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HomeMy WebLinkAbout0056 CAMP OPECHEE ROAD - Health 56 CAMP OPECHEE RD. CENTERVILLE A = 210 153 i No. 42101/3 ORA P"D Gm�&� Q G Ell 1000 ® m m �. ASSESSORS MAP No fQ a PARCEL N COMMONWEALTH OF MASSACHUSETTS N W EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS m o DEPARTMENT OF ENVIRONMENTAL PROTECTION pqM SVOv A 350 MAIN STREET WEST YARMOUTH,MA �O 508-775-2800 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION M-210 PARC-153 Property Address: 56 CAMP OPECHEE CENTERVILLE,MA 02632 Owner's Name: ROBERTS,CAROL Owner's Address: 56 CAMP OPECHEE CENTERVILLE,MA 02632 Date of Inspection 07-06-04 Name of Inspector:(please print) JAMES D. SEARS Company Name: A&B Canco Mailing Address: 350 Main Street West Yannouth,MA 02673 Telephone Number: 508-775-2800 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 Fails 7/ Inspector's Signature: � - 'L.� Date: / — G 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 systemar 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 tot he buyer,if applicable,and the approving authority. Notes and Comments MAIN HOUSE ****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 1 Page 2 of 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 56 CAMP OPECHEE CENTERVILLE,MA 02632 Owner: ROBERTS,CAROL Date of Inspection: 07-06-04 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N/A 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 complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health)" broken pipe(s)are replaced obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 2 L Page 3 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 56 CAMP OPECHEE CENTERVILLE,MA 02632 Owner: ROBERTS,CAROL Date of Inspection: 07-06-04 C. Further Evaluation is Required by the Board of Health:N/A 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 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 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: Title 5 Inspection Form 6/15/2000 3 Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 56 CAMP OPECHEE CENTERVILLE,MA 02632 Owner: ROBERTS,CAROL Date of Inspection: 07-06-04 D. System Failure Criteria applicable to all systems: N/A 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 �- 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 leaching 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 pipe(s). Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A 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 or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) NO (Yes/No)The system fails. I have detennined 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: N/A To be considered a large system the system must service 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 lI 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 is 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. Page 5 of 11 Title 5 Inspection Form 6/15/2000 4 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 56 CAMP OPECHEE CENTERVILLE,MA 02632 Owner: ROBERTS,CAROL Date of Inspection: 07-06-04 Check if the following have been done. You must indicate"yes"or"no"as to each of the following Yes No Pumping infonnation was provided by the owner,occupant,or Board of Health ./ Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? ./ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? ./ Was the site inspected for signs"of break out? Were all system components,excluding the SAS,located on site? Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum 4 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)has been determined based on: Yes No Existing information. For example,a plan at the Board of Health. ./ Detennined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CM 15.302(3)(b)] Title 5 Inspection Form 6/15/2000 5 Page 6 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 56 CAMP OPECHEE CENTERVILLE,MA 02632 Owner: ROBERTS,CAROL Date of Inspection: 07-06-04 FLOW CONDITIONS RESIDENTIAL J Number of Bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 440 Number of current residents: 1 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): YES Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): 2002-147,000 GAL/2003-103,000 GAL NOTE: HOUSE&COTTAGE Sump pump(yes or no) NO Last date of occupancy: PRESENT COMMERC IALANDUS TRIAL Type of establishment: Design flow(based on 310 CM 15.203): Basis of design flow(seats/persons/sqft,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 N/A Source of infonnation: NO Was system pumped as part of the inspection(yes or no): If yes,volume pumped: gallons—How was quantity pumped detennined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 2001 PERMIT#2001-452 Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 56 CAMP OPECHEE CENTERVILLE,MA 02632 Owner: ROBERTS,CAROL Date of Inspection: 07-06-04 BUILDING SEWER(locate on site plan): Depth below grade: 12" Materials of construction: Cast iron ,/ 40 PVC _ other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): Depth below grade: 2' Material of construction: ,/ concrete metal fiberglass polyethylene _ other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1500 GALLON H-20 PRE CAST Sludge depth: 2" Distance from top of sludge to the bottom of outlet tee or baffle: 28" Scum thickness: I,, Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottorn of scum to bottorn of outlet tee or baffle: 17" How were dimensions determined: AS BUILT AND TAPE Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): MAIN TANK AT WORKING LEVEL, INLET TEE—OUTLET TEE,NO SIGN OF OVER LAODING OR LEAKAGE. GREASE TRAP(located on site plan) N/A Depth below grade: Material of construction: e 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.): Title 5 Inspection Form 6/15/2000 7 I Page 8 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 56 CAMP OPECHEE CENTERVILLE,MA 02632 Owner: ROBERTS,CAROL Date of Inspection: 07-06-04 TIGHT or HOLDING TANK: N/A (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 Alann 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: 0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.,): D BOX IS 16"X16"— 18"BELOW GRADE,ONE LINE IN,ONE LINE OUT.BOX IS CLEAN. NO SIGN OF OVER LOADING OR SOLID CARRY OVER PUMP CHAMBER: N/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.): Title 5 Inspection Form 6/15/2000 8 Page 9 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 56 CAMP OPECHEE CENTERVILLE,MA 02632 Owner: ROBERTS,CAROL Date of Inspection: 07-06-04 SOIL ABSORPTION SYSTEM(SAS): ./ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: 3 leaching galleries,number leaching trenches,number,length leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)LEACHING IS THREE 500 GALLON DRY WELLS WITH 4' STONE. LEACHING IS 30" BELOW GRADE,6"WATER IN LEACHING. NO HIGH STAIN LINE OR SOLID CARRY OVER. CESSPOOLS: N/A (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: N/A (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.) Title 5 Inspection Form 6/15/2000 9 Pale 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property,address: 56 CAMP OPECHEE CENTERVILLE, iota 02632 Owner: ROBERTS, CAROL Date of Inspection: 0?-06-04 SKETCH OF SEWAGE DISPOSAL SYSTEM Pro\ide a sketch of the:ewu_e disposal ;vstem including ties to at least two permanent reference landmarks or benchmarks. Locate all well.,within I00 fret. Locate where public water supply enters the building. r 1 1a ? c , i T de Inspection t=orm 6, 15 2000 i,1 Paize I I of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SLBSDRFACE SEWAGE DISPOSAL SYSTE vI INSPECTION FORM PART C. SYSTEM ENFORMATION (continued) Property Address: 56 CAMP OPECHEE CENTERVILLE,CIA 02632 Owner: ROBERTS. CAROL Date of Inspection: 07-06-04 SITE EY.xNI Slope Surface water Check cellar Shallow well; Estimated depth to NO groundwater 10 feet Please indicate(check)all methods used to determine the hieh ,round water e!evation: _ Obtained from ; ;tem design plan;on record-It checked.date of desi_n plan reviewed: �— Obscr.ation site,abutting propemY observation hole within 150 feet of SAS) Checked with local Board of Hea;tit-explain: Checked with local excavators. installers-(attach documentation 1c:cessed 1 SGS database-explain: You must describe how you established the hi;h around water elevation`: 1-4 DU(- TEST HOLE IU' NO \V.-\TER IT-ST HOLEL BELOW GRADE OF LE a.CHIN6 I ( I _ I ! i "kja 'N.y..^'iw'^a'F` •,.,,�•.fv''2..� a'x ^S:a- i"b5 S t" -.ens F,,: ..+,. ✓' •---• a. i+ '4.� h 3" 0 TOWN OF�BARNSTABLE LOCATION S(P3 v7/`1/®D/`C � n� � SEWAGE VILLAGE CZV/t� cr1l/� ASSESSOR'S MAR Az LOT`ZIO-:/S'3. INSTALLER'S NAME PHONE.NO A & B::CANCO 775-6264 SEPTIC TANK CAPACITY d Ssd G 4 rf LEACHING FACILITY:(type) 6141 (size)%34 33 X Z NO.OF BEDROOMS PRIVATE.WELL OR PUBLIC WATER BUILDER OR OWNER C . CUC>IZ DATE PERMIT ISSUED. .O/ • DATE COMPLIANCE ISSUED: %I VARIANCE GRANTED Yes No qy to ... No. � � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS Yes /� Zippfication for Migpoml *p.5tem Cortgtruction Vermit Application for a Permit to Construct( )Repair( OcIlp'grade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's/Nr j,Add ;f and Trfl.No.� Assessor's Map/parcel Installer's Name,Addre*&13.GANCO Designer's Name,Address and Tel,No. S50 Main Street W. Yarmouth, MA 02673 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Ina J—Wntkc Nat re of Repairs or Iterations(Answer when applicable) �.n S A 7 20 S r. 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 E viro n tifi tal Code and not to place the system in operation until a Cer - cate of Compliance has been issued by this Boaz ofre th. Sign 17 Date a d Application Approved by Date Application Disapproved for the following reason xN Permit No. Date Issued 44. � - No. � �, `� Fee 50 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: --Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLEs MASSACHUSETTS ZIpprication for jDigpo.5ar *pttem Construction Vermit Application for a Permit to Construct( )Repair( Vrpgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.S�j /q ►I� (���2 h r—, Owner'sF Nam ,Add r and 1.No. w Assessor's Map/Parcel T�u2� ` Installer's Name,Address,—and Tel;No. ' Designer's Name,Address and Tef�No. Type of Building: ?.,welling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) } Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures r y Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S..Y Description of Soil /1'?eGr '5. 917Cc Nature of Repairs oTlte�tions(Answer when applicable) n S f A — J(�U ^fo / l U —o0 eal c-ocn C �Irr1 /,Cl� Li t_ I S � Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the E viro ental Code and not to place the system in operation until a Certifi- cate cate of Compliance has been issued by this Boar gHth.SignQDZV Date 6 t Application Approved by Date Application Disapproved for the following reason 00 Permit No. '� Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, tha he On-site Sewage Disposal System Constructed( ) Repaired ( graded( ) Abandoned( ) /�%V C C at 6.S C H C `•w_ has b constructed in a cordance with the provisions of Title 5 and the for Disposal System Construction Permit No �'' ted t0 7itl !� Installer Designer The issuance of this permf t shit / not be construed as a guarantee that the syst ill f c ' s des' Date /��i Inspector �_-N — /•-L2'=J '— — --------=--=—--=--Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSETTS =i$pool *p$tem �T_ on5truchon 3permtt Permission is hereby ranted to Construct( )Repair(✓) grade( )Abandon( ) System located at �;7�C 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: Constructio V IR leted within three years of the date of tfV Date: { j Approved by L' 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT WITHOUT DESIGNED PLANS) I,�J C—/41/1Y1 a-Y1 , hereby certify that the application for disposal works construction permit signed by me dated w �� 7 , concerning the property located at S (, ( /-1-�1p ��jLeL�l �-2Q meets all of the following criteria: ✓• This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within 100 feet of the proposed septic system There are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed • There are no variances requested or needed. /The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen (14)feet above the maximum adjusted groundwater table elevation, Please complete the following: ^a. A) Top of Ground Surface Elevation(using GIS information) J C' . B) G.W. Elevation +the MAX. High G.W.Adjustment.?j. DIFFERENCE BETWEEN A and B q SIGNED : DATE: [Please Sketch proposed plan of system on back]. NOTICE Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert ,�; . �. � �l. .�---- TOWN OF BARNSTABLE LOCATION -S LAMP O/� SEWAGE # VILLAGE C r tiT ASSESSOR'S MAP & LOT ®' l w.Sf Fc 1.P9 � P`� c /� /y C G �'S NAME& PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: NO. OF BEDROOMS BUILDER OR OWNER C �- O f/PAS /tiSP£C/ien- r) - 9 ' ay PERMITDATE: CONH' E DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 1 ,yI �^•� / �v �V t� � o ��, - r - - -- -f -3�:� _ _ 1 3� �� o 0 r TOWN OF BARNSTABLE 6LI LOCATION � /y/®®/���,�r� /Zo/�� SEWAGE #el°d VILLAGE C�/IJ/�}�I,�iI/� ASSESSOR'S MAP & LOT ZJO—/5"3 INSTALLER'S NAME 6i PHONE NO. A & B CANCO 775-6264 SEPTIC TANK CAPACITY ho"2- C rd0 Col LEACHING FACILITY:(type)(��r6064r VEY __ (size)/3x 33 X Z NO.OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER eoc;lullo!� DATE PERMIT ISSUED: - ZcF, -o/. DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ply Zb O 3� TOWN OF BARNSTABLE LOCATION . .t?�"SE WAGE #q q VILLAGE l f Nke-lrJ 1`�, ASSESSOR'S MAP & LOTQI@®. S3 INSTALLER'S NAME & PHONE NO.� SEPTIC TANK CAPACITY Co LEACHING FACILITY:(type) Pe . . (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER C Ct-C-0 DATE PERMIT ISSUED: ® \`f' DATE COMPLIANCE ISSUED: to Do • L. 1 54 VARIANCE GRANTED: Yes No �cX- 0 S9 des o ��e 76 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF ALT �ty/Tow - W _ I•° ; D P TMENT a ��0 ' ► / — � a 4VWADDRSES7�� X G1M SJey � / �-n ) TELEmPH• N� 7_!5 /30/ Address Occupant Floor / _ Apartment No. _-1 No. Occupants .� � 1 c No. of Habitable Rooms_d__— No. Sleeping Rooms (���No. dwelling or rooming units �_ No. Stories_ 1, Name and address of owner Z- 179—Al— Remarks Reg. Vio. YARD vOut Bld s.: Fences: Garbage and Rubbish: r w la Containers: ,I ,/ n"r Infestation Rats or other: �-�► ,/(__ / V STRUCTURE EXT. Steps, Stairs, Porches: Dual Egress: and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: ..,y Foundation: Chimney: BASEMENT Gen. Sanitation: 7 al 7 Dampness: �' �/� ` Sta�rrs: _ Lighting: `�"-� j ►�` STRUCTURE INT. Hall, Stairway: Obst'n.: co ° Hall, Floor, Wall, Ceiling: Hall Lighting: Hall Windows: zz HEATING Chimneys: z Central 0 Y ❑ N Equip. Repair W TYPE: Stacks, Flues,Vents: a PLUMBING: Supply Line: A )P e �� �" 1 ❑ MS ❑ ST ❑ P Waste Line: �• �rT i , m H.W.Tank(s) Saf t an 6—Kt(s) ELECTRICAL Panels, Meters,Cir.: �'4 l ❑ 110 ❑ 220 Fusing, Grnd.: o � AMP: Gen. Cond. Distrib. Box: �° Gen. Basement Wiring: DWELLING UNIT Ventil. Lgtng. Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen II Bathroom if Pantry Den Living Room _ Bedroom (1) Bedroom (2) Bedroom (3) Bedroom (4) Hot Water Facil. Sup.Ten., Gas, Oil, Elect.: _ Stacks Flues Vents Safeties: Kitchen Facilities Sink Stove Bathing, Toilet Facil. Vent., Plumb., Sanit'n.: Wash Basin, Shower or Tub: / Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted: ATAP, I Locks on doors: r ONE OR MORE OF THE VIOLATIONS CHE KED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR. (See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PERJURY." b d INSPECTOR TITLE SZA.DATE TIME A.M. THE NEXT SCHEDULED REINSPECTION P.M. 410.750: Conditions. Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of these items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter II, 105 CMR 410.000 through 410.499 stare minimum requirements of fitness for human habitation, any violation has the potential to fall within this category in any given situation but may not do so in every case and therefore cannot be included in this listing. Failure to include shall in no way be construed as.a determination that other violations may not be found-to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of the violation(s) pursuant to 410 CMR 410.830 through 410.833 nor shall it affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both -hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. I I k (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B) and 410.202. (C) Shut-off and/or failure to restore electricity or gas. (D) Failure to supply the electrical facilities required by 105 CMR 410.250(B); 410.251(A)„ 410.253(A), 410.253(B) and the lighting in common area required by 105 CMR' 410.254. (E) Failure to provide a safe supply of.water. (F) Failure to provide a toilet and maintain a sewage system in operable condition as required by 105 CMR 410.150(A)(1) and 410.300. (G)• Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by an object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450 and 410.451. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (I) Failure-to comply with any provisions of 105 CMR 410.600 through 410.602 which result's in any accumulation of garbage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or .otherwise contribute to accidents or to the creation or spread of disease.-- (J) The presence of lead-based paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regualtions for Lead Poisoning Prevention and Control 105 CMR 460.000. (K) Roof, foundation, or other structural defects that may expose the occupant or anyone'else to fire, burns, shock, accident or other dangers or impdii'ment to health'or dafety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilities as are required by 105 CMR 410.351 and 410.352 so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either operable. (2) failure to provide a washbasiAAnd a shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3) and any defect which renders.them inoperable. (3) . any defect in. the electrical, plumbing, or heating system which makes such system or any part thereof in violation of generally accepted plumbing heating, gas-fitting, or electrical wiring standards that do not create an immediate hazard. (4) failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A) and 410.503(B). (5) failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (N) Amy other violation of Chapter II not enumerated in 105 CMR 410.750(A) through (M) shall be deemed to be a condition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the board of health. r#•, ! THE COMMONWEALTH OF MASSACHUSETTS ARD OF� HEALTH Application for Disposal Works Tons rurfion % rrmid Application is hereby made for.a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .......... ...... ..................... v:. .11(,r. ........... ..............:._. .... Locati6n Add �- � ss or Lot..— -- - r ner ....-"" " -------------•---•-•-••••• Address .............._. ---------•--••------------------------------------- --------------------- ........................................... Installer Address Type of Building Size Lot............................Sq. feet U Dwelling No. of Bedrooms....... .....Ex Expansion Attic Garbage Grinder r~ ng— P ( ) g ( ) '4 Other—T e of Building No. of persons............................ Showers — Cafeteria a d Other fixtures ----------------•--•-•---........:...-------...._...-----•-----------•---....-------------..............---•-•----------...----•-•--------........... WW Design Flow.....t"tf`..... .............gallons per person per day. Total daily flow......7a.3.o.......I.............gallons. W . Septic Tank—Liquid capacity.[02M.gallons Length.......... Width..........._ Diameter................ Depth................. x Disposal Trench—No: ................... Width.................... Total Length:................... Total leaching area...................sq. ft. 3 Seepage Pit No.......J......... Diameter..-1.c;-...... 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........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a .................•---•---•---..............------......------•----•-•-•--------...................--......................................................... O Description of Soil............................................... .. W -•.............................•_...• ---•-----•--------••-•••-•------...--•-•-------------... --•-•--- ... . •••...-••-•----••----------------•--------•. ..........._..............-•-••-- U Nature of Repairs or Alterations—Answer when applicable...:.A..G_ .......C:1 .............................•. Et- ..�......---------------1._ .------.� P ` ----.fir• -lc._-----....� ------A/,a-1-----vee..f'.�? Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITIa' 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the boardoLlwalLh. +, - Signed.- ..•--- •-- ............ -------- ................................. Date Application Approved By............... (% 114- - ---------•----•-------- ,�/-Date '._'.. � Date Application Disapproved for the following reasons:................:..........................................................................................---- --•••-----------------•---•-•••--=---•-•----••--•--•-•-•-------•-••---•.......--------------••----....._.••----•----•--•----------.._..........•.....••---•••...------•••••----•--•-••......--•••-•---- Date PermitNo....... -` 7 ---•---------- -.. Issued--I------------ --------------------------------_ Date rZ N 1 10 No....1 .7:. 77,9' F$s... � THE COMMONWEALTH OF MASSACHUSETTS ' BOARD OF� HEALTH ----.--..OF...... .......1►!.<........ A 1L. .......................... Appliratinn for Disposal Works Tonstrurtion 11arAit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ......... ...._ Cii,.�Nc clD-, D P C-=`•Y`�-- • -- ............ c.c fin:. `� ............................. Location-Address or Lot No. ........�_ •4— A_t g'�..._..'_a.. .�.�f.��. C_�_E�................ ..................0_1)4 (.( ��n a �...... .. � •--�-�----c Ownr Address ------e �............................................. .•...•--.............t .�t .. _. ..�T.......------......-----------•---......-•---- Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms......... ..........:.....................Expansion Attic ( ) Garbage Grinder ( ) p, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other fixtures ............... -\; ----------- WW Design Flow..... ? °`.. .............gallons per person per day. Total daily flow...... .Z. ........_......... _gallons. Od Septic Tank—Liquid capacity.rCr7l_gallons Length.__....... Width..._........ Diameter............. Depth................ 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........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ------------------------------ --------- --------------------- .......... -•------------------------------------------------------------------------------•-- 0 Description of Soil......................... V ----------------•--•-••--------•---••••-•---•----------------•-------------•--------•---•-••-••............-----------------•---------•---------------------••-•---------------------•-------- ------- ---------------•---------------•----•-•------------------••---•--......_.......------------------••---•-----•------------------...............--•--------------...-•-••-•-•----•--- U Nature of Repairs or Alterations—Answer when applicable_-_-_ .......<::f ........................ Agreement: ) s The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The un/delrsigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of..health. -- Signed... d J ------------y-----...- :.......... ....•---•......... aDate Application Approved By.................�1_0 =- ... ' =- = - / ............... `��----- ( � j Date Application Disapproved for the following reasons:....................................................................................................... ............................. ---......-•------------------•--------•=--•---------------•-----•--------•---.....-------•--...•----•................----•----•-............................................................... Date Permit No.......'-.7..__-....72-r............__.... Issued..:......... --....--•......................... Date r -------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .e1.Y .. OF........ ..wc. ........................... TrrtifirtttV of (Sompltttnrr THIS IS TO CERTIFY, That-the Individual Sewage Disposal System constructed ( ) or Repaired Y-.............. / Installer n has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.....Q_7 ?....... ........... dated------------------------------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY.- DATE © �' �j D .............�r � ` '" ... r Inspector r .............•...... THE COMMONWEALTH OF MASSACHUSETTS BOAR OFOF HEALTH � ,A...!! -......0F...:.....1���_.Yr_,n:��<<.'�A!R................................ �7 Disposal Works TottotrWion f rrmit Permission is hereby granted....... ...=1.4.0.1.d--.0'._, �(_- _k0 � .................................................... to Construct ( ) or Repair ( c.,)—a"n Individual Sewage Disposal System atNo..............................•--- 4.,F�........' ,� Q ,.. . . .! "'.::......................................... I, Street as shown on the application for Disposal Works Construction Permit No..R:-.72_�L Dated.......................................... ~��ard�of DATE.. Health f _`L..-. ?--:.... ----•............. • TOWN OF BARNSTABLE LGCATION CA V%P 6 P69�C-C SEWAGE # 7 7�S VILLAGE 1"e- f2l � J ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. �or f'6et/ "9tI b- OG 6 SEPTIC TANK CAPACITY VW 5 4 q /00® !�ct/lm LEACHING FACILITY:(type) u� Alt 142�O (size) NO. OF BEDROOMS PRIVATE WELL O PUBLI�WAT�E BUILDER OR OWNERb61.?1ie 6U,1�� � � Y DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: lC VARIANCE GRANTED: Yes No s 0 j4ab P(Ze r,Os7- t.ea b-7— �'3 f .5Co w-Z e