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HomeMy WebLinkAbout0014 NELSON LANE - Health 14 NELSON RD. ,MARSTONS MILL--S e�_ e l d,� ©73 Commonwealth of Massachusetts �. Title 5 Official Inspection Form r,l fp. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments / u Property Address �/o/ Gj IV/ 7"a r:. Owner Owner's Name : information is required for every a rrs jr_ �/� �� ��6c��a /� o page. Cityrrown State Zip Code Date o Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector I r ation 13�a 8 filling out fors on the computer, use only the tab �'✓ key to move your Name of Inspector cursor-do not use the return Company Name key. �0 Company Address City/Town State Zip Code Telephone Number License Number 3 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;�Pyasses" 1. 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Inspector's ignature 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.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of t8 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /L /lle Is,oo Property Address Owner Owner's Name information is fs 40.1 S �/ required for every_ page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System sses: 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): t5insp.Goc-rev.7/26/2018 Title 5 Official Inspection Formi Subsurface Sewage Disposal System•Page 2 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name /��llf / ' , 1 ��6 �� information is a, NS required for every page. City/Town State Zip Code Date of fnspect on 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 Offical Inspection Form:subsurface sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts iTitle 5 Official Inspection Form �� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,,~�17 � /��lso o mil/ Property Address I� V Owner Owner's Name �Lt information is 11141,es-¢( � required for every page. Cityrrown State Zip Code Date of In ection 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 N;" Backup ❑ of sewage into facility or system component due to overloaded or ogged SAS or cesspool El ��i ischarge or ponding of effluent to the surface of the ground or surface waters ue to an overloaded or clogged SAS or cesspool Title 5 official Inspection Form:Subsurface sewage Disposal System-Page 4 of 18 t5insp.doc•rev.7/26/2018 c� Commonwealth of Massachusetts Title 5 Official Inspection Form i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information isAG If Qp� 9 �� required for every G rS page. Cityrrown State Zip Code Date of spec on 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 ' 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. ❑ ny 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.] he system is a cesspool serving a facility with a design flow of 2000 gpd- ❑ 10,000 gpd. El 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 El El Area system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7126/2018 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 j �4 A-e/so, si/ Property Address c� Z Owner Owner's Name --XDd 6'Pv information is a VIA-1-5 7 / required for every page. CitylTown State Zip Code Date of specti n 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 ❑ mping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ❑ s 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 El this inspection? Were as built plans of the system obtained and examined? (If they were not available note as NIA) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] 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 -Nof for Voluntary Assessment s �f Ale ISOva Property Address Vat 2-- Owner Owner's Name information is II required for every G1 rS7�DNs /�i AS /�/1,(� Od page. City/Town State Zip Code Date of Ins ection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): Sao DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: /000 G� �o �QL c N L� Caj 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 R 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.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ig Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I� 11 ,°lSoi i Z Property Address Owner Owner's Name AlAS �� information is rs� required for every � // page. City/Town State Zip Code Date of pecti D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): Q�i✓l2ll 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 Forth:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r l Ll ,die%sa L� Property Address P Owner Owner's Name / information is Glrs �S lS A e91 611 required for every page. City/Town State Zip Code Date of Inspq6tio,i D. System Information (cont.) f em: 4. Type o S 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: �L/-8`71>- Ihr4-Ile,cl I(P9- --- Were sewage odors detected when arriving at the site? ❑ Yes E;,M—o 5. Building Sewer(locate on site plan): 30 // Depth below grade: feet Material of construction: ❑ cast iron 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form r a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name V Q information is i Gi✓S�O4f /AS 4 da.6V'5 / �L l required for every State Zip Code Date of In ection page. City/Town D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: feet Material 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: Sludge depth: SY Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7N 4,, ea d 1—le-e-C 00 j (!�o in­j 17704 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts ip Title 5 Official Inspection Form 1i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments AI&600 /lam Property Address Owner Owner's Name I /✓/ information is r�J, H f WDd 6 V� 9 ��t //J required for every ��/ lll/// A O page. Cityfrown State Zip Code Date of In/pectiorf 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 15insp.doc-rev.7/26/2018 Title 5 OfBdal 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 Property Address Owner Owner'shame information is required for every page. City/Town State Zip Code Date of Insp ction D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): �'XI so l�s AT �ea4s Title 5 Official Inspection Form:Subsurface sewage Disposal System•Page 12 of 18 t5insp.doc•rev.7/26/2018 r - c� Commonwealth of Massachusetts f; Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a fl o.h Property Address Owner Owner's Name information is S� required for every page. City/Town State Zip Code Dat of Insp ction 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: uc�— leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: ---- ---- Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 t5insp.doc•rev.7/26/2018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l `f 411eham z_ 4.1, Property Address Owner Owner's Name information is 14jl required for every ry page. City/Town State Zip Code Date of I specti n D. System Information (cost.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 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 c°`•� Commonwealth of Massachusetts �d Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Ins ection 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 p Title 5 Official Inspection Form i- - a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � Alf l Z-. " Property Address Owner Owner's Name information is ,: rI,�t required for every page. City/Town State Zip Code Date of Ins ection 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 r benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the bui 'ng. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately �q S A a Q /4 y- ` O-. 5 Aa , ai? t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address he Owner Owner's Name ll information is q rS4o h S l/1 �,� required for every 1 ` 1� o` page. City/Town State Zip Code Date of Ins ection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: pate ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checke rith local Board of Health- explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describ ow you establi hed the high ground water elevation: vlcn�a� Jo _ /'p L4✓f &GV o1-e- 1.;21 -g s-k / l�-S?c !/('/ fir-- /�714;H , C7/_ st Vo u0 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t6insp.doc.•rev.7/26/2018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 17 of 18 r c� Commonwealth of Massachusetts i- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � f/sLN Property Address Cl Z- Owner Owner's Name information is required for every TTVV page. City/Town State Zip Code Date of In ectiol 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 XSyiste Criteria)and 6(Checklist)completed Dm Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:subsurface sewage Disposal system•Page 18 of 18 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °U 14 Nelson Lane M Property Address Paul Mockabee Owner Owner's Name information is required for every Mazrston Mills Ma 02648 6/2/11 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 A. General Information filling out forms on the computer, 14 / ^ use only the tab 1. Inspector: IlL//) key to move your 9D cursor-do not Ricky L. Wright use the return Name of Inspector key. B & B Excavation, Inc. r� Company Name 14 Teaberry Lane Company Address Sandwich MA 02563 City/Town State Zip Code 508-477-0653 S14595 Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this address and that fhe information reported below is true, accurate and complete as of the time of the inspection. The spe�fon .,was performed based on my training and experience in the proper function and mairitenance of on SR sewage disposal systems. I am a DEP approved system inspector pursuant to Section 1Q40 ob Title 5 (310 CMR 15.000). The system: yx•r"' ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority w m 6/2/11 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow'of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and,copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does address,how the system will perform m in the future under the same or different conditions of use. t5ins•09108 - - Title 5 Official Inspection Form:Subsurface Sewag sposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 14 Nelson Lane Property Address Paul Mockabee Owner Owner's Name information is required for every Mazrston Mills Ma 02648 6/2/11 page. City/Town 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: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 14 Nelson Lane Property Address Paul Mockabee Owner Owner's Name information is Mazrston Mills Ma 02648 6/2/11 required for every - page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ 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: El Cesspool or privy is within 50 feet of a surface water El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09108 - 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 M 14 Nelson Lane Property Address Paul Mockabee Owner Owner's Name information is required for every Mazrston Mills Ma 02648 6/2/11 page. Citylrown 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 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: w - Yes No Backup of sewage into facility or system component due to overloaded or El ® 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 El ® or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less ® than '/z day flow l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 14 Nelson Lane Property Address Paul Mockabee Owner Owner's Name information is required for every Mazrston Mills Ma 02648 6/2/11 page. City/Town 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 Q 0 4' the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone 11 of a public water supply well If,you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5.ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 w Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 14 Nelson Lane Property Address Paul Mockabee Owner Owner's Name information is required for every Mazrston Mills Ma 02648 6/2/11 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) ® ❑ 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): 4 Number of bedrooms (actual). 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•09/08 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 °M 14 Nelson Lane Property Address Paul Mockabee Owner Owner's Name information is required for every Mazrston Mills Ma 02648 6/2/11 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d n/a 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 14 Nelson Lane Property Address Paul Mockabee Owner Owner's Name information is required for every Mazrston Mills Ma 02648 6/2/11 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: B & B Excavation I Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? site glass on truck Reason for pumping: maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 14 Nelson Lane Property Address Paul Mockabee Owner Owner's Name information is required for every Mazrston Mills Ma 02648 6/2/11 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: 4/29/1985 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.5 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >20feet Comments(on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in good shape no signs of leakage or blockage. Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 5.8x5.8x10.6 Sludge depth: no sludge t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 14 Nelson Lane Property Address Paul Mockabee Owner Owner's Name information is required for every Mazrston Mills Ma 02648 6/2/11 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 no sludge Scum thickness no scum Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle no scum How were dimensions determined? scour stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection tank appeared to be in good shape concrete baffels present no sign of back up.Pumped tank as part of inspection. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): I 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 e A Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 14 Nelson Lane Property Address Paul Mockabee Owner Owner's Name information is required for every Mazrston Mills Ma 02648 6/2/11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 14 Nelson Lane Property Address Paul Mockabee Owner Owner's Name information is required for every Mazrston Mills Ma 02648 6/2/11 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.): At time of inspection d-box appeared to be in good shape.No sign of carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 14 Nelson Lane Property Address Paul Mockabee Owner Owner's Name information is required for every Mazrston Mills Ma 02648 6/2/11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ 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.): At time of inspection leaching appeared to be in good shape no sign of staining or hydraulic failure.Water level was three feet below invert. 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-09/08 1 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 14 Nelson Lane Property Address Paul Mockabee Owner Owner's Name information is required for every Mazrston Mills Ma 02648 6/2/11 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 n Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 14 Nelson Lane Property Address Paul Mockabee Owner Owner's Name information is required for every Mazrston Mills Ma 02648 6/2/11 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 Ac (� O � Z A� - 2� ` C2= 66 ' tsins•09/08 Title 5 Official Inspection Form:Subsurface sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 14 Nelson Lane Property Address Paul Mockabee Owner Owner's Name information is required for every Mazrston Mills Ma 02648 6/2/11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: >12feet 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: 4/29/1985 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 1 R + Before filing.this Inspection Report, please see Report Completeness Checklist on next page. t t5ins•09/08 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 14 Nelson Lane Property Address Paul Mockabee Owner Owner's Name information is required for every Mazrston Mills Ma 02648 6/2/11 page. Cityfrown 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 _=. TOWN OF BARNSTABLE BAR-W 1599 Ordinance or Regulation - WARNING NOTICE Name of Offfender//Manager p dV5 k" S Address of, Offender MV/MB Reg.# Village/State/Zip /"[ !_rj d v� S o ZGq7 Business Name am/pm; on Business Address S—O-uLX Signature of Enfo cing Officer Village/State/Zip Location of Offense WGZ.5/rWJ / a� j ��v�Sieiv► _//� a-� Enforcing Dept/Division Offense �t()�Cc.l`i�it�r V/ 1t�/G(.Q X��CIX �- �2 �f'kS� '7'� �u1,iY'oti`We-s Facts .19r L-&41 J 6-a S 7-0,4.1.do /-Pa 4 A,,,, 7-,-ck . Z j',0 �/_e- � (Y/t,c.e u�) � 6 S Cm-}haw►rw a*1% So c/ by tier h I-Pl A A't,e �_je �' "// This will serve only as a warning. At this time no legal action has been taken 4,/. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. TOWN OF BARNSTABLE BAR-W 1599 Ordinance or Regulation WARNING NOTICE Name of Offender/Manager 7 41'.ff ,1z oo Address of Offender I' - '�5 + / �fi� MV/MB Reg.# Village/State/Zip Business Name am/pm; on 19 Business Address S"et.•wt,X t ` Signature of Enfo cing Officer Village/State/Zip Location of Offense �.ft Enforcing Dept/Division Offense Vt'C!(CL4r61-1 01 .• VVC(f )(Y)(/)t. Pe (e' I.-C A �i��sii�o���` -.�✓"c�f � c..�� , Facts br� rn.,l J 1*.P cv? (6_1 -ra.ia & /.,*R & deGrr+ I--e.4s. . A Jjavtk e G/�.�l...G�vw) Omgt 6o j (�vn3tudf►<6t.` ' aE,t. l�E'�'ar fx+ fj. Ld (R." • l"/at. f z ge P--y al�r�/ This will serve only as a warning. At this time no legal action has been taken 1AC,/' It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. TOWN OF BARNSTABLE BAR-W y Ordinance or Regulation WARNING NOTICE Name of Offender/Manager P e y c 41"ll"Ct w l Address of Offender / ' Ai'..PlS rcr- lot er MV/MB Reg.# Village/State/Zip � ("r) h y7 S C% z(117 Business Name "' am/pm; on 19957, Business Address f e t*tj ` s r ,�.�"�"--, r Signature .of Enforcing Officer Village/State/Zip Location of Offense ,+f* ,ATE x�a jr rf n, r ;1/,, e�/ r. 'L Enforcing Dept/Division Offense ic, Ici - it-, � l � (. l !a i r � rf vs6« �' r f l t. 'd1 Facts F), C11 0�-*;j ..;7 ?"o"a .,0 4 co : t+4� ;vx t. 4_4 S, t Aeut l tt'l . A.t e zrto � +014t Xl'//fe This will serve only as a warning. At this time no legal action has been'taken(,,, ' It is the goal of Town agencies to achieve voluntary compliance of Town +. Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. JAN-25-98 01 :59 PM D WILLIAMSiAMERICNHOME 508 7751500-428 0318 P.01 AMERI ` .AWN HOME M'­­ 1 VIR _ NENTA.L 508-775-1 00 P.O. Box 1069 Cenrcrvillc, Massachusetts 02632 800-56,i 0 345 Building•Remodeling•Environmental Inspections Construction U Design •Lead paint Removal , DOUGLAS L_ WILLIAMS BUILDING CO. FACIMILE TRANSMISSION SHEET hrip:// www.quikpage.00mJAlameri=home FAX 790 I-ki to ,L�'P_ TO. dL=,A i-c-A -- ,EAj ( RP, ,J em�) SUBJECT 5-q9 FROM: NO/PG THIS TRANSMISSION IS INTENDED ONLY FOR THE USE OF THE INDIVIDUAL OR ENTITY TO WHICH IT IS ADDRESSED,AND MAY CONTAIN INFORMATION THAT IS PRIVILEGED,CONFIDENTIAL.,AND EXEMPT FROM DISCLOSURE UNDER APPUCABLE LAW. IF THE READER OF THIS TRANSMISSION IS NOT THE INTENDED RECIPIENT OR EMPLOYEE OR AGENT RESPONS113LE FOR THE TRANSMITTAL TO THE INTENDED RECIPIENT, YOU ARE HEREBY NOTIFIED THAT ANY DISSEMINATION, DISTRIBUTION,OR COPYING OF THIS COMMUNICATION IS STRICTLY PROHIBITED. iF YOU HAVE RECEIVED THIS COMMUNICATION IN ERROR, PLEASE NOTIFY US BY PHONE, (COLLECT),AND IMMEDIATELY RETURN THE ORIGINAL THROUGH THE U.S. MAIL THANK YOU. ASBESTOS BUILDING STR�TURE LEAD PAINT HEATING SYSTEMS CARBON MONOXIDE GAS UNDERGROUND TANKS ELECTROMAGNETIC RADIATION SEPTIC SYSTEMS RADON WOOD BORING INSECTS TOXIC GASSES ELECTRONIC SURVEILLANCE WATER QUALJTY PLUMBING UREA FORMALDEHYDE GAS SERVICES RESIDENTIAL AND COMMERCIAL BUILDING AND REMODELING-EXPERT TESTIMONEY-BANKRUPTCY PROPERTY ANALYSIS-LEAD PAINT REMOVAL& ENCAPSULATION-AUCTIONEERING WENSED BY Massachusetts Division of Registration Massachusetts Department of Public Safety Massachusetts Division of Building Regulations Massachusetts Department of Public Health Massachusetts Department of tabor and InKtustries Massadimtts Department of Environmental Protection JAN-25-98 02 :00 PM D WILLIAMSiAMERICNHOME 508 7751500+428 0318 P. 02 r AHE 10 Ameticm Home f Enviromenu Inc. Bug P.O. Box 1069 , Centerville, Mamachiisels , 02632 f% New Construction-R.emodoling- Building & Environmental Inspections Since 19 7 2 508--775-1500wYmm►sI 508-428-0318 (mnuium 800-564-0345 MI'm Licensed by: Commonwealthi of Massachusetts Div4sion of Pegistralion Lic # 111465 Commonwealth of Mau. Department of Environmental Drotection as Bub Surface Dispoaai AyAtr inA limpector/ Commonwealth of musachuaeU Department of Environmental Drotcrction Licensed Hazardous Waste Generator Lic . #MA000008413 Commonwealth of MaswchwctU Department.of Dublic. Health Lead paint Inspector Lic. # I1843 Commonwealth of Massachusctt.�Departtaenl of labor and work Porce Development Divb',lon of Tc elmloil gervices Licensed Deleader#DG000556 (contmetor) and Licensed Level II Deleader for Encapsulation Commonwealth of Massachusetts Division of Dublic 8afeLy Lic # 016981 No reztrichons Commonwealth of Massachusetts Board of P gistratlon lic.. # 111465 Commonwealth of Massachusetts Registry of Motcw Vehicle CDL license # 905061074 Commonwealth of Massachusou Division of Standards Lic. # 843 United Statcb Environmental protection Agency Division of Radiation Control , CcMftcd Secondary Testing Facility for Radon Gas. PROPERTY MAINTENANCE**CLEANING SERVICES«*BUILDING**REMODELING*OBUILDING AND ENVIRONMENTAL INSPECTIONS"LEAD PAINT INSPECTIONS"LEAD PAINT REMOVAL#AIR MONOTORING**UFFI TESTING"UNDEF�GROUND TANKS'`*RADON**SEPTIC INSPECTIONS** BANKRUPTCY ANALYSIS**VINYL SIDIN4&TRIM COVERAGE**ADDITIONS**KITCWENS$*ROOFS JAN-25-98 02 :00 PM D WILLIAMS.-AMERICHHOME 509 7751500+428 0318 P. 03 �... V AmERIC* Ai%z HOME ENVIR EN'TAL T,..'.'..-... 508-775-1500 P.O.Box 1069 Centerville,Massachusetts 02632 800-564-0345 Building-Remodeling-Environmental Inspeuinns Construction&Design -Lead faint Removal http://www.quickl;age.com,/A/americanhome Town of Barnstable Ilcahh Department Town Ball Mr.Glenn Harrington. 1-25-98 Dear Mr. Harrington , Due to my biusiness I am not readily available at all times an had to rely on this fax to speak with you on the violation herin. (Bar-W 1599) 1 understand the Fire Dept.had to notify you regarding the spill,however,your information is wrong. First.this is not a business address. My business is registered with the Town . Second.there is evicence that the spill was from a small can containing a paint brush in the back of a truck,not a tank leak. There was no vehicle there for you to see at your inspection,as it was being checked at a garage for a leak by the time you arrived. Second:I am a licensed hazardous Waste Generator in Mass. The 2 drums you saw on the ground contain no hazardous material and can remain. As needed they are brought to another site for use, and current Barnstable regulations do not require me to notify you of my generation at other sites of hazardous waste. Third:Contaminated soil,about 2 gallons was removed and containerized. The surrounding ground was checked for VOC's by use of air sampling and soil extraction testing equipment. All levels fall below required action limits. Fortunately the neighbor noticed the spill at the right time and the amount.probably about 1 pint of gasoline,was removtxi quickly. Should you have any questions please feel free to call.. Respectfully, Douglas L.Williams Sr. LOCATION { SEWAGE PERMIT NO. Jjo F,� 1 14- ,� SoGi'' lP VILLAGE I N S T A LLER'S NAME i ADDRESS ® U I L D E R OR OWNER DATE PERMIT ISSUED DATE - COMPLIANCE ISSUED ° Ai, % i ° t k�■ No.�I-- �7.7 r +Fss.. j....... THE COMMONWEALTH OF MASSACHUSETTS = 1-2 /,, r BOAR® OF HEALTH V ........ -TQ.Wn...................OF............Barnstable............................................ (� Application for Disposal Works Tonstrnrtiun Itumit Application is hereby made for a Permit to Construct (x) or Repair ( ) an Individual Sewage Disposal System at: ' .............. lei c .._.4:�f:_.... .�'!. ..._.....-- .................-----........._Lot--1 g--------------------....------------..........•. Location-Address or Lot No. D. WIlliams ..Nelson Lane ......................_....-.._........... --......----------------•--------•-------------_: ..........................-----------------------....--------•--•--------•----.._.....-------_... Owner - — Address a ..........."A.1...R -----------------•--------------- .........................Mar ja.tQ11*9...M.a .t.---------------------•----------- Installer Address Type of Building Size Lo`t'__4 7 , 2 4 4 __ Sq. feet Dwelling—No. of Bedrooms___.._4___________________________________Expansion Attic ( ) Garbage Grinder (N9 `-4 Other—Type of Building No. of ersons____________________________ Showers Pa YP g ---------------•----------•• P ( ) — Cafeteria ( ) 04 Other fixtures ----------------------•-•--••••---•---•-------•-•• -- W Design Flow............55--_-----______-------_gallons per person per day. Total daily flow.........4.4_Q...........................gallons. WSeptic Tank—Liquid*capacity_15-©.©gallons Lengthl Q_'__:n6." Width--- Diameter________________ Depth...J_'._-4_�� x Disposal Trench—No. .................... Width.................... Total Length.....................Total leaching area....................sq. ft. Seepage Pit No_____________2...... Diameter...1,D!...____._ Depth below inlet__a-.._b_7....... Total leaching area...51.4.......sq. ft. Z Other Distribution box (X) Dosing tank ) c �1 a Percolation Test Results Performed by.am �_.t m.r.Vay.__.V%. Ell ate.t7't,?1 �, __B:T...-. Test Pit No. 1......2.......minutes per inch Depth of Test Pit...... Depth to ground water_."'ti_St____ P P eP �- -- aTest Pit No. 2................minutes per inch Depth of Test Pit---- Depth to ground water_. t O Description of Soil...T2.#1_,_'Q-24._'...Tapsoil.... ...S-ubsnil.;----2.4'�_-12_1....Med:I.um------------ ----Rc ER ye V .t co.-.. oarse___sand......TP.#2-;-...I1=24_"___Taps-ai_1___&...&ubsa.i_l.;-2_4'�_-_7.98"---------------..... Mt IEWICZ N Fine---t o...Medium_.Sand---&_--Clay;----1_Q_8"-15.0_"---Fine----to---Ni d_iuln. 5and-.---...... 20 Nature of Repairs or Alterations—Answer when applicable.................................................................. �,��C IV 1 L �O D I fc Agreement E a The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in a rdai e the provisions of TIIL LE 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 bo rd of health. Signed____ ..,. ---------- --------_---- -------------------------------- Dpt Application Approved By....... 'Q'.. ....0._�_:�0°)Kw^.__.....----•---•----.....-•---•------ ---------1�/14.. �--...----- Date Application Disapproved for the following reasons:................................................................................................................ •--------------------------•-----•-----....___._...--------------------------------------------•-•-------••••••-...-••---•-••--•-•-----------------•••---•---•••-•------•-----•••••••---••-------•---- Date Permit No..............?.`. --�--------------------- Issued.-------.t Q ---�--•-��------------------- Date r q No................._..... F�s...........r,............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............Town..................OF.............Barnstable ---------------•--..._.....-----............_.... Allp iration for Eliopoiiai Works Tomitrurtion thrutit Application is hereby made for a Permit to Construct (X ) or Repair .( ) an Individual Sewage Disposal System r a_ESC�n 1 r�E'_ 1.44 Lot 18 Location-Address or Lot No. » -D. W�lliams Nelson Lane ....... .... .......................................... �} owner Marstons Mildtgs W Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms----4.....................................Expansion Attic ( ) Garbage Grinder ( N� Other—T e of Building ............................ No. of persons............................ Showers — Cafeteria Q' Other fixtures ................................. . d --------------------------------------------------------------•------- W Design Flow..........S5.............................gallons per person per day. Total daily flow......44.D..............................gallons. Septic Tank—Liquid capacity-15_0.0gallons Length l0.'=.Fi"Width---5..'.-8.''Diameter---------------- Depth5.'.-4"... x , ` Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.................... Diameter----lA,.......... Depth below inlet..5- fa.:Z.'... Total leaching area...514.......sq. ft. Z Other Distributionbox ( X) Dosing tank ( ) Percolation Test Results Performed by........Cape...Cod..Survay...4onsul.:1Datee......July. ....?3...... 984 Test Pit No. I.........2....minutes per inch Depth of Test Pit....1.0.1......... Depth to ground water__No-ne........... fi, Test Pit No. 2................minutes per inch Depth of Test Pit.l2,.5........ Depth to ground water.-Non x ---------------------------------------------------------------------------------------------------....................................... �� a O Description of v Soil......TP#_1.,__..Q-24."....Tapso-i1....&...Suhsnil.;....2.4."=12D."...Medium........ _s %---- 1D-8l ------ = F.;.--.-.-.-PAL t�...caar � l- = y �n W �� �� _ iQ NUCHNIEWIC2 x E in-e---ta__Medium...S and---&...Clay_;___-10.8___-15D-----Fsna---to-_-MediuM__.9and._.._..... auo-:a©aso Nature of Repairs or Alterations—Answer when applicable................................................................... CIVIL Agreement: E The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in c rda the provisions of TI'TIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in e- —q operation until a Certificate of Compliance �en ssueedCby tl}.b rd of h S th. ,- - Signed- 6'V- ------------------------------•---•-------••-•-----•----- 1 C 1�.Ca'" �f D te&q..» ,,By-----------------------------------Application Application Approved 1. Date Application Disapproved for the following reasons----------------------------•-----•-••---•-------....--------------•-•-----------•----._.._........--------.._._. -•--------••--•......................................•--•---.......---•--...------------.....----------.....----•--------------------------------------•-----------------•---------------------....---•-- Date Permit No:9.-S...- •------- ---------------------------- Issu THE COMMONWEALTH OF MASSACHUSETT -„ BOARD OF EALTH ...... .........OF.................: Trrtifiratr of Toutoianrr k• �� THIS'I-S-�D©-,CF-tPcTT Y; That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) e r c� Installer at .--.................................................................................................................................................................................... '� has been installed in accordance with the provisions of TIT ��_(/ 5 e State Sanitary Cod as c�es cr' a in the application for Disposal Works Construction Permit No.___.�`!.... ................................................Cod as -- datedr 1THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ` - q a --- Inspector ✓ �{ i i THE COMMONWEALTH OF MASSACHUSETTS BOARD���F .;��x•�Lv; .........................................OF...........---- •-.-..................................._.......................... No......................... FEE.......................... Zttiou�i1 g1r - oitotrtitttion rrutit Permissionis hereby granted..............................................................................................................................-........ .» to Construc ( ) or Repair ( ) an Inddiividual Sewag is osal ystetn atNo..... 4-X . ..:......................................................................................................... Street as shown on the application for Disposal Works Construction I'.erm'iT �rv �..�r�__ ••-------------------------------•- f � Board of Health DATE.... '`_................................................ FORM 1255 HOBBS & WARREN. INC., PUBLISHERS i, • ti. CEEITERVILLE-OSTEIVILLE-MARST®NS MILLS AFIRE DISTRICT 1875 ROUTE 28 • CERTERVILLE,MA 02632 (508) 790-23801I:AXC(508) 790-2385 O IL lM AZ ARDOUS MATERIAL RELEASE FORM F.A.tc LOCATION: ADDRESS OF RELEASE: A r%c.,+r,,a•t, DATE OF RELEASE: r /?2/c,Z PRODUCT RELEASED: r-',A I r4 ESTIMATED QUANTITY= J r�-Itc,) CORRECTIVE ACTION TAKEN BY RESPONSIBLE PARTY e r-7nl l�a,f I NOTIFICATIONS: FIRE DEPARTMENT: YES(k.) NO( ) DATE. # /.L2/c/r TIME: / 2t;r NATIONAL RESPONSE CENTER YES( ) NO( ) DATE: TIME DEPT.OF ENVIRONMENTAL PROTECTION YES( ) NO( ) DATE:-TIME- OIL SPILL COORDINATOR: YES( ) NO( ) DAfE:.__TIME: • TOWN BOARD OF HEALTH: YES60 NO( ) DATE:122-O&L TIME" ► z-r. r TOWN H ARBORM ASTER: YES( ) NO( ) D ATE TIME: OTHER AGENCIES: COMMENTS: Zt/rz 1, ,P. ,.... ., P,F .alyd Cr.I l L-r4 1 -i�.o G/+� f �I � F� (arc.-/�' I 1 -i•-r e 1✓1 s. f -c /! 11 1 I, r'�-� tnn,t�./ !-'1 I .:c! %e I 'r �- '•P /1 4., I `!`�•—inn -I', I 1 rt. :l.- r r r.�•4 /. -+ C., r', a r r. e. �. /k �- 'L !�� r,. <l I 1 \I a +:.,L tJ, i ./s+ �� d ,.` �.-- -J t 7 F /�Y' /., ./ C., n_-f�!. �1. •�l'. ,!!^k.�?/ REPORTED BY:, (�'i /,r�.�' I,-'�-� � z_/ n ATE: WHITE COPY-FIRE DEPARTMENT YELLOW COPY-D.E.P. PINK COPY-BOARD OF HEALTH C-O-MM FORM >a58 ' I f