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HomeMy WebLinkAbout0085 AMES WAY - Health n 85 Ames Way PF Centerville P A = 85 007 h 0 �a►J/�� ,�crc� INUPC ® J ,?.—53 • Mnalru�OaM yw U M TOWN OF BARNSTABLE LOCATION �SS /�'✓hc 5 SEWAGE# VILLAGE C— . .- - ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY .1000 LEACHING FACILITY: (type) (size) y S`/X- /•s NO.OF BEDROOMS a BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist `` r on site or within 200 feet of leaching facility) b s� Feet Edge of Wetland and Leaching Facility(If any wetlands exist i within 300 feet of leaching facility) rd 20 Feet Furnished by `:, �< < /-'t n-s as � 3� .ZJ� l 1952 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION MAP I �9 PARCEL , d�_ LOT TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 85 Ames Way Centerville, MA 02632 Owner's Name: Paul Gaudreau ' Owner's Address: Date of Inspection: March 24, 2004 t n Name of Inspector: (Please Print) James M. Ford ors M Company Name: James M. Ford o ` Mailing Address: P.O. Box 49 G Osterville,MA 02655-0049 — Telephone Number: (508)862-9400 x- m r m rn CERTIFICATION STATEMENT I certify that I have personally inspected-the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of 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 Needs Further Evaluation by the Local Approving Authority Ins F 'ls Inspector's Signature:1?� hn .�S Date: March 28, 2004 The system inspector shall sub ' 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. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 85 Ames Way Centerville, MA Owner: Paul Gaudreau Date of Inspection: March 24, 2004 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. Answer yes,no or not determined(Y,N,ND) in the 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. ND explain: 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 obstruction is removed distribution box is leveled or replaced ND explain: 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 obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 85 Ames Way Centerville, MA Owner: Paul Gaudreau Date of Inspection: March 24, 2004 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 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 and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 I Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 85 Ames Way _Centerville, AM Owner: Paul Gaudreau Date of Inspection: March 24, 2004 D. System Failure Criteria applicable to all systems: You must indicate either`yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either`yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA)or a mapped Zone tI 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 85 Ames Way Centerville, MA Owner: Paul Gaudreau Date of Inspection: March 24, 2004 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: Yes No ✓ 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(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 85 Ames Way Centerville, W Owner: Paul Gaudreau Date of Inspection: March 24, 2004 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: I Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system (yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): apd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part of the inspection (yes or no): No If yes, volume pumped: gallons-- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed 3129196-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 85 Ames Way Centerville, MA Owner: Paul Gaudreau Date of Inspection: March 24, 2004 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 2' Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: Measuring 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.): Cement tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage. GREASE TRAP: None (locate on site plan) Depth below grade: 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: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 85 Ames Way Centerville, MA Owner: Paul Gaudreau Date of Inspection: March 24, 2004 TIGHT or HOLDING TANK: None (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: allons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The D-box was level. No solids were present. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): 8 I Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 85 Ames Way Centerville, M4 Owner: Paul Gaudreau Date of Inspection: March 24, 2004 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: 2-500 Qal. drywells 24'x 13'x 2'(per as built card) 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.): The chambers had 6"of water on the bottom. The scum line was at the same level. There did not appear to be any signs or failure. CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 85 Ames Way Centerville, MA Owner: Paul Gaudreau Date of Inspection: March 24, 2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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. ,I I J I De-Jr, rr 33 3 a � 3s SI 10 Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 85 Ames Way Centerville, MA Owner: Paul Gaudreau Date of Inspection: March 24, 2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 12' +1- feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record- If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using the Barnstable topographic map and the Cape Cod Commission water contours map,the maps were showing approximately 12'+/-to ground water at this site. i 1 This report has,been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. tl ROMEO COMMONWEALTH OF MASSACHUSETTS NOV 2 5 1998 EXECUTIVE OFFICE OF ENVIRONMENTAL AI OWNOFBARNSigg� DEPARTMENT OF ENVIRONMENTAL PRO %PION HEAIiHDES ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 WILLIAM F.WELD TRUDY COXE Governor Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Lt. Governor Coaunissioner p r� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM `q — "4 PART A CERTIFICATION Property Address: 6�, \0,V11 ,4_Q, (�Jo�a.l t � lam- .Address of Owner: Date of Inspection: \0k1-1 lib 42� Z (If different) Name of Inspector: I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: Mailing Address:�.i�3 . r,k a.��,4_) A�y�t�r ey►� `jZ-by 1 Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true. accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: 1 G cp The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMTVIENTS: 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. Indicate yes, no. or not determined (Y, N. or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection. or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiitration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04125/97) Page I of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i.�s, .► PART A CERTIFICATION (continued) . %i u' Property Address: Owner: t Date of Inspection: BI SYSTEM CONDITIONALLY PASSES (continued) _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken. settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health. safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FLNCTIONLtiG I` A • MAN"NER WIUCH WILL PROTECT THE PUBLIC HEALTH AND SAFETY A.ND THE ENVIRON-PENT: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AIND PLBLIC WATER SUPPLIER, IF APPROPRIATE) DETEF-'YUNES THAT THE SYSTEM IS FUNCTIONIING IN A NIAN'N'ER THAT PROTECTS THE PLBLIC HEALTH AND SAFETY A.N- D THE EN-VIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (appro)imation not valid). 3 OTHER (revised 04/25/97) P2ge 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: D] SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System. cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria. volatile organic compounds. ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10.000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area -IWPA) or a mapped Zone II of a public water supply well) The owner.or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised O4/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: V-:1� J Owner: VtrouwC) Date of Inspection: Check if the follow ing have been done: You must indicate either "Yes" or "No" as to each of the following: Ch g Yes No � Pumping information was provided by the owner, occupant, or Board of Health. _ P g X _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as pan of this inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. X _ The facility or dwelling was inspected for signs of sewage back-up. 4 _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. All system components. excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, naterial of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)J (revised 04/25/97) Page 4 of 10 • - 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: S plw\ J Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: 6 M p.d./bedroom for S.A.S. Number of bedrooms: 03 Number of current residents: CD-2- Garbage grinder (yes or no):_t Laundry connected to system (yes or no): Seasonal use (yes or no):_h=S Water meter readings, if available (last two (2) year usage (gpd): 1'Q Sump Pump (yes or no): I� Last date of occupancy: i •�� COMNl ERCIAL/INDUSTRIAL: Type of establishment: Design flow: Qallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readines, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFOILti1ATION PUIVIPLtiG RECORDS and urce of information: �►w�Q�d\ System pumped as part of inspection: (yes or no)_ If yes, volume pumped: t allons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source•of information: Sewage odors detected when arriving at the site: (yes or no) (revised 04/25/97) Page 5 of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: as psw'�s Owner: \W 0(L k tJ C3 Date of Inspection: koAZ-Zkr;c' BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: _cast iron—40 PVC _other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints. venting, evidence of leakage, etc.) SEPTIC TANK:_ (locate on site plan) v Depth below grade: 1 b Material of construction: 4concrete _metal _Fiberglass _Polyethylene _other(explain) of Compliance es/No) Is age confirmed by Certificate p (Y If tank is metal, list are b — Dimensions: 060 06 T Sludge depth: -),t( Distanct; from top of sludge to bottom of outlet tee or baffle: Scum thickness: 1u - i( Distance from top of scum to top of outlet tee or baffle: �t Distance from bottom of scum to bottom of outlet to or baffle:_ How dimensions were determined: Comments: (recommendation for pumping. condition of inlet and outlet tees or baffles. depth of liquid level in relation too!�tle invert, tru ural rote ty. evidence of leakage. etc.) �iAtN et'k L GREASE TRAP: (locate on site plan) Depth below grade: 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: Comments: (recommendation for pumping, condition of inlet and.outlet tees or baffles,depth of liquid level in relation to outlet invert. structural integrity. evidence of leakage, etc.) (revised 04/25/97) Page 6 of IO l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: U C Owner: v t N J Date of Inspection: f TIGHT OR HOLDING TANK:_LL=�)(Tank must be pumped prior to, or 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/day Alarm level: Alarm in workinc order _ Yes. _ No Date of previous pumping: Comments: (condition of inlet tee. condition of alarm and float switches. etc.) USTRIBUTION BOX: (locate on site plan) (� Depth of liquid level above outlet invert: vc,�Cc•fC TIJ— Comments: (note if level and distribution is ual. evidence of solids carryover, eviden a of leakage into or ou of x. etc.) Q PUMP CHAMBER:_(--� (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/25/97) Page 7 or 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: S's Owner:QN-v,2`N -, Date of Inspection:' »\z.-t lq SOIL ABSORPTION SYSTEM (SAS): S (locate on site plan, if possible. excavation of required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number: SOS c�va\ _k l S leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool. number: Alternative system: Name of Technology: Comments: (note condition of soil. signs of hydraulic failure, level of ponding, condition of vege ion, tc.) t( SC — CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) 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.) (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:, Owner: \/e"r tN b Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) ra.c;NT 3 y �3-a1 ' 63' (revised 04/25/97) P2gc 9 0(10 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ` <� Owner: Q0-40-t t No Date of Inspection: Depth to Groundwater" Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators. installers A, Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) t 1 (revised 04/25197) Page 10 of 10 r TROY WILLIAMS AssEssoRs MAP Na � �q � PARCEL Na -7 SEPTIC INSPECTIONS A Certified by MA Department of Environmental Protection C�� ,.}j� (508) 760-1819 40 Old Bass River Road _ FFe �I South Dennis,MA 02660 r Q '996 conynO Wealth Of Massachusetts ExecutMe.Office of Er rAfOrxnental Affairs Department of p, U • Environmental Protection WtlUrn F.Wald osrsn,x David&s tim SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: i S 49 �-5 �"7 i CQH cr f 1¢ Address of Owner. �G.f J o i„'L tJ "At ie— Date of Inspection:a /1,3 /q of different) C fO t i3 ✓� Name of Inspector: ,_m f-j i I I .,, y Company Name,Address& Telephone Number. . Se'C c,. .je_ 19p 6 �3 CERTIFICATION STATEMENT 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection..The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _ Passes _ Conditionally Passes eeds Further Evaluation By the Local Approving Authority ails Inspector's Signature: Date: a//-3 /y6 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 god or greatef,'the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A.B,C,or D: A) SYSTEM PASSES: /J�11 I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: A" One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair, passes inspection. Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If'rot determined',explain why rot) The septic tank a metal,cracked, structurally unsound,shows substantial infiltration or exfltration,or tank failure is imminent. The system will pus inspection If the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 2/1S/9S) 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: S Owner: U W; 11 Date of Inspection: d,1017 b BI SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the :Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed CI FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:N4j- Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank ano sooi absorption system and is within 100 feel to a surface water supply or tributary lc a surface water supply. The system has a septic tank and soil absorption' system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm• I7IE FAILS: ave determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. ackup of se age We �s@Wiq-or system component due to an overloaded or dogged SAS or cesspool. S;y,,s af� (�[ ischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. revised 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: D] SYSTEM FAILS(continued): Static liquid level in the distribution box above outlet invert due to an overloaded or dogged SAS or cesspool. Liquid depth in � f�an-�=Welerr hive rt-or available volume is less than 1/2 day flow. N Required pumping more than 4 times in the last year NOT due to dogged or obstructed pipe(s). Number of times pumped 7_4 /? Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. 6— v546( d,y �'C 04"K: o Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ^Z0 Any portion of a cesspool or privy is within a Zone I of.a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. i Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. L, e is 6- -' . nj wf� CA-.,A -te.,fiti7 -� wt� tom✓ y�� �' l E) LARGE SYSTEM FAILS:/�� The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area(IWPA) or a mapped Zone If of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: 11/i ( 1 Date of Inspection: Check*if the following have been done: _-�/_Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. AIAAs built plans have been obtained and examined. Note if they are not available with WA. IzThe facility or dwelling was inspected for signs of sewage back-up. ZThe system does not receive non-sanitary or industrial waste flow The site was inspected for signs of breakout. _S,/AII system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge,depth of scum. (ZThe size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. The facility omme• (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow:A�O gallons Number of bedrooms: Number of current residents: O Garbage grinder (yes or no): A/- Laundry connected to system (yes or no)::(S Seasonal use (yes or no):_/v Water meter readings, if available: f Last date of occupancy: COMMERCIAUINDUSTRIAL: /V'�/'? Type of establishment: Design flow:_ allonstday Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no) Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Syst m pumped is part of inspection: (yes or no)_&a , If yes, volume pumped tzallons Reason for pumping: TYPE F SYSTEM Septic tank/disuibuti-A WvJsoil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) - APPROXIMATE AGE of all components, date installed (if known) and source of information: :.',1 - aJc /7 L 4(. T Sewage odors detected when arriving at the site: (yes or no)L O (revised 8/15/95) S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection:c2 113 SEPTIC TANK: c (locate on site plan) Depth below grade: Material of construction: concrete _metal _FRP —other(explain) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: ,2 Distance from top of scum to top of outlet tee or baffle:,_ Distance from bottom of scum to bottom of outlet tee or baffle: I Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Ca ti o v tte0. ti d v. a GREASE TRAP:YM (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of crtlrn t^hotior^ of otelei tee or battle- Comments: teecommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) :revised 6/15/95) 6 „ r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: g s- n�►t S Owner. Date of Inspection: d/i3/�F 6 TIGHT OR HOLDING TANK:Ylt7 (locate on site plan) Depth below grade: Material of construction: _concrete_metal _FRP other(explain) Dimensions: Capacity: gallons Design flow: aallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION 60k: (locate on site plan) Depth of liquid level above outlet invert: Comments: mote if lev,S�and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) At- PUMP CHAMBER: N��I (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc) (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: .S 1-9vti c S Owner: i Date of Inspection: p, �cp, 3 �� SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: G S � � / .S �� �� ZQ�1-4. overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) C- W c' G c— LIN Qf MLJ C. y. W.t CR f' e— CESSPOOLS: _,66� (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) 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.) trevised 8/15/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM:- Include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' L. S D ,ZE' fH/ as 321 fink. 30 S G s- X S� L e-�c,L -K- Ic( DEPTH TO GROUNDWATER Wµ''v: 5 aC ' Depth to groundwater. � feet — adjusted high groundwater level method of determination or approximation: ,o ti f r ✓ < 5 / / •GsM J I �4. ti ✓ L / �'f'- .L . d ✓ C (revised 6/15/95) 9 9 2SETTS THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE. MASSAC 2pplication for Oigozaf *p!Aem Construction permit Application is hereby made for a Permit to Construct( )or Repair( Xan On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. y5,40les W&Y �Qc,� II&I—erJwe ems_ y8s9 Gy��ervi/le �� I&, / wc���Ys �, Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms J Garbage Grinder 4X0 Other Type of Building GP No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow /l a gallons per day. Calculated daily flow ( gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs or Alteration (Answer when applicable) t'l f v we IJ-5 ul Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued s d o ealth Signed Date /z/4 Application Approved by Application Disapproved for the following reasons Permit No. '� G"� Date Issued N No. Fee--� _. _.. C. THE.COMMONWEALTH OF MASSACHUSETTS w i PUBLIC HEALTH"DIVISION - TOWN OF BARNSTABLE, MASSAC SETTS Z[pprication for Migozal Opgtem Construction Permit Application is hereby made for a Permit to Construct( )or Repair( Van On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. yu ;F Gc�,�rt�i e -AW Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: t Dwelling No.of Bedrooms ✓� Garbage Grinder4/4-© Other Type of Building ��Sl P No. of Persons Showers( ) Cafeteria( ) Other Fixtures i Design Flow gallons per day. Calculated daily flow -12a gallons. Plan Date Number of sheets Revision Date Title Description of Soil i Nature of Repairs or Alteration (Answer when applicable) drv. was u/l 'D sr�tiPY'r4va .ire s Date last inspected. Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance.has been issued is and of,iealth. Signed Date .. .Application Approved-.by •.�� .. ,.. : _: -.�,- _ .. -- Application Disapproved for the following reasons I` nn Permit No. Flo Q .�� ,� Date Issued ————————— _ —, ----------- THE COMMONWEALTH OF MASSACHUSETTS I FQ—e5® 7 PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of Compliance, THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced( &,-<on by ,QO/y�iGory; G�rl�y-✓L+C)'`-iOh for -TQc.0 I'lelei^irld as VS 4 i"S Wa y has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 19d dated 3 —2 4 Use of this system is conditioned on compliance with the provisions set forth below: E 12 No. `" 7 / `� Fee �y THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migo!W *pftem Construction Permit Permission is hereby granted to BOl4Lo / CB�SrUG j``%OyI to construct( )repair( cyan On-site Sewage System located at gh1�S Gr.�Y and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within two years of the date below. t Date: Approved by i i l,�✓C Pc) I g`—cs-;-7A-C- I ----------- ��i9� Cr.1111 ICICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONS'1'RUC ION I,EltIl1l'l' (�VI'1'1[OU'I'DESIGNED PLANS) 1, ����,�y ,7` ,e!!®�j g/or/ ereby certify that the application for'disposal works construction permit signed by me dated /��9� , concerning the property located at S` �'�s �/aY Get j'r// e meets all of the following criteria: 4, Thcre are no wetlands within 3oo feet of the proposed septic system Y There are no private wells within I5o feet of the proposed septic system I✓/he observed groundwater table is 14 feet or greater below the bottom of the leaching facility here is no increase in now and/or change in use proposed There are no variances requested or needed. SIGNED: DAIR LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER IAttach a sketch plan of the proposed system. Also if the licensed Installer posesses a certified plot plan. this plan should be submiltcdl. TOWNoOzr BARNSTABLE LOCATION /�M(.S �n1/ay SEWAGE # _ VILLAGE �Q nTirv�11� ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY WN a- s�o A 1. ?� well ay x !3 X a' LEACHING FACILrN: (type) " !(size) NO.OF BEDROOMS 3 JJ BUILDER OR OWNER PAJ 64U C rtAu PERMITDATE: COMPLIANCE DATE: 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)facility) 1 Feet Furnished by (n Foi Z j D� 33 3 a as 3-1 c 3 aq 3g� � 3S Si C, TOWN OF BARNSTABLE LOCH fION 6J-1.1tMe,3 SEWAGE # `%II.LAGE Gel �Y �. ASSESSOR'S MAP&LOT! �®7 INSTALLER'S NAME&PHONE NO. AlAe'llflO�iCe�?"57: SEPTIC TANK CAPACITY 1,O oO 4111V- L LEACHING FACILITY: (type) S'OOGx.L. bklwell (size),99`X13 � 07 NO.OF BEDROOMS 3 BUILDER OR OWNER Pe PERMTTDATE: �J—'Zl'"��7 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any.wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by r l,. a ® �I 3q- 3 a , TOWN OF BARNSTABLE LOCATION M &,. WCUU SEWAGE # VILLAGE VJ2�LQ ASSESSOR'S MAP&LOT O INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER �V�t,G24-1 ICY +ERMITDATE: XD i-I kcOD, COMPLIANCE DATE: 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) (YN Feet Edge of Wetland and Leaching Facility(If any wetlands exist . within 300 feet rof leaching facility) N(� Feet o . Furnished by _ l.D, �� l 0 0