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0056 BENT TREE DRIVE - Health
56 Bent Tree Drive Centerville F/R A = 168 025 4 Ri r M'J•, camIw UPC 12543 c No. 53LOR `} a M4CTIY�Q ,/y TOWN OF BARNSTABLE / ✓y- SEWAGE# LOCATION6 VILLAGE � � ASSESSOR'S MAP &LOT -D INSTALLEWS NAME'&PHONE NO. SEPTIC TANK CAPACITY e • LEACHING FACILITY: (type) �® C�� des � (size) /;� oX 3-Y1-'�c.� ! NO.OF BEDROOMS BUILDEROWNS '{ . PERMITDATE: q COMPLIANCE DATE: Separation Distance Between t 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 feefleaching facility) Feet tof Furnished by t t9d Sy /TOWN OF BARNSTABLE Jrc 'LOCATION r 4 SEWAGE # VILLAGE ��'/�!�"dr//Y ASSESSOR'S MAP & LOT —07 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 00 6,Z (size) 13 N0.OF BEDROOMS y BUILDER OWNS 4 Pl✓RMITDATE: q11V,e COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within.100 feeLof leaching facility) Feet Furnished by �- ?VVf Z'17 g&—,�r 3O• ~ ,6 r `' IO v No. f Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZippliCAtton for MizposW 6potem Congtrurtiun Vermtt Application for a Permit to Construct( )Repair(Y)Upgrade( )Abandon( ) ❑Complete System 21ndividual Components Location Address or Lot No. Owner's N4me,Address and Tel.No. Assessor's Map/Parcel � Installer's Name,Address,and Tel.No. / / Designer's Name,Address and Tel.No. _ Type of Building: Dwelling No.of Bedrooms Lot Size ✓�v�u' sq.ft. Garbage Grinder Other Type of Building & No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 1 1 gallons per day. Calculated daily flow `l �5-5—gallons. Plan Date Number of sheets Revision Date Title 4 .$� I` Size of Septic Tank g�/X `i�( Type of S.A.S. Description of Soil 3:15—A /Z Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b is oar f alth. 41 Signed Date Application Approved by Date L- _ Application Disapproved for e following reasons Permit No. �p W S2 1 Date Issued ll E�� -Noe'. — ll 1 rtj Q$ k Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ ,4 Yes �. PUBLIC HEALTH DIVISION; TOWN OF;BARNSTABLE., MASSACHUSETTS 0[pprication for-M4 ogal *pgtern Congtructfon Permit ' Application for a Permit to Construct( )Repair(V)Upgrade( )Abandon( ) El Complete System CeIndividual Components Location Address or Lot No. y �yq Owner'sOme�dress and Tel.No. Assess r'sMap azcel J /e&l Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 7 7,1 ?37 Type of Building: Dwelling No.of Bedrooms Lot Size �.�,✓z7sq.ft. Garbage Grinder( 46 Other Type of Building _51251�e*?No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow l/ 7`7� gallons per day. Calculated daily flow `T`7 d �- _gallons. Plan Date 9 /y dy Number of sheets / Revision Date Title ✓r 5/ 1-e qy e�> /erelll ` Size of Septic Tank /JDO 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 Certifi- cate of Compliance has been issued b . i oardpf Healt >, , Signed Date Application Approved by s Date e L/ Application Disapproved forte following reasons Permit No. 2C)U 1'� a ( Date Issued 3U U THE COMMONWEALTH OF MASSACHUSETTS AFT /furl �,.BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTJFY, that the n-site Sewage is osal System Constructed ( ) Repaired ( �pgraded( ) r Abandoned . )by / � �>S at b.leylw, 7`e-VC/1 l/ftas been constructe in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. W L/- -57-2/ dated 30 IU 1' 0 Installer Designer The issuance of this permit shall not be construed as a guarantee that the sy rn'Nil /as Asigned.n r Date I u - a Inspector /�Y QS (�--} No. �U L� ! S. ( -- —---------- ----- —Fee - THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -,BARNSTABLE,: MASSACHUSETTS Mf6pogal bpgtemCon5truction Permit Permission is hereby granted/to Construct( )Repair( Upgrade( Abandon( ) System located at ��to ' l�l C e w ;,Ie r 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 thspethni�� Date: 1�7 r v l.� Approved by ��.�. � I C ? i Town of Barnstable Regulatory Services Thomas F. Geiler,Director ' B" `�MASS. ' Public Health Division i aa+16 Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form I I Date: 2� Sewage Permit# Assessor's Map�Parcel (o16 d 5 'I Desi er: a — Installer: L I .o- ,, Address: Address: PAo UI/l r( 1 .�,,,n q On r 3 0 _D� _f !�orb )A_ was issued a permit to install a f . dat (installer) septic system at `��^� ��P n ✓Q based on a design drawn by (address) I f 4 p waled ` 1 ` 16� (de igner) )&I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic .system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. ARNE H yGN A((InstVasnature) IA vIL No. 30792 o� _P o �� 0� �G/STERN � �ss10 ENG\ I (Designer's Signature (Affix URVWV Stamp Here) I PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. f Q:Health/Septic/Designer Certification Form 3-26-04.doc { i TOWN OF BARNSTABLE LOCATION �6 � TY��i �' SEWAGE # —177 VII,LAGE - >< �y�ll� ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. OD/p,�e1yAJe®f1aJ, 7,/'"�3� SEPTIC TANK CAPACITY LEACHING FACULITY: (type) Zj® �l�/r� i (size) NO.OF BEDROOMS J _ BUILDER 0 PERMTTDATE: `LL�—�� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by t 165 ® z57 No..2r.-J.7.7 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Ap,phration for Dint 3Ml Warkii Cnnnitrnrtiun rrrmit Application is hereby made for a Permit to Construct ( ) or Repair (C< an Individual Sewage Disposal System at: ....... ........................................E.. ........._......_......_....._............_. _.._..___..........................._.__.. 1-14 1/lLP 7 _......Loca3 .6....ss �/`/ °" .. Owner Address ................................................s' �►ille..l 74 S sil/1..lC..Q'f ... ..... (, Installer Address d Type of Building Size Lot................ q. feet Dwelling—No. of Bedrooms.............. _-_____________--__--_Expansion Attic (. ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons......................... Showers ( ) — Cafeteria ( ) a' Other fixtures _______________________________ _ _ W Design Flow--_------------- .........gallons per person per day. Total daily flow............ ....................gallons. WSeptic Tank—Liquid capacity&Oq...gallons Length________________ Width................ Diameter---------------- Depth--------------_ x Disposal Trench—No. .................... Width----_..._-__________ Total Length----_--------------- Total leaching area....................sq. ft. 3 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------------------------ rrX, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ W ----------------------------••----•-----------•----•----------.....-----------•-•------•------------......................................................... 0 Description of Soil....................................................................................................................................................................... W x ----•-------------------------------------------•------------._........_.....---------------------•------------------------------•------------------------•-----------------------------••-•-...._.--.-- U Nature of Repairs or Alterations—Answer when applicable....... ---- _____l wu _____Agreement: The 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 en ' sued by b rd of health. Signed ..................... ........ . .......�-..... ................................. ............. .... ..e.................. Application Approved By ............ r -- .. D, ." Application Disapproved for the following reasons: ...................... ............................................................................. . ........................ ......... ............................. . ... . .................. .....--..--.... . ...................................--............ ---------------------------------------- DarPermit No. .......- '.-.17�-� Issued -------------- ................. .......-. Date M 165 oz5" No...1 ..1....1..�7 a F�a......'3Q.... ..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Dhip ial Workii Towitrnrtiun rrrnnit Application is hereby made for a Permit to Construct ( ) or Repair (1-wj an Individual Sewage Disposal System at: -�6�T"��EL 4Q� I C I E/L�v� t I -- ... .... ----------------------------------------------------- ---•------------------•••--•-•-•----•••---- •--- -•-•••••--•--•..........-•.....----...----- Location- Address or Lot No. ...................... �a --------- ------.... Owner Address W G"/li Cl o rT/ �t &+j `7G5... •°! '/..i /'-lZ G�►S •�2.1/C1 ,.� ------------- ----------*----------•-- ----- -------------- -------------------------------------------- S Installer Address Q Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms..............._..._____.._._._._.._Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building -------------------_------ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) QOther fixtures -------------------------------------------------------------------------------------............................................................... W Design Flow................... ............gallons per person per day. Total daily flow----------- - C7....................gallons. WSeptic Tank—Liquid capacity 00._.gallons 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 ( ) Percolation Test Results- Performed by.......................................................................... Date........................................ .aj --Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water--.__.-_-.-.-__-..---.-. (Z4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ..................................•----•--••-----•----•.......---•--------------•-•-----•---................................................................. 0 Description of Soil........................................................................................................................................................................ x U ------------•------•-----•-----••••---------•---------•---------------•---•-----•-------------......-----•----•-----•-------•---••---------------------•----•--•----•-••-•--------------•------••--•... W UNature of Repairs or Alterations—Answer when applicable--------f_,0__D_----A,---...LGuuj�---- - SF,...%?L_-.��..!.. 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 teen issued by/th- ba rd of health. Signed .................../........__. ................._. ...._..........----............. -- Date Application Approved By ............ v ... .�+.v,1 --------- =--------------------------------- ------------- ID, Application Disapproved for the following reasons- ------------------------------------------------------------------------------------------------------------------------------------ --------------------------------------------------------------------------------------------------------------------------------------------------------------=----------------------------------------- -------------------------------------- Date Permit No. ......... ,ar 7----------------------- Issued ...... ..... Date ----------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE 11��ertifirate of 01—ampliance THIS IS TO CERTIFYshat the Individual Sewage,Disposal System constructed ( ) or Repaired (ate ) by ........................................................ .�U./� -Gc F---n.-.-_...------ - 3,J /G.�c�---t ----------------------------.........--------------------------------- InstaIler at ..................... -- r!p-..-._....... zn-r i %.` - < t�/.�..................... - c r�Ji..��/ t ...... has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. _._.....f 0-------_/-7?...... dated ..... .................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE. t....... ..._...��..._-------------------------------------- Inspector _.... (--- 7Z�-------------------__------------- ---------------------- ---- ---------------------------------------------------------- --------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1V TOWN OF BARNSTABLE Dispasal Workii Tnmitrurtion "muff Permission is hereby granted....................... � `..........................................................G c-F1e� C-d�'�1`S'�2'tl t• ' iGN to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at No. ------------ 4 ..... ------- ��n��/ _.. ....--�--f�/l�tJ(_C�E.................... as shown on the application for Disposal Works Construction Permit Street No.L4 /77--- Dated........ _.- .-. .4........ r „Board of Health DATE................. a'�l r=� V FORM 36508 HOBBS&WARREN.INC..PUBLISHERS //�� TOWN OF BARNSTABLE !� LOCATION 6 AWr T7'�� r% - SEWAGE VILLAGE Ge47`L°J'' ASSESSOR'S MAP&LOT /Xf"-B�5 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 15`G�O %.`LEACHING FACILITY: (type) /��d901i�%r�Xi (size) NO.OF BEDROOMS 3 -BUILDER OI��WNER PERMTTDATE: `L ✓� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by TOWN OF BARNSTABLE % 9� l LOCKf TON r7 6 �/t%�� T�Pi �✓�'� SEWAGE # 77 .VILLAGE �/� �y/J�'� ASSESSOR'S MAP &LOT /Xf`®�5 _ *INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) /�®d9a"l/�/�r �`�S�(size) NG.OF BEDROOMS BULDER OXi WNER PERMITDATE: `Z COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet r Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by r r Fms�d. ..... ._ THE COMMONWEALTH OF MASSACHUSETTS 1-17 BOARD OF HEALTH � ,' `,.� TOWN OF BARNSTABLE , ppliration for Disposal Works Tonstrnrtinn Frrutit Application is hereby made for a Permit to Construct ( ) or Repair (>4 an Individual Sewage Disposal System at: �r�v� ........... . - 4 •---- - ------------'---------•' .._..- - ---- - .L c ion-Address No. hr--- or Lot Owner Address Installer Address Type of Building Size Lot ©fA�Q�.Sq. feet Dwelling—No. of Bedrooms................. ......................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria P4 Other fixtures --------------- --------------- . W Design Flow.................... .................gallons per person per day. Total daily flow........... ..................gallons. WSeptic Tank—Liquid capacity_A allons 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 ( ) Percolation Test Results Performed by.......................................................................... Date------------------....------------...... aTest Pit No. 1................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........................ . ------•--•........... ........................................................ 0 Description of Soil---------.e:!2� ---4, - -- .__SSQ/ ....... ---------__ Q-------------------------- W c, W ---------------------------------------- --------------------------•-----------------•----•---------------------------------------------------------------- ........................................ U Nature of Repairs or Alterations—Answer when applicable____ ---------- ,n . -__........�r �?� Z V�7 --------------------------- ........... ------- % ^---------------------------------------••----------------•--------------------------------------------------------------------------......---........ 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 Compliant has been iss d b the board of health. Signed ---- --------- -- ---------- -... ----------------- -------- p ApplicationApproved By -------- ------Z-- . - - ------------............................ ................................ �-'iaet Application Disapproved for the following reasons- ----------------- ---- - ---------------- ------------------------------------ ............................................ ---------------------------------------------- - ------ -------------------------- -------------........ -----...--------------------------------------....------. -- ----------------------------------- PermitNo. 9� --o- Q---------------------------- Issued ........................................................----------- Dace ------ -- Dare Fpsd. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appftratioa for Uiiipaoal Works Tnnitrnrtion Permit Application is hereby made for a Permit to Construct ( ) or Repair (5<5 an Individual Sewage Disposal System at: --.........�...._.._sc......�N�-/��� f�tJ/CGE'-------•--•----------------•------.............._.. L `on-Address �-y �-- or Lot No. ......................—.......................................................................... r•-••••-••-•--_........•-•••-......_...---... Owner Addres W �o.�TZJLD j'377;, 7CeLL.S Installer Address d Type of Building Size Lotc:: .6_..:.-Sq. feet U Dwelling—No. of Bedrooms................ _________.___._____...Expansion Attic ( ) Garbage Grinder ( ) '4 Other—T e of Building No. of persons............................ Showers — Cafeteria Pa Other fixtures ........................................................ W Design Flow.................._�_.........�--_•__gallons per person per day. Total daily flow......... ..................gallons. W Septic Tank—Liquid'capacity.Z��gallons 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 ( ) ~' Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................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........................ R+' ---•-----------------------------•-----•------------------•---•--............._•--••--•-••--•-••---........................................................ O Description of Soil.......... f I:X -� =--f6_A.:? `_SA- Zl....... __—.......� --.---- U .....-•----------------=-------------••--•----------•----------•--•--•-•---•--------...-•-•-----•-------------------------------------------••.......-•-•------------...................--•----------••- W .....................................................----•---------•-------•------------•-------••---•-•--•------•------•----•-----••••-------------------------------------------•-------------------- Nature of airs or Alterations—Answer when a hcable_.__ .. n!? _� ........................................ -•---------•.............•----•.........••-•••---•---------•------------------------------•-----••-•---••----••--•--•----•---•-------...---..........------•--•--.............-------•--•••-•-•----•---- 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 issued by the board of health. 01 Signed /�. ..... ....r............................ .; 9 ... Application Approved BY ------------------------------------------------------------- ----- ---------I'.= -r- Date Application Disapproved for the following reasons- -------------------------------------------------------------------------------------------------------------------------------------- t -------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------- Date Permit No. ...---....9..,/....-... '�� �-------------------------- Issued ..................................... �re THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE QTkezttft ate of 01.10rtylianve THIS IS TO CERTIFY, That,the Individual Sewage Disc osal S stem constructed ( ) or Repaired (< ) x�o�ac D Vo•�sr/2c>c '7 o.�J.......by..................... ---...--------- ..---------------......------ ._.------------...... Installer at �Id � >/1•t._.� itJE EdiLGE----------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ----......` 1.. ...' .1.f-)........ dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL F.UNCTIO SATISFACTORY. DATE .., Q Inspector --------. .. �'� -------------------------- .J---------............--------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE ••i✓ Y Disposal kp Tunstrnrtion .�Permit Permission is hereby granted...............!gr"--:t�Ge C'-� �............................. t to Construct ( ) or Rep • (k) an Individual Sewa a Disposal System at No Street �� 1 as shown on the application for Disposal Works Construction.Permit No.._. _..'..._.... ated.......................................... 75 ............................. ..._.. .i .............._......._-••••..._•••-•-----•- ( _ / / rd of Health DATE..................... '.............•-•-•---•-------••---•------......---- FORM 36508 H088S&WARREN.INC..PUBLISHERS (N •,L:� ./ TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO.1,&e4E 7V.0>0! dAJ S7- SEPTIC TANK CAPACITY L C'r�,C>40<_ LEACHING FACILITY:(type). _(size) >ef/6j NO. OF BEDROOMS PRIVATE WELL OR BLIC WA BUILDER OR OWNER �QvtJ DATE PERMIT ISSUED: �Z/��'/ T v DATE COMPLIANCE ISSUED: �"' VARIANCE GRANTED: Yes t v' 4/ 56 a � 31 A` 1 V Z� `"-6 COMMONWEALTH OF KkSSACHUSETTS ~ EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION FAILED INSPECTION TITLE 5 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENT'S SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATIOT 10AP PARCE4 • O Property Address: /�>p p f OT . Owner's Name: -gip 9 y Owner's Address. . RECEIVED Date of Inspection: cf Name of Inspect • (please print) Dpr�--j glpj -4 JUN 14 2004 .Company Name: "/ � , Mailing Address: ,0 4ev ���L, TOWN OF BARNSTABLE HEALTH DEPT, Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.,The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes _ Needs Further Evaluation by the Local Approving Authority F ' s Inspector's Signature: Date: r 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. ` Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system Will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 1 Page 2 of I I OFFICIAL INSPECTION FORM,-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: p /A 'Z,2 ,e OOza e Owner, Date of Inspection: (� Inspection.Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 314.CMR 15:303 Orin 3I0 CP,1R 15.304'exist.Any failure criteria not evaluated are indicated below. Comments: B: System Conditionally Passes:. One or more system components as described in the"Conditional Pass"section need to be replaced.or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*.or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank.is replaced with a complying septic tank as*approved by the Board of Health. *A metal septic tank will pass.inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Obse..'rvation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with. approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than'4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health):. broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of Il OFFICIAL INSPECTION FORMT -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART 'A CERTIFICATION(continued) Property Address: Owner: Date of Inspection: 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(l)(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 I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100.feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A-copy of the analysis must be attached to this form. 3. Other: Page 4 of I I OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: ��7�p 4 '722 Owner: 4 4� Date of Inspection: oop S1 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Y—�- No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or /clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times.pumped _ Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. / _✓ Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well-with no acceptable water quality analysis. [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 \ r are triggered.A copy of the analysis must be attached to this form.] U16 5(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"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat.under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'FORM PART B CHECKLIST Property Address: Owner: dt� Date of Inspection: �;. j(1(L _ Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes _ o 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 ? ul-1,_ 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? l� 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. -iZ— Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION,FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: Date of Inspection: PLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):- Number of bedrooms(actual): DESIGN flow based on 310.CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: _ Does residence have a garbage grinder(yes or no): A Is laundry on a separate sewage system (yes or 6):A .[if yes separate inspection required]. Laundry system inspected(yes or no): /Yd Seasonal use: (yes or no): ,UU . . Water meter readings, if available(last 2 years usage(gpd)): �3 J'•J���(� Sump pump(yes or no):A)0 Last date of occupancy:MA AM COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design.flow('seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):A Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: l3 Was system pumped as part of the inspection(yes or no): If yes, volume pumped: gallons--How was quantity pumped determined? Reason'for pumping: _.. TYPFiOF SYSTEM eptic tank, distribution box, soil absorption system _Single cesspool _Overflow cesspool _Privy, _Shared system.(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP.approval _Other(describe): Approximate age of all components, date installed if known)and source of information`. Were sewage odors detected when arriving at the site(yes or no)i/ j-- 6 Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owne�&A 4A cz) Date of Inspection: d? BUILDING SEWER(locate on site plan),'.(}' Depth below grade: Materials of construction:_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: cate on site plan) /62 Depth below grade: Material of construction:%ncrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: �O•�S X kS Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle:. 517, Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: /itC10 A� p Comments(on pumping recommeridationg, inlet and outlet tee or baffle condition, structural integrity, liquid levels related to outlet invert vidence of leakage, etc Gl. ADDA - 10/11 GREASE TRAP/X ocate 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 OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: j Owner:. P •L Date of Inspection: 0 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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 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:/(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ` % `� Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):__Lz�locate on site plan, excavation not required) If SAS not located explain why: Type eaching.pits,number: J leaching chambers, number: leaching galleries,number: leaching trenches,number, length: leaching fields,number; dimensions: overflow cesspool.number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation. CESSPOOLS/2k(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow-(yes or.no): `.: . Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.): PRIVY• bcate 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.): q Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: y41 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. 0-�` 3 . 10 Paae I 1 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of.In SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water !Meet Please indicate(check)all methods used to determine the high.around 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: Necked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: 11 l F S 5 9 ;a�S WI f 4 yt i 3 F k gs M}a s 2 t = 5 p � Permit Number: Date: �lw Completed by: —BERM -1 I; ,.P,MMK resin 4 - HIGH GROUfJD-'WATER LEVEL COMPUTATION _ � t i �.si'S i 55 Site Location: 0 Lot No. rs ` i r O : r� Address: �y `"Owner: 6. Contractor: /7`i� v� Address: ��-.l/SJ`3�Y STEP 1 Measure depth to water table to nearest 1/10 ft. Date -y month/day/year ;;... STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: ^ .•:,-, OA Appropriate index well.................... B Water-level range zone ............................................. ....... STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to ylptl water level for index, well ........................... month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) 3 determine water-level adjustni.ent .......................................................................................... STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) ( from measured depth to water / level at site (STEP 1) ........................................................... ............. t.. Figure 11--Reproducible computation form. 15 ;� �- `�,- .,� _ . . . L,. S_� . --------._.�.._ �� .j �� �. . 3 f � � �- _� .1 j ` . t� �� 1 1�� rt � ; . ,A ; } R o � i ., s .�,� �.. � � t � -.� { ;' : . � �. � �. f s� s . � ;� ; . _ j; I � : �. �. .. 6 . � u?j . ' � � l� � s. i . � s �. � � � t , •i i ; .;, 3�_�. '��T � �_ - � 1 E ` � � � .:o. ; �(. � 1 � i i f , l 1 n/� � _ ) \v . �� � y �'�/\ °g - \ i COMMONWEALTH OF MASSACHUSETTS z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF.ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION; Property Address:. 0 k&QZ;e-, z. Owner's Name: Owner's Address:C �� Date of Inspection. AN 2 Name of Inspector• pleas print , (. t 7-0�I,NOF 4 ?00' Company Nam Z c� ,�L� J/J ��✓'?, ,.. NFq eqR Mailing Address: �TNaFpTge�F qT Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at his address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant 7passes ection 15.340 of Title 5(310 CMR 15.000). The system: Conditionally Passes . Needs.Further Evaluation by the Local Approving Authority I F ,ls _ � f Inspector's Signature: Date: /r d v,4- 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 rep6rt to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection;and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different. conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of I I OFFICIAL INSPECTION`FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) . Property Address: ,4560 P�.cr. 9, PLI 41 Owner: � Date of Inspection. g Inspection Summary: Check A,%C .be E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described.in 310,CMR 15.303 or in 310 CMR 15,304 exist.Any failure criteria not evaluated arezindicatea below. r 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 ofthe 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 dr exfiltration or tank failure'is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as'approved by the.Board of.Health. *A metal septic tank will pass inspection.if it is structurally sound;not.leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box dice to broken or obstructed.pipe(s)or due'to:a broken;settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or.replaced ND explain: The system required pumping more than'4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Baard'of Health):. broken.pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 1'l OFFICIAL INSPECTION FORM - NOT FOR,VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTI±M INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Au Owner: Date of Inspection: x 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 wilt 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 healtli,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 aseptic 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.I00.feet but 50 feet or more from a private water supply well**. Method used to determine.distance- **This.system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A,copy of the analysis must be attached.to this form. 3. Other: 3. Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS Su SURFACE SE WAGE DISPOSAL'SYSTEM INSPECTION I+ORM PART A ii CERTIFICATION(continued) Property Address: '.-2-�tW I Owner: Date of Inspection' _S061-a D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each'Of thIe-following for all inspections: Yes N Backup of sewage into.facilify or system component due`to"overloaded or'clogged SAS or eesspo'ol _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or / clogged SAS or cesspool (� Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _f Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow Required pumping more than 4 times in the last year NOT due to clogged or.obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or priory 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. l+/ Any portion of a cesspool or privy is within SO.feet of a private water supply well,; Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well-with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the'analysis must he attached to this form.) JA 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"yes"to any question in Section E the system is considered a significant threat, or answered "yes"in Section.D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304..The system owner should contact''the appropriate regional office of the Department. 4 Page.5 of 1.1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENT'S SUBSURFACE SEWAGE]DISPOSAL SYSTEM INSPECTION FORM PART B C11ECKLIST Property Address: t 4 ZzUp 012t�/�' Owner: Date of Inspection: Check if the following have been done You must indicate"yes"or"iio"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 nonnal flows in the previous two week period? Have large.voluntes 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 iiiterior 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).pro.vided mith information on the proper maintenance of subsurface sewage disposal systems The s.ize and location of the Soil Absorption System(SAS)U. the site has been determined based on: Yes no — Existing,information.For example,a plan.at the Board of Health. V"` _ Determined in the field(if any of the"failure criteria related to Part C is at issue.approximation of distance is unacceptable) [310 CMR 15302(3)(b)] - 5 Page 6 of 1] OFFICIAL>INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGr DISPOSAL SYSTEM. INSPECTI,ON.FORM PART C SYSTEM INFORMATION Property Address: 0 y 9��� - Owner: it rx. - Date of Inspection: � � LOW CONDITIONS RESIDENTIAL Number of bedrooms(design): . Number of bedrooms:(acnral): DESIGN flow based on 310 C 11 15.20'3 (for example 1 :0 gpd x#of bedrooms): Ninnber of current residents: Does residence'have a garbage grinder(yes o:•na):Ia& Is laundry on a separate sewage system`'(yes or no) [if yes separate inspection required] Laundry system inspected(yes or no)� Seasonal use:(yes or no): e�jj6-. Water meter readings, if available(last 2 years usage Sump pump(yes or n%VI& P Last date of occupancy ! • ,�� .✓�,� .✓ COMMER CIA`I:/INDUSTRIAI/)U- Type of establishment: Design flow(based on 310 CMR.15.203): gpcl Basis of design flow(§eats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe):. GENERAL INFORMATION Pumping Records Source of information:. Was system.pumped as Part of the in pection(yes or n If yes, volume pumped: gallons--Tlo;v was ypum pumped ecl determined?d? q p Reason'for.pumping: . 7 E Or SYSTEM —Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool .Privy _Shared system.(yes or no)(if yes,attach previous inspection records, if any) Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) -Tight tank _Attach:a copyof the DEP.approval Other`(describe): pproximate age of .11 components date installed(if known and source of information- r Were:sewage odors detected when arriving at the site(yes or no) 9-- Page 7 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE,SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C. SYSTEM INFORMATION(continued) Property Address: fL--/4 Owner:- I Date of Inspectio 1: z 0061/ BUILDING SEWER(locate on site plan) (/� Depth below grade: Materials of construction: cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage, etc.):' SEPTIC TANK: t0'(locate on site plan) Depth below grade; Material of construction: w,"concrete_metal_fiberglass___polyethylene —other(explain) If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: �1,Y Sludge depth; /�r_ ei Distance from top of sludge to bottom of outlet tee or baffle: J I 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' f"� How were dimensions determined�i Comments(on.pumping recommendations, mlet and outlet tee or baffle condition,structural integrity, liquid levels related to outlet invert, evidence of leakage, etc. . `% 1X/t. 4rAoi 1A. GREASE TRA1,/ locate on.site plan) Depth below grade:- -Material of construction: concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): a 7 i;.. Page 8 of 11 OFFICIAL INSPECTION`.FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART SYST'Ll M INFOIAMATI'ON(continued) Property Addressi l oL if�O� Owner:./ i .Date of Inspection: � ������ TIriHT'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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and'float switches, etc.): DISTRIBUTION BOX: "✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:l �Z � Comments(note if box is level and distribution equal,any evidence of solids carryover, any evidence of leakage into or out of box, etc. : PUMP CHAMBER(locate on siteplan) Pumps in working order(yes or no): Alarms in working order'(yes-or;no):. Comments (note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS 44 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIONS FORM PART C SYSTEM I.NFORMATION(continued) Property Address: C A_' . A Owner: Date of Inspection: �GO SOIL ABSORPTION.SYSTEM(SAS):: / (locate on site plan,.excavation not required) If SAS not located explain why: Type �ching.pits,number: leaching chambers, number: leaching galleries,number: leaching trenches,number, length: leaching fields,number, dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, /9 4 , . a CESSPOOLS�(cesspool must be pumped as part of inspection)(locate on site plan) Number and ✓dcconfiguration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater 'inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition,of vegetation,etc.): PRIV\,:Y�. ocate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.): 9 Page 10 of l 1 OFFICIAL INSPECTION I'ORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .TART C SYSTEM INFORMATION(continued) Property Address: fi-�� Owner: IffI11.1fj - Date of,Inspection: 15,000Q , 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. � � 04 31 t/ 0 3� 10 Page l.I of II OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 41 Owner: Date of Inspection: yq Aft JqA �bo , SITE EXAM. Slope Surface water Check cellar. Shallow wells 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: 5 © ? E I.l r Mom. Completed by: �A - HIGH GROUND-WATER LEVEL COMPUTATION Site Location:_ S�, bill— ��/,fYelItIlIle Lot No. Owner: �` /�/,tI' Address: 3,e elll e— Contractor,: Address: �S— �I Gl✓ Y / eir57�/��$ Notes: STEP 1 Measure depth to water table. to nearest 1/10 ft. ............................................................................ ..... .Date month/day/year STEP 2 Using Water-Level Range Zone and Index Well.Map locate site and determine: OA .Appropriate index,well.........:... RNO . ® Water-level range zone.....................................................L�J STEP 3 Using monthly report 'Current Water Resources Conditions" determine current depth to /Z f®L , water level for index we'll ........................... month/year STEP 4 Using.Table of Water-level Adjustments Tor.i.ndex well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone STEP 23) determine water level adjustment ......................................:................................................. .. STEP 5 Estimate depth to high water by subtracting-the water- level adjustment (STEP 4) Trom measured depth to water l level at site (STEP 1). .......................... Figure 13,—Reproducibie computation Torm. 15 r O , �. kA 1 TOP NDN. AT EL. 56.1' SYSTEM PROFILE TEST HOLE LOGS F , ACCESS COVER TO WITHIN 6' OF FIN. GRADE (NOT TO SCALE) PROVIDE INSPECTION PORT WITHIN 6' OF FINISH GRADE LISA LYONS, IRS AccEss COVER (WATERTIGHT) To ENGINEER: MINIMUM .75' OF COVER OVER PRECAST WITHIN 6" OF FIN. GRADE 2% SLOPE REQUIRED OVER SYSTEM DONNA MIORANDI, RS '4 58.0 WITNESS: � s ELEV. 54.35' RUN PIPE LEVEL 2' DOUBLE WASHED P ONE DATE: SEPT. 10, 2004 FOR FIRST 2' L PERC. RATE = < 2 MIN/INCH EXISTING 1500 rp T�� w GALLON SEPTIC 52.95'f* 31y CLASS I SOILS P# 10801 M '"4c rN TANK (H- 10 ) RD BAFFLE 52.J.-', 52.25' �'.[� 0 C� F�,R F"IR-52.14 a 0 0 0 O 0 ED 0 C: 4' AROUND �" Ap 6" CRUSHED STONE OR MECHANICAL go �� ELEV. COMPACTION. 15.221 2 $o Fs 2' 0 � � 0 � 0 0 0 50.14' �" 59.0' DEPTH of FLOW = 4 ( 1 x SLOPE) ( 1 % SLOPE) 3/4" TO 1 1/2" DOUBLE WASHED 'STONE 0 wN TEE SIZES: loss 5" INLET DEPTH OUTLET DEPTH = 1 4" E MS LOCATION MAP NTS FOUNDATION LEACHING 1OYR 4/1 EXIST. SEPTIC TANK 53� D' BOX 3' FACILITY 11" ASSESSORS MAP 168 PARCEL 25 3.14' 25't B *THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL UTILITIES AND ALL LS **DELTA BETWEEN ASSUMED DATUI" ; BUILDING SEWER OUTLETS AND ELEVATIONS • PRIOR TO INSTALLING ANY PORTION OF 10YR 5/8 15't. GROUNDWATER, BASED ON A ER r .61' :�, IS AT ELEVATION 25't (RELATED :C 'r- ... SEPTIC SYSTEM PROP. VENT WITH CHARCOAL FILTER 60.9 AND BUGSCREEN (FINAL PLACEMENT BY 26" 56.8' CONTRACTOR WITH HOMEOWNER 47.0' / CONSULTATION) C G-W EXPECTED AT EL. 25't** 60 0 CONTRACTOR TO CONFIRM SUITABLE MS P SOILS FOR 5' BENEATH" LEACHING PERC 6 Sg + 59. FACILITY ELEVATION PRIOR TO 4 , TH INSTALLATION 2.5Y 5/6 58.� 59 72SO', (�� 5c"�s _ 5 + [ 2 (J 144" 47.0' 58.7 -t N GW E s NOTES: 5 + -7.5 6 ASSUMED** LP SEPTIC DESIGN: (GARBAGE DISPOSER is NOT ALLOWED ) 1. DATUM IS `�- 57 ---� 440 EXISTING ` .9 + ss8 + 57.9 DESIGN FLOW: 4 BEDROOMS ( 110 GPD) - GPD 2. MUNICIPAL WATER IS * ��S 6 + 57.9 USE A 440 GPD DESIGN FLOW 3. MINIMUM PIPE PITCH TO BE 1/8- PER FOOT. 57.4 / �� SEPTIC TANK: 440 GPD ( 2 ) 880 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO H- 10 CIV- - n S� / �+ 55 1500 5. PIPE JOINTS TO BE MADE WATERTIGHT. 56 DECK // USE A GALLON SEPTIC TANK (RE-USE EXISTING) 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. G 56.5 / 5 ' + 56.4 LEACHING: ENVIRONMENTAL CODE TITLE V. 74)83) 2 (5 + 12 6.0 . . 137 7. THIS PLAN IS FOR PROPOSED SEPTIC SYSTEM ONLY AND IS NOT 56. SIDES: ' 2(33. 33.5 x 12.83 (.74) 318 TO BE USED FOR ANY OTHER PURPOSE. = 5s.6 --� `ss BOTTOM: 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. ss.s EXIST. � ssr s DWELL. S3 TOTAL. 615 S.F. 455 GPD 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT BENCH MARK TOP OF. 4 `S2 USE (3) 500 GAL. LEACHING CHAMBERS (ACME OR INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED WATER SHUT OFF VALVE / / S� FROM BOARD OF HEALTH. ELEVATION = 51.6 . EQUAL) WITH 4 STONE ALL AROUND y� O 48.5 8� o/ �4.9 10. PUMP & REMOVE (OR FILL W/CLEAN SAND) EXISTING SEPTIC SYSTEM 54. o�fr - a LEGEND TI TL E 5 SITE PLAN 47.9 100.0 PROPOSED SPOT ELEVATION + �S LOT 38 °F 56 BENT TREE DRIVE -k 48.4 so.> 51.6 15,384t SQ. FT. \ 3�00, 100x0 EXISTING SPOT ELEVATION IN THE TOWN OF: 10O PROPOSED CONTOUR 2 \ / (C ENTERVI LLEI BAR N STAB LE �47.8 47. 100 EXISTING CONTOUR ASS 46.9 PREPARED FOR: BORTOLOTTI CONSTRUCTION/DURKIN -+.,46.6 � 46.6 - F 20 0 20 40 60 BOARD OF HEALTH 46.3 APPROVED DATE MA SCALE: 1" = 20' DATE: SEPTEMBER 14, 2004 45.7 \ + .0 off 508-362-4541 45.2 fax 506 362-9880 \+ 44.7 down cape ` engineering, Inc, °Fr �S � o1"or "�Ss9 ,o ARNE"H G ARNEG� CIVIL ENGINEERS �o" OJALA ��, o H. CIVIL cn " JALA N LAND SURVEYORS o.30792 . � 0.26348 04-234 939 slain st, yarmouth, ma 02675 A, JAL.,4 P. . ° S` DA E _ - ___