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HomeMy WebLinkAbout0125 HOLDER LANE - Health !- Holder Lane Marstons Mills V A= 174— 001 —006 No. 'l.J�.7� � Fee ✓�� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes applit ion for Disposal *pst ConstrUtti01Y 3pPrmit Application for a Permit to Construct( ) Repair( ) Upgrade( Abandon V Complete System ❑Individual Components Location Address or Lot N B Owner's ame,Address,and Tel.No. Assessor's Map/Parcel fy7 C�1 � t e a Installer' ame,Acl♦d*s , nd Te N _ I Designer's Name, ddres d Tel N r'I w Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.,r uir d) gpd Design flow provided gpd Plan Date 9 � ��Q Number of sheets Revision Date Title Size of Septic Tank I® , Type of S.A.S. '— Description of Soil !6" Nature of Repairs or Alterations(Answer when a plicable) �► Y 1 1 t� 1 u' U W 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 C de and not to place the syst in operation until a Certificate of Compliance has been issued by thi ealt SigrV d Date C1 Application Approved by Date Application Disapproved by Date for the following reasons Permit No,,—,;, ,�t �j Date Issued �.,.,.a:..�t�.-.��ar...�,. �� ,.,;..+�.tea,.., �..r �-.�•�.•,.r,.f ...�. �, �i..ftr ,,.r .',�+� z"1a ryr F.'Mt.:� '"F•.��. T` ^��t,..ah.. �.i+. ...,r-r *+�4�m,,,,...,..«-.-•..iM+-r.,� ..R.,�..:i y ;r 'Fy 7 .. :'� . No. '�d T�.1 . . Fee ✓ � THE COMMONWEALTH"OF MASSACHUSETTS'. Entetedincomputer: Yeses✓ }, PUBLIC HEALTH DIVISION'- TOWN OF BARNSTABLE, MASSACHUSETTS 0(ppYicaStion for P-isposal *p..steln �OnBtCUctton ertnit Application for a,Permit to Construct Repair Upgrade(f) Abandon(j ®�Complete System El Components Location Address or Lot NQ� e Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 1-714 c>r->% MR S , Installer's Name,Address,and ATe�No. � Desi n-e-r;'ss N,,ame�,Address,and Tel.No. . �t , .. L C.� Vj J,.. .,.. 7Z Type of Building: a Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria Other Fixtures , Design Flow(min.re` uired) gpd Design flow provided gpd ' ». 'Plan Date. �.� Number of sheets , •• 1 1 Revision Date �/�� Title ✓ Y` i o 5�10� - Size of Septic Tank ttC. O � Type of S.A.S. C6 Description of Soil 601 C L. r 1. I Nature�ofyReppa�irss or Alteration It s �(Answer when applicable)' 21D 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 syst in operation until a Certificate of Compliance has been issued by this -© ealt n Signed Date C4 7,AWr-N Application Approved by _ Date Application Disapprovedrby Date 1 for the fol l4 ing reasons s Permit No,,, , 3' / rJ —�.... � Date Issued ' ', yF THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS W Certificate of Compliance i• THIS IS TO CERTIFY,that the On Sewage Disposal system Constructed( ) Repaired( ) Upgraded )°`�+ 5 10t1 Abandoned by _ » r at has been constructed in accordance v with the provi ions of Title 5 and the for...Disposal System Construction Permit N9��r <. aced Y f 71>4 °)1� H Yi � . Installer 1 Designer #bedrooms Approved design fl ` gpd The issuance of this permit hall not a construed as a guarantee that the syste will fia c'on a del]signed. t Date ��t" Inspector\ No.­-Or90 a " * Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS ` Misposal �6pstem Construction J9.Prmit f Permission is hereby granted to P1 nstruct( ) Repair( ) Upgrade(1,,.)o' Abandon System located at arid as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. , r _ Provided:Construction 77se b 24Pleted within three years of the date of this peN two imr }Date /�( Approved by S Town of Barnstable Inspectional Services 1 Public Health Division > &63 j' Thomas McKean,Director r 200 Main Street,Hyannis,MA 02601 Office: 508-8624644 Fax: 508-790-6304 .,, �i Installer&Designer Certification Form Date: 1\--1(o72wn Sewage Permit# 33 Assessor's Map\Parcel/?-Y D01/fie" Designer: �DI,4v)O & 1" 4564) Installer: ��ik'laie��C Address: 54 4 0 w i c- '1114 Address: 5z On 2 W �°������C- �btis% was issued a permit to install a (dat ) (installer) septic system at 0114OLe-0e 1, based on a design drawn by (address) �4v;0 1v /11 4 dated Q/-LIW (designer) I certify that the septic system referenced above was installed substantially according to the design, which'may.include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils. were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State &Local Regulations. Plan revision or certified as-built by designer to follow. Strip out (if required)was inspected and the soils . were found satisfactory. I ce fy that the system referenced above was constructed in compliance with the to rms of approval letters if applicable) the PP ( PP ) . OF A4gsdq� DA�ID yG nger' na e) 1JIAS�NEQ No.1066(Des) rs Signature) (Affix. ,��1 #� 1 Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. 11toa\depts\HEALTHISEWER connecASEPTIC09signer Certification Form Rev 8.14713.DOC TOWN OF BARNSTABLE LOCATION/07'57 41-OCIR A/41U_ SEWAGE# - VILLAGE�L)e,S7 '134,e r g/ASSESSOR'S M��ArrP&PARCEL/7i1 06� INSTALLER'S NAME&PHONE NO0'e61 4C -c. AO, fp9'�- SEPTIC TANK CAPACITY 16&-0 94C. T°f,,Ko too,, 94 L /0010?o SOW, a v Cfl9��x�S N�' LEACHING FACILITY:(type) � j /�=?� (size)�>J`x /2 4 r r NO.OF BEDROOMS "7 OWNERr� PERMIT DATE: COMPLIANCE DATE: t0 V .0 Separation-Distance Between the: ` Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY l R P � ��y �h F ,�. �� �� � e �_ � � 11-S O �" � ���I.e,� TOWN OF BARNSTABLE LOCATION IPS' 1161MZ LA/ SEWAGE # 7— VILLAGE _ ASSESSOR'S MAP Cz LOT INSTALLER'S NAME & PHONE NO. A & B CANCO 775-6264 SEPTIC TANK CAPACITY X0,06 43AP LEACHING FACILITY:(type) L (size) �e (o 2 s���' e NO OF BEDROOMS -7 PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER �Iq de DATE PERMIT ISSUED: 49 7 DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes N6 �� its r v TOWN OF BARNSTAB.LE ,LOC.4.TION 3 L SEWAGE # VILLAGE ff..nTt a2dl C57-,,X, ASSESSOR'S MAP dz LOT INSTALLER'S NAME & PHONE NO. j Qe,� '(a co -7 wn Or- R toSEPTIC TANK CAPACITY /r/)py ug ky"?S LEACHING FACILITY:(type) ' �,"i (size)/ riw,� `6.6y NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER M cGr e r� 1 DATE PERMIT ISSUED: J=2 '­/—S/ DATE COMPLIANCE ISSUED:!a VARIANCE GRANTED: Yes No .� .��? i 6 fl /s9 �3 a9,y ea, °�<<r _wry b' ��/ So� c Commonwealth of Massachusetts Do(, Title 5 Official Inspection Form .1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 125 Holder Ln Property Address Bank Owned Contact David Holt ' ( @Today Real Estate 1-800-966-2448) �. Owner Owner's Name w' information is required for every W. Barnstable MA 02668 2-13-20 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. Inspector Information l IN 3�a-- Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that:l 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 theproperty 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. ❑ Passes 2. ❑ Conditionally Passes +. 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ® Fails 2-13-20 Wspector'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 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 form should be sent to the system owner and copies 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 s Commonwealth of`Massachusetts ' r� ,w Title 5 Official Inspection Form �,I'I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments W ,lam` ;> 125 Holder Ln Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is ?f required for every W. Barnstable MA 02668 2-13-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) SystemPasses: ❑ 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form S�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 125 Holder Ln Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every W. Barnstable MA 02668 2-13-20 page. City/Town 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 ON ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑Y ❑ N ' ❑ 'ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑Y ❑N ❑ ND (Explain below): ❑ obstruction is removed ❑Y ❑N ❑ ND (Explain below): 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 15.303(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 c Commonwealth of Massachusetts Title 5 Official Inspection Form i i-'l Subsurface Sewage Disposal System Form -*Not-for Voluntary Assessments rfd% 125 Holder Ln Property Address Bank Owned (Contact David'Holt c@ Today Real Estate 1-800-966-2448) Owner Owner's Name information is W. Barnstable MA 02668 2-13-20 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 ® ' E 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 s Commonwealth of Massachusetts 1 Title 5 Official Inspection Form hi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 125 Holder Ln Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every W. Barnstable MA 02668 2-13-20 page. City/Town 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 '/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 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- 10,000 gpd. ® ❑ 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. 5) 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 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 11 of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts ,,;� Title 5 Official Inspection Form ��r� 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - Q:: ? 125 Holder Ln Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every W. Barnstable MA 02668 2-13-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 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 all 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? ® ❑ Wasthe 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts k f I � ,. Title 5 Official Inspection Form i 111) Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 125 Holder Ln r� Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every W. Barnstable MA 02668 2-13-20 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms(actual): 4 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Description: Number of current residents: 0 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 ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No g Last date of occupancy: Unknown t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts r� �3� Title 5 Official. Inspection Form curl Subsurface Sewage Disposal System Form-Not-for Voluntary Assessments a 125 Holder Ln J- Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every W. Barnstable MA 02668 2-13-20 page. City/Town 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: N/A 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 w Title 5 Official Inspection Form ! C�l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 125 Holder Ln Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every W. Barnstable MA 02668 2-13-20 page. City/Town 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: 1990 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 24"feet i 1 Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. t5insp.doc-rev.7/26/2018 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts 3 Title 5 Official Inspection Form w:� i�l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 125 Holder Ln Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every W. Barnstable MA 02668 2-13-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) - 6. Septic Tank (locate on site plan): Depth below grade: 18"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate.of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 12" Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 a Commonwealth of Massachusetts Title 5 Official Inspection Form w., I11I Subsurface Sewage Disposal System Form -Not.for Voluntary Assessments � ._ 125 Holder Ln � Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every W. Barnstable MA 02668 2-13=20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet f 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 c � Commonwealth of Massachusetts 0 Title 5 Official Inspection Form w:,I� i�l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 125 Holder Ln Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every W. Barnstable MA 02668 2-13-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) 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 opgned)(locatb on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box had stain lines above inlet invert. , t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 cam` Commonwealth of Massachusetts T r� 4. Title 5 Official Inspection .Form } < I Subsurface Sewage Disposal System Form -Not.for Voluntary Assessments 125 Holder Ln Property Address Bank Owned (Contact.David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every W. Barnstable MA 02668 2-13120 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 s Commonwealth of Massachusetts Title 5 Official Inspection Form C�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 125 Holder Ln Property Address Bank Owned (Contact David Holt a Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every W. Barnstable MA 02668 2-13-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) 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 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box had stain lines above inlet invert. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 f , c Commonwealth of Massachusetts ,w Title 5 Official Inspection Form hI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 125 Holder Ln Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every W. Barnstable MA 02668 2-13-20 page. City/Town 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: Type: ` ® leaching pits number: 2-1000 gal ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection form i i>,I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .�.:� 125 Holder Ln Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every W. Barnstable MA 02668 2-13-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System(SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pits had stain lines above inlet inverts and into riser. 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form il + "' i�4 Subsurface Sewage Disposal System Form Not for Voluntary Assessments 125 Holder Ln Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every W. Barnstable MA 02668 2-13-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts - 3 Title 5 Official Inspection Form il ill Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 125 Holder Ln Property Address Bank Owned (Contact"David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every W. Barnstable MA 02668 2-13-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 f C 3 °j- r � cp.- -36 A- 3 y �. ad t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts A Title 5 Official Inspection form bl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 125 Holder Ln Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every W. Barnstable MA 02668 2-13-20 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: 20'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database- explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 20'. 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 s Commonwealth of Massachusetts r� Title 5 Official Inspection Form Ir' o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 125 Holder Ln Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every W. Barnstable MA 02668 2-13-20 page. City/Town 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 t t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Town of Barnstable Inspectional Services Department ` FUNAM Public Health Division i639 �0 'moo Mai" 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1730 0001 4988 0787 February 20, 2020 } SIFFLARD, WILLIAM A & SUSAN M 125 HOLDER LANE WEST BARNSTABLE, MA 02668 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 The septic system located at 125 Holder Lane, Marstons Mills was inspected on 02/13/2020 by Shawn Mcelroy, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. You are ordered to repair or replace the septic system within one (1)year from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF T BOARD OF HEALTH �hoci]Kean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title'V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\125 Holder Lane Marstons Mills.doc a�°f t�r°wti Town of Barnstable • BARVSfABLE, 6 q Inspectional Services Department lfD MA'S� Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 4/26/19 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An "x" marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ❑ Structurally unsound septic tank or SAS O T 1 YEAR DEADLINE CRITERIA Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any "conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc VOW No. " Fee THE COMMONWEALTH OF MASSA HUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pprication for Digoal *pgtem Con6truction Permit Application for a Permit to Construct( )Repair(✓Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. �a d e J/,4i2�_ Owner's Name,Add d Tel. Assessor's Map/Parcel �' �a��ff��✓ fit E� �r q- 01. 001, Installer's Name,Addts&alj TdArgC0 Designer's Name,Address and Tel.No. 350 Main Street W.Yarmouth. MA 02673 Type of Building: Dwelling No.of Bedrooms Lot Size 19JQQ 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 q O Number of sheets 1 Revision Date Title Size of Septic Tank /000 Type of S.A.S. k do foo� tJ J,I Description of Soil _e,r d t A-A j Nature of Repairs or Alterations(Answer when applicable) 245 fA/ ---e Se,r v-c. ck ✓c o` n 4e l- 4 P /&-o0 tj 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 B of r . SignedV Date Application Approved by ZICIf Date �' � Application Disapproved for the following reasons Permit No. s' Date Issued :0 —0 -� f k " No. � ~ Fee THE COMMONWEALTH OF MASSA(HUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS P 01pprication for Migpogaf *pgtem Congtructton Permit Application for a Permit to Construct( )Repair( -),Upgiade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. �a S � l�qr(,� Owner's Name,Address and Tel. p. Assessor's Map/Parcel 3 1'1 1 S; Installer's Name,Addressn �N�ANCA Designer's Name,Address and Tel.No. 350 Main Street u�H W.Yarmouth, MA. 02633 Type of Building: Dwelling No.of Bedrooms_.2 Lot Size o42 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showeis( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date 19 9 1�1 Number of sheets I Revision Date Title �t Size of Septic Tank /one) Type of S.A.S. _ 419 ivoo LJ/1 ' Description of Soil ;?3. f 4 At 4_2 #- V Nature of Repairs or Alterations(Answer when applicable) 27,15 bq/ r_e Cc r a-r ck e- n e ` n 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- cateof Compliance has been issued by this Board of ea I . Signed Date -9 '7 r Application Approved by ag Date Application Disapproved for the following reasons Permit No. � Date Issued 0- 2 � 0 �^ux g THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( .,.)'Upgraded( ) Abandoned( )by e_"w /,d i at /,)S- 4(011w,! & e- /6e has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. _rl dated Q2 ��'!_ 9' Installer r'14-"to Designer The issuance of this permit shall not be construed as a guarantee that the s t 1 function as d_e nedd Date �� Inspect - �i No. / Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migpogal *pgtem Congtruction Permit Permission is hereby granted to Construct( )Repair( ✓rUpgrade( )Abandon( / System located at /c?s /�P�/ �i4i'ZP�/o�����.,fff a6 GP 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 rmit. Date: < Approved �5e__ � 12 � , • n. 1 �--� � DS YI 1.2 9-7 �n Si-Ac, rzX Pao CY So ASSESSORS MAP NO:No . x .,.. .... ... PMCELNO: '20/.-'�o r Fes$ o A THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiun for Disposal Works Tonstrndiun rumit Application is ��readgok Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: �j J ._ �......../�o�� ...�:-�....------ --------------------------------------------- 07/0 -----.........---- Location-Address or Lot No. ----------.......----._ �G ...................... _ -------- / Owner Address ,W1 I G C C/ . ..1�1-X d.!1....._D I. 1,24 C2,? c Installer Address � Type of Building Size Lot___________________________S q. feet V Dwelling—No. of Bedrooms....__.3.....r_---_-.-__._ -Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ..(,s........_...... No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures --------------------------------------------------------------------------------------------•---•-----------------------....--------------"--------- W Design Flow......... 3_a.he_a._B lons per person per day. Total da�y flow--------------- ..................gallons. WSeptic Tank—Liquid capacity/.0-0 -gallons Length------- Width..._........ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length...................... Total leaching area....................sq. ft. Seepage Pit No--------/---------- Diameter......... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '-� Percolation Test Results Performed by........................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_.___________..----.._-. Li, Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water........................ a ............................................ --5-'-. 0 Description of Soil-------------------------------'----............--•-------------- ���^----------'--------..-..------•-....'..... (� ----------------- ----------------------------------------------------------------•--•-••-----••------ ---------------------------------------•-----------------------------------------•---•------------------------------------------•---------------------------'------'-----------------------"-......---- V 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 TITLE 5 of the State Environmental 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 ......... -------------------- ------------------ � Dace Application Approved By ........ -- `^ � Application Disapproved for e followang reasons• .........................................................................._---- .................................................... .-. ---------- ---------- - --------------------------- ----------------------- --------------------- --------------------------------------------------------- ........................................ ----- �j - ----------- - -- --- ---- - a PermitNo. ! 0--^--),0------------------------------ Issued ------------------------...............................D te-- Dace �. ..No..... lJ ............ " THE COMMONWEALTH OF MASSACHUSETTS A BOARD OF HEALTH P '3 TOWN OF BARNSTABLE Appliratiou for Disposal Works Tonstrur#inrt trruti# 9 Application is hereby made for a,Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: /� C'4'{ �''�16 Location-Address or Lot No. ----------------------- = -...�/5. ..--........... --- Owner Address - (- r-? ---- - ---- v -- --+- -----7.... ..._ ........---'=ii1., ._ Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms _ _!-y'� ___________Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building Q a yp g _______�__________________ No. of persons._.__..________________._.__ Showers ( ) — Cafeteria ( ) dOther fixtures .-----------•----•--•-----•------------•-------•-......--•----------••---------------------- --------•-----••------•-••-•-- W Design Flow.__.....:?3.0._/72:?i ...�&lions per person per day. Total daily flow..............._3-?_0............_....gallons. WSeptic Tank—Liquid capacity-//t gallons Length____________ Width...... Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area_______^_._...._...sq. ft. Seepage Pit No---------/--------- Diameter........../_?_...... Depth below inlet____________________ Total leaching area..._L�j .......sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 4 " Percolation Test Results Performed by.......................................................................... Date........I.---....---------••-......--- �l Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water.....................ri:,. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.........4..__.__._. Depth to ground water--------4 __ _ a �'' --�.......ri:'-----........................................................ O Description of Soil---------------•------------•--•---....----.....-----..._......•• i._..-----•--- U -•••--••-•••-••--•------•--------•••-•-•-•••---....---•------------------••-•--•-••-•.........----•-.....---•••......-•-•---------------••.------•••••......----•••....._.......--•-••...---...... UW ---------------------------------------------------------------------------------------•-----------------------------------------------------------------------------------------------......•---•-••... 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 TITLE 5 of the State Environmental 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. r Signed l,`Jr.�� � l/ r .......... Date Application Approved By ......... . ... .......Z ..... .. .. --- . •, Application Disapproved for the following reasons• ------------------ ----------------------- ------------------------------------------------------------------------------------- `�.,,. �y Date tPermit No. .........-1.... "" ............................ Issued -------- ............................ Z Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C9Prtt£t.cato of Compliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( ) at------------------------- -- - ----------------- -- - 4 .i------ ------------------ - ------ .................................................---------------- ................�1� .. ...----.- --- .................. �--i.-.•F�..- N.fi-:.�.---..�,.x..1. ..--- ..---..1.ea ..........., Ri .p_ f!- ---------------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. .....y��C>- "f "---.------- dated ............................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. �^ n DATE -��.:"-- +----- � 7------------------------------------ -------- Inspector .....................................................................................'.�... Y � � W THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No .... 'EE.. Disposal Works Tonstrudilan "prrutit Permissionis hereby granted.............................................................................................................................................. to Construct (,C) or Repair ( ) an Individual Sewage Disposal System at No...... / a'T t-• - 1 �P„�0�_-� `� \�1- !_�.. a- Ys� ______ __________________Y_..._._.____.._____._..__..........--.......___..___.____.__.__.___. _._...___.__..___._._..__.___._____-._._..___..................... i Street as shown on the application for Disposal Works Construction Penn- it No._ Dated..........:............................... Board of Health DATE / ��.... ------ FORM 36508 HOBBS h WARREN,INC..PUBLISHERS - Town of Barnstable Inspectional Services Department MAS&BAWA Public Health Division v 59. 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1730 0001 4988 0787 February 20, 2020 -- —SIFFLARD,WILLIAM A& SUSAN M - - 125 HOLDER LANE WEST BARNSTABLE, MA 02668 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 125 Holder Lane, Marstons Mills was inspected on 02/13/2020 by Shawn Mcelroy, certified Title V Septic Inspector for the State of _. Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE V(310 CMR 15.00) due to the following: • Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. You are ordered to repair or replace the septic system within one (1)year from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF T BOARD OF HEALTH ho cKean, R. CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mail ing\Failed or Needs Further Evaluation Letters\l25 Holder Lane Marstons Mills.doc 11HE Town of Barnstable U.S.Py POSTAGE 130WES Public Health Division >>PITNEY T M ABLE. 9. Af 200 Main Street =Q.W �prFD.0 Hyannis,MA 02601 FAA ID 3 ...... ZIP 02601 02 4VV $ 006.900 7015 1730 0001 4988 0787 0000336455 FE B 19 2020 IFFLARD, WILLIAM A&SUSAN M 125 HOLDER LANE NaZice 1� 1 RetIffned NOT DELIVERABLE AS ADDRESSED UNASLE TO F-OF VAIR D U TF: BC: 02601400200 *1022-00470-19-42 a 7 r,vi 1 ,a n n,5 It it dill III III I lilt I III J1 dilld 11111111.1111 it d I j -COMPLETE THIS., . . . - . . SECTION . A. Signature I 1 ■ Complete items-1,2,and I [I Agent ... j ■ Print your name and address on the reverse X [I Addressee so that we can return the card to you. B. Received by(Printed Name) C. Date of Delivery I ■ Attach this card to the back of the mailpiece, or on the front if space permits. D is delivery address different from item 1? Yes 'r delivery address below: ❑No 1 f SIFFLARD, WILLIAM A & SUSAN M I! {- 125 HOLDER LANE 1I MT BARNSTABLE, MA 02668 [I Priority Mail Express® I II I n ❑Registered M ail— IIIIIII'lll1IIillliilIIIII'I11IIIIIIIIIIIII ❑AdutSigatueRestricted Delivery ❑Registered Mail R e stricted petuvery m Receipt fa Cet fled Mified eI Restricted Delivery 9590 9402 5357 9189 1905 86 ❑Collect on Delivery ry Merchandise iI ationT"' ❑Signature Confirm ❑Collect on Delivery Restricted Delivery g � 2, nniric NnmY.�.T^�f�+m. �o^�^�r'�0 ❑Signature Confirmation I 1 17 3 0 m 0 0 01 4 9 8 8 0 7 8 7 1 Restricted Delivery Restricted Delivery 7015 Domestic Return Receipt PS Form 3811,July 2015 PSN 7530-02-000-9053 x ,a*r �=tit-�R." .r. a..wn^..rti�c..xrir .,,.,..,r.t,a•�s•+,... �. - .. , ..+-+;a: - __ .... ... 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