HomeMy WebLinkAbout0015 BEE LANE - Health FA =
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i, Commonwealth of Massachusetts
. :- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
15 Bee Lane
v
Property Address
Daniel Hostetter
Owner Owner's Name
information is required for every Centerville Ma 02635 11-9-2020
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information ��# j col(P
on the computer, Brett Hickey
use only the tab y
key to move your Name of Inspector
cursor-do not B&B Excavation
use the return Company Name
key.
374 Route 130
Company Address
Sandwich Ma 02563
City/Town State Zip Code
r (508)477-0653 S113747
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above;the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. Al Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
Brett Hickey "Oae 202011.110B26:23-k05!001 11-9-2020
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp:doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
u
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
15 Bee Lane
Property Address
Daniel Hostetter
Owner Owner's Name
information is Centerville Ma 02635 11-9-2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System 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:
The system was in working order at the time of inspection.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
__
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
---. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
. . 15 Bee Lane
Property Address
Daniel Hostetter
Owner Owner's Name
information is Centerville Ma 02635 11-9-2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (Cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ .The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t51nsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
c� Commonwealth of Massachusetts
-11P Title 5 Official Inspection Form
ll� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
P'
`I 15 Bee Lane
Property Address
Daniel Hostetter
Owner Owner's Name
information is Centerville Ma 02635 11-9-2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ❑ Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
a Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp:doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
15 Bee Lane
Property Address
Daniel Hostetter
Owner Owner's Name
information is Centerville Ma 02635 11-9-2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ O 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'/2 day flow
❑ o 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.
❑ O Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ 0 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.]
El The system is a cesspool serving a facility with a design flow of 2000 gpd-
❑ 10,000 gpd.
❑ F-1 The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section CA. i
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
t5insp:doc•MY.7/2 612 0 1 8. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
...... .. ......... y
15 Bee Lane
Property Address
Daniel Hostetter
Owner Owner's Name
information is Centerville Ma 02635 11-9-2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
❑ ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ El Were any of the system components pumped out in the previous two weeks?
0 ❑ Has the system received normal flows in the previous two week period?
❑ El Have large volumes of water been introduced to the system recently or as part of
this inspection?
Q ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
❑ n Was the facility or dwelling inspected for signs of sewage back up?
0 ❑ Was the site inspected for signs of break out?
El ❑ Were all system components, excluding the SAS, located on site?
0 ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
El 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:
El ❑ Existing information. For example, a plan at the Board of Health.
❑ a Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 10
1 Commonwealth of Massachusetts
_= Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
15 Bee Lane
Property Address
Daniel Hostetter
Owner Owner's Name
information is Centerville Ma 02635 11-9-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
3 Number of bedrooms (design): Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330/GPD
Description:
3
Number of current residents:
Does residence have a garbage grinder? ❑ Yes [j] No
Does residence have a water treatment unit? ❑ Yes ❑ No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonaluse? ❑ Yes No
See below
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
2019- 93,000gallons 2018- 77,000gallons
Sump pump? ❑ Yes ❑■ No
current
Last date of occupancy: Date
t5inspAoc•rev,7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
c� Commonwealth of Massachusetts
Title 5 Official Inspection Form
..........
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
15 Bee Lane
Property Address
Daniel Hostetter
Owner Owner's Name
information is Centerville Ma 02635 11-9-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
NA
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Owner- date of last pump is unknown
Source of information:
Was system pumped as part of the inspection? ❑ Yes ❑■ No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp:doc•rev.7/26/2018 Me 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
=-......... Ti Sewage tle 5Official Inspection Form
Susurface Disposal System Form -Not for Voluntary Assessments
/ 15 Bee Lane
Property Address
Daniel Hostetter
Owner Owner's Name
information is Centerville Ma 02635 11-9-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
0 Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under_contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
1995 per permit
Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No
5. Building Sewer(locate on site plan):
31
Depth below grade: feet
Material of construction:
❑ cast iron ❑■ 40 PVC ❑ other(explain):
Town water
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
t5lnspAoc•'rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.•Page 9 of 18
Commonwealth of Massachusetts ,
Title 5 Official Inspection Form
'- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
15 Bee Lane
Property Address
Daniel Hostetter
Owner Owner's Name
information is Centerville Ma 02635 11-9-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
2'
Depth below grade: 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: 1500gallons ,
1211
Sludge depth:
24"
Distance from top of sludge to bottom of outlet tee or baffle
3"
Scum thickness
611
Distance from top of scum to top of outlet tee or baffle
1491
Distance from bottom of scum to bottom of outlet tee or baffle
measured
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The tank was in working order at the time of inspection. The tank is in need of pumping
at this time and should be pumped every two years for maintenance.
t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
15 Bee Lane
V
Property Address
Daniel Hostetter
Owner Owner's Name
information is Centerville Ma 02635 11-9-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
NA
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
NA
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
t5insp.doc-rev.7/26/2018. Title 5 Official Inspection Form:Subsurface Sewage Disposal System.•Page 11 of 18
Commonwealth of Massachusetts
► Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
15 Bee Lane
Property Address
Daniel Hostetter
Owner Owner's Name
information is Centerville Ma 02635 11-9-2020
required for every
St
page. City/Town ate Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
0"
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
The d-box was in working order at the time of inspection.
t5insp:doc•rev.7/2672018 Title 5 Official Inspection Form;Subsurface Sewage Disposal System Page 12 of 18
I
Commonwealth of Massachusetts
___:-1 Title 5 Official Inspection Form
fir-
} Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
15 Bee Lane
Property Address
Daniel Hostetter
Owner Owner's Name
information is Centerville Ma 02635 11-9-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
NA
" If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
(4)infiltrators w/4'stone
Q leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp:doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
f Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
15 Bee Lane
Property Address
Daniel Hostetter
Owner Owner's Name
information is Centerville Ma 02635 11-9-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS)(cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
The SAS was in working order at the time of inspection. Leaching had no ponding or
evidence of past back up when viewed.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
NA
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp:doc•rev.7l2612D18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
:___ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
15 Bee Lane
Property Address
Daniel Hostetter
Owner Owner's Name
information is Centerville Ma 02635 11-9-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
NA
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
-_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
15 Bee Lane
u-
Property Address
Daniel Hostetter
Owner Owner's Name
information is Centerville Ma 02635 11-9-2020
required for every
page. CityfTown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
P Y
Provide a view of the sewage disposal system, including ties to at least two permanent reference
9 P Y 9
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 i"' TOWN OFBA.FtThTSTABLE. ._
SEI7 A t�/�:e�
VILLAGE-. S. �✓'�- 't lS ASSESSOR&MAP Ak I-OT, +3 (7
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INSTALLER s NAmm.;Bc -
SEPTIC TANK CAPACI I Y G�
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LEACIIINL3 AcILJT�r (type) �s£,_-t-lc (size)�,j gr,P* -�,.
No.OF BEr) 00Ms ->c-�.-ers
� 0LYMr),EI2,OIZ OWNER
PERMIT n,k-m: -
5epurat3on:Distance Bctyvccn the.- f!'G'
—, r—
Maximum Adjusted Groundwateir Table and Bottom of Leaching Facility
Private Water Su i Well and
I>P y beaching I=acility (If any wells exist
oil 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)
Furnished by c c14A,
a
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' s-4 2 r,4 �
f3 �3 t u. Cam, ��c•. -�
t5insp:doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
-= - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
15 Bee Lane
Property Address
Daniel Hostetter
Owner Owner's Name
information is Centerville Ma 02635 11-9-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑■ Check Slope
❑■ Surface water
Check cellar
❑■ Shallow wells
Estimated depth to high ground water: NoGW@14'feet
Please indicate all methods used to determine the high ground water elevation:
El Obtained from system design plans on record
If checked, date of design plan reviewed: Permit dated 7-28-1995Date t
❑ 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:
A plan on file at the local Board of Health was used to determine high groundwater.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
c Commonwealth of Massachusetts
=e Title 5 Official Inspection Form
W�o Subsurface Sewage Disposal System Form -Not'for Voluntary Assessments
r 15 Bee Lane
U Property Address
Daniel Hostetter
Owner Owner's Name
information is Centerville Ma 02635 11-9-2020
required for every
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
0■ A. Inspector Information: Complete all fields in this section.
QQ B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6(Checklist)completed
❑■ D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
YOU WISH TO OPEN A BUSINESS? A
For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you 5
must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis.
Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is
required by law.
�. DATE: Fill in please:
APPLICANT'S YOUR NAME/S:
02& BU INESS YOUR HOME ADDRESS:
$' cx ppd —°
' ELEPHO # Home Telephone Number
NAME OF::CORPORATbN:
NAME OF NEW BUSINESS ` TYPE OF BUSINESS
ISTHIS A;HOME OCCUPATIONS NO
ADDRESS`OF.BUS INESS MAP PARCEL NUMBE ? Assessor" ( gi
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. — (corner of Yarmouth
Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operatb your business in this town.
1. BUILDING COIVIMISSIOI ER'S OF ICE
This individual hi as, gni d f any p m't requirements that pertain to this type of business.'
Uv MUST COMPLY WITH HOME OCCUPATION
'1 Au rize i at r ** r✓ �- -. RULES AND REGULATIONS. FAILURE TO
C�MMENGOA4121VIVIAV RESULT it! FINES.
ti f
2. BOARD OF HEALTH
This individual has beeMforr�ed of the permit requirements that pertain to this type of business. MUST oOMPLYWITH ALL
L . Net rfl0 �r1ZARDOLJS N.AATFRIAI_S REC1.111_ATInNl
Authorized Signature*
COMMENTS:
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature**
COMMENTS:
i
7/3��
TOWN OF BARNSTABLE Date:
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAME OF BUSINESS:
BUSINESS LOCATION: INVENTORY
MAILING ADDRESS: �. . d2- TOTAL AMOUNT:
TELEPHONE NUMBER: Gf�L/� CQ/9
CONTACT PERSON:.
EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE?
TYPE OF BUSINESS: - ./'T.��i� g _
INFORMATION / RECOMMENDATIONS: Fire District:
Waste Transportation: Last shipment of hazardous waste:
Name of Hauler: Destination:
Waste Product: Licensed? Yes
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health and the Public Health Division have determined that the following products exhibit toxic or
hazardous characteristics and must be registered regardless of volume.
Observed / Maximum Observed / Maximum
Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive
❑ NEW ❑ USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road salts(Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
❑ NEW ❑ USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers)
Diesel Fuel, kerosene,#2 heating oil ❑ NEW ❑ USED
Miscellaneous petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil ❑ NEW ❑ USED
Degreasers for engines and metal Printing ink
Degreasers for driveways&garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Miscellaneous Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt& roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (including carbon tetrachloride)
❑ NEW ❑ USED Any other products with "poison" labels
(including chloroform, formaldehyde,
Paint&varnish removers, deglossers hydrochloric acid, other acids)
Miscellaneous. Flammables Other products not listed which you feel
Floor&furniture strippers may be toxic or hazardous (please list):
Metal polishes '-. ,,i!9 � ���.
Laundry soil &stain removers
(including bleach) ��
Spot removers&cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Windshield wash
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials
TOWN OF BARN$TABLE BAR-W 594
Ordinance or Regulation
WARNING NOTICE
Name of Off ender/Manager 1e
Address of Offender 1< _MV/MB Reg.#
Village/State/Zip l/rAl) /3 _
Business Name '` ram/pm, on 20_
Business Address 1 1 AA_ ���
SI§n°atuie of Enforcing Officer
Village/State/Zip
Location of Offense A'_
Enforcin-g/Vept/Division
Offense
Facts
�IOo.rlcl�ffln+ � �Ln�
This will serve only as /a wa,rning.' At this time no legal action has -beven taken.
It is the goal of Town agencies to achieve voluntary compliance of Town
Ordinances, Rules and Regulations. Education efforts and warning notices are
attempts to gain voluntary compliance. Subsequent violations will result in
appropriate legal action by the Town.
WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT.
t 4 TOWN OF BARNSTABLE BAR—W C94
Ordinance or Regulation
WARNING NOTICE
Name of Offender/Manager d . .
Address of Offender i<, f MV/MB Reg.#
Business Name ram/pm, on 20_
Business Address - 1 �` '
s Signature `of 'Enf'orcing`Officer
N
Village/State/Zip
+
Location of Offense J/
"Y Enforcing/Dept/D 4rision
Offense
� r1
Facts
This will serve only as /a warriiiig.` At this time no legal; action has 'bee"n 't"aken.
It is the goal of Town agencies to achieve voluntary compliance of Town
Ordinances, Rules and Regulations. Education efforts and warning notices are
attempts to gain voluntary compliance. Subsequent violations will result in
appropriate legal action by the Town.
WHITE—OFFENDER CANARY-ORD./REG.—PROG. PINK—ENFORCING OFFICER GOLD-ENFORCING DEPT.
TOWN OF BARNSTABLE
BOARD OF HEALTH
ARTICLE I1:MINIMUM STANDARDS FOR HUMAN HABITATION
Date . a d
Owner c a - c v aLe, Tenant
Address S �� CP�1 M'lJP Address
Complionce Remarks or
Regulation# Yes No Recommendations
2. Kitchen Facilities
3. Bathroom Facilities
4. Water Supply
5. Hot Water Facilities
6. Heating Facilities
7. Lighting and Electrical Facilities
8. Ventilation
9. Installation and Maintenance of Facilities M4, "ba
10. Curtailment of Service
11. Space and Use N 0
12. Exits a .Ak
13. Installation and Maintenance of Structural
Elements
14. Insects and Rodents
15. Garbage and Rubbish Storage and Disposal
16. Sewage Disposal
17. Temporary Housing ''— ut
.,.J-!n 2 vC y1 v�
PART II q
�e�rtl c rHf l
37. Placarding of Condemned Dwelling; S�—1��3� � O ,I
Removal of Occupants; Demolition .� . 61= f
4cL
Person(s) Interviewed Inspector
If Public Building such as Store or Hotel/Motel specify here
t:
� !�' . ,.._..♦..4 ..fs`r•_.ram` f��I�--tf...c"d.... .-b;'d�,�y.ir"'k."5. a✓'• " ,. - .. , e� .�, -if..-. f-i iw
TOWN OF BARNSTABLE
BOARD OF HEALTH
ARTICLE II:MINIMUM STANDARDS FOR HUMAN HABITATION
Date !a-7% !
i l /�
Owner 00 fUt�%lvn 4� ��J C_ ! -FJ, , 0(mcx k Tenant
r Address 1_401"n / (,Pn A,/ Ile Address
Compliance ' Remarks or'
Regulation# Yes No Recommendations
2. Kitchen Facilities k
3. Bathroom Facilities .. °•
4. Water Supply
5. Hot Water Facilities
6. Heating Facilities
7. Lighting and Electrical Facilities _
8. Ventilation
9. Installation and Maintenance of FacilitiesbrA A.,
10. Curtailment of Service r
11. Space and Use V p 11,- � „ S n�,a f'
12. Exits ?��"1
13. Installation and Maintenance of Structural ` `I
Elements
14. Insects and Rodents
15. Garbage and Rubbish Storage and Disposal
1
16. Sewage Disposal
ti 17. Temporary Housing 1, ✓ �+ t�
fit
PART II p
37. Placarding of Condemned Dwelling; / \
Removal of Occupants; Demolition
Person(s) Interviewed Inspector
If Public Building such as Store or Hotel/Motel specify here
y
r`
d
' COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
RECEIVED
�i
5
pair. 2 0 2002
TOWN OF BARNSTABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A CERTIFICATION (9
Property Address: 6-'E �:n
�-ems'.-•� c rv;l/1 /y�
Owner's Name:
Owner's Address: %�L {` �:^v.�► ��r/J.�
Date of Inspection: T1,2 e, 61-,4
Name of Inspector: (please print) / ' /G i r 4—
Company Name:
Mailing Address: r" i G'X
Telephone Number: 5 C. > )' %—=6 4�
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
belo-.y 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:
+1 Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: </ �N' b Date: ,L42
The system inspector shall submit a cope 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.
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: �� ���' e
Owner: .
Date of Inspection: U�
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Syst Passes:
I have not found anv information which indicates that anv 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:
/G/Gne 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 enfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced Mth 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 v_ear 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:
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner: J 06 c,✓l -IL
Date of Inspection: G-T-
C. Further Evaluation is Required by the Board of Health:
If/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-,,.:ell**. 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:
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: L/�
Owner.
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_ ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
ischarge 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
sspool
i/ iquid depth in cesspool is less than 6"below invert or available volume is less than %2 day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed p: s).Number
' /of times pumped .
_ (/ y 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.
_ v 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. [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.]
v (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 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.
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 II of a public water supply well
If you have answered"ves' 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 anv 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.
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: /Tz
Owner: UG u",7 f-t
Date of Inspection: 212ch G'
Check if the following have been done. You must indicate"ves"or"no"as to each of the following:
Yes -'I�o
l/ _ Pumping information was provided by the owner,occupant, or Board of Health
ere any of the system components pumped out in the previous two weeks
Has the system received normal flows in the previous two week period
i/ 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
6� 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 Cis at issue approximation.of distance
is unacceptable) [310 CMR 15.302(3)(b)]
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: r /
Owner: DC yc�
Date of Inspection: d.o f%L
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 33G'
Number of current residents:
Does residence have a garbage grinder(yes or no):�(J
Is laundry on a separate sewage system(yes or no):jL4�[if yes separate inspection required]
Laundry system inspected(yes or no):�J
Seasonal use: (yes or no): ;fJ
Water meter readings.if available(last 2 years usage(gpd)):
Sump pump(yes or no):�-
Last date of occupancy:Zu
COMMERCIALIINDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgff.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: /" 7 C 0
Was system pumped as part of the inspection(yes or no):lv
If yes.volume pumped: _gallons—How was quantity pumped determined?
Reason for pumping:
OF SYSTEM
_Septic tattle 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)an source of�ormation:
��J7
Were sewage odors detected when arriving at the site(yes or no): /�
f
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
/ -✓, �. 4
Owner. Lc:'rc-.�' /
Date of Inspection: _
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: (_,-cast iron _ 0 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints.venting,evidence of leakage,etc.):
SEPTIC TANK:Z(Iocate on site plan)
Depth below grade: _
Material of construction: concrete_metal_fiberglass_polvethvlene
—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:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: sil
Scum thickness: 0
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:,1V& -Sc. <.• 47
How were dimensions determined: K�;; " _�('it
Comments(on pumping recommendations. inlet and ou&et tee or baffle condition. structural integrity, liquid levels
as related to outlet invert. zdence of leJakagel etc.):
rev L✓
GREASE TRAP: /J�t�icate 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.):
Page 8 of 11
r
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: ' L
Owner:-ZaC V L4
Date of Inspection: z%
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(erplain):
Dimensions:
Capacity: gallons
Design Flow: gallons/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:Z(ifpresent must be opened)(locate on site plan)
Depth of liquid level above outlet invert: j2j2, 1v'1,1M /
Comments(note if box is level and distribution to outlets equal•any evidence of solids carryover•any evidence of
leakage into or out of box.etc.):
PUMP CHAMBER A' (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.):
r
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
✓�/ , /i
Owner. J ��
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan.excavation not required)
If SAS not located explain why:
Type
leaching pits.number:— ..L�� r /1 '�'' ' i"�S // �'`�/y S7�JN
leaching chambers.number: /� �� ti v) Nr,.�
leaching galleries.number:
leaching trenches,number.length:
leaching fields.number.dimensions:
overflow cesspool. number:
umovative/alternative system Tv
pe/name of technology:
Comments(note condition of soil. signs of hydraulic failure.level of ponding,damp soil.condition of vegetation.
etc.):
,//cess of must be as of i on)(locate on site plan)
CESSPOOLS: � ( po P�P� P� ��
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids laver:
Depth of scum laver:
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: (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.):
Page 10 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: '
Owner. Cif z�c
Date of Inspection: ' ?�
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.
Fr 0 Of t
3-
<< i
7� O
t ,
� >
:3
Page 11 of 11
r
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: l /
Owner:
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
i
Estimated depth to ground water 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:
Checked with local excavators.installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
C/i•I G ' � ���� �/C) l�inCLv:. j'Cy `���G��r^'.
s iv4a J CL� �'•
o V7c_ - ��'
TOWN OF BARNSTABLE BAR-W 5943
Ordinance or Regulation
WARNING NOTICE
Name of Offender/Manager / ylen '�>U ta,4_ e
Address of Offender /S- &2,c L,P MV/MB Reg.#
Village/State/Zip C.'*'A�erv.`Ilf &A a2 62 :1-
Business Name /pm on 20_
Business Address
ature o�hforcing Officer
Village/State/Zip !
Location of Offense / u L414e
nn )) nn �7 �/ E/n�f� rcing ept/Division
Offense vwn a L3r�rnsTm�IP C�cCP /0 7a �Pr�t�'cdRep-rLb ate►
4/1
Facts 'u ` ✓ n ; v4 e ` V ,2
This will serve only, as a w r ing. At t�/' s time no legall action has bq,6n taken.
It is the goal". of Town agencies to achieve voluntary compliance of Town
Ordinances, Rules and Regulations. Education efforts and warning notices are
attempts to gain voluntary compliance. Subsequent violations will result in
appropriate legal action by the Town.
WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT.
�- TOWN OF BARNSTABLE
LOCATION � �- SEWAGE # s /6
tb
VILLAGE hr lh ASSESSOR'S MAP & LOT .
INSTALLER'S NAME&PHONE N--O--..��SC c>
SEPTIC TANK CAPACITY �C�y�tt �� PC) u cJ�TC
LEACHING FACILITY: (type) (size) r/Q (fPf 340-9, t
NO. OF BEDROOMS_
BUILDER OR OWNER 4 oAQ. -,& LC�COn�
PERMITDATE: �/7 SC( `'l S COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facilityk)01 4/ Feet
Private Water Supply Well and Leaching Facility (If any wells exist �r1V
on site or within 200.feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands existL rl
within 300 feet of leaching facility) U Feet
Furnished by Sco\A
V J
V
/coo CS$
63 , s � 3 �
) s
No.... �. L1`� .f Fps....... -
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
Appliration for Di-nVotiul Work,6 Tott9trnrtinn Vernfit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
Sy§tem_a ..�C.. �1t.------.-Ll"l��scs`►\�� ------ --------------------------------------------------
Location-:\ddress t, or t No
(� Owner Address
----------------•--------------------- ---aj....s.tns ------
Installer Address
U Type of Building Size Lot----_.......................
sq.
"��
►, Dwelling—No. of Bedrooms___.____._-_____________________________Expansion Attic ( ) Garbage Grinder �v
aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a' Other fixtures ---------------------
W Design Flow___________________________________yy_ _rrJJ.-gallons per person per day. Total daily flow-------------------------------------,......gallons.
WSeptic Tank—Liquid capacity---lAgallons Length________________ Width---------------- Diameter-_._.__-._..._ Depth______-____-----
x Disposal Trench—No. .................... Width-------------------- Total Length-------------------- Total leaching area--------------------sq. ft.
Seepage Pit No.---.---. __------- Diameter.................... Depth below inlet-------------------- Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by------- -------- ......................................................... Date........................................
Test Pit No. I--------------__minutes per inch Depth of Test Pit.................... Depth to ground water-.__--.-__-____-_.-_-...
fi Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water_._-_----_-______--_--.
P4 ...--•-•--••----------------•••-•-•--•--•-•-•-•-••-•••••••-•---------••-•-•••••••--••--•------------.........................................................
0 Description of Soil........................................................................................................................................................................
x
u
w
-------------------------------------------------------------------------------------------------------- ••....
Ua }� of e�airs or Alterations— nswgr when applicable.___._C _ C,f!___.���5 _ __--_- --____(.�Z�l?
V� '�
1 x-- "f c -�icS ---- - ._...----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been iss oard of health.
igned . -.. Dace
Application.Approved By ---- - - - - ---------- -------/1- ... . ... .---------------------------
to
Application.Disapproved for the following reasons- ------- ------------------- ---------------------------------------------------- -----------------------
...... ................... .. .... ..--.._._........_......_...
........... ....... ----...._..---------------------------------
n / Dace
- Permit No- ----------�_"�- f.-... --.t .. Issued ....._......... — ------
Dace
r
00
No.-- = S-�.(9�..� Fri$.......S o
THE COMMONWEALTH OF MASSACHUSETTS r
BOARD OF HEALTH
TOWN OF BARNSTABLE f
Apphratinn fur Biti-pwi l lVaarkri (nomitrurtion Frrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( k) an Individual Sewage Disposal
System at
Location-Address
--......r ,I4 Q. Lr"- aUr SrSar-__- � ._ 1,� �`��C�_� t_N�c,1
M"'... -
Owner Address
I
Installer Address
UType of Building Size Lot....................
T
Sq j�
Dwelling— No. of Bedrooms.__-_-----_-'__________________________.__Expansion Attic ( ) Garbage Grinder
aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria >»>(
dOther fixtures ------------------------- ------------------------------------------------------------- ---------------------------------------
w Design Flow....................................
__ __ _gallons per person per day. Total daily flow-------------------------------------,......gallons.
WSeptic Tank—Liquid capacitv.__ gallons Length---------------- Width________________ Diameter-.._.._-..____- Depth................
y�x Disposal Trench—No. .................... Width-------------------- Total Length-------------------- Total leaching area--------------------sq. ft.
Seepage Pit No________________---- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed bY------------------------ ------------------------------------------------- Date........................................
Test Pit No. 1________________minutes per inch Depth of Test Pit_--__.________---_- Depth to ground water..__-__-__.____---_.---
f4 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water..............:.........
P4 •--•--•------•---------------•--•-•--••----•------•------•-••-----.........-----•----------••-------..........................................................
0 Description of Soil.....................................................................------------------------ --------------------------------------------------------------------------
x
c, -------------------------------------------- ------•-----------------------------------......-----------------------------------------------------....------------------......------•...------•--•-----
Uw __ ____ __ __ ____ __ _
Natur�e„„ of a airs or Alterations— nsw r when applicable.___-_�cL_ _',�..__C f-'Wco�_..__.W.____I_San...C9c.�—
'tC U`! ` QX -------t_- x � Vic^�t�9 ----�------q---- ._. .---
Agreement:
V_\0{f
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
r system in'operation until a Certificate of.Compliance,has been issited r oard of health.
igned <% R - ---- ------- ) .<
Application.Approved BY - - �� -._......---------------- --------------------- __Q -......-'- - ------ ------------ � e
Application.Disapproved for the following rearons: --------- ------------------------------------------------------------------------------------------ -----------------------
_.------ --------------------------------------------------.----------------------------------------------------
Dace
--------------- ...-....
Permit No. / -....._. Issued � _--..-----_
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
C'IErtifirate of Complian e
THI IS T ERTIFY hat the Individual Sewage Disposal System constructed ( ) or Repaired
by �Ca� -�,,.-----. rZr^- -------------------------------- -----------------------------------._...------...._--------------..--------------------
Installer
at .------- --- C.--......L. `- ....... c J"'. -ram�. -Q--------------------------------------------------------_----.._.
has been installed in accordance with the provisions of TITLE 5 f The Sate nvironmental Code des ibed in
the application for Disposal Works Construction Permit No. -.. ..""..- -.-ate ..--...- dated
..._..? 1 .-__..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. *�.,,
DATE----------------------?. ---...J� --------------------- ----- ---- Inspector ---------------- -A---- r'-------- -------....---- -------------------------
---------- --------------------
THE COMMONWEALTH OF MASSACHUSETTS
TOWN OF BARNSTABLE
BOARD OF HEALTH.
s.�-�� t .�d
No..............•-------... FEE............_._..........
DispilB tl Workii Taann#rudiaan aPrini
Permission is hereby granted----------co_-�----�---- c-T.,, ( C,-------------------------------------------
to Construct ( ) or Repair (bran Individual Sewage Disposal System
�C _.......� ti ��_�. .................
at No.
Street
as shown on the application for Disposal Works Construction Permit No______________. ______ ted___ __ ._ _.___..
�f _` � - .
f..... a-•--- --- - ._
Q Board of Health
DATE /--- --------------------------------
FORM 36508 HOBBS&WARREN,INC..PUBLISHERS
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated �� C��� , concerning the
property located at meets all of the
following criteria:
• There are no wetlands within 300 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• The observed groundwater table is:14 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
SIGNED: DATE:
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
C k S cAII�11'\6
f �
TOWN OF BARNSTABLE _
LOCATION T�—�{ LO r - SEWAGE # S s I6
VILLAGE ltr' lJ`�� ASSESSOR'S MAP&LOT oZ -
INSTALLER'S NAME&PHONE NO. SC y
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) 8�-���"l� �J (size) (111i 340�
NO.OF BEDROOMS -I ��I�-�S vim/
BUILDER OR OWNER �n/lC]^V0 Lc�-C_0r\+<
PERMITDATE: �l�k( �1 S COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching FacilityPouAd Gt/ /Feet
Private Water Supply Well and Leaching Facility (If any wells exist , ]r1
on site or within 200 feet of leaching facility) /vy Feet
Edge of Wetland and Leaching Facility(If any wetlands exist rl
within 300 feet of leaching facility) U Feet
Furnished by S�o
lS
A
O (3c, S-0
/A-�a
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