails 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 thirty (30)days of completing this inspection. If the system is a shared system or has a design flow of 10.000 gpd or greater.the inspector and the system owner shall submit the report to the appropriate regional office of the Depanment of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable. and the approving authority. NOTES AND COMMENTS rev:..S e--i 9/2/9- Pape 1 of I1 w pan" SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION leans"wo �ropatyAdd►esa: 61 Hilltop Drive, Marstons Mills awner: Saladino Dow of Mspeebon: INSPECTION SUMMARY: Check 0 B, C, o. D: A 'SYSTEM PASSES: +,YS 1 have not found any information which indicates that*any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: E. STEIN CONDITIONALLY PASSES: no or more system components as described in the 'Conditional Pass'section creed to be replaced or repaired. The system.upon mpletion of the replacement or repair,as approved by the Board of Health.will pass. Indicate yes,no, or not determined(Y.N.or ND). Describe basis of determination in all instances. N'not determined*.explain why not. _ The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance lattached)indicating that the tank was installed within twenty 120)years prior to the date of the inspection: or the septic tank,whether or not metal,is cracked.structurally unsound,shows substantial infiltration ur e:filtration. or tank failure is imminent. The system will pass inspection If the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipets)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipets). The system will pass inspection if(with approval of the Board of Health): broken pipets)are replaced obstruction is removed rp J-2 Se A- 5 j G/G y Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Iconorrued) P.opartyAddress:61 Hilltop Drive, Marstons Mills Owner: Saladino Oote of Irfypae n etio C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES N ACCORDANCE WITH 310 CUR 15.303 1111b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is'within 50 feet of a bordering vegetated wetland or a salt marsh. 2) STEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS NCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance lapproximation not valid). 3, OTHER PaRc3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Icontuaied) Property Address: 61 Hilltop Drive, Marstons Mills Owner: Saladino Date of on: O. SYSTEM FAILS: u must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure Y s No Backup of sewage into facility or system component due to an overloaded orelogged SAS or cesspool. Discharge or pondmg of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 day flow. _ _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipets). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E. RGE SYSTEM FAILS: You ust indicate either "Yes or "No' to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facihty with a design flow of 10,000 god or greater(Large System)and the system is a significant threat to public health and safer and the environment Y o meat because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone If of a public water supply well) The ow er or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412). Please consult the local regional office o the Department for further information. PaRr 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Prowny Address: 61 Hilltop Drive, Marstons Mills Dwner:Saladino Date of inspection: Check if the following have been done: You must indicate either `Yes- or 'No" as to each of the following: Yes No ✓/ _ Pumping information was provided by the owner,occupant, or Board of Health. None of the system components have been pumped for at least two weeks an&the system has been receiving wermal flow rates during that period. Large volumes.of water have not been introduced into the system recently or as part of this inspection. �( _ As built plans have been obtained and examined. Note if they are not available with NIA. _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components,excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions.depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _ Existing information. For example. Plan at B.O.N. J,,/ _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) 115.302(3)1b)) v _ The facility owner land occupants,if different from owner) were provided with information on the proper nwintanaixesof SubSurface Disposal Systems. I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION '►opeRy Address: 61 Hilltop Drive, Marstons Mills Owner: Saladino Date of inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: Z/SD g.p.d.lbed►oom. Number of bedrooms(design):-& Number of bedrooms lactual):J-1 Total DESIGN flow 1-/,s0 Number of current residents:`a Garbage grinder lyes or no):A c) Laundry(separate system) (yes or no):Aa; If yes.separate inspection required Laundry system inspected (yes or nol Seasonal use (yes or no):li o Water meter readings,if available llast two year's usage Igpd): 4999• — -f-��o—Gal Sump Pump (yes or no;:A- v Last date of occupancy:lU_5-a— . 1998 53,000 gal. COMMERCIALANDUSTRIAL: Type o establishment: Design ►ow: opd 1 Based on 15.203) Basis of design flow Grease rap present: (yes or no)_ Industri I Waste Holding Tank present: (yes or no)_ Non-sa itary waste discharged to the Title 5 system: (yes or no)_ Water eter readings, if available: Last ate of occupancy: O : (Describe! Last date of occupancy. GENERAL INFORMATION PUMPING RECORDS and source of information: /q9 9 /lm 2 s- System pumped as part of inspection: lyes or no)/-L-U If yes. volume pumped-o 0-U gallons Reason for pumping Ic a; 1,0 is TYPE OtF,.S1STEM Septic tank%distribution boxisoil absorption system Single cesspool Overflow cesspool Privy Shared system Ives or no) (if yes. attach previous inspection records.if any) VA Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other ,I APPROXIMATE AGE of all components, date installed(if known) and source of information: li Sewage odors detected when arriving at the site: (yes or no)-A-v `' • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION IearOrwd) -rop"Address: 61 Hilltop Drive, Marstons Mills owner: Saladino Date of hupeebon: a ING SEWER: floe to on site plan) Depth elow grade:_ Materi I of construction:_cast iron_40 PVC_other(explain) Disten a from private water supply well or suction line Diamet r Comm nts: Icondition of joints. venting. evidence of leakage,etc.) SEPTIC TANK: (locate on site plan) �d I Depth below grade:GL Material of construction:_'concrete_metal_Fiberglass _Polyethylene—other(explain) If tank is metal,list age_ Is age confirmed by Certificate of Compliance_ (Yes/No) A Dimensions: Sludge depth: + Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: +� Distance from top of scum to top of outlet tee or baffle: i Distance from bottom of scum to bottom of outlet tee or baffle How dimensions were determined: loc— ] y. :oniments: Irecommendation for pumping, condition of inlet anc outlet tees or baffles,depth of liquid level in relation to outlet invert. structural integrity, evidence pf leakage. e3.) b / �. + S +i. �,L 02 GREA RAP: (locate on ite plan) Depth below grade:_ Material of c nstruction: _concrete_metal_Fiberglass _Polyethylene_otherlexplain) Dimensions: Scum thicknes Distance from op of scum to top of outlet tee or baffle: Distance from ottom of scum to bottom of outlet tee or baffle: Date of last pu ping: Comments: irecommendaY in for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of le cage. etc.) + — L c Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION lean*wso 'roperty Address: 61 Hilltop Drive, Marstons MIlls Owner: Saladino Date of Inspection: TIGHT R HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate o site plan) Depth bel w grade:_ Material c construction:_concrete_metal_Fiberglass_Polyethylene otherleuplain) Dimension Capacity: gallons Design flo gallonslday Alarm pre ent Alarm le" I: Alarm in working order: Yes_ No_ Date of evious pumping Comma ts: (cond ton of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX:_✓ (locate on site plan; Depth of,liquid level above outlet invert: Comments: mote if level and distribution is equal, v'den tx of olids carryover, evidence of leakage into or out of box, etc.) - PUMP HAMBER:_ (locate n site plan Pumps i working order: (Yes or No Alarms n working order(Yes or No) Comm nts: (note onditton of pump chamber, condition of pumps and appurtenances. etc.) =e ` ' ` Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(eorttirttrlidl top"Address: 61 Hilltop Drive, Marstons Mills Owner: Saladino Date of/Inspection: SOIL ABSORPTION SYSTEM(SASI:j_.,/ (locate on site plan,if possible:excavation not required,location may be approximated by non intrusive methods' If not located, explain: Type: leaching pits, number:_ leaching chambers,number:-2—LL— leaching galleries. number:_ leaching trenches, number, length: leaching fields. number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: Inote condition of soil, signs of hydra c failure. level f ponding. damp soil, condition of vegetation, tic.) �- 5 7-6 a---� s c t'.�,,-- of CESSPOOLS:_ (locate on site plan) /1 Number and configuration. o Q, Depth top of liquid to inlet rover . ')epth of solids layer: Jiepth of scum layer: l Dimensions of cesspool. Materials of construction Indication of groundwater. inflow Icisspooi must be pumped as part of inspection; Comm nts tnote c ndition of soil, signs of hydraulic failure. level of ponding, condition of vegetation, etc.) PRIVY: Notate o site plan) Materia of construction Deoth f solids: Dimensions: Coro a s: Inote con ition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PAP(9 of I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION leontim adl -'rop"Address: 61 Hilltop Drive, Marstons Mills .)Wrw: Saladino Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) t i� • rA r� P.Rc 10 of I I SUBSURFACE SEWAGE DISPOSAIL SYST6N NSPECTION FORM PART C SYSTEM WFORMAT11ON leonsrnatdl ,opeityAd&*": 61 Hilltop Drive, Marstons Mills Owner: Saladino Dote of lnspeceon. /1- 7-�--' NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Deep Groundwater depth: Shallow Moderate SITE EXAM Slope Surface water - Check Cellar '' Shallow wells i Estimated Depth to Groundwater'3 7 Feet Please indicate all the methods used to determine High Groundwater Elevation: -Obtained from Design Plans on record Observed Site (Abutting propenY.observation hole. basement sump etc.). Determined from local conditions 1/Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators.installers Used USGS Data Describe how you established the High Grounowater Elevation. (Must be completed) 9/2 /7E PaRc11of11 .t O CATION SEWAGE PERMIT NO. r �21 '0jL,-r0P A 6-2.--2- VILLAGE INSTALLER'S NAME & ADDRESS H . Co LAlByTE ® U I L D E R OR OWNER DATE PERMIT ISSUED __ q DATE COMPLIANCE ISSUED I 13°gee .. .. 0 'Fowa -NCO - 4 "41 FRic ..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..... .Owl ................................ .......I.........OF....... Appliration for Bigpviial Murks, Tomitrurtion ramit Application is hereby made for a Permit to Construct (V-1"or Repair an Individual Sewage Disposal System at: ............................4u�L-Tnp....... .................. ....................................L. .....Pr ........................ Location-Addr or Lot No. ................................. ....... ...�.A.tj................. .................................................................................................. T.a Own A ks.s. Pi!;j.0 " .........Lnel_w Installer Address PQ d Type of Building Size Lot_14+.'5 JQ......Sq. feet U Dwelling—No. of Bedroo ms____._._.._............13.............................Expansion Attie Garbage Grinder (Other—Type of Building ............................ No. of persons......................_.._.. Showers Cafeteria ( PL4 Other fiytpres ...................................................................................................... .•............ .. I -t� _"" , ---------------------------- Design Flow............... _5........ gallons per person per day. Total daily flow-----------------350.............gallons. 'Abb' 11 ; Length................ Width__......_.......W Septic Tank—Liquid'capacit, -- ga om Diameter................ Depth...........— L �. .................... Width-,v. Total leaching area--------------------sq. ft. Disposal Trench N Total Length....._......I-.----_I------- Seepage Pit No_________ __ ------ iameter......172........ Depth below inlet......4.......... Total leaching area...'Z&-,3- ..sq. ft. Z Other Distribution box Dosir;g tank ( ) Percolation Test Results Performed by-64- .4Ayw.....k.JC*J'*...P.6 Date.....4:!7 _-.-5 ...... Test Pit No. 1.....�---minutesperinch Depth of Test Pit------------....... Depth to ground water------------------------ fi, Test Pit No. 2................minutes per inch Depth of Test Pit..... ......_....... Depth to ground water......_____..__....____. 4 . ......................... ............... ................................................................................. ............. b., 0 Description of Soil------.................. ......M.................S Al _----------------------------------------------------------------------------- -------------*---------*--------------- --------*..............---------------------*-------- -------------------------------------------------------*--------------------------------------- .........I......................................................................................................................... ................................................................... U Nature 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 TIT 1.2' 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beenjssued by the board of health. Signed... ail j. ...................... ................................ Date Application Approved By---------------------d�.F, Date Application Disapproved for the following reasons:................................................................................................................ ........................................................................................................................................................................................................ Date Permit No....::.Ii�....... 7.Y--'-'-•--------------- Issued-....--------...7- /- 7 -"X— ......................................... Date r•.Y �• k No....... FEs............................_ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH tf. �f,..................OF....._RA(_1 ................................. Apphratiun for Bispvaml,. aarks (nomitrnrtton ramit Application is hereby made for a Permit to Construct (✓ or Repair ( ) an Individual Sewage Disposal System at: ILt,'EQP-•-•-•-••-•- 12 Utz (� Location-Addre s or Lot No. Own r Address W G JT t P gal_#`.b b .-----•...:.............. .... .........••• -•---....._..__... s......... ............................... Installer Address Q Typeg `�U®------Sq. feet of Building Size Lot_______________ Dwelling—No. of Bedrooms.______.__.................................Expansion Attic ( ) Garbage Grinder ( ) 'k Other—T e of Building No. of persons---:......................... Showers — Cafeteria QIOther fires ...........................................___ Design Flow_________________``?__................'.__gallons per person per day!. Total daily flow____._._____.__.____._____.0._._._.___gal W _.__ Ions. 9 Septic Tank—Liquid capacity_ .gallons 1 Length________________:Width................ Diameter................ Depth................ Disposals-Trench—No. .................... Width__._____._ Total Length._.__.______..____ Total leaching area....................sq. ft. Seepage Pit No___________________ Diameter.___..7_........ Depth below inlet..... .......... Total leaching area__. _1___sq. ft. Z Other Distribution box (Ix) Dosi tank ( ) aPercolation Test Results Performed by r p_ -- _ 1 ...._ ...__ .___ 1 Date___4�:..Er Test Pit No. 1.....7�-r....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........................ PG ------•-- ------•-•---------•--••---•• ------------------------------------------------------------------------------ 0 t7 t ----•--------.__- D Description of Soil......................... - -----------------------•-------- U ---..--•---------------•-•------------..._.,..-----....------------....__._...__.:.---------••----------•-•----------------•--------•-------------------•----------------------------•--•-•--••--------- W --••--------------••-•-•••---•-•---••-••----•-•--••••-••••-•----------••-•..__.....••-••-••-•---••-----•------------•--------•-------•--- ---•••••----.............................................. U Nature 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`:.TILT.1:IW. 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed -•---------------------••---•--• ,f y Date ApplicationApproved BY--------- -----y 4------..._....._._..._....__.......•--•----•---------•-------•- ........................................ % Date 00 Application Disapproved for the following reasons_________________ _ .......................................................4-_4.et!_41.____..._. ....•----------•-•--••-•-•-----•------•-•••-•••-••---•••---.....---•-----••--•-••-•-----•--•-•----••-•••- Date PermitNo.......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS ,-ro r ,I�OARD C .....................................OF..................................................................................... Cyr gf iratr of Tautlitianrr THIS I 'CERndividual Sewage Disposal System constr •ted ( ) or Repaired ( ) by ----------------- --- .....•• -----._... ''� ...•-- ...........nstaller at.........................................-•-----•------•----•-----------------•-----------------•—--, tom/ has been installed in accordance with the provisions of �I_IL., f) of ®✓Sta e 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 WILL FUNCTION SATISFACTORY. 1 v- DATE----------=-=----•--=-=•----:_._.....-•----...:..........-------•-•-----•-•---- Inspector............�.....__..__.._..__.. ............................................ THE COMMONWEALTH OF MASSACHUSETTS . BOARD CSP IEALTH z" No......................... , FEE........................ . Permission�' ereby granted -.-•-. r' ..._.. IV to ConstructI�e�air ( V_P` rtt'--I•' di al a �a a Disp�yst �. atNo..................................•.......................................................................... ------------------------ e i reel as shown on the application for Disposal Works Construction- ? %mit N _ !�� e _____________________________________ — 1 77 f_^ Board of Health DATE =" = - ----•-----•------------•-•--•-----•--`='...............:w, ,. FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS" LIJ It Ij 117, ti - WO GAQB -r AGU- P%-Ow Itv x 3 = 330C.Pt? P T I C, T A, 149 f G.P. D If G 015PD.!5AL P17 U�E7 00 CAL-. t V- k5o l?,0TT0M AIZEA-r it -Tc>TAL- cow NVATIOpJ -T V4 3 3 0 r-- Q-C 0 L A-r c>u P-A-T r-- I N Z M M C>r,'-L r= m W. LOT N 7,& 01 io V-X 1p .19 4L ►Z- -T 5T TOP F"D 1 0 G.L 1-ID L p r, 44� c>c>0 tw\j. ji %),% Soft_ DIST. INS lefst... 169.00 INS( TANK I G PS,I- it LGACIA INV. .IN\/ IdlTta iI A'-I V2- WASqV-D STUNS jj 9--r t V- PLOT A7r I&W CA L S SATE vr�lolBZ.. �a wAT�IZ 4 /z3/8Z PLAN REP61ZE►� GE' G6R-T P -T itA AT 'T S-- I`KOr- FO L)14 t>, :!5"0 WKI "sq-v--0w COMPLY!S Wj-TVA -XHrc- �1--c)-T� t 0 AZT \-0 wrr"w T1Ac-- V%000 PLINAW o A-r c-- B^-Y.-rsv_a WYL- INC. 5rT T--7-S•D').AM 0 IS u F-V C-Yc-E`5 -T41t!5 PLN- KI I d!>I'd AN C:O 5rC-9-\/I LLr-- wAA ,!5. -THE I -T 5G STF\,(Z-- n-.ate # -� x•s� =.T •• -.c�..,n.�„,� ,•. „�.. G. „1 a"d' tad- ''JTB.. i� 51�.tGuC FAMIL.V '^„3 RFO.tZooM NO GARpAGC- t!j2.1/JDEQ II DAII.y F►.ow m Ilo x ;s �30G.Pt? L- -r Ij .5EPT%G TAuK = 330x1 C>% a.49!76.P. Q /1, % ' ol,pos�t. F'IT u<,F !o 00 GLl1.. . .,�°�• . i� 9 3 5%DF WALL AV-SA, BOT-rOM AIZI~Aa 113 S.F•. 10i'. L 11.3 S.l~ x I• o 3 i6-Po6.P s ' ' � •ToTA I- CIS516N= .4.g8 GRl7 T:N•. t�otosis�`° 1'�r 50u.So. I -TaTA%- DA 1 LY F1-ow ,- 33o G?a a woo 1 `! PC2G0LATIpI4 RATE. I•�IN ?-MIN 09-141✓5rs pj 0%x` o' .� LOT 11 o o �°° ,, PIT ci WILUAM `J'•�;. �� AInN O.. (� / C. M.r E 'er Jar w,a . . .t oS•t R '~ r: ,p INo. 1.1'14, G I, •T1=ST TOP FWD 0 /OL 101. �I 7M.�• ir- _ (WV-loa. s. oco INv. oa.-/ DIET. INV. ff�.. 1oo.po Butt5 r, G II GAC IWd, 9�.8 TANK I LEAC.t.{ 99 L . PIT. . INY. .._. .1yV _. ..... .__.. _........_ .. --... ._.._ . HgcwM I W I Tu wj 9U. . . . . . . a L. ,AND, WASN'.p ... .. ..i + I GEP-TIFtCD PLOT. PLAN F7ROFILE • M A.RS-T O to S qO' z "• 1J0 =�GALtc -. SGAL.E • .____.-____ �'=.moo.: . ATE s/. Io l.e z 4/L3/8 L P t-A n.► RE t=rc1ZEN G6 1 E F-RT_I r-S! -T H AT -r N E-- P%6r. ro V N t), SHo WN NEREo►a GotAPL%(5-WITN-tWE .G,tT.►St_%WGr :LOT i O AM0 SETtcNAGK' rc-t.00112> i�F_NTy oFTµE- 1't.-All iK• 1'Z"� t��. .� 09 'ToWN Or- SARRSTAbL-'EAND I,� NOT' 1..0CATe0 WITHIN TNf•_ C%poj> PLAIN DAT BAXTEI a NYE FNC. REG i SZ rr-zrwi>ILAt t 0 S u vve rvYoe-s Tu15 P1.0.1J t�� Nc�T'$A�Eta: r�►d.;:At� OSTC-2.VILL& • i►JSTR.v.M6.hi, S�i2YC y 'T.HE•' cis c-5�� Sttou� NoT dE V��l-:.DTb 174Tt=:�J�1►�tE._LaT 4.INE.�j _ APPI.ICAI�JT �TtYC G 2�L 92,274, 7 �� =P(Afg4 �*y .r t ' n ! `J G t