HomeMy WebLinkAbout0059 NELSON LANE - Health �:�MARSTOIINS
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5 9-NELSON LANE .
MILLS 0264.8 +,
MAP/PARCEL 126/085 _
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$�gC 9 CIN rG CF{r�nje
TOWN OF BARNSTABLE
LOCATION Sr% t`I CLSON %as N E SEWAGE#
VILLAGE MArsroc,16 91WIS ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY I O O '(y
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
OWNER
PERMIT DATE: COMPLIANCE DATE: r130 s Lf
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY ��P�c,�c D E CN 1 c2AscS LC G
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No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
application for Disposal 6pstem Coustruttion Permit
Application for a Permit to Construct( ) Repair K Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.59 N E"O N L n,ihPfsitm IM 1115 Owner's Name,Address,and Tel.No.
/ Am DAZA P_a SNy DER
Assessor'sMap/Parcel 0S5 y 91`4 IM�1►N ST'R Z T0a41A1?S-DiA, FAA• 194(v5
Installer's Name,Address,and Tel.No. Sro$-411-$ 17 Designer's Name,Address,and Tel.No.
Cprpa L�_I-0E tc_a
Is � (0VAMtdL(_%*k Nks,49M A4&, bZ(,%A1 (A
Type of Building:
Dwelling No.of Bedrooms I v " Lot Size ± sq.ft. Garbage Grinder( )
Other Type of Building lac. i Oe4,-1T c R 1 No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) 1��PL►Ar�F- -l3oY. �+-� 1+2p
�tt��Ace uhe t-ftc,%A o-TL4 To Ntw O -13oy PEi= ukce 1lY p_
i1r�YY� b-(3,D X `T o ! _-.A� Prr w. I SLIn.- Lt% P vc
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date D
Application Approved by Date
Application Disapproved by Date
for the following reasons Permit No. cl2 o l L4 _iL 5 Date Issued
No. G/LI ^ ' ./ Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
s' J 2pplitation- for Disposal *pstrm Construction Permit
Application for a Permit to Construct( )- Repair K Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
( , otNo. Sq Nso .r . � rsor v (ISLocation Address or, Owner's Name,Address,and Tel.No.
A,-4MEA E. SNYDER
Assessor's Map/Narcel 2,(, offs 9l L{ mA i r•1 sro-cEr TN om?so N , I>A. 1?`f G 5
Installer's Name,Address,and Tel.No. Sta)- Li l-) -$1?11 Designer's Name,Address,and Tel.No.
cP1'i�E`i�tDE 1=1v�iz-.Pa,S�zJ Lc� -
1 S 3 (6MMt_4LL%A\ ' T- NkSVtPf-e Mh. bZ(O'A9 N
Type of Building:
Dwelling No.of Bedrooms J" Lot Size �P .5 GO± sq.ft. Garbage Grinder( )
Other Type of Building IZc sti be .,c A i No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) A v A gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) R, Pt-►fie: -f3 ox w•/ 14 Z p b Qox ,
T2,L t>%-Ace 1_..vte �row1 6vTL4 SeP�cT00-11k To NEB - t3op t IZt F��r4ce (1�1e
Pv 1�-r3�x 'T L' +��H `t'�T w. S<<.• 4t P,JG
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
_- Signed Date 5`�_9 pZ!)(
Application Approved by = Date
Application,Disapproved by Date
` w for the following reasons
Permit No. G' �" I 5 Date Issued S - f
- - ------ - - -------------------------------------- 1 ---- ------------- ------------- ------ -------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( )
Abandoned( )by CAPcw(pr C L.0
at 59 o N 1 r+ • %NA A 2 S 11%Q s to 111 S has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit Nod b�L `/7 5 dated
Installer C.A'9IL—I t>0 Ch'1 fi�tzPr i scs LL G. Designer NI 'A
#bedrooms Approved design flow /1/ /-/- , f gpd:
r r /`a'• �10
The issuance of this permits all nJot+be construed as a guarantee that the system w�llfun/ctiongas designed.
Date ) Ins ector i
-------- -------------------.---------------- --- ------------------------------------ - - - -.:--------------------------------
No. ;61 Ll ( Fee
THE COMMONWEALTH OF-MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal *pstem (Construction permit
Permission is hereby granted to Construct( ) Repair(x) Upgrade( ) Abandon( )
System located at S'� N G LS or-A L ek tiu C V\AikkLS 1-M i M t 1\S "r\-• O z k g
and as described in the above Application for Disposal.System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit. �- r � ,
Date "a - L Approved by 6
AsBuilt Page I of 1
LOCATION SEWAGE PERMIT NO.
VILLAGE --`
INSTA LLER'S NAME A ADDRESS
R U I L D E R OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
y
1 6 s
?.ttp://issgl2/intranet/propdata/prebuilt.aspx?mappar--126085&seq=1 5/12/2014
Jun 02 1409:54p p.18
Commonwealth of Massachusetts
Title 5 Official, Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
59 Nelson Lane
Property Address
Andrea Snyder
Owner Owner's Name
information is Marstons Mills MA 02648 6-2-14
required for every City/Town
page. 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,out forms rhen A. General Information -
on the computer, ���`�'I"`OF'MAssq%i,
use only the tab •°1. Inspector a`'o=�: ' yam
key to move your , = .iA M E S '"
cursor.-do not James D.Seafs
se the return Name of Inspector
=U
key.
,y CapewideEnterprises,LLC
Company Name '�,,�/'�•..L�FTt...�•
i 153 Commercial Street '�n�fr, ,N.�a``
Company Address
Mashpee MA 02649
City/Town State Zip Code
50BA77-8877 S 1623
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
6-2-14
spector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30.days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP.The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
"""*This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3M 3 - Tile 5 Offidel brag arm:Subsurface Sewage Dispose!System•Page r of 17
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Jun 02 14 09:54p p.19
Commonwealth.of Massachusetts
Title 5 Official; Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
59 Nelson Lane
Property Address
Andrea Snyder
Owner Owner's Name
information is Marstons Mills MA 02648 6-2-14
required for every
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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.
1
Comments:
t:
t
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
t
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
i inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
i 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):
f
i
ISfns•3l13 Title 5 Official Inspection Form:Subsurface Sewage Disposal Syslem•?age 2 of 17
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Jun 02 14 09:55p p.20
Commonwealth of Massachusetts
Title 5 officiate Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
h ,
59 Nelson Lane
Property Address
Andrea Snyder
Owner Owners Name
information is required for every Marstons Mills MA 02648 6-2-14
page. Cityn-own State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumpsialarms not operational. System will pass with Board of Health approval if
pumpslalarms 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
i 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 ElN ElND (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
15lim[3113 Title 5 Official Impaction Form;Subsurface Sewage Disposal System•Page 3 of 17
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Jun 02 14 09:55p p.21
Commonwealth of Massachusetts
I UTCIL
Title 5 Official` Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
, 59 Nelson Lane
Property Address
Andrea Snyder
Owner Owner's Name
informrequired tion
is Marstons Mills MA 02646 6-2-14
required for every
page olIty/Town State Zip Code Date of Inspectlon
B. Certification (cunt.)
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 pubtic 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 they 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
® Stabc`liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El Liquid depth in is less than 6" below invert or available volume is less
® than %2 day flow P/r
1
g 3ry3 Tills 5 Qffidal Vapedioe Form:StAmrta a Sewage Disposal System•Page 4 of 47
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Jun 021409:55p p.22
Commonwealth of Massachusetts
Title 5 official` Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
59 Nelson Lane
Property Address
Andrea Snyder
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-2-14
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,ODOgpd.
❑ ® 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
F 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 systOm 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,
f 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 O shall upgrade the
system in accordance with 310 GMR 15.304.The system owner should contact the appropriate
regional office of the Department.
t5ins 31r 3 Tale 5 Official Inspection Fo=Subsurface Sewage Disposal System-Page 5 of 17
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Jun 02 1409:56p p.23
Commonwealth of Massachusetts
Title 5 Official Inspection Form
'x Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
59 Nelson Lane _
Property Address
Andrea Snyder
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-2-14
page. CityrTown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done.You must indicate"yes" or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any,of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
❑ Were all system components,excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
0 ® Was the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems?
The siie 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.
El ® Determined in the field(i€any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information'
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310:CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5iru'•3113 rile 5 Offdd hspWion Form:Subsurface Sewage Disposal System•Page 6 of 17
Jun 0214 09:57p p.24
Commonwealth of Massachusetts
Title 5 Official, Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
59 Nelson Lane
Property Address
Andrea Snyder
Owner Owner's Name
information is Marstons Mills MA 02648 B-2-14
required for every
page . Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
The system is a 10od Gallon Tank, D Box and pit.
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No
information in this report.) a
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
OGal
Water meter readings, if available last 2 ears usage d 213,1 1 ,0O Gal's
9 ( Y 9e(9p ))= 2013,119,OOOGaPs
Detail: , ---.-'
Sump pump? r' ❑ Yes ® No
NA
Last date of occupancy: Date
E Commercial/Industrial Flow,Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day t9pd>
Basis of design flow(seats/personslsq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
151ns'•3113 Tile 5 Official inspedon Form Subsurface Sewage Disposal System•Page 7 of 17
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Jun 02 14 09:57p p.25
Commonwealth of Massachusetts
Title 5 Official Inspection Form
ME a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
59 Nelson Lane
Property Address
Andrea Snyder
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-2-14
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use, Date
Other(describe below):
S
i
id
General Information
Pumping Records:
Source of information: NA
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
a
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
i
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ InnovativetAltemative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3113 Title 5 OFfidal Inspedon Form Substaface Sewage Disposal System•Page 8 of 17
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Jun 02 14 09:57p p.26
CommonweaHh of Massachusetts
Title 5 Official!, Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
`Y 59 Nelson Lane
Property Address
Andrea Snyder -
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 6-2-14
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont)
Approximate age of all components, date installed (if known) and source of information:
1980 Permit#80-61
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
31
Depth below grade: a feet
Material of construction:
i
❑cast iron ®40 PVC ❑other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Pipeing is 4" PVC SCH 40 I _
Septic Tank(locate on site plan):
Depth below grade: ?e5et
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 Gal.Precast
41'
Sludge depth.
(sins f 3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
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Jun 0214 09:58p p.27
Commonwealth of Massachusetts
Title 5 official- Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
59 Nelson Lane
Properly Address
Andrea Snyder
Owner Owners Name
information is Marstons Mills MA 02648 6-2-14
required for every
page. CitylTown State Zlp Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
i Distance from top of sludge to bottom of outlet tee or baffle
26!'
3"
Scum thickness
1 2„
Distance from top of scum to top of outlet tee or baffle
I Distance from bottom of scum to bottom of outlet tee or baffle 15,
a
How were dimensions determined? Asbuilt-Tape
Sludge Judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank at working level.Tank and covers at 25" below grade. Inlet tee, outlet tee. No sign of
leakage or overloading.
t
i Grease Trap (locate on site plan):
3
Depth below grade: feet
t
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions: r
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
tskts;•3/t a - Mile 5 Official Inspeetlon Form:Subsurface Sewage Disposal System•Page 10 of iT
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Jun 02 14 09:58p p.28
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
59 Nelson Lane
Property Address
Andrea Snyder
Owner owner's Name
information is Marstons Mills MA 02648 6-2-14
required for every
page.. City/Town State Zlp 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 El 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: gate
Comments (condition of,alarm and float switches, etc.):
j
t
Attach copy of current pumping contract(required). Is dopy attached? ❑ Yes ❑ No
t5ins�•3113 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Jun 02 1409:59p p.29
Commonwealth of Massachusetts
Title 5 Official Inspection Form
F
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
59 Nelson Lane
Property Address
Andrea Snyder
Owner Owner's Name
information is MA 02648 6-2-1d
required for every Marstons Mills
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.):
D Box is new H 20 in stone drive way. Box is 28" below grade, wlone Sine out. Cover at 8"
below 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:
t5cu 3113 Title 5 Mimi Inspeclon Form:Subsurface Sewage Disposal System•Page 12 of 17
Jun 02 14 09:59p p.30
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
59 Nelson Lane
Property Address
Andrea Snyder
Owner Owner's Name
informationairedfor every is
required for Marstons Mills MA 02648 6-2-14
page. City/Town State Zip Code Date of Inspection
D. System Information (cons_)
Type:
® leaching pits number:
1
❑ leaching chambers number:
1 ❑ leaching galleries number:
1 i
❑ leaching trenches number, length:
i
❑ leaching fields number, dimensions:
❑ overflow cesspool number.
❑ innovative/alternative system '
Typeiname of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is a 1000 Gal.Precast Pit. Pit and cover at 40" below grade. 18"water in
pit w/stain line at 30". No sign of over loading or solid carry over.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inletinvert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t51m!Y13 Title 5 Official Inspection Faun:Subsulm Semage Disposal System•Page 13 or 17
i ,
Jun 0214 09:59p p.31
Commonwealth of Massachusetts
Title 5 Official Inspection Form
"s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
59 Nelson Lane
Property Address
Andrea Snyder__
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 6-2-14
page- Cityrrown state Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
I,
i
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.):
f
i
t5ins 3113 Title 5 Official Ip3petlion Form:Subsuftw Sewage Disposai System Page 14 of IT
Jun 02 14 09:59p p.32
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
59 Nelson Lane
Property Address
Andrea Snyder
Owner. Owner's Name
information is Marstons Mills MA 02648 6-2-14
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
hand-sketch in the area below
❑ drawing attached separately
� 9Y.e
I Q
�a = i
0
03
P
Omit-3/13 Title 5 p#Rdat Irispechw Form:Subsurface Sewage Dlsposel system-Page 15 of f 7
E.
i
Jun 02 1410:00p p.33
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
59 Nelson Lane
Property Address
Andrea Snyder
Owner Owner's Name
information is Marstons Mills MA 02648 6-2-14
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
f ❑ Check Slope
❑ Surface water
❑ Check cellar
's
❑ Shallow wells
Estimated depth to sigh ground water. 12'
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: 12-21-79
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:
i
You must describe how you established the high ground water elevation.-
T.H.on design plan 12-21-79. No G.W. at 12'. Bottom of pit at 9'-4"below grade. Bottom of pit at 2'-
6"above T.H.Depth.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t51ns :i 13 TWe 5 Official Inspection Form:SubsWeoe Sewage Disposal System-Page 16 of 17
i
i
t
Jun 021410:00p p.34
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
59 Nelson Lane
Property Address
Andrea Snyder
Owner Owner's Name
information is required for every Marstons Mills MA 02648 6-2-14
page.< Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, or E checked
0 Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
0 System Information—Estimated depth to high groundwater
0 Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
i
x
� I
t5ins•'3113 Trtie 5 Official IrmpeeGon fomx Stpsurtaoe Sewage Disposal System•page 17 of 17
i
JUN-22-2012 12:57P FROM: 5088624722 TO:95087906304 P. 1/2
Town of Barnstable
Assessing Division
• ' s''NAPR 1�
MABB. ' 367 Main Street,Hyannis MA 02601
1e3o ��'
� www.town.barnstable.ma.us
Office: 508-862-4022 Jeffrey A.Rudzisk,MAA
FAX: 508-862-4722 Director of Assessing
FAX SHEET
5
PAGES INCLUDING COVER: 2
TO: Health Department )
(508) 790-6304
l�
� Q
FROM: DENISE RADLEY
PROPERTY TRANSFER ASSISTANT
(P) 608-862-4018
• June 22, 2012
RE: ANDREA E. SNYDER
59 NELSON LANE, MARSTONS MILLS
Hello:
I just came across Parcel 1261085 which is noted as an Unfurnished Rental.
Thank you,
Denise Radley
•
JUN-22-2012 12:57P FROM: 5oee624722 TO:95oe7906304 P.2/2
Town of Barnstable
s Assessing Division
' eAl�'aM ' 367 Main Street,Hyannis MA 02601
. ,�
so,,,uv" m,ww.tcrwn.barnstable.m.t.us
Office: 508-862.4022 Jeffrey A.Rudziak,MAA
FAX: 508-8624722 Director of Assessing
ADDRESS CHANGE/VERIFICATION FORM
For Real Estate&Personal Property tax bills ONLY
To change the address on your motor vehicle excise tax bill,contact the Registry of Motor Vehicles
To change the address on.your boat excise tax bill,contact the Massachusetts Environmental Police
PLEASE COMPLETE THE FORM BELOW AND RETURN IT TO THE ASSESSING DEPARTMENT
Fared or eina;led changes not accepted.Form rrmust incli.ide original.P-ignatnre and be mailed to:
Town of Barnstable,Assessor's Office,367 Main Street,Hyannis,MA 02601,
l7'IS IMPORTANT THAT YOU.RETURNN THIS FORM. IF YOU DO NOT RECEIVE YOUR TAX BILL YOU WILL
STILL BE RESPONSIBLE FOR ANY INTEREST AND/OR LATE CHARGES
This property is:(please check all that apply)
My primary residence My secondary home
Rental property_Z (and CommerciaUlndustrial or Vacant Land_
is)furnished_unfurnished ✓ Personal Property
PROPERTY LOCATION: 1V02—S e.)nJ
MAP/BLOCK/LOT#u2/D 3,-/
OWNER'S NAME: ;C-�d/I C7f
Mailing Address
STREET: ,S r-X�2,)—
or
P.O.BOX: — ,p
CITY,STATE(CTRY),ZIP:
This form must be signed by the 'owner/or Trustee as shown on the recorded deed.
OWNER'S SIGNATURE:��Vy�C/ L4z— DATE:
(Subscribed under the penalties of perjury) 2-yea �y33 2 - -2.-O&-Iv/e" `
•
LOCATION SEWAGE PERMIT NO.
VILLAGE
I N S T A LLER'S NA III E i ADDRESS
/� cz��-
D UILDE R OR OWNER
DATE PERMIT ISSUED
DATE C 0 M P L I A N C E ISSUED � -
c
��(�
i � 1 �.y
' �
!/
6 �!
���
SL�
„llll` .
...�__ ._
THE COMMONWEALTH OF MASSACHUSETTS
-� BOARD OF HEALTH O,.
Q1�. �.... ..............OF..f !` 1" ---•----
�I Appliratiou for Dig naafi Wurkfi Tougtrttrttont Prrutit
Application is hereby made for a Permit to Construct (..—) or Repair ( ) an Individual Sewage Disposal
System at:
----- -----------
Location-Address _ or Lot No.
....................... .................. ..... •---------••-
Owner Address �Q,q
�✓� .... ��' ?e'v _______________• i.������P
................
nstaller Address
Type of Building Size feet
Dwelling—No. of Bedrooms____ ___________________Expansion Attic Garbage Grinder (,V�
aOther—Type of Building _ '.__ %_____________ No. of persons__X*1..e.e-------- Showers — Cafeteria (a/4
Q' Other fixtures ......................................................
d •••-------------------------
W Design Flow..................Ila.................gallons per person per day. Total daily flow----------------------- _®.........gallons.
WSeptic Tank—Liquid capacityleQ?a.gallons Length................ Width---------------- Diameter---------------- Depth................
x Disposal Trench—No_____________________ Width.................... Total Length......._____��_mm------ Total leaching area____________________sq. ft.
Seepage Pit No------------/....... Diameter________:{ :____ Depth below inlet.........C�-_...... Total leaching area__2_.0_`_sq. ft.
Z Other Distribution box (i ) Dosing tank
Percolation Test Results Performed b ___________________ Date__f _' �_.'Y ............
Test Pit No. I___________ __minutes per inch Eept i of Test Pit------!d.......... Depth to ground wateiV0-_e..........
(T Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
P .........• - •'•-•-••---•-••-••••'•••••----••-'-'.............••-•-•'----•-••'•--•--••-•-••'•'---•-•-•-••--••---••-•'•"...._..._..-
Description of Soil ` X.aef
---...................-------------------------------------•-------------
U ---••---••--••-••-•---••••'•-•-•..... a-•'--•....-•••••-------•--' 'c v� ..... -_-----------_------------------------------------•-----••------
W -------------� �vt
-. ---- ®a '✓ ' Y C� •y" '�
UNature 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 iiT�..:
p 5 of the State Sanitary Code— The undersigned further agrees not to place the,system in
operation until a Certificate of Compliance has been issued by the board of health.
D e
Application Approved By.... ---- d_ • °= s -
Date
Application Disapproved for the following reasons:-•---------------•-•-------•--•-----------------•---•------------•--•-•-•-------'-----------_----------------
-•-•._...--••••----••--••--'-•-••-••-'••••--'•••--•-•-------...•-•--••---•-•-••••---••"•--•'-•--'--••'•_._•-•••-•-'••-•-••••-•-••-•--•-•---•-•-------..--•---------------------------••-•--•...........
Date
PermitNo......................................................... Issued.-'/••--- -....-- --------•---•--•----
Date
No.40. .............. FnB..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
VI—,.................._0 F...,6/, ZW .....................................
Aplifiration for Uh4posal Works Tomitrurtion lirrutit
Application is hereby made for a Permit to Construct L" or Repair an Individual Sewage Disposal
System at:
...... 0
..............................
.. .. ............. ......oe
L tin Address or I', No.
........ .....40
< . .....
.... ....... 2_1..... ..........
2wner Address
.......Are ......M.C'' ......................................... .....eez?!: 9 P.e ..... ...........&?Z:
Inst�1_r Address
Type of Building Size Lot.!K3e ----Sq. feet
Dwelling—No. of Bedrooms ........................Expansion Attic W4; Garbage Grinder (.wd)
P4 Other—Type of Building ................... No. of persons-_;-+,f�e------------ Showers Cafeteria
04 Other fixtures ---------------------------------------------------------------------------------------------------------
------ ---- -------------------------Design Flow............ .......................gallons per person per day. Total daily flow................... ...........gallons.
1:4 Septic Tank—Liquid capacit�.OV...gallons Length................ Width__......_._.____ Diameter._...._......._. Depth_....__.._._._..
Disposal Trench—No..................... Width_...__.._........... Total Length......__._.......... Total leaching area....................sq. f t.
Seepage Pit No----------------/---- Diameter..............(-->---- Depth below inlet............e.... Total leaching area.......2, ft.
Z Other Distribution box DosirIF-tank
Percolation Test Results Performed by--------- ----------- 9
......... Date....Zv?.... .Z..7.........
Test Pit No. I....ZI.........minutes per inch Pt st Zit.,_"N .. .... Depth to ground water.....0.40.e........
01 1A
rXq Test Pit No. 2................minutes per inch Depth of Test Pit.._...........____._ Depth to ground water______.............._...
P4 ............................................................................................................................................. .............
0 Description of Soil....... ........X0_12- _V-_S`�/.B� Q!�<................................................................7.................
Ux ..................................... (v.......... ---:��.o�'..
........ ........................................................................................
--------------------------------------- ----------------- ....................................................................
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'TTLE,
5 of the State-Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed........................................................................................ ...............................
Date
Application Approved By........ . .. . .. ..... ............. ........................... ......;Z......��_iiig...........
4 op -D
Application Disapproved for the following reasons:------------ ---------- -----------------------------------------------------------------------------------
...................I........................................................................................................................................................................................
Date
PermitNo......................................................... k Issued........................•..
..............................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALT14
7_............. 'e-a-M.......OF.... ....Alf...t.......................................................
...fo,"*i" I'it'a'''u,....r,r..........
Crriirtt
THIS IS TO C RTIEY, That the Individual Sewage Disposal System constructed Repaired
by--------- .......#.......
- - -- --------------------------------------------------------------------------------------------------------------------------------------------
AInstaller
A
at .....X ...44......;:;::........,
----------------
T �P,.vi?lon; of ed in the
actor ante the �A(
4
has been installed in per e ale'..... ... 0 /cri
application for Disposal Works Construction Permit No ------1�---/---_----------- date ...... ------------------
id OT BE CONSTRUED AS A G
THE ISSUANCE OF THIS CERTIFICATE SHA)L" XNTEE TWAT THE
SYSTEM WILL, FUNCTION SATISFACTORY.
DATE. =/ Inspector'.
..........
7THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No.ie ............OF...... ........................ FEE 7
145vosal IVnrku notrudion Phrmit
Permissi6n is hereby granted-.-..-. ---- ---..............................................................................
du S e 'ge o
e,
to Construct Y or Repair- S n ividu tem
.at No.. ... . . . .. ........ . ....... ..... . .........
Z '00
as. shown on the application for Di posal Works Construction Permit No Dat�eXd �.,,,..........
A ---------------------------
DATE....... ..........................................
FORM 1255 HOSES & WARREN. INC., PUBLISHERS
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