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HomeMy WebLinkAbout0522 BAY LANE - Health 522 BAY LANE CENTERVILLE A = 187 068 Ei 45 m a � UPC 12534 No. 2 1_ 53LORQOST.GONS��� HASTINGS, MN r eb 2714 08:11 a p.1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 522 Bay Lane Property Address Susan Butler Owner Owner's Name information is required for every Centerville MA 02632 2-26-14 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 fiNingoutforms on the computer, \.�`�� yZH OFA fgSsry��i, use only the tab key to move your 1 Inspector: '� •N= cursor-do not JAMES James D.Sears hill use the return '�� key. Name of Inspector CapewideEntefprises,LLC Q,• my Company Name /,,��i,�, 5 1 N SPEcj-\p`� 153 Commercial Street Company Address Mash pee MA 02649 City/Town State Zip Code 508477-8877 S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 9'1�2n� sy 2-26-14 I ors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of Completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""'This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. �3I3 � 2oI y t5ins•3113 Title 5 Ofiasl Impedlon kksurfi=sawage Dispwal Syslem•Page 1 of 17 Feb 2714 08:11 a p.2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 522 Bay Lane Property Address Susan Butler Owner Owner's Name requir required is Centerville MA 02632 2-26-14 required for every page_ cityrrown State Zip Code CWe of Inspection B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the`Conditional Pass" section need to be replaced or repaired.The system, upon completion of the replacement or repair. as approved by the Board of Health,will pass. Check the box for"yes', "no"or"not determined"(Y, N, ND)for the following statements. If'not determined," please explain. The septic tank is metal and over 20 years old' or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exl"iltration 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): One•3M3 Tole 5 Mold Inspection Form:Subsurfaoa Sewepe Disposal System•Page 2 or 17 I Feb 2714 08:11 a p.3 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 522 Say Lane Property Address Susan Butler Owner Owner's Name informations required for every Centerville MA 02632 2-26-14 page_ Cityrrown State Zip Code Date of Inspection B. Certification (cant.) ❑ Pump Chamber pumpstalarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cunt.): ❑ 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 ❑ 1( ❑ N ❑ ND(Explain below): C) Further Evaluation Is Required by the Board of Health: , ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment_ 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system Is not functioning In a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Mine•3113 Tlae 5 Offidal Inspection Fomr.Subsurface Sewage Disposal System•Page 3 of 17 Feb 2714 08:12a p.4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 522 Bay Lane Property Address Susan Butler Owner Owner's Name information is required for every Centerville MA 02632 2-26-14 page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment ❑ The system has a septic tank and soil absorption system(SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. Q 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 Y pe fY. coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must Indicate"Yes"or"No"to each of the following for all inspections: Yes No ® Backup of sewage into facility or system component due to overloaded or dogged SAS or cesspool Ej ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Q ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® Liquid depth in is less than 6" below invert or available volume is less than Y2 day flowr 4 eWlAl e rains•3M3 Title 5 O fi"Inspecfion Fam:Subsurface Sewage Disposal System•Page 4 of 17 Feb 2714 08:12a p.5 K Commonwealth of Massachusetts Title 5 Official Inspection Form 6 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 522 Bay Lane Property Address Susan Butler Owner Owner's Name information is Centerville MA 02632 2-26-14 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) Yes No ❑ ® Required pumping more than 4 times in the last year NOTdue 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 0. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5im•3113 We 5 Omdel Impecton Form:Sdmurrece SawMe Disposal Syetem•Page 5 of 17 i Feb 2714 08:12a p.6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 522 Bay Lane Propetty Address Susan Butler Owner Owner's Name information is required for every Centerville MA 02632 2-26-14 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. El ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CM 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•3113 Title 5 Ofrdal Inspection Form:Subsurfam Sewage Disposal System•Page 6 d 17 Feb 2714 08:13a p.7 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 522 Bay Lane Property Address Susan Butler Owner Owner's Name information is required fDr every Centerville MA 02632 2-26-14 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1500 Gal.Tank D Box and three 500 Gal.Drywell Chambers. Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 2012-87,000Gais 2013-71,000Ga1 s Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date Commerciallindustrial Flow Conditions: Type of Establishment Design flow(based on 310 CMR 15.203): Cations per day(spd) 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: l5na-3113 Title 5 Dffmial Inspection Foam Subsurface Sewage Disposal System-Page 7 of V Feb 2714 08:13a p.8 Commonweait i of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 522 Bay Lane Property Address Susan Butler Owner Owner's Name information is required for every Centerville MA 02632 2-26-14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ lnnovabve/Aitemative 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): t5its•:3l13 Title 5 OffldW Inspection Form SuDsufaoe Sewage MsPossl System-Page 8 of 17 Feb 2714 08:13a p.9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 522 Bay Lane Property Address Susan Butler Owner pruners Name information is required for every Centerville MA 02632 2-26-14 page. Cityrrown state Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed (if known)and source of information: 1986 Permit#86-702 Tank f 2000 Permit 2000-590 leaching chambers/New-D Box 2-26-14 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 32" Depth below grade: feet Material of construction: ❑cast iron ® 40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting,evidence of leakage, etc.): Pipeing is 4" PVC SCH 40 Septic Tank(locate on site plan): Depth below grade: 20" 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: 1500 Gal. Precast Sludge depth: lit 151nS•8f13 Title 5 OlRdel kuped7on Form SubsuAaoe Sewage Disposes System•Pap 9 of 17 Feb 2714 08:14a p.10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 522 Bay Lane Property Address Susan Butler Owner Owner's Name information is required for every Centerville MA 02632 2-26-14 page. cityfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 18" Asbui It-Tape How were dimensions determined? Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level.Tank and cover's at 20"below grade. In and outlet tee's. No sign of leakage or over loading. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Dale Mrs•3/13 Title 5 Official Wpecdon Form:Subsurlaoe Serape Disposal Syslem•Pape 10 of 17 Feb 2714 08:14a p.11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 522 Bay Lane Property Address Susan Butler Owner Owner's Name information is reequiredred for every Centerville MA 02632 2-26-14 page. Cityrrown State Zip Code Date of lWecUon 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 15in3•3113 Title 5 lhfldel bispection Form:Subsurface Sewage Disposal System Page 1 f o!17 Feb 2714 08:14a p.12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 522 Bay Lane Property Address Susan Butler Owner Owner's Narne information is Centerville MA 02632 2-26-14 required for every page. Cityfrown Shale Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x 21"-30" below grade, wlthree lines out: Box is new 2-26-14. Cover at 6" below grade. Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No` Alarms in working order. ❑ Yes ❑ No` Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located,explain why: t5ins•3/13 Tile 5 Oftal Inspection Forth:Subsuda®Sewage D"reposal System•Page 12 of 17 Feb 2714 08:15a p.13 Commonwealth of Massachusetts Title 5 Official Inspection Form UVSubsurface Sewage Disposal System Form-Not for Voluntary Assessments 522 Bay Lane Property Address Susan Butler Owner Owners Name information is required for every Centerville MA 02632 2-26-14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cons) Type: ❑ leaching pits number. ® leaching chambers number. 3 ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovativelalternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): Leaching is three 500 Gal. Dry Well Chamber's. Chamber's are 43"below,grade w/one cover at 26". Chambers are clean,wet bottom. Wall's clean like new, No sign of over loading or stain line. 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 15I�s•3/13 Title 5 Offidal Inspection Form Subsurface Sewage Disposal System•Page 13 of 17 Feb 2714 08:15a p.14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 522 Bay Lane Property Address Susan Butler Owner owner's Name information is required for every Centerville MA 02632 2-26-14 page. Cityrrown I Stale Zap 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 sod, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): it ISIns•3%13 Title 5 Ortkial Inspedicn Form,S�sWBre Sehmge Disposal System-Page 14 of 17 t Feb 2714 08:15a p.15 Commonwealth of Massachusetts U Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 522 Bay Lane Property Address Susan Butler Owner Owner's Name rM on is requiredaired for every Centerville MA 02632 2-26-14 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.Check one of the boxes below. ® hand-sketch in the area below ❑ drawing attached separately A- 3, �rar� £ /—Pt 0X" 8 P to 0 .8 3� -G P -3 /3—3 = 39 sl 0 - V_-5-Ai �- V= 3�! 15ff18.3f13 Title 5 Mist UlspecWn Form:Subsufaos Sewapa Disposal System-Pape 15 of 17 i Feb 2714 08:16a p.16 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 522 Bay Lane Property Address Susan Butler Owner Owner's Name informatrequired for is Centerville MA 02632 2-26-14 required for every 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. 10' 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: 5-6-82 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: T.H.on Design plan 5-6-82 no G.W.at 10'. Bottom of leaching at 6' below grade. Bottom of leaching at 4'above T.H.Depth. Before filing this Inspection Report,please see Report Completeness Checklist on next page. tSms•3/13 Title b Oftat Inspection Form:SubWace Sewage DiepOsal System-Page 18 of I T r Feb 2714 08:16a p.17 � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 522 Bay Lane Property Address Susan Butler Owner Owner's Name information is required for every Centerville MA 02632 2-26-14 CityfTown page. 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 LtM5113 Title 5 Offidal hlspection Form Submalace Sewage Disposal System•Page 17 of 17 No. � FeA/ / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2pplitation for Misposal opstem Construction Permit Application for a Permit to Construct( ) Repair(X Upgrade( ) Abandon( ) ❑Complete System X Individual Components Location Address or Lot No. 5a;� (5AV (s!) 1r Owner's Name,Address,and Tel.No. Cewm vitL - "50p4-1 1bCTrlk_7^Z Assessor's Map/Parcel + $ ® g J Installer's Name,Address,and fel.No. $v$-411 Designer's Name,Address,and Tel.No. CADatvto� 6wTW&,sS u-c- 3 QA 1A-(.. 64 Type of Building: Dwelling No.of Bedrooms Lot Size :226-ISO sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) /V6 gpd Design flow provided N/4 gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) R C-Pc d-("e D-Rox Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Sigued Date ,Z/—Zq "`�'0 Application Approved by Date Application Disapproved Date for the following reasons Permit No. Za I N r O"y^� Date Issued Z Z I Z0'1 No. ZD( L - V 'f G J Fee 3 ompute? THE COMMONWEALTH OF MASSACHUSETTS Entered in c Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01pprication for ]Disposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair(X Upgrade( ) Abandon( ) ❑Complete System X Individual Components Location Address or Lot No. S.A;l DAV L4WU Owner's Name,Address,and Tel.No. Assessor's Map/Parcel I g#7 0 8 "- ytLC.0 Installer's Name,Address,and fel.No.50%-4'71 -gejj Designer's Name,Address,and Tel.No. - - CAoEcvAoE tFk)TWizsse!;: LA c ec Type of Building: Dwelling No.of Bedrooms ► A Lot Size Z.PS1-S40 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) IV E} gpd Design flow provided '1/4 gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: - Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Si ed Date 2.•Z- - 3.0 0 Application Approved by Date Z (2 Y Zo/ Application Disapproved Date for the'following reasons Permit No. 201 H - O K Date Issued Z1,7 y Z, / - -- \ TH E COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of Corn liance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( ) Abandoned( )by �AP �1 ht= ��Z CAC:... at J� QA SJ (A I C/,eQ AIL t_fE has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.00ILI- 9ql dated Installer Aff.10 060 9U7ty-PLIM uc_ Designer A #bedrooms /J Pr ? Approved design flow Q gpd 'The issuance of this permit/shall not b�construed as a guarantee that the system � functi� as/desig�ed. Date / Inspector ---------------------- No. Zo i Ll C7 Lj Fee Zi�I(D c� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction permit Permission is hereby granted to Construct( ) Repair( � Upgrade( ) Abandon( ) System located at 5aaSoCY LA U 6 G V(C _(___ and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit: Date 1717 9 Approved b�-- 1 TOWN OF BARNSTABLE LOCH 1"ON ✓��Z ��Y l�I. SEWAGE # D 1 VELT AGE ASSESSOR'S MAP & LOT/ 7-a INSTALLER'S NAME&PHONE NO. �3 r)o °Ld /' COi15J� 7 7" SEPTIC TANK CAPACITY.r 3 LEACHING FACILITY: (type) AM64Y C.�a<s C �►swJ size) t12 5> _-r NO. OF BEDROOMS BUILDER OR& �T/Low PERMITDATE: /012-1®® COMPLIANCE DATE: 4,9439/oo 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) 41k Feet Furnished by o ' I �7, } No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2pplication for lke;poar 6potem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. /� Oe,/ A Owner's Name,Address and Tel.No. Assessor's Map/Parcel c> 8h 7Lt- AQ7 rrrl'/I e `"/'/Gk a�I� -l el- Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Rol-tple el evjw` 77/-93�q Type of Building: Dwelling No.of Bedrooms —! Lot Size sq.ft. Garbage Grinder( ® Other Type of Building e,5 hq e -e No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow LNO gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 4Y/571-JAr62 Type of S.A.S. 3 SOO 9Q'1®n e Description of Soil G CtI�1YJG�✓-3 Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Bi d Health. ` Signed Date r/1Z� Z.) Application Approved by Date l d " Z_ Application Disapproved for the following reasons Permit No. Date Issued Fee I .. No. • THE COMMONWE 'HUSE4TS Entered in computer: ✓ ' Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,, MASSACHUSETTS 0ppYtcation for Mtgpogat *pgmem Con.5truction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Jr_Z Z �Q� �/'I, Owner's Name,Address and Tel.No. Assessor's Map/Parcel C eR 7�°rill//e e��Vl/el- i Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 771--43�� Type of Building: Dwelling No.of Bedrooms / Lot Size sq.ft. Garbage Grinder(11�/o " Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow PIP gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Sizeyof Septic Tank Ae�X13t)# Type of S.A.S. 3 — 5WO 9q•�dri Description of Soil f J Nature of Repairs or Alterations(Answer when applicable) 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 b his B d f Health. Signed p Date 91411� Application Approved by l Date /o - Z—Z" Application Disapproved for the following reasons Permit No. S D Date Issued �d Z ZvYa --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERT%C�`that t O�ie Sew ge Disposal System Constructed( )Repaired(UpgradedVAI ( ) Abandoned _ )by ©�✓`T' at Z Z y /�i ��`i , 'J'Y/l/. has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.Z4WG's9 dated /e) Installer Designer / d 4 A 0.7 The issuance of this guarantee o strued as a e t shal n9 b ce that the s� stem1.will,function as del ned r a ti Date Inspector �N �� i- _1g No. f7------------------- � V �-7/V p --Fee J V THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE,, MASSACHUSETTS Mtopool *pgtem con5tructton Permtt Permission is hereby granted to Construct( )repair( 4Upgrade( )Abandon( ) System located at Z i 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. Provided: Construction must be completed within three years of the date of this e .'t. Date: Approved by F �� ' U�6199 - NOTICE: This Form Is To Betsed For the Repair Of Failed Se -tic Systems Only. - CERTIFICATION OF SKETCH AND APPLICATION FO R A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) I, D erT ,(,D/-/P/hereby certify that the application for disposal works construction permit signed by me dated ?/L9l10 concerrting the property located,at ✓�`Z Z �3�y Ge� 1Y//��� meets all of the following criteria:. i/ the failed system is connected to a residential dwelling only. There are no commercial or business cues associated with the dwelling. v/ine soil is classified as CLASS I and the percoiation rate is less than or equal :o : minutes per inert /7-nere are no wetlands within 100 feet of:he proposed septic s✓stem /71her.-are no private wells within 1:0 feet of the proposed sezac system. I✓ i aere is no increase in flow and/or change in use proposed There are no variances.requested or needed. The bottom of the proposed leaching facility will not be located less than five feet above the ma.-durum adjusted groundwater table elevation. [Adjust the groundwater.tabte.using the:rimptor method when applicable] Ilf the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please.complete the following: A) Top of Ground Surface Elevation(using GIS information) �— B) G.W.Elevation +the MAX High G.W. Adjustment. DIFFERENCE BETWEEN A and B 1 r/ SIGNED: DATE: [Mcdch purposed plan of system on back]. 4F hnith Iowa:a:c t 0 0 0 �r i ' /G,WOte ,��r aJlted soils Zq ` bay le, � 3f2-x - = z�, y ZX 7 zj ,q �sLxz : 31 . 6 1 oX Z 3 b .a y >X 2 - `� y 13,zXy. oL1 � 3,7, X 17q TOWN OF BARNSTABLE LOCATION y ,0 SEWAGE # � D'✓ D VILLAGE 60 ASSESSOR'S MAP & LOT IINSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /jOo G 6 LEACHING FACILITY: (type) SAD 6,y C.1ats J sine) NO.OF BEDROOMS BUILDER OR�G'�,r LNE PERMTTDATE: lee_ DD COMPLIANCE DATE: 00 I 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) /l/ Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by I fa/ ,t� 1 c.£ i LO_E:;ITION -2 SEWAGE� PERMIT N0. Lot 4 $AY w VILLAGE INSTALLER'S NAME i ADDRESS ZBee' g.OUte, co I uG i 4aUJI", IU4sS L-R UIL DIE R OR OWNER �isJlh re, J,WIk Sor . R� PA I ILE ST, l" S DATE PERMIT ISSUED -7-1 $ (: DAT E COMPLIANCE ISSUED r�- I � t I � V I 1 � I � W e 3AY LAVE J THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH tDu1u ST' l O F.............. ..... ............................---................----- Appliration for Diopniittl Works Tonotrudion 11prutit Application is hereby made for a Permit to Construct (-)4) or Repair ( ) an Individual Sewage Disposal System at: ....�:°T` .-_ Y._. .� ... ............X=tt��- ............._......._.. ............ .---_••---------.--------------------•-------- .---------..—_.._..... ,,Cation-Address WA ILL or I�t No. S�W1j.� tl�lA. 5�_ '�`ILL ST:.......l.BAlTE1P-v!l.(��_. d!�s - .............•-----.._---...._..._�.. ......_.....................-•--.....---...... -- g ......................................... .........................•• ...:.. ..... ......................._....................... g: f i owns '�C. (--I�.(.(11 Address Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.................3..... .....Expansion Attic ( ) Garbage Grinder ( ) .04. Other—T e of Building No. of persons............................ Showers — Cafeteria 04 Other fixquW O W Design Flow............................................gallons per person per day. Total daily flow............._...?J.3..--...._.__.__._.._.gallons. WSeptic Tank—Liquid capacity��12.gallons Length................ Width................ Diameter............:... Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area.....................sq. ft. 3 Seepage Pit No..............I.__... Diameter_.._.lz'S...... Depth below inlet_.,.._.I......... Total leaching area 488......sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by........................................................................... Date........................................ t Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Li Test Pit No. 2................minutes per inch Depth of Test Pit................. Depth to ground water........................ Ri t._.......r.._.. --........t......;7 -�� C �........ .......... _l ..O C) • 2 Lort,~.c a Srn3 SOt� Z Description of Soil....... ..................................................... -•-•-• v.P ...... ........ V --•--•------ --•----------•• - �4E�1Z4aE�4Ex �iVG1i�f i=fi"t�AC7Bf"'�[7�1=�VfSE -----•-----•--------------•--•--•--•--------...............................•-------...".. TA1-LATIE� } N �, -� ---------------------------- Nature of Repairs�r Alterations—Answer when:apltclq- 6!° }vcte ala ..� �,. 6!:_.. �. 7 .......... 3/u�1� .....1 ............ CE--i 0-PLAN:...............YP. ............................................... Agreement: The undersigned agrees to install the afore ibed Individual S age Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary de—The undersi urther agrees not to place the system in operation until a Certificate of Compliance has ssued W the b d ed.. ...... ....... ....................... ... Application Approved By.... ..... . . ... ': ........................_ .............. .... Date Application Disapproved for the foil reasons:..........................................................................................................--- ..----•---•------------------------•-----....._..-----••----•---........-----........----.........•----............----....------....---•--•--•--•-••........................................ Permit No.--c'.. (. .. ��� ., Issued................ - ........._Dat�...... - Daft ' .+K,3r 'i7^•L.r w,:, r-'fe^`,�l"at'17.,.e3'i."'�.�rs �s�#g'y'#,o�,'�1��ur{�'"�•+•.rmxgw�xy,'�;._�a'tr.A�.. �7 'h,.YF' - 'tom y . ,1f770-2, = Y + yTHE COMMONWEALTH OF MASSACHUSETTS , BOARD OF HEALTH ....77MA.. _.................OF_........... ?n.a5TAi3L.E............................... .,. Appliratiotn for 13isposal Works Tonsfrt dwi n Veruiif Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: �l ... LoT A BAY lh1i(. 1 k7k1�w IL.I.t✓'' ._................................................--------- ......................-_......................_.......--..................._......_.._».... Location-Address �Y or Lot No. Si W r&,P �i l la I �iT• t J _--- -..... . ...______......._....._.. ......_......... .......•........-•--••.._... ............................................... ' Owper Address C6 !&1 C �.1r�S Installer Address Type of Building Size Lot............................Sq. feet V Dwelling—No. of Bedrooms.................3.............._.........Expansion Attic ( ) Garbage Grinder ( ) Other—Type e of-Buildin No. of persons......................... Showers a YP g ............................ P --- ( ) — Cafeteria ( ) Otherfixtures .......................•--•••--'---•--........--•---.....---•--..t..................................:................................................ W Design Flow.............. ....��_- ........-.•-..._..gallons per person per day. `Total daily flow................:330.................gallons. WSeptic Tank—Liquid capacitysa!2.gallons Length................ Width................ Diameter...........-:... Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area.....................sq. ft. 3 Seepage Pit No..............J_..... Diameter.....1 'S.......\!Depth below inlet........A......... Total leaching area.Q6S......sq. ft. Z Other Distribution box ( ) Dosing tank ( ) I Percolation Test Results Performed b .a Y .... ............ •..:..... -..D-......... Date........................................ ,-a Test Pit No. 1................minutes per inch Depth of Test Pit.. ......_.. Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.................. ._.. a :........................................ .....!../A � 2 - '; .----------.. ...... ...- ...._... -..Co"SF_ �PY �aun_ 7 - 0' VEt, �. t VO Description of Soil: ...--- ...•--•---•-•-•-•-•---•-------••-•-•--•-•................... ....._.... .W .--------•. ........................... ............. ......... ............. -------- ............ ...... -----•- ------- ......................•-------"-'.......------...'---...-•------'-----............................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable...............................................Sf c - (�u __�A _WA.y l 1.4Ti.... t�hi 3+7 .......--•--•---•....................................••--•---- ..... - --- Agreement:, The undersigned agrees to install the afored r bed Individual Swage Disposal System in accordance with the provisions of .ITLE 5 of the State Sanitary Code—The unders!ig,�e&further agrees not to place the system in operation until a Certificate of Compliance has been issued the board o l-ealth. Sign"ed..................�"` `� �. \- . ...................................... ........ � .........................._.... Application Approved By... ......_..... t PP PP By... ......_.. --Y--.......-•-_--..»----•------•.............._ ...------•--•-------ate-•----•-----.. Date Application Disapproved for the follow n—g reosons:...............................•..............................•..__..__.__....................._..........___ •--•.............•-•---------•---...---.......-...........-•----.....---------..._....-----•........--.................. -•--•-•----------•-----•--.._...----••-----•------.....---•--••-------..._ Permit NO...»_�5\(-!>» _ ._ Issued......_....................».....----...Date Daft THE COMMONWEALTH OF MASSACHUSETTS +f� 1 BOARD OF HEALTH V .................................�1 OF........... " s T ertifutt#r of Toutphnna - THIS IS TO CERTIFY; That the Individual Sewage Disposal System constructed or Repaired by............ ... .........................................JI ..t C »-...-----..............:---------.-----------•----------- Installer at-..._�:�.�..`�".. 6w Lm, G�1117WJ�LL� �SI W�!� " S11Urf��....................... .................••-----•----------------------.---.---.......... has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No �'�'C ..__'7.0 dated...........�1 ............... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL,FUNCTION SATISFACTORY. DATE............... 1 Inspector •- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............ - FEE................ Disposal Norks Tonstrurtion f rrutif Permission is hereby granted...... �� '2 !`'. ,............................................•.......--•---..........................-_.... to Construct ( )Z) or Repair ( ) an Individual Sewage/Disposal System \ at No.....�PT...4----....R ............................11 lt ( �t11� �- C,ttV�1 5 e ) ................ .....-'------'.................................. Street as shown on the application for Disposal Works Construction Permit No�S :"7d 2 Dated...a. �. �-� .. ........... Board of Health DATE...............///.... l •-•------...........----• FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS �'�'•— BAXTER & NYE INC. Registered Land Surveyors and Civil Engineers 7 Parker Road/Osterville,Massachusetts 02655/Tel. (617)428-9131 WILLIAM C.NYE,R.L.S.-President RICHARD A.BAXTER,R.L.S.-Vice President PETER SULLIVAN,P.E.-Vice President-Engineering August 6 , 1.986 Town of Barnstable Board of Health P .O. Box 534 Hyannis, MA 02601 RE. Lot 4 Bay Lane, Centerville Installer : Robert Our Applicant : Silvia & Silvia Gentlemen: In accordance with your request, I have inspected the septic system at Lot 4 Bay Lane. - The proposed system has been installed as per the approved plan dated September 30 , 1983 . I trust that this meets your present needs. Very truly yours, Peter Sullivan, P . E. Baxter & Nye, Inc , PS/bc CC : Silvia & Silvia , OF 414. PETER SULLIVAN No. 29733 �J C d A'POA, ISTER� FsU/OA+A L MEMBERS OF CAPE COD SOCIETY OF PROFESSIONAL ENGINEERS AND LAND SURVEYORS/AMERICAN CONGRESS ON SURVEYING AND MAPPING MASSACHUSETPS ASSOCIATION OF LAND SURVEYORS AND CIVIL ENGINEERS vr tq, 'AK kF . 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