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HomeMy WebLinkAbout0040 INDUSTRY ROAD UNIT 1 - Health (2) 40 Industry Road Huntingest Management Marstons Mills. i I i I, d i �I 0 osg -oa8- ooA Commonwealth of Massachusetts Title 5 Official Inspection Form 21 Subsurface Sewage Disposal System Form - Not for Voluntary Assessment 56 s 40 Industry Road Property Address t* 40 Industry Condominium Owner Owner's Name T„ information is ✓ required for every Marstons Mills Ma: 02648 02-19-2019 page. Cityrrown State Zip Code Date of Inspection r Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information Paua0 on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. 52 Rivers End Road � Company Address Teaticket Ma. 02536 City(rown State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails } a 02-19-2019 I spectoes 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 Commonwealth of Massachusetts Ip Title 5 Official Inspection Form l; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u- 40 Industry Road Property Address 40 Industry Condominium Owner Owner's Name information is required for every Marstons Mills Ma. 02648 02-19-2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 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: 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): t5ins :doc•r - p 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 b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 Industry Road Property Address 40 Industry Condominium Owner Owner's Name information is required for every Marstons Mills Ma. 02648 02-19-2019 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 ❑ 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): 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 Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments g p Y rY ~. 40Indust Road u Industry Property Address 40 Industry Condominium Owner Owner's Name information is required for every Marstons Mills Ma. 02648 02-19-2019 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 ❑ ® 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 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Industry Road Property Address 40 Industry Condominium Owner. Owner's Name information is required for every Marstons Mills Ma. 02648 02-19-2019 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 '/z 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 II of a public water supply well 15insp.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 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u- 40 Industry Road Property Address 40 Industry Condominium Owner Owner's Name information is required for every Marstons Mills Ma. 02648 02-19-2019 . page. Cityfrown 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? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Industry Road Property Address 40 Industry Condominium Owner Owner's Name information is required for every Marstons Mills Ma. 02648 02-19-2019 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: Number of current residents: 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 Seasonaluse? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date t5insp:doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Industry Road Property Address 40 Industry Condominium Owner Owner's Name information is required for every Marstons Mills Ma. 02648 02-19-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Office ,work shop,storage Design flow(based on 310 CMR 15.203): 898 Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): sq ft 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: occupied Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form y Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 Industry Road Property Address 40 Industry Condominium Owner Owner's Name information is Marstons Mills Ma. 02648 02-19-2019 required for every 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: 1986 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 22"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.): t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 40 Industry Road Property Address 40 Industry Condominium Owner Owner's Name inf required for every ormation is Marstons Mills Ma. 02648 02-19-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 12 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: Standard 1500 gallon Sludge depth: 3„ Distance from top of sludge to bottom of outlet tee or baffle 32" Scum thickness 411 Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? 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.): The septic tank is on a maint. plan. The tank has two steel covers at grade. t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form '_ ,III? Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Industry Road Property Address 40 Industry Condominium Owner Owner's Name information is Marstons Mills Ma. 02648 02-19-2019 required for every page. Cityrrown 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 I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Industry Road Property Address 40 Industry Condominium Owner Owner's Name information is required for every Marstons Mills Ma. 02648 02-19-2019 page. Cityrrown 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): Oil Depth of liquid level above outlet invert 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.): At the time of the inspection there were no visible signs of leakage there is a steel cover at grade t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form _ b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 Industry Road u� Property Address 40 Industry Condominium Owner Owner's Name information is required for every Marstons Mills Ma. 02648 02-19-2019 page. CitylTown 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 ❑ 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 n Title 5 Official Inspection Form _ 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c 40 Industry Road Property Address 40 Industry Condominium Owner Owner's Name information is required for every Marstons Mills Ma. 02648 02-19-2019 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.): At the time of the inspection one leaching pit was 3/4 full and the other half full. 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 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 Industry Road Property Address 40 Industry Condominium Owner Owner's Name information is required for every Marstons Mills Ma. 02648 02-19-2019 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts 91- -. Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments . u 40 Industry Road Property Address 40 Industry Condominium Owner Owner's Name information is Marstons Mills Ma. 02648 02-19-2019 required for every page. Cityrrown 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 �l j t5insp:doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Assessing As-Built Cards Page 1 of 2 TOWN OF BARNSTABLE LOCATION.d J 10 �D,rvL�CtL1,Z' 7CY. seaacB Y7�� VILLAGE' 1A491,_1�� <- 1. . ASSESSOR'S MAP 6�tJLOT r-IN STALLER'S NAME&PHONE ti SBPTIC TANK CAPACITY t-LEACHING FACILITY{type) 2 (size) I - &0.OF BEDROOMS 0 PRIVATE WELL OR PUBLIC WATER['G� 0C- OR OWNER 'fYZ�XI �Z �'1 . DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: 5— 1�L VARIANCE GRANTED: Yes No: �r G .;http://www.town.bamstable.ma.us/assessing/HMdisplay.asp?mappar=05802800B&seq=l 12/17/2014 Commonwealth of Massachusetts Title 5 Official Inspection Form II Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% 40 Industry Road Property Address 40 Industry Condominium Owner Owner's Name information is required for every Marstons Mills Ma. 02648 02-19-2019 page. Cityrrown 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: 17 plus feet 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: I augered a hole at a lower elevation and I shot it with a transit. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 Industry Road Property Address 40 Industry Condominium Owner Owner's Name information is required for every Marstons Mills Ma. 02648 02-19-2019 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 f�a�TJwr orJ; Aj Nb /,Fw t5insp:doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates [cost$40.00 for 4 years). A business certificate ONLY-REGISTERS YOUR NAME in town (which you must do by M.G.L. -it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take th.e completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis; MA 02601. (Town Hall) and get the Business Certificate that is required by law. DATE: 0-1l'19 Fill in please: '•';:'.ph:a',Yt' x.=4� j'' :I . APPLICANT'S YOUR NAME/S: G3 t I "A-01 t- +/ ° I•:^:il.: t;,r,r;:y' ;;; rt;j''.;: t;,.,,, _ S A N �/� h � 60 1IrvS YOUR HQME ADDRESS .. _ t•.r W lY' s�➢if� p� .. TELEPHONE # Home Telephone Number �yi iJ�rlLd OR EIN 9 e E—MAIL rLaJ l�o F �. •r ''7 NAME OF CORPORATION:Z)Ivh �rvl yt.�Grv�- N� NAME OF-NEW BUSINESS TYPE OF BUSINESS 'o+u- IS THIS A HOME OCCUPATION? YES • NO ADDRESS OF BUSINESS-Uti►i� 4 �s A- MAP/PARCEL NUMBER I {Assessing) j'yja�2S v S r rvvl l l S , wt� .'Q_6\4 . When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to"assist you in obtaining the information you may need. You MUST GO TO 200 Main St. (corner of Yarmouth ' Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMTAu NER'S OFFIC This individue n ' of ny ermit re ireme 'ts that pertain to this type of business. orizerl Si re COMMENTS: r / . 2. BOARD OF HEALTH This individual has been in •rme of.the p �t requirements that pertain to this type of business. A orized Signature** COMMENTS: ✓ ' z 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** 88*1 Wd 9Zj 6I 130 COMMENTS: . Commonwealth of Massachusetts 20)3o — ogj - odd' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y 40 Industry Road Property Address 40 Industry Condominium Owner Owners Name information is required for every Marstons Mills Ma. 02648 10/30/2015 ` page. Cityrrown State Zip Code Date of Inspection r 7 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms S/# �/ on the computer, 2—7 use only the tab 1. Inspector: key to move your cursor-do not Michael T Bisienere key the return Name of Inspector Y Cape Septic Inspections Q Company Name 624 Old Barnstable Road Company Address Mashpee Ma. 02649 Ci /T own � State Zip Code 508-280-3356 S13938 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 —� �. — 10/30/2015 Ins ector'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. Qv Vs t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal Syst ..1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M - 40 Industry Road Property Address 40 Industry Condominium Owner Owners Name information is required for every Marstons Mills Ma. 02648 10/30/2015 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: 13 System Conditionally y 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Vo luntary oluntary Assessments M 40 Industry Road Property Address 40 Industry Condominium Owner Owner's Name information is required for every Marstons Mills — Ma. 02648 10/30/2015 page. Cityrrown State Zip Code Date of Inspection B. Certification (coat.) ❑ 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 40 Industry Road Property Address 40 Industry Condominium Owner Owner's Name information is Marstons Mills required for every _ Ma. 02648 10/30/2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Z Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ 0 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M . 40 Indust Road Property Address 40 Industry Condominium_ Owner Owner's Name information is required for every Marstons Mills Ma. 02648 10/30/2015 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Z 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.] ❑ L7 The system is a cesspool serving a facility with a design flow of 2000gpd- 10;000gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the.system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments •' 40 Industry Road Property Address 40 Industry Condominium Owner Owner's Name information is MarStonS Mills required for every _ Ma. 02648 10/30/2015 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) 1Z ❑ 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? 0 ❑ 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? Z ❑ 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): Number of bedrooms (actual): f DESIGN flow based on 310 CMR 15.203 (f or or example: 110 gpd x#of bedrooms): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Industry Road Property Address 40 Indust�Condar,inium Owner Owner's Name information is required for every Marstons Mills Ma. 02648 10/30/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: office ,work shop,Take out only pizza Design flow(based on 310 CMR 15.203): 898 Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): no seats in pizza shop Grease trap present? ® Yes ❑ No Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts -- - Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 40 Industry Road Property Address 40 Industry Condomnium Owner Owner's Name information is required for every Marstons Mills Ma. 02648 10/30/2015 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: 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 LJ Overflow cesspool I -1 Privy LJ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 commonwe alth of Massachusetts w - _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 4040 1� Road _ Property Address 40 Industry Condo ..ir;ium Owner Owner's Name information is required for every Marstons Mills _ Ma. 02648 10/30/2015 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: 1986 Were sewage ocors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 22° feet Material of construction: ❑ cast iron 1-5\-/l 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 12 feet Material of construction: �<l concrete ❑ metal ❑ fiberglass ❑ polyethylene El 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: standard 1500 gallon Sludge depth: 311 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Industry Road Property Address 40 Industry Condominium Owner Owner's Name information is required for every Marstons Mills Ma. 02648 10/30/2015 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (con:.) Distance from top of s udge to bottom of outlet tee or baffle apx. 35" Scum thickness 1" Distance from ton of scum to top of outlet tee or baffle apx. 5" Distance from bottom of scum to bottom of outlet tee or baffle apx. 12" How were dimensions determined? 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.): TLe septic is o,n a rnairt. plan and will be pumped after the inspection for maint 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 scu-n to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 40 Industry Road _ Property Address 40 Industry Condominium Owner Owner's Name information is required for every Marstons Mills Ma. 02648 10/30/2015 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade.- Material of construction: [) concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 Industry Road_ Property Address 40 Industry Condominium Owner information is Owner's Name required for every Marstons Mills Ma. 02648 10/30/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" 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.): The D-Box has a steel cover to grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Indust Road Property Address 40 Industry Condorninium Owner Owner's Name information is required for every Marstons Mills Ma. 02648 10/30/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: leaching pits number: Two leaching chambers number: 7_1 beaching galleries number: i l leaching trenches number, length: iJ leaching fields number, dimensions: overflow cesspool number: L 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.): There are two leaching pit between the two there is enough volume availble to pass Title 5 Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Selvage Disposal System Form -Not for Voluntary Assessments •' 40 Industry Road Property Address 40 IndustrvCondom-::.iurn Owner Owner's Name information is required for every Marstons Mills Ma. 02648 10/30/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts M Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .• 40 Industry Road__ Property Address 40 Industry Condom;r;ium Owner information is Owner's Name required for every Marstons Mills Ma. 02648 10/30/2015 page. Cityrrown 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 pe,rranent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: Z. nar;Q-sketc; ;n the, area below ❑ drawing attached separately t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 AJJIiJJlll�AJ�iJ Ulll L.GLIUJ Page 1 of 2 OWN OF BARNST�)ABLE LOCATION SEWAGE# L y ,7 r VILLAGE ASSESSOR'S MAP&LOT NNSTALLER'S NAME&PHONE NO.�� �J-± '66 -- �SEPTIC TANK CAPACITY / 5-0 `LEACHING FACILITY.-(type) 2 - ( ) J Q('III.e� NO.OF BEDROOMS 0 PRIVATE WELL OR PUBLIC WATER Pit cJC OR OWNER - ,�Ec'27'dR,Ct 1 DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: I 5- L VARIANCE GRANTED: Yes No �f hh G G r G.. 3 http://www.town.bamstable.ma.us/assessing/HMdisplay.asp?mappar=0580280OB&seq=1 12/17/2014 Commonwealth of Massachusetts . --- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M •'� 40 Industry Road Property Address 40 Ind ustl Condo�;;nium Owner _--- -- — Owner's Name information is required for every Marstons Mills Ma. 02648 10/30/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: Check Slope Surface water �I Check cellar ZI Shallow wells Estimated depth to high ground water: 17 plus feet feet Please indicate aH methods used to determine the high ground water elevation: I) Octained from system design plans on record If checked, date of design plan reviewed: Date © Observed sire (abutting property/observation hole within 150 feet of SAS) ! Che keo with local Board of Health -explain: Checked with local excavators, installers- (attach documentation) L Accessed USGS database-explain: You must describe how you established the high ground water elevation: I augered a hole at a lower elevation and shot it with a transit to show five plus feet of seperation Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form!Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 Industry Road Property Address 40 Industry Condc.;.',iurr; Owner Owner's Name information is required for every Marstons Mills Ma. 02648 10/30/2015 page. citW own State Zip Code Date of Inspection E. Deport Completeness Checklist Z, Inspection Surnmary: A, B, C, D, or E checked Inspection Surmmary D (System Failure Criteria Applicable to All Systems) completed System Informaticn—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 14 re e"r A)J 14 z t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Charles M. Sabatt PC Attorney At LaNv 540 Main Street — Suite 8 Telephone Hyannis, MA o26ol Facsimile 508-775-5050 5o8-778-4600 i May 12, 2015 Mr. Thomas McKean Health Department Town of Barnstable 200 Main Street Hyannis, MA 02601 RE: Shaun Breau Dear Mr. McKean: This is to notify you that Mr. Breau is withdrawing his request for a hearing with respect to the premises at 40 Industry Road, Unit 15, Marstons Mills. Please delete the matter from the Board of Health agenda of May 12, 2015. 1 am advised that the materials at issue have been removed from the premises. I believe that you can confirm this with Ms. Robin Anderson of the Building Department. Please contact me with any questions. Thank you very much for your attention to this matter and your assistance. Sincerely, Charles M. Sabatt Cc: Shaun Breau (e-mail) Lavelle, Timothy From: Crocker, Sharon Sent: Monday, May 11, 2015 4:32 PM To: McKean, Thomas; Lavelle, Timothy; Wayne Miller, M.D. (wamdoc@verizon.net) Subject: BOH May 12, 2015 - Hearing - Haz. Mat FYI Attorney Sabatt just called. He will be sending me a formal withdrawal for the Hearing for Haz. Mat which Shaun Breau, The Pool Man, had requested (regarding 40 Industry Road, Unit#15) Atty. Sabatt said he has vacated the premises and has spoken with Robin Anderson, Building, and the Fire Department. -Sharon i Charles M. Sabatt PC Attorney At Law 540 Main Street— Suite 8 Telephone Hyannis, MA 026oi Facsimiles' 5o8-775-5050 5o8-778-4600 Ill `;DTI �n April 10, 2015 Mr. Thomas A McKean Public Health Division Dir. Town of Barnstable 200 Main St., Hyannis, MA 02601 RE: Mr. Sean Breau. , uoi� 15. E Dear Mr. McKean: Please be advised that the undersigned represents Mr. Shean Breau to whom you addressed a notice dated April 2, 2015. Pursuant to your notification, on behalf of Mr. Breau I hereby request a hearing before the Town of Barnstable Board of Health with regard to the Notice of April 2, 2015. 1 would appreciate your advising me as to the hearing date once it has been established. Thank you very much for your attention to this matter and your assistance. Sincerely, Charles M. Sabatt Cc: Shaun Breau F A w c Town of Barnstable OpIME Tp� Regulatory Services '4o Richard V. Scali,Director Public Health Division BARNSTABLE, Thomas McKean,Director 9� i6 S. 200 Main Street, Hyannis,MA 02601 a Phone: 508-862-4644 Email: health@town.bamstable.ma.us � f 7 6 0-e odD- i�g- 1S 75- Fax: 508-790-6304 Office Hours: M-F 8:00—4:30 April 2,2015 Mr. Shaun Breau RE: Hazardous Materials-Violation PO Box 715 The Pool Man 128 Ensign Rd 40 Industry Rd Unit 15 Centerville,MA 02632 Marstons Mills,MA Dear Mr. Breau: Pursuant to Barnstable Town Code Chapter 108,the Town of Barnstable Public Health Division has the authority to enforce the Hazardous Materials Ordinance. On March 17, 2015, Michael Grossman, Fire Prevention Officer of the C.O.M.M. Fire/Rescue Department, discovered large quantities of pool chemicals stored at 40 Industry Rd Unit 15 in Marstons Mills which is leased to your company,The Pool Man. Storage of hazardous materials is prohibited in town-designated Water Protection Districts by a town zoning bylaw. I am aware that the Zoning Officer of Barnstable has ordered you to remove the chemicals from this location. When you have chosen a new facility to store these chemicals, you are required to notify the Town of Barnstable of the location of the facility and show proof of a new lease. If the new storage facility is located within the Town of Barnstable,you will be required to comply with all aspects of the Town's Hazardous Materials Ordinance, including registration, inspection, and licensure. Regardless of the location of the new storage facility, because of the quantity of hazardous materials stored for your business,you may also be required to file an annual Tier II inventory report under the federal Emergency Planning and Community Right to Know Act. Barnstable County Regional Emergency Planning has been notified. Your business is currently in violation of the Hazardous Materials Ordinance and this letter should be considered a warning notice to comply. If you wish to dispute this finding and compliance order,you may request a hearing before the Town of Barnstable Board of Health. Please submit your request in writing within the next 10 days. ' Thomas A. Mc ean, RS, CHO Public Health Division,Director 'k SST, CENTERVILLE-OSTERVILLE-MARSTONS MILLS FIRE DISTRICT ( DEPARTMENT OF FIRE-RESCUE & EMERGENCY SERVICES 1 1875 Route 28 - Centerville, MA 02632-3117 1926 508-790-2375 x1 - FAX: 508-790-2385 Michael J.Winn,Chief Martin O'L.MacNeely, Fire Prevention Officer Byron L.Eldridge,Deputy Chief Michael G.Grossman, Fire Prevention Officer March 17, 2015 TO: Mr. Thomas McKeon Director, Health Department Town of Barnstable 200 Main Street Hyannis, MA. 02601 In accordance with 527 CMR 1 1.7.6.1.2 the Centerville-Osterville-Marstons Mills Fire/Rescue Department brings to your attention the following potential health code violations for your review and/or interpretation of same. NAME/BUSINESS: The Pool Man ADDRESS: 40 Industry Road Unit 15, Marstons Mills On March 17, 2015 while conducting a routine business inspection, I observed a large amount of pool chemicals and oxidizers stored inside the unit. I have requested MSDS from the owner with maximum quantities that are stored on site. The unit is owned by Donna Sabo (508)-771-3876 and the business is owned by Shaun Breau (508)-420-0300. 1 advised the unit owner that I would be notifying the Board of Health due to concerns with the quantity of chemicals and proximity to the Water District well field. Michael Gross n e Prevention Officer C.O.M.M. . ire District "Commitment to Our Community" P�oFI►E Town of Barnstable Barnstable Board of Health `�"'w'cacft ' nAEtNSTABLE, ' q'prfa MAC 200 Main Street, Hyannis MA 02601 2007 OFFICE: 508-862-4644 Wayne Miller,M.D. FAX: 508-790-6304 Paul Canniff,D.M.D. Junichi Sawayanagi Charles M Sabatt, PC, 540 Main Street, Suite B,Hyannis, MA 02601 ACKNOWLEDGEMENT OF RECEIPT: April 28, 2015 We have received your submission for your client, Sean Breau, to the Board of Yfealth Re: 40 Industry road, `Unit# 15, 9d arstons Mills and storage of hazardous materials. Thankyou. Your item is scheduled to be heard at the Board of Health Meeting on the: Date of: Tuesday, May 12, 2015 Meeting Location: Town Hall, 367 Main St, Hyannis Hearing Room, Second Floor Time: 3:00—6:00 P.M. Approximately three days prior to meeting, an agenda will be sent out to you— once it is available. It will also be available on line at the town website: www.town.barnstable.ma.us Go to ..."Boards & Committees > Board of Health - or- Go to Official Agendas Any questions, please call Sharon Crocker at 508-862-4739. Thank you. QAAGENDAS BOH\let Receipt of BOH Submission 40 Industry Rd Unit15 MM MAY2015.doc I _ Town of Barnstable oFtME rpm Regulatory Services '4o Richard V. Scali,Director Public Health Division snxxsrAsLE, Thomas McKean,Director 9� MASS. � 200 Main Street, Hyannis,MA 02601 1639. Phone: 508-862-4644 Email: health@town.bamstable.ma.us town.barnstable.ma.us 6 'oZ ' U d_°10d0- Fax: 508-790-6304 Office Hours: M-F 8:00—4:30 April 2, 2015 Mr. Shaun Breau RE: Hazardous Materials-Violation PO Box 715 The Pool Man 128 Ensign Rd 40 Industry Rd Unit 15 Centerville, MA 02632 Marstons Mills,MA Dear Mr. Breau: Pursuant to Barnstable Town Code Chapter 108,the Town of Barnstable Public Health Division has the authority to enforce the Hazardous Materials Ordinance. On March 17, 2015, Michael Grossman, Fire Prevention Officer of the C.O.M.M. Fire/Rescue Department, discovered large quantities of pool chemicals stored at 40 Industry Rd Unit 15 in Marstons Mills which is leased to your company,The Pool Man. Storage of hazardous materials is prohibited in town-designated Water Protection Districts by a town zoning bylaw. I am aware that the Zoning Officer of Barnstable has ordered you to remove. the chemicals from this location. When you have chosen a new facility to store these chemicals, you are required to notify the Town of Barnstable of the location of the facility and show proof of a new lease. If the new storage facility is located within the Town of Barnstable,you will be required to comply with all aspects of the Town's Hazardous Materials Ordinance, including registration, inspection, and licensure. Regardless of the location of the new storage facility, because of the quantity of hazardous materials stored for your business,you may also be required to file an annual Tier II inventory report under the federal Emergency Planning and Community Right to Know Act. Barnstable County Regional Emergency Planning has been notified. Your business is currently in violation of the Hazardous Materials Ordinance and this letter should be considered a warning notice to comply. If you wish to dispute this finding and compliance order,you may request a hearing before the Town of Barnstable Board of Health. Please submit your request in writing within the next 10 days. Thomas A. Mc ean, RS, CHO Public Health Division, Director -• X Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Industry Road Property Address 40 Industry Condo Trust Owner Owner's Name information is required for every Marstons Millis Ma. 02648 11/16/2013 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: (1 key to move your cursor-do not Michael T Bisienere vl key the return Name of Inspector Y Cape Septic Inspections 4:1 Company Name 624 Old Barnstable Road Company Address rem Mashpee Ma. 02649 City/Town State Zip Code 508-280-3356 S13938 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 11/20/20 t 13 Inspector's Signaure 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. U1 t5ins•3/13 Title 5 Ofri2nin Form:Subsurface Sewage Disposal System•Page 1 of 17 • Commonwealth of Massachusetts 4 W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 't 40 Ind ustry Road Property Address 40 Industry Condo Trust Owner Owners Name information is required for every Marstons Millls Ma. 02648 11/16/2013 page. Ci frown 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: ® 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: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 Industry Road Property Address 40 Industry Condo Trust Owner Owner's Name information is every Marstons Millls required for eve Ma. 02648 11/16/2013 page. Cityrrown 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .'' 40 Industry Road Property Address 40 Industry Condo Trust Owner Owner's Name information is required for every Marstons Millls Ma. 02648 11/16/2013 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well*". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 Industry Road Property Address 40 Industry Condo Trust Owner Owner's Name information is required for every Marstons Millls Ma. 02648 11/16/2013 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M . ' 40 Industry Road Property Address 40 Industry Condo Trust Owner Owner's Name information is every Marstons Millis required for eve Ma. 02648 11/16/2013 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"n "y o as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all"system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form " Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,.•' 40 Industry Road Property Address 40 Industry Condo Trust Owner Owner's Name information is every Marstons Millis required Ma. 02648 11/16/2013 page. Ciiyr own State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) ❑ Yes ❑ No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Office/Pizza take-out only/warehouse/ shop Design flow(based on 310 CMR 15.203): 898 Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): no seats Grease trap present? ® Yes ❑ No Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 Industry Road Property Address 40 Industry Condo Trust Owner Owner's Name information is required for every Marstons Millls Ma. 02648 11/16/2013 page. Cltyr own State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: occupied Date Other(describe below): grease trap inside pizza shop General Information Pumping Records: Source of information: A and K Pumping 508-540-6706 Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons gallons How was quantity Drivers est. q y pumped determined? Reason for pumping: Owners request Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 C f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s.•'' 40 Industry Road Property Address 40 Industry Condo Trust Owner Owner's Name information is required for every MarstonsMillls Ma. 02648 11/16/2013 page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1211 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.): Septic Tank (locate on site plan): Depth below grade: 1011feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallon septic Sludge depth: < 1 11 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 Industry Road Property Address 40 Industry Condo Trust Owner Owner's Name information is required for every Marstons Millls Ma. 02648 11/16/2013 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 39" Scum thickness Distance from top of s:,um to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 11" How were dimensions determined? field instruments Comments(on pumpirg recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Industry Road Property Address 40 Industry Condo Trust Owner Owner's Name information isequired for every Marstons Millls Ma. 02648 11/16/2013 page. Citylfown 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 El other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Industry Road Property Address 40 Industry Condo Trust Owner Owner's Name information is every Marstons Millls required for eve Ma. 02648 11/16/2013 page. Cityrrown 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •''� 40 Industry Road Property Address 40 Industry Condo Trust Owner Owners Name information isequired for every very Marstons Millls Ma. 02648 11/16/2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: Two ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M ,.•'' 40 Industry Road Property Address 40 Industry Condo Trust Owner Owner's Name information is required for every Marstons Millls Ma. 02648 11/16/2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal •System Page 14 of 17 Y 9 - Commonwealth of Massachusetts I Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Industry Road Property Address 40 Industry Condo Trust Owner Owner's Name information is every Marstons Millls re wired for eve Ma. 02648 11/16/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately I ,k . 0 . w THE SKETCH OF THIS SEWAGE DISPOSAL SYSTEM(AS BUILD)AS SHOWN ON THIS PAGE IS APPROXIMATE ONLY,NOT TO . SCALE. IT MUST NOT BE USED FOR VARIENCE OR BUILDING PLAN PURPOSES. i t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Industry Road Property Address 40 Industry Condo Trust Owner Owners Name required fo is every Marstons Millls required Ma. 02648 11/16/2013 page. 6i 7 own 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: 16 plus feet 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 database Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 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 M 40 Industry Road Property Address 40 Industry Condo Trust Owner Owner's Name information is Marstons Millls required for every Ma. 02648 11/16/2013 page. City/Town 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 00 Py Commonwealth of Massachusetts BOG Executive Office of Environmental Affairs k a Department of °yotisl 199� Environmental Protection WIIBam F.Weld F, Y Coxe Argeo Paul Gllued DavidStruhs Conten`bnw SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 40 Industry Rd Marstons MWIcirrss of Owner: (manager) Mycock Agency Date of Inspection: 12/0 5/9 6 (if different) School St Name of Inspector: Frederick Kiely I Cotuit Ma Company Name, Address and Telephone Number: Environmental Reclamation Inc. 446 Waquoit Hwy. Waquoit Ma CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _C Fails Inspector's Signature: Date: The System Inspector shall submit a copy of this inspect' n report to the Approving Authority within thirty(30) days of completing this inspection. If the system is a shared system or has a esign flow of 10,000 gpd or greater, the inspector pector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defin ed In 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 One WIntsr Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)ZU-SSOO w Pnnted on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: BI SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a secitic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 3) OTHER (revised.11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: "CJ-S% MM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. --4ij-60GE-SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. ;reviled 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Prop"Address: 44k 1lJ'),; i ej kZ, i11 AR�-7k?N.3 M 1/iS Owner Date of.Inspection: Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow The site was inspected for signs of breakout. All system components,-fta msdiag•the Soil Absorption System, have been located on the site. tic tank was ins P petted for rendition of baffles o� X The septic tank manholes were uncovered, opened, and the interior of the se tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based existing infommatioa-or approximated by non-intrusive methods. The facilit)Aowner(and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/9S) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: L(( l�L JJ:�i Rti ft;D ^'Iile Ii Owner: Date of Inspection: FLOW CONDITIONS �BEpT17Ii: Design flow: gallons Number of bedrooms: Number of current residents:_ Garbage grinder(yes or no):_ Laundry connected to system (yes or no):_ Seasonai use(yes or no):_ Water meter readings, if available: Last date of occupancy: U,'tz'enj�- COMMERCIAL/INDUSTRIAL: Type of establishment: Co:.,j b Design flow: gailons/day Grease trap present: (yes or no) O Industrial Waste Holding Tank present: (yes or no) AJ4� Non-sanitary waste discharged to the Title 5 system: (yes or no) iI Water meter readings, if available: 'ast date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: AAJAJVA( ( mj 4A-)t+rt.2 System pumped as part-of inspection: (yes or no)-WU If yes, volume pumped: gallons Reason for pumping: — TYPE OF SYSTEM _ Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) 1 (revised 11/03/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4G J NZQS'7jCu RD Owner: / Date of Inspection: SEPTIC TANK:_ (locate on site plan) Depth below grade: Material of construction: Lconcrete_metal _FRP_other(explain) Dimensions: ! Sludge depth: .1 Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: ' V Distance from top of scum to top of outlet tee or baffle:,,_ Distance from bottom of scum to bottom of outlet tee or baffler Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc) 131E6F'TRAL (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP—other(explain) Dimensions: Scum thidmess: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 11/03/9S) 6 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM / PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: ING TANK:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP—other(explain) Dimensions: Capacity: —lions r Design flow: Qallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc) Lg✓t I M0 a71/,DS PUM --, (locate on site plan) Pumps in working order.(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: L{0 �;,_�TfZu c Owner. / >�� ,�/�RS%ON5 !1)1 f JS Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): iZ x Jc:Oc f}� (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) -CZ" '6Ak5-,_ (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(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) -PRW YT—_ (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.) (revised.11/03/95) $ r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ( PART C SYSTEM INFORMATION (continued) Property Address: ` Owner: Date of Inspection; SKETCH OF SEWAGE DISPOSAL SYSTEM: indude ties to at least two Dermanent references landmarks or benchmarks locate ail wells within 100' ol Z Depth to grounchvater lL feet method of determination or approximation: L L /rl (revised 11/03/9S) 9 Permit Number: Date: lF Completed by: /��DEr?ICiC Kip=/y HIGH GROUND-WATER LEVEL COMPUTATION Site Location: �(O ��;}� ;r2,a Lr}D Il'f}RCf SUS AI ; Lot No. (� Owner: S I-{L M�,pJ Address: Contractor: /Q=r 1,4m,4.7ia.UAddress: `Iy�)UU r Notes:_ OBSE:PIPF-"0,1, iJ�=ll M�t4SU2tD /�T Sil9� iM✓��'cKCi 8�l✓i +9 STEP 1 Measure depth to water table to nearest 1/10 ft. .............................................................................. Date ' 2 C(4 montt/davAyear STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: OAppropriate index well.................................................... `�DIN�J3 OB Water-level range zone ..................................................... C S STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to _ water levell for index well mo' hlYear °q , STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) determine ivater-level adjustment ................ y,0 .......................................................................... STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water level at site (STEP 1) t, TOWN OF BARNSTABLE o�-/J . , LOCATION , y �' l. SEWAGE # VILLAGE ASSESSOR'S MAP & LOT ,,�-&Vlo t" tINSTALLER'S NAME & PHONE NO. /a' -• aOA, "-.2 1 e_ ti SEPTIC TANK CAPACITY 5-61 G , k t`LEACHING FACILITY:(type) � � (size) �N-O. OF BEDROOMS 0 PRIVATE WELL OR PUBLIC WATER Jw OR OWNER DATE PERMIT ISSUED: DATE . COMPLIANCE ISSUED: I 1 VARIANCE GRANTED: Yes No 4 1 r,- ,. THE COMMGNVVEALTH OF MASSACHUSETTS BOAR® OF HEALTH t ............................. ............OF.............................-......... " pplirFation for Uhipmal Work, 4owitrurtinat rantit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage D,ispposal System fit• °1 . ..-- ...... ...._ .................. ...o.r..••... 1 ....................... . --._... ...... :......... � . . •-••••-•• Loca ress .. erAd _....__ . ...--•-•..............................�;' ..__r .. ... a Installer Address r/Type of Building Size Lot----------------------------Sq. feet V Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other-J �pe of Building A ....... No. of persons..._,. -�= Showers ( ) — Cafeteria ( ) a Other fixtures ------------------•-------•-•..... •-- -------------•--•-••-----------•--------------•----- g f ...e�-()_....gallons per person per day. Total daily Howl-� � .............gallons. W Desi n Flow______________________ WSeptic Tank—Liquid capacity/Otq.gallons Length................ Width---------------- Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No._1`.'*_,(P1­1.P0Diameter.................... Depth below inlet.................... Total leaching area.....__......_....sq. ft. Z Other Distribution box (i.� Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water......................... (s, .Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a' ........................... _... 0 Description of Soil....v�` '_ ���^�....--•` !` -- - -... - - x x U Nature of Repairs or Alterations—Answer when applicable...__________________________•_________________________•-•-.-_--------•-------------_---__-•_-. -------•----------------------------------------------------------------•-•--•-----•---•-----------------------------------------------------•----------------------------•------•. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of LITL is 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of 1 lth. ined -- ................. .........•-•--... ......._......----- T_j/A � DatApplication Approved By------- ---------- • --- . ...--- -------- •-•--•..�' .--C_�------ Da te Application Disapproved for the following reason ................................................... ....---•--------------------••-----...........---...-----•-•--...---------------------------•-------•--...------------------•--------------------•----------------------------------------------••-_•-••- Date IPermit No......................................................... Issued -- Date ��°r r RAXTER & NYE INC. Registered Land Surveyors and Civil Engineers 7 Parker Road/Osterville, Massachusetts 02655/Tel. (617)428-9131 WILLIAM C.NYE,R.L.S.-President RICHARD A.BAXTER,R.L.S.-Vice President PETER SULLIVAN,P.E.-Vice President-Engineering November 7 , 1986 Town of Barnstable Board of Health P .O. Box 534 Hyannis, MA 02601 RE: Applicant : M'. Sherman, Lot 110 Industry Road, Marstons Mills Installer : A. Fuller Gentlemen: Per your request, on November 6 I made an inspection of the installed system at Lot 110 Industry Road. The system has been installed in accordance with the approved plan . I trust that this meets your present needs . Very truly yours , Peter Sullivan, P . E. Baxter & Nye, Inc. PS/fmj ° Pt TER �yN SULLIVAN v No. 29733 h ��•�` `���sreR�� AL E��'��� MEMBERS OF CAPE COD SOCIETY OF PROFESSIONAL ENGINEERS AND LAND SURVEYORS/AMERICAN CONGRESS ON SURVEYING AND MAPPING MASSACHUSETTS ASSOCIATION OF LAND SURVEYORS AND CIVIL ENGINEERS Na .......... r ,Y f FEE............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................O F...........................................................................------------... Appliration for Uhipsal Workii Towitrnrtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at:. .....!....*..nt 0......... �1 .._... �. .....;, ......... ................................ ----•-- ................................... Locati n Address or tp ,. 40 .... .... --. .. --- ------ .......................... ner Ad s Installer Address PQ d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms................................._-.........Expansion Attic ( ) Garbage Grinder ( ) Other hype of Building ...... No. of persons_... Showers ( ) — Cafeteria ( ) al Other fixtures -----•--------------------------------------- ------------�ii'o­_­ ..Flow......... .._..gallons per person per day. Total daily flow ;''t gallons. P4 Septic Tank—Liquid capacityAri.gallons Length................ Width....._.......... Diameter -___ ..._- Depth................ W .__ Width.................... Total Length Total leaching area___.......•.........s . ft. Disposal Trench—No. ............... . W t g g q x P Seepage Pit Nolkp"01 Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (�s�" Dosing tank ( ) Percolation Test Results Performed by............... --•-•-------------•--------•--•--------------------------- Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ .--- ------ ............................ .............................Soil... ... .. .................... x W --------------- ----------------------------------------••-----------------------------••••--------------•-•-•••--------------------------------------•--•--...--------------------------------•-------- i U Nature of Repairs or Alterations—Answer when applicable............................................................................................... -------------------------------------------•----------------------------------------------••-•----...----•---------------------------------------------•---------------------------......-----........_. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT I.s^-. 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of larealth. Signe «./ .P Application Approved By......... •-�---- -- ---t--- _. ....:- -•-----•- --...•..-�---`�- �-- --�� Date Application`Disapproved for the following reason -------•--------------------•--•-------------------------------------------------------------------------------- .............••-•--......--.....------------------..•---------•---------•--------------._._...•---•--•-------•----••----•--••-----•--•---•--------------------------------------------•------......... Date PermitNo......................................................... Issued............................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL, H ...........a. .....OF.. ......... .,....... Trr#ifiratr of Tomphanrr THIS IS TO GER.TI Y, That th "Ind1 al Sewage Disposal System constructed ( ) or Repaired ( ) by... ........... - ......-.....---•••----•-----------••-----------......-------•---......................--------............ `r Installer at... /1.0..•----_ • --------..-------------------------------•------•-------•--- . ............................... has been installed in accordance witl the provisions of TITLE 5 of The State Sanitary Code as icjibed in`the application for Disposal Works Construction Permit No.:. ............. dated------�1.).-q......................`� THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE',, SYSTEM WILL FUNCTION SATISFACTORY. DATE............... � 1, ....................................... Inspector...................................................................................... iFhI�jh-et'Y' e'"4t; 'HE COMMONWEALTH OF MASSACHUSETTS 8e4Drt � 81 -cc c tSacm ASaw)LT Ah(,A Of BOARD OF HEAL ........../ �.........OF... `. ................................................ No.......` _-_' .4 ! FEE.__.. ._... lkopooa1 Works o lion rrnti Permission is hereby granted :___ ----------------------------------------------- -------------•-•--- to Construct ( ) or R air ( ) 'n ndivi. al Sewage Disposal System atNo._ t-4---AD...-- " -•----------------------------------------------------------•-- Street � �P_1/ t mil' vT . as shown on the application forrDisposal Works Construction Permit No___________________ Dated_._ .... __ . __-.-.-... _____... r -------•----. ---------•-feh DATE 9,�- . ��, I ... FORM 1255 HOBBS & WARREN, INC., PUBLISHERS l Town of Barnstable a UMVMAOL& kt@' Board of Health 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Wayne Miller,M.D. FAX: 508-790-6304 Sumner Kaufman,MSPH Paul Canniff,D.M.D. March 6, 2006 Mr. Henry Askew 384 Edgell Rd. Framingham, MA 01701 Dornn�sl =zz� 40 dtistiy koadG,te s apar� ce ; Dear Mr. Askew, You are granted a conditional variance,from the Board of Health Regulation, PART II SECTION 1.00, which requires minimum 1,000 gallon capacity grease traps at all food establishments. This variance will allow you to operate a food establishment, utilizing a grease recovery device at Domino's Pizza, 40 Industry Road, Marstons Mills with the following conditions: (1) The grease recovery device shall be installed and maintained in accordance with the State Plumbing Code. (2) This variance is not transferable to another owner or leasee of this establishment. This variance is granted because it has been demonstrated that a grease recovery device (G.R.D.) would be effective in removing grease, fats, and oils. kcrelyour , - Way e Miller, M.D. Cha man Q:DominosPizzaGRDVariance ISODATE: /G�/V�J OFIHE rpm FEE: snatasrAat.e, + y� !Me 9. j REC- BY- ' Town of Barnstable8 b� SCHED. DATE:O Board of Health 200 Main Street,Hyannis MA 02601 Office: 508-862-4644 Susan G.Rask,R.S. FAX: 508-790-6304 Sumner Kaufman,M.S.P.H. Wayne A.Miller,M.D. VARIANCE REQUEST FORM LOCATION Property Address: _6 iA Gi m fv—) a�S 0 n 5 M Assessor's Map and Parcel Number: Size of Lot: Wetlands Within 300 Ft. Yes Business Name: p 61M I y),p11 S No Subdivision Name: APPLICANT'S NAME:� 2=Y1 ve�? Phone Did the owner of the property authorize you to represent him or her? Yes ✓ No PROPERTY OWNER'S NAME CONTACT PERSON Name: ��f i)r,/ �5 kf(� Name: S� n Address: W�r vi��a*j Address: Phone: 7 y 2 3 Phone: VARIANCE FROM REGULATION UJA Rag.) REASON FOR VARIANCE(May attach if more space needed) NATURE OF WORK: House Addition 000000 House Renovation 13 Repair of Failed Septic System E3 Checklist (to be completed by office staff-person receiving variance request application) / Please submit copies in 4 separate completed sets. Four(4)copies of the completed variance request form Four(4)copies of engineered plan submitted(e.g.septic system plans) Four(4)copies of labeled dimensional floor plans submitted(e.g.house plans or restaurant kitchen plans) _ Signed letter stating that the property owner authorized you to represent himther for this request Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applijexpense (for Title V and/or local sewage regulation variances only) _ Full menu submitted(for grease trap variance requests only) _ Variance request application fee collected (no fee for lifeguard modification renewals, grease trap variance rowner/leasee only], outside dining variance renewals [same owner/leasee only], and variances to repair failed sewage d [only if no expansion to the building proposed]) Variance request submitted at least 15 days prior to meeting date LM Wayne A Miller,M.D.Chairman VMUA14CE APPROVED NOT`APPROVED Sumner Kaufman,M.S.P.H. Susan G.Rask,RS. REASON FOR DISAPPROVAL Q:\HEALTH\Application Forms\VARIREQ.DOC 31HIG DIPPER® IS Unit Operatic"- Skimming Wheel Programmable Timer �Field Reversible Top Solids CollectionBasket Cover ' i Clean Water �� Outlet �' � Inlet from Sink t� Outlet Baffle I Grease Collection Container Cutaway Drawing of Big Dipper® -J-200-IS BIG DIPPER® Product Features and Benefits ® Big Dipper units separate fats, oils and grease with a proven efficiency of up to 98.6%. Automatic removal of grease retains unit separation efficiency. * Fully automatic self cleaning cycle with 24-1 our programmable timer. Removes collected grease&oils from tank without any operator assistance. g Constructed of corrosion resistant materials. Suitable for installation in virtually any location. Integrated Motor/Crease Outlet/Heater/Lid on the IS Series. Enables fast, do-it-yourself unit operation reversal. Incidental solids automatically removed in AST Series. No strainer basket to manually empty. ® Easy lift grease collector in the 1S Series. Simplifies grease collection container emptying. Compact footprint. Makes installation possible in tight spaces. rhermaco,Inc.www.big-dipper.com 1-800-633-4204 Copyright 0 2003 Thermaco,Inc. • 5 BIG DIPPER® IS_ nit-k Dili Dinpei- InternaS crrai e-. 'T')series units utilize an internal strainer basket to capture incidental solids in kitchen wastewater flows. A skimming wheel system inside the unit skims the grease & oils out of the retention.area when activated b -an integral programmable timer. IS units work well inside fast food-type restaurants or food preparation facilities�� ere grease removal directly at the source is paramount. Big Dipper IS unit sizes handle kitchen flows of 20 to 50 gallons per minute. Point Source Grease Removal Units Units in the 20-30 GPM(1.26-3.15 1/s)range typically service a single fixture such as a pot sink or pre-rinse station and are installed as close as possible to the device being serviced. W-200-IS 20 GPM 0.26 1/0 Exterior Construction:304 Stainless Steel,Bright Finish SolidsSkimming trainer Ca acity: 1.16 gal�o/its(4.41) 2"Inlet/Outlet(Trim) 350W/115V/6OHz* W-250-IS 25 GPM (1.58 1/5) Exterior Construction:304 Stainless Steel,Bright Finish { Skimming Rate:35 lb./hr.(15.9 kg/hr) Solids Strainer Capacity: gallons(4.41) p 2"Inlet/Outlet(50 mm) . 350W/115V/60Hz* R �,F _ 3 W-350-IS 35 GPM (2.21 1/0 Exterior Construction:304 Stainless Steel,Bright Finish e Skimming Rate:35 lb./hr.(15.9 kg/hr) s v t Solids Strainer Capacity:2.5 gallons(9.51) 3y" 3"Inlet/Outlet(75 mm) r 350W/115V/60Hz* W-500-IS 50 GPM (3.15 1/s) Exterior Construction:304 Stainless Steel,Bright Finish Skimming Rate:35 lb./hr. (15.9 kg/hr) z . Solids Strainer Ca aci :2.5 gallons(9.51) 3"Inlet/Outlet(A mm { 3 1 350W/115V/60Hz* � � , F W-300-AS`1° 30 GPM (1.89 1/5) . a Exterior Construction:304 Stainless Steel,Bright Finish — --- Skimming Rate:52.5 lb./hr. (23.9 k /hr) BIG DOPPER@ W-200-15 Automatic Solids Transfer Feature 3"Inlet/Outlet(75 mm) 1500W/115V/60Hz* *220-240V/50hz models available "*Big Dipper Model W 300-AST requires a separate facility-supplied 5 GPM(.31511s)water supply for operation. Thermaco,Inc.provides a 0.5"(13 mm)male connector to accommodate this connection. Minimum water supply pressure should be 40 PSI (2.76 Bar); maximum water supply pressure should be 70 PSI (4.83 Bar). ote: InIsta11 t Ml�s IUSt COMMY With all applicable local, state. and national codes for your area. 6 Thermaco,Inc.www.big-dipper.com 1-800-633-4204 Copyright©2003 Thermaco,Inc s n A lu ry � s S I rr� II � I . r5 -�o N SHEET I nF 2 LOCUS INDUSTRY ROAD > 0 - -n LOCUS MAP j 1:25,000 -ONE: s a D L F; rn;i MAP 58 PCL. 28 ZOE F. NARNER 20 10 N61 06 39E C.B. FND. 57. 35 0 I HEREBY CERTIFY THAT THE PROPEMY LINES S"O" HEREON ARE TME UNES DIVO"ev; EXISTING OWNERS"PS, ANO TK LW3 Of' edge 0� pavement 57 0 STREETS AND WAYS S"OWW ARE Tm= Or� . PUBLtC OR l*RtVATE STREETS OR WAYS rW LM FOR ESTABLISM0 AND T"AT No NL DIVISION OF EXISTNG OWNEFMW OIR NIN WAYS ARE S"OWK VE-D PARI.(ING LOF DATE: ..... �l V."L 80. 00 -REWTEWO LAND Z%0fVV%TlIA NIN, BUILDING #/ 2 -STC- RY C C On C. CONCRE-TE BLOCK BUILDING Conc. I CERTIFY T4AT THIS ACTUAL A pron Q� SURVEY WAS MADE THE GROUND IN A C'C 0 R IN C E 'T_H_E �ND WITH -OURT Q) INSTRUCTIONS OF 1971 ON OR BETWEEN UNITS #6 to #13 6 JUNE 61, !9861 AND JUNE 11, 1967. THIS SECTION 00 LQ Q) ro DATE <97 w i, WAREHOUSES LOWER C� co N S-170RAGE UPPER REGISTERED LAND SURVf�_YOR 7 PARKER ROAD OSTERVILLE, MASS. z Conc. C017C. "SHERMSIX CONOOMINIU41 LLI /0. 00 /0.001 slep THIS SEC TION Q 41 RETAIL UNITS #/ to #5 LOWER (IV Conc. 1�j , ev a C� (-'onc. Pcd CO IV Pod OFFICE UNITS #14 to #18 UPPER Q) TOWN OF SITE PLA!! R 'All CONDOMINIUM SITE PLAN DEC 2 9 1994 N 60 - 03 - 12E I �ERTIFY THAT THIS PLAN FULLY AND Lz 'ACCURATELY DEPICTS .THE LOCATION AND Foundation Foundcfibi7 IN E C E Concrete A pron DIMENSIONS OF THE BUILDING AS BUILT, AND FULLY LISTS THE UNITS CONTAINED (MARSTON'S MILLS) THEREIN. BARNSTABLE MASS. IR, -Z FOR MOSES H. 8 CLARE SHERMAN REF: LOT I 10 LAND COURT CASE 22824G Tj 112 . 80 -SCALE: 1" 20' JULY 1 , 19 4 7. 20 S60 31 22W 43 C.B. BAXTER NYE, INC. FND REGISTERED LAND SURVEYORS f v CIVIL ENGINEERS OSTERVLLF., MASS. IND.1-0.1.5. TA? )l (PRIVATE 40' WIDE) ROAD V", tor MASTER DEED APF 's I jo '0 - !� 1U17C'1711011 6�' .7.4 t ,- i .. rrn _4S tr a r 1 DORMER I d s+ i I0 - 0 80 - 0 1, Ago , tea• .'ry ,, ..��:� ! �t.x. :., I , tip# .I r .L..r ', .rlr• •,,, � +-.rrr ..� nllr . .+ � .i... 0"m Am..r Ilrrlw Mob � +— rlrr• 1 ... rrwi rli�tr ,. Y..,, �i•r.I. -•, },- •- . ~. „ 1 n 39 0 3 ,. � E 21 OC1CS ,. i• UNIT # 13 - LOWER UNIT # 12 - . LOWER u,. 1 1 WAREHOUSE WAREHOUSE , 0 I OVERHEAD - . r."- ; ♦ I , -13-7 r--- i3 , DOOR 1 � 11 1 11 1 11 1 11 1 11 1 col �ONCRE'�'� F�A101�. .. TYPICAL 3 0 4 -0 , 5 -0 5 -0 4-0 3-0 UNI 3 - U WT"* 1 T r T t UPPER 2 - UPPER •w; , y — - i j m I _ a m L2 3 �t *� I i L N s'�RA�GE STORAGE , I y _ • CONCRETE FCii4Tit • - I t II 1 I O O -. stairs ! _ r tyollo- L , I c_1112 -If — dONIV1 1 j+(} 1 stairs R C�l �.. rIIIL o 0 TYPICAL — — — — _ O_ '° I down 'R ,,,,�k „ - 00 No 5"LE xc: CD or 12 t ' I r 3- 4 0 5 0 5 - -0 0 I4 0 �3'-0 j cy CIO W UNIT # l l - LOWER _ UNIT # 10 LO WER L UNIT 11 - UPPER UNT 0 10 UPPER WAREHOUSE WAREHOUSE STORAGE STORAGE k rt; I v N • e. C 1 n 1 11 1 „ 3 8 - 9 3 8 9 11 �, Cn - 37_ .•.• I Q — � � FRONT B�G'1'ICyN / .___ I , a I ht FLOOR 16905 o `�' '` ht CEILAV�i s 8 tb `h't cr- r Z W . 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