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HomeMy WebLinkAbout0067 HUCKLEBERRY LANE - Health 67 Huckleberry Lane, M. Mills —' A=102-188 �n 21 2016 22:53 Jim The Inspector Man 5085349919 page 1 1A2 -/8Y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Huckleberry Lane tV Property Address �+ Mariana Costa Owner Owner's Name information is required for every Marstons Mills MA 02648 1-19-16 page. CitylTown 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 A. General Information 5/ / filling out forms �' �3�YJ "�►p►uururrr on the computer, use only he tab �` hOFgggq���� 1. Inspector: y� • 9 key to move your 2 oy cursor-do not James D.Sears _'��:' JAMES N use the return key. Name of Inspector m p �v: c Ca ewide Enter v�i=rises, LLC =*�• :: rep Company Name 153 Commercial Street '�i s I N sPE��°° Company Address Mashpee MA 02649 Cltyrrown State Zip Code 508-477-8877 S1623 Telephone Number license Number B. Certification 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 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 16.340 of Title 5 (310 CM 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 1-21-16 /Mspector'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. !Sins•M3 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Jan 21 2016 22:53 Jim The Inspector Man 5085349919 page 2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth - Not for Voluntary Assessments , 67 Huckleberry Lane Property Address Mariana Costa Owner Owner's Name information is required for every Marstons Mills MA 02648 1-19-16 page. . Cltyfrown 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: The system is a 1500 Gal. Tank D Box and five 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 orexfiltration 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): t5iris•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Jan 21 2016 22:53 Jim The Inspector Man 5085349919 page 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments , 67 Huckleberry Lane Property Address Mariana Costa Owner Owner's Name Information is required for every Marstons Mills MA D2648 1-19-16 page. CityrTown 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 ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system Is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 151ns•3113 Titie 5 Official Inspection Form:Subsurface Sewage Disposal Syslem•Page 3 of 17 Jan 21 2016 22:53 Jim The Inspector Man 5085349919 page 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Huckleberry. Lane Property Address Mariana Costa Owner Owner's Name information is Marstons Mills MA 02648 1-19-16 required for every 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 ❑ Z 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 is less than 6" below invert or available volume is less than Y day flow -/- &4l e/yitiG. t5ins-3113 Title 5 Official Inspection Form:Subsur`aos Sewage Disposal System•Page 4 of 17 Jan 21 2016 22:53 Jim The Inspector Man 5085349919 page 5 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Huckleberry Lane Property Address Mariana Costa Owner Owner's Name information fired is for-every Marstons Mills re wired foreve MA 02648 1-19-16 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: ❑ [R 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. t51ns•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Jan 21 2016 22:53 Jim The Inspector Man 5085349919 page 6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Huckleberry Lane Property Address Mariana Costa Owner Owner's Name information is required for every Marstons Mills MA 02648 1-19-16 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 NIA) ® ❑ 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): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5lns•3/13 Title 5 Orficlat rrspection Form:Subsurface Sewage Disposal System•Page 6 or 17 Jan 21 2016 22:54 Jim The inspector Man 5085349919 page 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Huckleberry Lane Property Address Mariana Costa Owner Owner's Name informationefired is every Marstons Mills required for eve MA 02848 1-19-16 page. Cityl7rown State Zip Code Date of Inspection .D. System Information Description: The system is a 1500 Gal. Tank D Box and five chamber's Number of current residents: 1 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 years usage (gpd)): 2014-35,000Gals 2015-30,000Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date CommerciallIndustrial 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: 15ins-3113 rifle 5 Official Inspection Form:Subsurface Sewage Disposed System-Page 7 of 17 Jan 21 2016 22:54 Jim The Inspector Man 5085349919 page 8 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments rt 67 Huckleberry Lane Property Address Mariana Costa Owner Owner's Name information is required for every Marstons Mills MA 02648 1-19-16. page. Cityrrown 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: NA 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 Jan 21 2016 22:54 Jim The Inspector Man 5085349919 page 9 N Commonwealth of Massachusetts lug, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . 67 Huckleberry Lane Property Address Mariana Costal Owner Owner's Name i on is required for every Marstons Mills MA 02648 1-19-16 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: 1996 Permit#96- 131. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 22" Depth below grade: 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.): Pipeing is 4" PVC SCH 40. Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene, ❑ other(explain) If tank is metal, list age: 1' years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gal. Precast H-10 1 Sludge depth: 15tns•3/13 Title 5 Official Inspection Form:subsurfaoe Sewage Disposal System•Page 9 or 17 n 21 2016 22:56 Jim The Inspector Man 5085349019 page 1 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments. 67 Huckleberry Lane Property Address Mariana Costa Owner Owner's Name information is required for every Marstons Mills MA 02648 1-19-16 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 29" o„ 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 18" How were dimensions determined? Asbuilt-Tape Sludge Judge 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 at working level. Tank at 1' below grade. In and outlet,tees, No sign of leakage or over loading 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 1506•3/'3 Tale 5 Official Inspedion Form:Subsurface Sewage Disposal System-Page 10 of 17 Jan 21 2016 22:59 Jim The Inspector Man 5085349919 page 2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Huckleberry Lane Property Address Mariana Costa Owner Owner's Name information is required for every Marstons Mills MA 02648 1-19-16 page. Cityrrown 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 [I 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 15ins-3113 Tige 5 Official Inspection Forth;Subsurtwe Sewage Disposal System•Page 11 of 17 Jan 21 2016 22:59 Jim The Inspector Man 5085349919 page 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Huckleberry Lane Property Address Mariana Costa Owner Owner's Name information is .required for every Marstons Mills MA 02648 1-19-16 page. Cityr town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 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 is 16"x 16"-30" below grade. Box is solid w/two lines out, No sign of over loading or solid cant' over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes' ❑ No' Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official he peUion Form:Subsurface Sewage.Disposel System•Page 12 of 17 Jan 21 2016 22:59 Jim The Inspector Man 5085349919 page 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Huckleberry Lane Property Address Mariana Costa Owner Owner's Name information is required for every Marstons Mills MA 02648 1-19-16 page. City/rows State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 5 ❑ 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.): Leaching is five infiltrators w/2' stone 9'w/35' U1.51). Ck D Box and camera out lines. No sign of over loading or solid carry over. 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•3N 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 13 of 17 Jan 21. 2016 22:59 Jim The Inspector Man 5085349919 page 5 4 Commonwealth of Massachusetts Title 5 Official Inspection Form 6 Subsurface Sewage Disposal System Farm-Not for Voluntary Assessments 67 Huckleberry Lane Property Address Mariana Costa Owner Owner's Name information is required for every Marstons Mills MA 02648 1-19-16 page. CitylTown State Zip Code Date of Inspection D. System Information (cost.) 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.): l5ins•V13 Title 5 Official Ins action Farm:Subsurface Sewage Disposal S p ag sp ys/em•Page 14 of 17 Jan 21 2016 22:59 Jim The Inspector Man 5085349919 page 6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Huckleberry Lane _ Property Address Mariana Costa Owner Owners Name information is required for every Marstons Mills MA 02648 1-19-16 page. Citylrown 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 n r 1 EllI � I 13 I _y _ 3%4 I 4 Mrs•3/13 Title 5 Official hapedion Form:Subsurface Sewage Disposal System-Page 15 of 17 Jan 21 2016 22:59 Jim The Inspector Man 5085349919 page 7 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Huckleberry Lane Property Address Mariana Costa Owner Owner's Name information Marstons Mills MA 02648 1-19-16 required forr every e page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells No Estimated depth to high ground water: 1 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: pate ® 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: Past report auger hole at 12' no G.H.. Rear of lot drops of w/walk out basement 124. Bottom of chamber's at 5' below grade. Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 17 Jan 21 2016 22:59 Jim The, Insper-tor Man 5085349919 page 8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Huckleberry Lane Property Address Mariana Costa Owner Owner's Name information is required for every Marstons Mills MA 02648 1-19-16 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 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Huckleberry Lane Property Address Cecere Owner Owner's Name information is required for Marstons Mills MA 02648 January 17,2012 every 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: A. General Information When filling out farms on the computer,use 1. Inspector: only the tab key to move your Darren M. Meyer cursor-do not Name of Inspector '=- CD use the return ^,� key. n/a Company Name _PO Box 981 Company Address :. East Sandwich MA 02537 µ f°dd0 City/Town State Zip Code 781-424-6748 S13920t 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 Local Approving Authority Inspector's Signature Date The system inspector shall submit Ropy 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. t5lns•09/08 Tide 5 Official inspection Farm:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Huckleberry Lane Property Address Cecere Owner owner's Name information is Marstons Mills MA 02648 January 17, 2012 required for every page. City/'Town State Zip Code Date of Inspection B. Certification (cons.) Inspection Summary: Check A,B,C,D or E I 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: i 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-09/08 Titte 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Tit p Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Huckleberry Lane Property Address ' Cecere Owner Owner's Name information is required for Marstons Mills MA 02648 January 17,2012 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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): Cl 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 ❑ ND(Explain below): ❑ obstruction is removed ❑ Y. ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board.of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1.. System will pass unless Board of Health determines In accordance with 310 CMR 16.303(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 5ns•09/08 Me 6 Mdal Inspedion Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts = v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Huckleberry Lane Property Address Cecere Owner Owner's Name Information is required for Marstons Mills MA 02648 January 17, 2012 every page. Cityrrown State Zip Code [Pate of Inspection B. Certification (cont.) 2. System will fall unless the Board of Health(and Public Water Supplier, If any) determines that the system is functioning In a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria 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 El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® 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 161ns•09108 Title 6 Offidal Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Huckleberry Lane Property Address Cecere Owner Owner's Name information is required for Marstons Mills MA 02648 January 17, 2012 every page. ClWrown 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 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304,The system owner should contact the appropriate regional office of the Department. tSlns•09108 Title 5 Official tnspecton Form:Subsurface Sewage Disposat System•Page 5 of 17 N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Huckleberry Lane Property Address Cecere Owner Owner's Name information is Marstons Mills MA 02648 January 17, 2012 required for -- every page. CitYrrown State Zip Code pate 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 NIA) ® ❑ 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)1310 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): 330.78 gpd t5ins•09108 'title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 6 of 17 a Commonwealth of Massachusetts Title 5 Official Inspection .Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Huckleberry Lane Property Address Cecere Owner Owner's Name Information is rewired for Marstons Mills MA 02648 January 17,2012 every page. Citynown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does resldence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(if yes separate inspection required), ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 131 gpd . 2010:10: 134 gpd Detail: Sump pump? ❑ Yes ® No Last date of occupancy: unknownDate 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: t5lns•OW08 Title 5 Official Inspection Form:Subsurface Semge Disposed System•Page 7 of V Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Huckleberry Lane Property Address Cecere Owner Owner's Name information is required for Marstons Mills MA 02648 January 17,2012 every page. City/Town 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: treatment plant 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Huckleberry Lane Property Address Cecere Owner Owner's Name information is required for Marstons Mills MA 02648 January 17, 2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cost.) Approximate age of all components,date installed(if known)and source of information: System installed 1996, system is approx. 16 years old. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade' 12"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.): No skins of leakage. Septic Tank(locate on site plan): Depth below grade: 12 inches p g 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: typical 1,50013 tank Sludge depth: 12 inches t5lns•008 TiNe 5 Of flat Inspection Forth:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form»Not for Voluntary Assessments 67 Huckleberry Lane Property Address Cecere Owner Owner's Name information is Marstons Mills MA 02648 January 17,2012 required for Y every page. City/Town State Zip Code Date of Inspection D. System Information (cons.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 22 inches Scum thickness 6 inches Distance from top of scum to top of outlet tee or baffle 1 inches Distance from bottom of scum to bottom of outlet tee or baffle 8 inches How were dimensions determined? tapes and rods Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Liquid level equal to outlet pipe, structural integrity is sound, no sign of leakage, no sign of hydraulic failure, PVC tees with baffle is in place, tank in need of pumping. 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 t5lns•09t08 Title 5 Dfficiai Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 M Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments t 67 Huckleberry Lane Property Address Cecere - Owner Owner's Name information is Marstons Mills MA 02648 Janua 17, 2012 required for � every 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•09/08 We 5 Official Inspection Forth:Subsurface Sewage Disposal System Page 11 of W i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Huckleberry Lane Property Address Cecere Owner Owner's Name information is required for Marstons Mills MA 02648 January 17, 2012 every page. Cityrrown state Zip Code Date of Inspection D. System Information (cons.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert - Na 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 is level, box 24"below grade, no riser in place, distinct signs of solids carry-over, no sign of leakage, no sign of hydraulic failure or overflow. 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.): Soil Absorption System(SAS)(locate on site plan,excavation not required): If SAS not located,explain why: t5ins•O9108 Title 5 Official Inspedon Form:Subsurface Sewage Disposal System•Page 12 of 17 III Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Huckleberry Lane Property Address Cecere Owner Owner's Name informred fortion Marstons Mills MA 02M January 17,2012 every page, City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 5 infiltrator units ❑ 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.): 5-Infiltrator units 351 x 9'W x 15D, system 5 ft below grade. Inspection port not located, used camera for visual inspection. Vegetation normal, soils normal, infitrators were dry. 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 *ns-09108 Title 5 Of clal 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 67 Huckleberry Lane Property Address Cecere Owner Owner's Name information Is required for Marstons Mills MA 02648 January 17, 2012 every 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•09108 Me 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 67 Huckleberry Lane Property Address Cecere Owner Owner's Name Information is required for Marstons Mills MA 02648 January 17, 2012 every page. City[rown State Zip Code Date.of Inspection D. System Information (cons.) 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 w R' 1 l �j i 2 � o g Q + s 35 r.� !-2. zl 8-Z' t5ins•CW6 Title 6 Off clal Inspection Form:Subsurface sewage oisposai System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Huckleberry Lane Property Address Cecere Owner Owner's Name information Is required for Marstons Mills MA 02648 January 17,2012 every page. City/town state Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 138 + 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: Reviewed Town Water Maps You must describe how you established the high ground water elevation: Bottom of system approx 6.5 ft. below grade, based on hand auger to 12 feet, no water was observed in auger hole, system is not within adjusted groundwater. Before filing this Inspection Report,please see Report Completeness Checklist on next page. Wns 09108 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 67 Huckleberry Lane Property Address Cecere Owner Owner's Name information Is required for Marstons Mills MA 02648 January 17,2012 every page. Cityrbwn 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 151ns•09108 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 117 of 17 1 I 1 - - JOB t^ -- ---------- - -- � a 1 i S f - e T - r w FIZZ i Lf UCJ 79 �a a �v J L do VN Aes A�c N L4L l ��00 M ` Town of Barnstable Health Inspector F114E r Re ulator Services Office Hours Regulatory 8:30—9:30 o� Thomas F.Geiler,Director 3:30—4:30 lABLE, l Public Health Division 9 MASS. �A 039. A�0 Thomas McKean,Director rED MA'S 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT — SEPTIC QUESTIONNAIRE Date: September 16,2010 1. General Information: Size of Property: 0.22 acres Address: 67 HUCKLEBERRY LANE MARSTONS MILLS MA 02648 Map 102 Parcel 188 Name: STEVE CECERE JR 2a. How many bedrooms exist at your property now?2 2b. Are you planning to add any bedrooms? Yes If yes,how many? 1 2c. How many bedrooms total are proposed at this property(including the amnesty unit)? 3 2d.Please include a copy of the floor plans for the entire property. Neatly use a straight-edge. Show all existing rooms in the home and the proposed amnesty apartment. Provide width measurements of any open doorways. Please label each room clearly. 3. Is the dwelling connected to public sewer? NO If the dwelling is connected to public sewer,skip questions#4 through#9 below. W O 4. Location of&tvellg is INSIDE or OUTSIDE a Saltwater.Estuary Protection Zone? Q � 5 . Location ofidweigt g is INSIDE or OUTSIDE a Zone of Contribution to public supply wells? Z � a 6. Is the dwel�g connected to PUBLIC WATER? YES N ti. ^� 7. Is a disposd:Dwo*&construction permit on file? YES 2 0 8. If yes,hov anvAedrooms were approved according to this permit? 3 Bedrooms. F— R J 9. Were any building permits obtained for construction of additional bedrooms? NO(upon receipt of Comp Permit) 10. Is there an engineered septic system plan on file at the Health Division? YES or NO 11. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO ------------------------------------------------------------------------------------------------------------------- FOR OFFICE USE ONLY The Public Health Division has no objection to bedrooms at this property. Special Conditions: Signed:. Date: I i { .,....��.�...._..__ _.....�.._--.._,_.-, �.� _.�-:_.__>.�...a�..-....Y....._...,._......-, _..-__. _ . ___..:. .._ •-----_ _.:...-�..�._�.:'.-,.w.,�—_.:_-.�>.•,- ;��....____-._w.__. � w.,�.. . ..._�� ICI r 4 s do j k5m tD _ �� < ec n --�- Town of Barnstable Health Inspector pFT Office HoursHE Tpy� Regulatory Services 8:30—9:30 o� Thomas F.Geiler,Director 3:30—4:30 10 STAB . Public Health Division MASS. 039.prFO��p Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 � Office: 508-862-4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT — SEPTIC QUESTIONNAIRE Date: September 16,2010 1. General Information: Size of Property: 0.22 acres Address: 67 HUCKLEBERRY LANE MARSTONS MILLS MA 02648 Map 102 Parcel 188 Name: STEVE CECERE JR 2a. How many bedrooms exist at your property now?2 2b. Are you planning to add any bedrooms? Yes If yes,how many? 1 2c. How many bedrooms total are proposed at this property(including the amnesty unit)?3 2d.Please include a copy of the floor plans for the entire property. Neatly use a straight-edge. Show all existing rooms in the home and the proposed amnesty apartment. Provide width measurements of any open doorways. Please label each room clearly. 3. Is the dwelling connected to public sewer? NO If the dwelling is connected to public sewer,skip questions#4 through#9 below. 4. Location of dwelling is INSIDE or OUTSIDE a Saltwater Estuary Protection Zone? 5 . Location of dwelling is INSIDE or OUTSIDE a Zone of Contribution to public supply wells? 6. Is the dwelling connected to PUBLIC WATER? YES 7. Is a disposal works construction permit on file? YES 8. If yes,how many bedrooms were approved according to this permit? 3 Bedrooms. 9. Were any building permits obtained for construction of additional bedrooms? NO(upon receipt of Comp Permit) 10. Is there an engineered septic system plan on file at the Health Division? YES or NO 11. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO ---- ------------------------------------------------------------------------------------------------------------- CE USE ONLY 117 e P lic Health Division has no objectio to bedrooms at this propetBy 1cial Conditions: EP2 0 REC'D r o Signe Date: VW12,1jr > b ` S Fax Send Report OCT-19-2010 09:46 TUE Fax Number : 15087906304 Name BARNST HEALTH Name/Number GMD Page 0 Start Time OCT-19-2010 09:44 TUE Elapsed Time 00,001, Mode STD G3 Results [No Answer] Town of Barnstable Health Inspector TME►Gyp Regulatory Services Office Hours 8:30—9:30 Q Thomas F.Geller,Director 3:30- 4:30 "RWEA NW ML��pp Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 01?ice; 508-862-4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT-SEPTIC QUESTIONNAIRE, bale:September 16,2010 1. f ienem)Information: Size of Property:0.22 acres Address:67 HUCKLEBERRY LAN[i MARSTONS MILLS MA 02648 Map 102 Parcel 188 Name:STEVE CECERE JR 2a. Ilow many bedrooms exist at your property now?2 2b. Arc you planning to add any bedrooms? Yes If ycs,how many? I 2c. flow many bedrooms total are proposed at this properly(including the amnesty unit)?3 2d.Please include a copy of the!lour plans for the entire property. Neatly use a straight-edge. Show all existing roams in the home and the proposed amnesty apartment. Provide width measurements of any open doorways. Please label each room clearly. 3. is the dwelling connected to public seweel NO If the dwelling is connected to public sewer,skip questions#4 through#9 below. 4. Location of dwelling is INSIDE or OUTSIDE a Saltwater Estuary Protection Zone? 5. LOCation of dwelling is INSillL or OUTSIDE, a Zone of Contrihution to public supply wells? 6. Is the dwelling connected to PUIILIC WATER? YES 7. Is a disposal works eonslr'uetiuu poruit on file? YES 8. 1fycs,how many bedrooms were approved according to this permit? 3 Bedrooms. 9. Were any building permits obtained for construction ol'additional bedrooms? NO(upon receipt of Comp PermiO 10. Is there an engineered septic system plan on file.at the Health Division? YFS or NO 11. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO r CB USL ONLY 3 e he Health Thvision has no objectio. to_ bedrooms at this propelty)��' i lal Conditions: -SEp o REC _ liji 2 'D f s�� °y��-10 Signe ' Date: 2U Z4, Approval for AAAP site 67 Huckleberry Lane MM Page 1 of 1 McKean, Thomas From: McKean, Thomas Sent: Friday, October 08, 2010 4:57 PM To: Dabkowski, Cindy Subject: Re: Approval for AAAP site 67 Huckleberry Lane MM The approval was Faxed over to you this afternoon. From: Dabkowski, Cindy To: McKean, Thomas Sent: Fri Oct 08 14:52:56 2010 Subject: Approval for AAAP site 67 Huckleberry Lane MM Hello Mr. McKean Just want to make sure you received the application for 67 Huckleberry Lane MM Thank you Cindy Dabkowski 10/8/2010 r . 3 i IX k. it 4 � -._._.-....�....-_-..__. ,,x __.�_.... _....._ .+,.-...-... -._.__...«.. ...-...... ..___.> .. .^+.a4•-•...•..o.. _-.ic•-+,xa... ate^::.::x. .�.«�_.�._...._...-,...� � -.. �.+=.cr��r�"�` } . 6 F 5�V'\c �1ao✓ n "AA 4 ,W. Q . r . 3 4:9 - = • �•l `���(({+,\\mow\�„ r � I � Q - r Loan Activity ;t Page 2 of 2 L Misapplied 10/22/2007 01/01/2007 Payment $0.00 $40,259.32 $221.46- $197.10- $128.68- $0.00. $173.93- $547.24 Corr loon Misapplied 10/22/2007 02/01/2007 Payment $0.00 $40,037.86 $222.54- $196.02- $128.68- $0.00 $45.25- $547.24 CID., On Misapplied 10/22/2007 03/01/2007 Payment $0.00 $39,815.32 $223.63- $194.93- $128.68- $0.00 $83.43 $547.24 Correction ' 10/16/2007 10/01/2007 City Tax $274.77- $39,591.69 $0.00 $0.00 $274.77- $0.00 $212.11 $0.00. Disbursement National City Corporation Linking Policy Privacy Notice Security Terms and Conditions Site Map About Us ©2007 National City Mortgage,a division of National City Bank. 8 RFLIAR�W1► i EttUal®ng LeiWM IROORliM . - Copyrigld®2006-2008.Fidelity National Information Servioes,!Inc.All Rights Reserved. `. . 1 . v..istpnn secured -Vi i1FVF i ' .A. https://carenet.fnfismd.com/ncm/MenuServlet?MenuID=CNAV312%2C2%2C0%2C+%2C... 3/4/2008 L4CA It lv No. Fee jut q - 1 (0 - 10 n THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS Application for Mgool *p.5tem Construction Permit Application is hereby made for a Permit to Construct( )or Repair( vl'*an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. h 7 AweAle be A- tie,,isy e A1w11..1' Qn Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No. of Bedrooms 3 Garbage Grinder( � Other Type of Building ��s� iQ99/G� No. of Persons Showers ( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 330 gallons. Plan Date Number of sheets - f Revision Date Title Description of Soil Nature of Repairs or Alter tions( nswer when applicable) �i 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 t 's Bo ea Signed Date Application Approved by Application Disapproved for the following reasons Permit No. Date Issued OM42 ----------- _ --------_... THE COMMONWEALTH OF MASSACHUSETTS /�L / PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced on by &!fC zllY/ 6deS7` for 0�O�i,: as h s ben constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Use of this system is conditioned on compliance with the provisions set foj4h be o V. No. ;= — . Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Moon[ *pztem Con.9truction Permit Permission is hereby granted to to construct( )repair( 4an Ol-site Sewage System located atk'C A /�u �T and as described in the above Application for Disposal System Construction Permit. The applicant recognize his/her duty to comply with Title 5 and the following local provisions or special conditions. / //^/ /• All construction musVc om eted within tvv�o year of the date below. Date: Approved by r J 0 t, AA twS 000, p �� I TOWN OF BARNSTABLE LOCATION b /,�G �����y ``9� SEWAGE # VILLAGE /v�� T®�lS Oi ASSESSOR'S MAP &LOT`G R INSTALLER'S NAME&PHONE NO. 4j!�eolde �G0457 7 7 93t� SEPTIC TANK CAPACITY f✓r�� LEACHING FACILITY: (type) i /j`r�)�rs (size) NO.OF BEDROOMS 3 BUILDER OR OWNER PERMITDATE: — 9-ai!L—COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wedand and Leaching Facility(If any wetlands exist ' within 300 feet of leaching facility) Feet Furnished by ,for 0- 4Y i l C . k l p� No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Apphrattou for Mi5pool bpeteut Cougtructiou Perron Application is hereby made for a Permit to Construct( )or Repair( VJan On-site Sewage Disposal System at: Location Address or of No. Owner's Name,Address and Tel.No. 4 7 AVeAle berry 101, Wwll: ow Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �gA��OLcr/-1 Co�sf ° Type of Building: Dwelling No.of Bedrooms 3 Garbage Grinder( � Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures - - r Design Flow //V gallons per day. Calculated daily flow gallons. Plan Date tr, Number of sheets ! Revision e Title Description of Soil Nature of Repairs or Alter tions(Answer when applicable) AP.Y 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 t 's Bo ea . Signed Date �< Application Approved by Application Disapproved for the following reasons Permit No. Date Issued . r 43 J_ �?,. Fee- - THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS} 01pprication for nitpaal 44pgtem Congtruction 3permit Application is hereby made for a Permit to Construct or Repair v ,/an On-site Sewage Disposal System at: PP Y ( ) P ( V1 g P Y Location Address or Lot No. Owner's Name,Address and Tel.No. �S"0,z z fyonrr/ .�,y Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Garbage Grinder(Ztfa Other Type of Building Psil.aeClf No.of Persons Showers( ) Cafeteria( ) Other Fixtures j Design Flow // gallons per day. Calculated daily flow .7✓36 i gallons. Plan Date ✓"kefG Number of sheets Revision Date-`"-- Title Description of Soil i f Nature of Repairs or Alter tions(Answer when applicable) hp,X aww 0 1-mekng '0 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 t 's Bo /of--' eali Signed �% 4 Date 17 Application Approved by Application Disapproved for the following reasons + 41 Permit No. '� Date Issued — i THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS { i Certificate of Compliance THIS IS TO CERTIFY,that the On-.site Sewage Disposal System installed( ,)or repaired/replaced(V)on by D!''40AI CDas-7" for /n�i/�Jy4r;r as has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Use of this system is conditioned on compliance with the provisions set fo h be o No. Fee t THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 3igpogar *pgtem Congtruction Vernfit Permission is hereby granted to to construct( )repair( ✓�an Oqq-site Sewage System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognize his/her duty to comply with Title 5 and the following local provisions or special conditions. j All construction must com eted within t oye�ar of the date below. Date: '� Approved by ! % r CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL 1VOI(KS CONS')ItUC1 ION 1'[?IN11 I' (1 ITHOUI'DESIGNED PLANS) 1, /����r�-✓ ,�ollol-41; hereby certify that the application for disposal works construction permit signed by me dated l , concerning the property located at d 7 �rG ��e�''�°'°'f 1�l meets all of the following criteria: 4/ re no wetlands wilhin 3ou feet of the proposed septic system T re a p po ere are no private wells within I5o feet of the proposed septic system Tie observed ground«•aler 11ble is 14 feet or greater below The bottom of the leaching facility There is no increase in flow and/or change in use proposed There are no variances requested or needed. SIGNED: DATE: AXX LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OFBARNSTABLE NUMBER ]Allach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, lids plan should be submitted]. O U-7 OA ✓A v�.T �6 000 I � � TOWN OF BARNSTABLE LOCATION 7 SEWAGE# VII.LAGB GrS73 ASSESS 'S MAP&LOT , 0 Q �'S NAME&PHONE NO�36rVO�6 � d71S� �660-f� SEPTIC TANK CAPACITY 1060 (i4Ilel) U� iL ll/)1C --LEACHING FACELrrY: (type) Oja S,t�O (size) F 6 X S'Le) NO.OF BEDRO "?- -J r1- BUILDER R OWNER 71c ! PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Faci 'ty(If any wetlands exist within 300 t of eachin fa ) Feet Furnished byv4/` poi idI'� 0 '0