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0108 CAP'N CROSBY ROAD - Health
103 Cap'n Crosby Road,Centerville r A=193-096 �I UPC 12534 No.2_5_ HASTINGS,MN c-�� ��. � d- Via- I --o l� I �°'� 1 i TOWN OF BARNSTABLE LOCATION /018 Cap'go Cro55y Rot SEWAGE# ZO21 ^ OGI VILLAGE Ccnjcru:)IG ASSESSOR'S MAP&PARCEL 193-9G INSTALLER'S NAME&PHONE NO. R,.B CXCaucd;O►^ q7').OGS3 SEPTIC TANK CAPACITY /ODO .� rw, LEACHING FACILITY. (type) S00!�ct� (2) (size) 13 X 25 X'.Z NO.OF BEDROOMS . OWNER f7i-a4NK PERMIT DATE: ^3-21 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY A►- y ` � Zt t3 Az" 9 . A 32' zq Z" O +3sIt, Alf O 63, 2315 3 O AW 401 �y -ZG� IM a : N Ok i e r a a a: vi Y a P r K yJ' X 9 4 a p.: F. ^ t No. / Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftplitation for Vsposal ,pstem Const union 3pPrmit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System' ❑Individual Components Location Address or Lot No. % .� CC-,qS C,)) Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 19 -3 e04 Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. &4 v� 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(min.required) �13 gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) �h Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. oe Signe Date Application Approved by �— Date Application Disapproved by Date for the following reasons Permit No. & Date Issued No. '/ � Fee J G/a THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Zipplication for -Misposal 6pstem Construction 3permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. /� j�,� rQg� � � Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. T"e�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(min.required) j Q gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: - Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed-^'-.,, Date Application Approved by tt. � Date / Application Disapproved by Date for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(�yh) Upgraded( ) Abandoned( )by pp ` at )(.k t_Oc��h! C'aS has been constructed in accordance with the provisions o(f�Title 5 and the for Disposal,"System Construction Permit No.- ) dated / c Installer `., Designer #bedrooms Approved design flow _ 70 gpd The issuance of this permit shall not be construed as a guarantee that the system wiil-11unction as,designed. Date -D, .. Inspector \� No_ Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS disposal 6pstem Construction 3permit Permission is Hereby granted to Construct(. ) Repair( ) Upgrade( ) Abandon System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date Approved by r Town of Barnstable Inspectional Services Public Health Division BAMSR'ABM KAM Thomas McKean,Director 039.c3° 200 Main Street,Hyannis,MA 02601 Office: 508-8624644 Fax: 508-790-6304 Installer& Designer Certification Form Date: S -21.21 Sewage Permit# 2021 -O G I Assessor's Map\Parcel 193-96 Designer: FIahcrA Env i ron►N►cr6k l Installer: (34,B Exeauo,.A i o^, Address: l?O ,(fox 331 Address: ►q "fcaSerrLA. L. &-J 140.r-w;al. Fores-Ida lc On 3-3 -21 {3,� R Exeacc-lion was issued a permit to install a (date) (installer) septic system at Iog Goya o eros►au Rd(. based on a design drawn by (address) �Dbue Flal.er�c. dated 2-22. 2 (designer) _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. Strip out (if required) was inspected and the soils were found satisfactory. 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. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed ionp "ar3ee with the to rms of the I\A approval letters (if applicable) DAVIC 2 ' FLAiaERT,IR. (I taller's Sin a nro. ?211 \`` a cis rw a'� ` 41, 1Tgpo\,r, esigner's Signatur (Affix Designer's Stamp Here) 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. WoMdeptMEALTUSEWER connect\SEPTIC1Designer Certification Form Rev&14-13.DOC Town of Barnstable Inspectional Services Public (Health Division MASS 1 9. Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-8624644 Fax: 508-790-6304 Installer& Designer Certification Form Date: 21.-21 Sewage Permit# ZoZ 1 -o(.1 Assessor's Map\Parcel 193.9E Designer: F1cahcravrE'nv; ronmc:nd L1 Installer: J3�,:B Cxcc0.00-1io,\ Address: 4)O. RaX 331 Address: N t_, lro rw',Qk Fores- cols_ On -3-3-Z 1 (3�,S3 C-Agck�i a/\ was issued a permit to install a (date) (installer) septic system at fog Cmp 0 eros5u R.C. based on a design drawn by (address) �S�auc Flo t^ct-�c. dated _2.22- Z 1 (designer) 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. Strip out (if required) was inspected and the soils were found satisfactory. 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. Strip out (if required) was inspected and the soils were found satisfactory. I certify,that the system referenced above was constructed in compOance<with the to rms.of the 11A approval letters (if applicable) (Installer's Sin e) a', c &N J 7,1411 / Designer's Signaturel' /� (Affix Designer's Stamp Here) 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. \\toa\depts\HEALTH\SEWERconnect\SEPTICOesignerCertification Form Rev&14-13.DOC TOWN OF BARINSTA13LE LOCATION Crosby kct SEWAGE# Z07 1 ^ D(,I VILLAGE_CgnJ<-ru,)I G ASSESSOR'S MAP&PARCEL f 9 G INSTALLER'S NAME&PHONE NO. E Q Cxeaya-1 t O� �Z't-C?GS� SEPTIC TANK CAPACITY %ODO 9a.y LEACHING FACILITY:(type) SO_ 0!F cx J We (?� (size) 13 x 25 x 2 NO.OF BEDROOMS OWNER, racsK PERMIT DATE: 8.3-21 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 o,fleaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within :00 feet of.leaching facility) Feet I FURNISHED BY At- Be- Zt y iz l AZ- 9 A 32' zy'z" �' Z3�5�� AW" &A v, Town of Barnstable Inspectional Services Department r r ` B" `�MAS& ` Public Health Division � MASS. '°rfD 59. 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1730 0001 4987 8326 January 22, 2021 CARLINO, JOSEPH 108 CAP'N CROSBY ROAD CENTERVILLE, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 The septic system located at 108 Cap'n Crosby Road, Centerville,MA was inspected on 12/11/2020 by Sean M. Jones, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • The distribution box is rotted and needs to be replaced. • Leaching facility with standing liquid level at or above the invert pipe (per Town Code 360-20 h). You are ordered to repair or replace the septic system within two (2)years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OFARD OF HEALTH omas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\108 Capn Crosby Road Centerville.doc THE IN, Town of Barnstable RN^ABM � Inspectional Services Department Public Health Division 200 Main Street, Hyannis MA 02601 Oft ice: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CI10 Feb 6, 2007 Rev. 4/26/19 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An "x" marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ❑ Structurally unsound septic tank or SAS ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box is above the outlet invert due to an overloaded or clogged SAS or cesspool ❑ A portion of the SAS, cesspool, or privy is below the high groundwater elevation ❑ A portion of the cesspool is located within a Zone 1 to a public well ❑ A portion of the cesspool is located within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any "'conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) /eaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER 64ed o, Repair deadline: ���^ T�� ��rJ A dd J1 e S 6C/k) Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc 47 MCommonwealth of Massachusetts q Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 108 Cap N'Crosby Rd Property Address Joseph Carlino Owner Owner's Name / information is required for every Centerville V Ma 02632 12/11/2020 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:when A. Inspector Information �� b 1 0-i— on out forms on the computer, use only the tab Sean M. Jones key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. 74 Beldan Lane Company Address Centerville Ma 02632 Cityrrown State Zip Code fen 774-248-4850 smjonestitle5@gmail.com, SI4522 sean@smjonesbtle5.com License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ❑ Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local 712/11/2020 onty 4. ® Fails Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of i re appropriate 10,000 gpd or greater,the Inspector and the system owner shall submit the report to the pp priate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/OM18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 108 Ca N'Crosby Rd Property Address Joseph Carlino owner Owner's Name information is Centerville Ma 02632 12/11/2020 required for every page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of and 6. 1) System Passes: ❑ 1 have not found.any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: ❑ one or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): s .doc•rev.7(2812018 Title 5 official inspection Forth:Subsurface Sewage Disposal System-Page 2 of 18 t5ur P I , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 108 Cap N'Crosby Rd Property Address Joseph Carlino Owner Owner's Name information is Centerville Ma 02632 12/11/2020 required for every City mown State Zip Code Date of Inspection page. C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: Title 5 Official Inspection Form!Subsurface Sewage Disposal System•Page 3 of 18 t5insp.doc•rev.712 612 01 8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 108 Cap N'Crosby Rd Property Address Joseph Carlino Owner Owner's Name information is Centerville Ma 02632 12/11/2020 required for every State Zip Code Date of Inspection page. Cityrrown C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: _ **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5hrsp.doc•rev.7/26J2018 Title 5 official inspection Form:Subsurface Sewage Disposal System•page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 108 Cap N'Crosby Rd _ Property Address Joseph Cariino Owner Owner's Name information is Centerville Ma 02632 12/11/2020 required for every Citylrown State Zip Code Date of Inspection page. C. Inspection Summary (cunt.) 4) System Failure Criteria Applicable to All Systems:(cont.) Yes No El ® 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 Y2 day flow El ® 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. El ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ® The system fails. I have determined that one or more of the above failure El criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. 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 El ❑ 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 Title 5 official Inspection Form:subsurface sewage Disposal System•Page 5 at 18 tSlnsp.doc-ray.7128l2018 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 108 Cap N' Crosby Rd Property Address Joseph Cariino Owner Owner's Name information is Centerville Ma 02632 12/11/2020 required for every State Zip Code Date of inspection page Cityrrown C. Inspection Summary (cunt.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section GA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must Indicate"yes"or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® 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 El available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® El approximation in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)1310 CMR 15.302(5)] t5ucsp.doc•rev.72WO18 Title 5 Official inspection Forth:subsurface Sewage Disposal System-page 6 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 108 Cap N'Crosby Rd Property Address Joseph Carlino Owner Owner's Name information is Centerville Ma 02632 12111/2020 required for every Cityrfown State Zip Code Date of Inspection page. D. System Information 1. Residential Flow Conditions: 3 Number of bedrooms(design): 3 — Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd Description: unknown Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? El Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No current Last date of occupancy: Date Title 5 Official inspection Foml:Subsurface Sewage Disposal System•Page 7 of 16 t5msp.doc-rev.7126r2076 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 108 Cap N'Crosby Rd Property Address Joseph Carlino Owner Owner's Name information is Centerville Ma _ 02632 12/11/2020 required for every City/Town State Zip Code Date of Inspection page. D. System Information (cont.) 2. Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Ga1oons per day(gpd) Basis of design flow(seats/persons/sq.fG, etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? El Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Idle s Official Inspection Fond:Subsurface Sewage Disposal System•Page 8 of 18 tsinsp.doc•rev.72812M Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 108 Cap N'Crosby Rd Property Address Joseph Carlino Owner Owner's Name information is Ma 02632 12/11/2020 required for every Centerville CityfTown State Zip Code Date of Inspection page. D. System Information (cont.) 4. 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/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: original system, leach pit added 1995 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 1.5 Depth below grade: feet Material of construction: ❑cast iron ❑40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting, evidence of leakage, etc.): t5insp.doc•rev.7f26=i 8 Title 5 official inspection Form:subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 108 Cap N' Crosby Rd Property Address Joseph Carlino Owner Owners Name information is Centerville Ma 02632 12/11/2020 required for every City/Town State Zip Code Date of Inspection page. D. System Information (cont.) 6. Septic Tank(locate on site plan): 1 Depth below grade: feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 1000 gallons Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 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 Measurements not taken How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 t5bisp.doc•rev.71262018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 108 Cap N'Crosby Rd Property Address Joseph Carlino Owner Owner's Name information is Centerville Ma 02632 12/11/2020 required for every Cityrrown State Zip Code Date of Inspection page. D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Title 5 official Inspection Forth:Subsurface Sewage Disposal System Page 11 of 18 t5insp.doc•rev.7126/2018 c Commonwealth of Massachusetts Title 5 Official Inspection Form sments Subsurface Sewage Disposal System Form Not for Voluntary Assessments 108 Cap N' Crosby Rd Property Address Joseph Carlino Owner Owner's Name information is Centerville Ma 02632 12/11/2020 required for every City/Town State Zip Code Date of inspection page. D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): 2" 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.): Distribution box has 2 outlets.Water level was 2"above outlet one inlet and even with the other. D- box is rotted and in poor condition. Title 5 official inspection Form:Subsurface Sewage Disposal system-Page 12 of 18 t5irsp.doc-rev.R2612018 i c Commonwealth of Massachusetts Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 108 Cap N'.Crosby Rd Property Address Joseph Carlino Owner Owner's Name information is Centerville Ma 02632 12/11/2020 required for every Cityrrown State Zip Code Date of inspection page. D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order. ❑ Yes ❑ No" Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): "if pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System(SAS) (locate on site.,plan, excavation not required): If SAS not located, explain why: Type: 2 ® leaching pits number: n leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: [j leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovative/alternative system I Type/name of technology: Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 t5amp.doc•rev.7M/Wl8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 108 Cap N'Crosby Rd Property Address Joseph Carlino Owner Owner's Name information is Centerville Ma 02632 12/11/2020 required for every State Zip Code Date of Inspection page. Cityrrown D. System Information (cont.) 11. Soil Absorption System (SAS)(cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): One leach pit is full into the inlet pipe.The second pit added 9/13/1995 was located and opened.This pit has inlet pipe into concrete riser,water level in pit was approx 2'from top of pit with dark stain lines above top indicating that it has been hydraulically overloaded. 12. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 t5insp.doc•rev.72612018 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 108 Cap N' Crosby Rd Property Address Joseph Carlino Owner Owner's Name - information is Centerville Ma . 02632 12/11/2020 required for every State Zip Code Date of Inspection page City/Town D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5lnsp.doc•rev.7/CMI8 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts IFTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 108 Cap N'Crosby Rd Property Address Joseph Carlino Owner owner's Name information is Ma 02632 12/11/2020 required for every Centerville State Zip Code Date of Inspection page. CityfTown D. system Information (cont.) 14. Sketch of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Rear 1 l We 5 official inspection Form:SL6%dam sewage Disposal System•Page 16 of 18 t5W.doe•rev.7I 8Wl8 Commonwealth of Massachusetts Title 5 Official , Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 108 Cap N' Crosby Rd Property Address Joseph Canino Owner Owner's Name information is Centerville Ma 02632 12/11/2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 151rwp doc rev 7/28l2018 Title 5 official Inspection Forth:Su Subsurface Sewage Disposal system•Page 18 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 108 Cap N' Crosby Rd Property Address Joseph Carlino Owner Owner's Name information is Centerville _ Ma 02632 12/11/2020 required for every State Zip Code Date of Inspection page cityrrown D. System Information (cont.) 15. Site Exam: ® Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 100'+ Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Property is located on a slope. Before fling this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7IAMI8 Title 5 Official hispedion Forth.Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .� 108 Cap N' Crosby Rd Property Address Joseph Carlino Owner Owner's Name information is Centerville _ Ma 02632 12/11/2020 reqpage. for every Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed& Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1,2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8:Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5lnsp.doc-rev.7r2M18 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 McKean, Thomas From: McKean, Thomas Sent: Tuesday, April 11, 2017 11:21 AM To: O'Connell, Timothy Subject: 108 Cap'n Crosby Road FYI Ms. Maureen Carlino called and requested another 15 days to remove the debris. She already removed one dumpster load of debris but due to her low finances (social security) she needs to come up with more funds for the second dumpster. I approved an additional 15 days via telephone today. I also informed her that if additional time is needed beyond this additional 15 days, she will need to request a hearing before the Board of Health. 1 • • COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2;and 3. A. Sig ature ■ Print,your name and address on the reverse X l ❑Agent so that we.can-return the card to you. ❑Addressee IN Attach this card to the back of the mailpiece, ived Printed Narrie) C.._D to of Pelivery or on the front if space permits, 1. Ari `� D. Is deliverddress different from item 1? ❑Yes If YES.renter delivery address below: ❑No Josefh.Carlino 108 Cap'n Ctosby Road Centerville, MA 02632 , - I ,II IIII�'III'IIIIIIIIIIII (IIIIII IIII'lIIll�)II 3. Service Type 0gte ss® n Adult Signature ❑Reisterd MailTM O"Adult Signature Restricted Delivery ❑Registered Mail Restricted ❑Certified Mail® Delivery 9590 9402 2480 6306 7773 81 ❑Certified Mail Restricted Delivery ❑Retum Receipt:for ❑Collect on Delivery Merchandise ❑Collect on Delivery Restricted Delivery Signature ConfirmationTM 7 D 15 17 3 D 0 D D 1 E 4 9 9 0 2 6:9 4 ; I0 Insured Mail 0 Signature Confirmation i O Insured Mail Restricted Delivery Restricted Delivery (over$500) PS.Form:3811-,.July 2015 PSN 7530-02-000-9053 Domestic Return Receipt E First-Class Mail Postage&Fees Paid. USPS Permit No.G-10 9590 9402 2480 6306 7773 81 ` WWII: •Sender:Please print your name;address,and ZIP+4®in this box" Postal.Service. I � Town of Barnstable Health Division 200 Main Street Hyannis, AAA 02601_T :�i��,ll,lj�it'li'l'�I11j,t�►�lfttlilj,ijt�ti,�tliil+il�fl�lff, I� SENDER:'COMPLETE THIS SECTION 1 COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3. A. Signature ■ Print your name and address on the reverse X ❑Agent so that we can return the card to you. ❑Addressee ■ Attach this card to the back of the mailpiece, B. R eived by(Printed Name) C. Da Zes elivery or on the front if space permits. 1. Article Addressed to: l D. Is—delivery address different from item 11 ❑ If YES...enter•delivery address below: p No t� ,!I I IIIIII IIII III(III I II I II I I I I IIII I I II III I III 3. Service Type O Priority Mail Express® O Adult Signature ❑Registered MaiIT^� ❑Adult Signature Restricted Delivery ❑Registered Mail Restricted ❑Certified Mail® Delivery 9590 9402 2480 6306 7773 67 ❑Certified Mall Restricted Deilvery o Return Receipt for ❑Collect on Delivery Merchandise ❑Collect on Delivery Restricted Delivery" ❑Signature CohfirmationTm +1❑Insured Mail - ❑-Signature Confirmation 015 17 3 0 '6 0 01 4 9 9 0 2 700 ❑,Insured Mail Restricted Delivery Restricted Delivery (over$500) PS Form 3811„July 2015 PSN 7530-02-000-9053 Domestic Return Receipt .I W.$PS..TRA� IJNG.# First-Class Mail t Postage&Fees Paid LISPS, Permit No.G-10 I 9590 9402 2480 6306 7773 67 United States •Sender:Please print your name,address,and ZIP+4®in this box* Postal So rvi(i �- l & T��r�nrn- of Barnstable a i Health Division 200 Main Street Hyannis, MA 02601 pF�HE roh, Town of Barnstable Regulatory Services saB'"E'� Richard Scali, Director i639• ''TE°MAv° Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Certified Mail: 7015 1730 0001 4990 2994 March 30,2017 Joseph Carlino 108 Cap'n Crosby Road Centerville, MA Finding of Unfitness for Human Habitation and Determination of Immediate Danger within the Basement Portion of Dwelling. In accordance with M.G.L. c.111, sec. 127A and 127B, 105_CMR 400.000: State Sanitary Code, Chapter I: General Administrative Procedures and 105 CMR 410.000: State Sanitary Code, Chapter II: Minimum Standards of Fitness for Humans. Timothy B. O'Connell, R.S.;Health Inspector for the Town of Barnstable on March 29, 2017 conducted an investigation of a dwelling unit within the basement located at 108 Cap'n Crosby Road Centerville, MA. The owner's name of this dwelling unit is Joseph Carlino. The occupant(s)name(s) of the basement unit is Joshua Carlino. Based on the results of that investigation,the Barnstable Health Department finds that the basement portion of this dwelling is unfit for human habitation. Pursuant to M.G.L. c. 127B and 105 CMR 410.831 (D), (E) the Health Department further finds that the conditions within the basement dwelling are such that the danger to the life or health of the occupants of the subject dwelling is so immediate that no delay maybe permitted in making this finding. Conditions found within the basement of this dwelling, which give rise to the emergency finding of unfitness and determination of immediate danger, include: 410. 750: Conditions Deemed to Endanger or Impair Health or Safety 410.750 (C)-Electrical service shut off within basement area. 410.750 (G)-Failure to provide adequate exits due to clutter and debris within basement area. 410.750 (P)- Failure to maintain walls, floors and ceilings. Current conditions within basement consist of concrete floor without finished ceilings or walls. QAOrder Letters\Condemnations\108 cap'n Crosby 3-30-17 F Based upon these findings any and all occupants are hereby ordered to vacate the basement within(24)twenty-four hours and the landlord/owner is ordered to secure the subject dwelling within 48 hours of receipt of this order. If any person refuses to leave a dwelling or portion thereof, which was ordered vacated they may be forcibly removed by the local Board of Health(Massachusetts General Laws C. 127B), or by local police authorities at request of the Board of Health. Furthermore, anyone who fails to comply with any order of the board of health may be subject to fines ranging from $104500. Each day's failure to comply with an order shall constitute a separate violation. Once vacated this unit may not be occupied without the written approval of the Board of Health. Note: This is an important legal document. It may affect your rights. PER ORDER OF THE BOARD OF HEALTH omas A. McKean, CHOIRS Director of Public Health Town of Barnstable Q:\Order Letters\Condemnations\108 cap'n Crosby 3-30-17 Town of Barnstable MAM ` Regulatory Services i639• Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Joseph Carlino 108 Cap'n Crosby Road Centerville,MA 02632 April 3, 2017 NOTICE TO ABATE VIOLATIONS OF TOWN OF BARNSTABLE BOARD OF HEALTH REGULATIONS,NUISANCE CONTROL REGULATION NO. 1 The property owned by you located at 108 Cap'n Crosby Road Centerville, MA was inspected on March 29, 2017 by Timothy B. O'Connell, R.S., Health Inspector, because of a complaint from Comm Fire. The following violations of the Town of Barnstable Board of Health Regulations, Chapter 54 Building and Premises Maintenance were observed: §54-2. Building and Premises Maintenance. Observed large amount of appliances; large amount of plumbing pipes, plumbing supplies and tools stored at said property. Along with assorted debris, trash and garbage. All of mentioned items not within enclosed structure or screened from public view. You are directed to correct the violations within fifteen (15) days of receipt of this order letter by either moving items into enclosed structure or removing them from property. You may request a hearing before the Board of Health if written petition requesting same is received within ten (10) days after the date the order is served. Please be advised that failure to comply with an order could result in a fine of$100.00. Each day's failure to comply with an order shall constitute a separate violation. PER O F H BOARD OF HEALTH i omas A. McKean, R.S. irector of Public Health Town of Barnstable CERTIFIED MAIL: 7015 1730 0001 4990 2700 Q:Health/orderletters/refuse/108 cap'n Crosby 4 3-17.doc b- COMMONWEALTH OF MASSACHUSETTS ` Q EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION lop IeePP Of 9S.. A-q7 "C71d 193 e0 9 4 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION V, Property Address: Gq h C/'0s6 ti 8r✓i Owner's Name: . Owner's Address: Date of Inspection: Name of Inspector: lease print) , a�,.� �� co } Company Name: 1/ — 7L Mailing Address: o 19 t 46" VaGtfd` c� Telephone Number: .S0 Iy, 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 fimction and maintenance of on site sewage disposal systems,I am s DEP approved system inspector pursuant to Section 40 of Title S(310 CMR 15.000). The system; Passes ' Conditionally Passes Needs Further Evaluation by the Local Approving Authority P Fails Inspector's Signature: I/M�_ /� d a Date: p The system inspector shall sub 't a copy of this inspection report to the Approving Authority DEP)within 30 days of completing this inspection.If the system is a shared system or has a design now of 10 000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be.sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Q 1 Owner• per, Date of Inspection: �. a Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Syste sses: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15. 003 or in 310 CUR 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 repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level is 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 per ).The s pass inspection if(with approval of the Board of Health): system will broken pipe(s)are replaced obstruction is removed ND explain: Title c Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) / Property Address: 0 q r N cr/O S 7 0�;� `/ Owner: ✓,/,G *-rvti Date of Inspection: d o 0 C. Further Evaluation is Required by the Board of Health: 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 15303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. — The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**.Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: © h Crp f b rv( �� Owner: e-G Date of Inspection: V- D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No kup 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 gged SAS or cesspool ailed or — tic liquid level in the distribution box above outlet invert due to an overloaded or clo ,ees�l gged SAS or �/Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow _ Required Pumping more than 4 times in the last year NOT due to clogged or obstructed s ,e�f tunes pumped P ).Number &0" 9ny portion of the SAS,cesspool or privy is below high ground water elevation. _f-Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. � y portion of a cesspool or privy is within a Zone 1 of a public well. —� y 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 pp provided provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (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 �• 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 drinldng 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 H of a public water supply well If you ve 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. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: to h 4510 X b el A- /v Owner: J 4Gd' Date of Inspection• yd o Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No // L/Pu ping information was provided by the owner,occupant,or Board of Health _.�ere any of the system components pumped out in the previous two weeks? ./ Has the system received normal flows in the previous two week period? 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 b s 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 mai � ntenance of subsurface sewage disposal systems? The size and location of the Soi!Absorption System(SAS)on the site has been determined based on: Yes q% xisting information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)J 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Gj C/'O.s � R11.j Owner: Ue G0'4t� z;=, Date of Inspection: 1-4 ge 0 0 -35 RESIDENTIAL FLOW CONDITIONS Ave- Number of bedrooms(design):3 Number of bedrooms(actual): 3 r DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): ,�jf0 Number of current residents: O Does residence have a garbage grinder(yes or no): ICID Is laundry on a separate sewage system(yes or no):Z&[if yes separate inspection required] Laundry system inspected(yes or no): �P Seasonal use:(yes or no):AW Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):&SO Last date of occupancy: C H COMMERCIALA NDUSTRIAL Type of establishment. Design flow(based on 310 CMR 15.203): d Basis of design flow(seats/persons/sgfl;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 INFORMA N Pumping Records Source of information: Was system pumped as part of the inspection(yes or no):�O If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYP 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/Altemative 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 a e of all corpPonents,date installed(if]mown)and source of information- / G h k' Oao l SI✓1 y( � C✓ 3;,./0 f (9 95 Were sewage odors detected when arriving at the site(yes or no):A22 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: G h Coleipx � Owner: Date of Inspection: atp BUILDING SEWER(locate on site plan) Depth below grade: / _ Materials of construction:_cast iron —b PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_<locate`� on site plan) Depth below grade: �<on�crete Material of construction: _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: 's Sludge depth: Sc Distance from top of sludge to bottom of outlet tee or baffle: 02 6 Scum thickness: -3� _ Distance from top of scum to top of outlet tee or baffle: 6 Distance from bottom of scum to bottom��ff tlet tee or baffle: S How were dimensions determined: /moo/e �4s ay Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as elated to outlet invert,evidence of leakage,,etc.): q H ✓� o► f r✓� J/fog / _s O H . �i0► . GREASE TRAP(locate on site plan) Depth below grade:— Material of construction:_concrete metal fiberglass_polyethylene other (explain): — — — Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, as related to outlet invert,evidence of leakage,etc.): liquid levels Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: C-r- Owner: Date of Inspection: d o 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 o e ocate on site plan)P� �� P ) Depth of liquid level above outlet invert: q L Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage in r 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 ofpumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) (� Property Address: 0 i7 ��-o s`j A_f Owner: Ul0-C- Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: /' �/ Type /\ iD — J leaching pits,number: leaching chambers,number: leaching galleries,number: / — / k/ LI/ �O 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.): „ O 1 < 11111''pill'- po...... ................ 11! CESSPOOLS: �(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: `y(locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: l 0 4 r'1 61-qj� Owner: w• Date of Inspection: 0A� 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. C� 01) Itxe w /Q1 , 1 /YJ Z/ d�f- 10 . Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C r SYSTEM INFORMATION(continued) Property Address: Owner: d�6�Z Date of Inspection: SITE EXAM Slope Surface water q0. - Check cellar Shallow wells �- Estimated depth to 2 ep ground water �v�eet o✓►.gyp J' J 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: rved site(abutting property/observation hole within 150 feet of SAS) Loof Checked with local Board of Health-explain: r/"l Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You muAdes e how you established the high ound wader elevad n:/ a ta off'('0 101 I - 0 1 9- 1 i II I I i {� I {/ � , Fiz$.3 ........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Utti-poottl Mork,i Tonotrnrtion Frrmit Application is hereby made for a Permit to Construct ( ) or Repair (b<) an Individual Sewage Disposal System at: ........1r0p1 ( C' Sa e....®.,e� C , -✓at. ... --- ------ V---------------------------------------------- -Add ss eXW qjY ..4------ ................d' --------•--------- �......... .�-L-......•-•---•................... w Addresssvt-mooU-� Owews., 7g- - ---` -----Installer Address d Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms------------`7-----------------------Expansion Attic ( ) Garbage Grinder aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) 04 Other fixture ------------------------------------------------------ w Design Flow............. ___________________-.--____gallons per person �er da Total Bail ow--__._.--_--__��_0-----__-___•__•-.gallons. WSeptic Tank—Liquid capacity 1000_gallons Length__._a_' Width_-_-�- Diameter---------------- Depth....Z....... x Disposal Trench—No_ ____________________ Width-------------------- Total Length.................... Total leaching area....................sq. ft. � _.... Depth below inlet...... Total leaching area..................s ft. � Seepage Pit No._._____..�..-_-_-. Diameter----- p g q. Z Other Distribution box (be,) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I________________minutes per inch Depth of Test Pit.................... Depth to ground water........................ rX4 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water------_................. P4 -•--•••---••-----------------•--••••------------•-••---••.....----•-----•-•••------------....................--••-----------•••--•-•............------•----• ODescription of Soil.................................................................................................................. ..................................................... x w V Naturg of Repairs or Alterations—Answer when a licable._.,4_-&0____-4- 100 d ti6¢----p�T --_-- !..) gp_...sz,....z: c1� /�....a-...... Agreement: c-3 Y 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 as been issu b the board of health. Signed ------ ---- 19G� ... ................................................... .................Date-.-..--..--...... Application Approved By ............ ....... .... ------- Application Disapproved for the following reasons- ------------------------------------------------------------------------------------------------------------------------------------- -----------------------------------------------G--------------------.-....---.......-----...--------...............................------...-:----------------------------------------------------------- ---------------------------------------- Permit No. ----- 1� 5----.-1-&..... Issued Date t ,, d _._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Xppliratiuu for Dhi-pauttl lVurku Tunutrnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair (p<) an Individual Sewage Disposal System at: ... .. ............................................................................. .l-____.._._...__..................__.........----.................---............................ -Addr ss Or Lot O. ,.d �tr, ��J �,✓l.�s�y a Owner �t11. .............................. ----------------------- - O c.ey e s -7 J.— , Address w- 'zF > vd�t e�cS Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No, of Bedrooms._:.._...._ -ems ..................__-_Expansion Attic ( ) Garbage Grinder (—} ►���J a1 Other—Type of Building ......:......................No. of persons---------------------------- Showers ( ) — Cafeteria ( ) .< Other fixtures. ---�....g...... -----------•------- --•----•-----------=-==- ---••-----....-••---••------•---....-----•---------.......... w Design Flow..............---_-.____--.______-gallons per person per day. Total dailyflow.-__........._� .................gallons. R: Septic Tank—I iquid capacity ZU __gallons Length______.'_ _ Width_____ _____ Diameter---------------- Depth..........._.. Disposal Trench—No. ----- ::....... Width__j..:............. Total Length-------------....... Total leaching area....................sq. ft. Seepage Pit No--------- Diameter----- Depth below inlet------4^.......... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing,tank ( ) IH - a Percolation Testl 6AItS Performed by.......................................................................... Date........................................ a Test Pit No.1----------------minutes per inch Depth of Test Pit....--..---__-__-__- Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to g round water........................ a ........--••---------------------•--•----•----------------••-----••--•-••-•-•---•--------------•---.........._......_........---------•--......-------•----- 0 Description of Soil....................................................................................................................................................................... x U w -----•----------------------------------------------------------------------------------------------- •-••------------•--------••••-------••.....----...-•--•---•-••------•--••--••-••--------------•- U Natur of Repairs or Alterations—Answer when/applicable.-_A .��.._. ---_---_ .......... .... - :..._ ! __.... �v 7...............................................1" = ( /C_ s � /?✓c i7J. 7_0 _ -� i�c.� s 7' --------- -- Agreement: 5 V 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, "as been issuV-3 b the board of health. J Signed ` — i Dare Application Approved By ---------�a �4 - - - -------L-��.. ,r. .. � Dare Application Disapproved for the following reasons: ..... .... . . ................................ ....... ..................................... ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ...................--------------------- Dare Permit No. .. .(.,..... i---�-------------------- Issued -------------- ..- ( _- %�................. ------------------- Dare — — -- --- — — THE COMMONWEALTH OF MASSACHUSETTS ------------ ��"' l �----_ BOARD OF HEALTH TOWN OF BARNSTABLE Certifirate of (gomplial-i.re THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by ---------------------------------------------------------- ,( 'r ti ................ 1--n1 S.---�C--TurJ--------------------------------._----._------. 5 1 r Insrdler r s Q (� /t�L at ...._. ....._............_ .......... ....14.)..� � I--....------------.,-..---------------------------------------------------------- ------------ has been installed in accordance with t e provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. .._9_5_ /f,•...S---7 dated ..... ..�-�- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.......� "r'l.--.. -'. ---------------------------- Inspector--...i----- ------------------._.-------------------------- ----------------- -- -fit---------------------------- --------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ty TOWN OF BARNSTABLE No.-. ..........4 FEE........................ 1iupnuttl urku Tunutrurtiun Kermit Permission is hereby granted.................._-___2 'OiC.,-U-1-0-T71 -.-� f.)QS. .'�?�o✓ _� -------------------------------------------•--- to Construct ( ) or Repair an Individual Sewage Disposal System atNo..••-•--•-•-----•--••------•......`..----••l U `-------•-• --`-------•- -----`qs. `..------ -- C �v�.. c;C. ....-........... Street as shown on the application for Disposal Works Construction Permit Nod ,r _ Dated...._Ur1----- r�._.:;. ._.... Health DATE.............. 7..............•...•----_......... Board of�----�--rv--•-�--�-------- FORM 36508 HOBBS 6 WARREN.INC.,PUBLISHERS I Q •jR h y_x 43"Y Y# ` a r w , CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) f I j 55�'cr�C.Zw 7 hereby certify that the application for disposal works _ p w moo , construction pernut signed by me dated /9� , concerning the property located at /0 C4*ON C' 6-5,9 y D meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNED : DATE: S/ 9�9-� LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted). '� 3,R.ti�-r"s`etfi 3 a k v ``r'rns''���etj�,�?✓��'4w �,CTz r* - 'C yr�s�t r.�'�✓ t �t 'g 1 �9: v} - . r�,rn e�71`•,xf*µ�9.f",r��" �.�N ro-���(�"$ ^7� .k'h�'+��'#�.�.�� Y;,k :-..,� .+.,a;S�Ar�r4�r dc:.��'•"'dy�1..�e k y..;. e;."�, 3 •i As p,.� 3 a-_r1+w ,+fi" �� u.', '�"^...,,�'_:? �. wr, s,:rat �,.:, s � :yM,.r -�.M ,±,-,,a� r e, s.�� .� t r `.dQ,; � �° 1 .� '•" '.. .ti._.s� �•.tx'"�-. s;:',, � ,,+, '�w.s.: �n �:. � .��'"' ,, .�"� : 'wn-a- x _`,i,,�.?.� K � ,r' 'S�. ?:.:�`.� .;,! :�` -.x:, _, �€ty ; a ro . „a�+^�"mr n:z. ,, �r t � y.c,•�„�;�:n. i'� �%�:�� � s °'�F �' °-ac...� �,?:c. >�a(,p.-';y`'��n-', "-''h'�"��� 3+ .. ,-H� s ,s-.��.�a�; .. �ry -:'.ts 5`SG.+�'�''y�..,'„rk,"' al'�?r'^,k x.�.., c✓ -"' .1!"��.fi- '�'i`�.''* .5 'f� x" �.,iu q ��J,2F'S.r.,�.„ ? �xJ�7 .�.r Nam-rt:,'ty ^r'_ s"•...;..• •�i .,�. r 5 r u xj'''$t` T �,�.'�" --,y' s` '" '�r,.: :".-.,.. •,:�'.�. ._:_"?ia;�"� •,` `h �.�`�� k, ,p a, 'r°r• >�, ,� � �3c s�'+�4���,,x� x �x r���r� -'r y� ,R,.x� �.a�",tT"��{,��: OF ST E Q I LOCATION G�•(� C� SEWAGE# VILLAG ASSESSO MA1P&LL T ,pcSD'���0 INSTALLER'S NAME&PHONE NO. 0 / SEPTIC TANK CAPACITY / 2L2 Cr LEACHING FACILITY: (type) / i(/e•� (size) NO.OF BEDROOMS BUILDER OR OWNER ti-ab itc. PERMITDATE: COMPLIANCE DATE: 9 Separation Distance Between the: r�/,, Maximum Adjusted Groundwater Table and Bottom of Leaching Facility ✓ Feet Private Water Supply Well and Leaching Facility (If any wells exist q on site or within 200 feet of leaching facility) / Feet Edge of Wetland and Leaching Facility(If any wetlands exist 07- within 300 feet of leaching facility) Feet Furnished by R<ar lb r 1 r IJa�E SILL ►JATUPI�L6Mw►r{ 1t] 6MAw 1x�DlsluftcD' { 1 04, 1 6 Lox rQav+ `eLvB of wrrta=Q vutess A �Jrsl�ct_ ota ZU71=LJT t9 . 'Lr-o PeP_ T-4a 5TA-E WETLAuDs A..=r, I F u C V i L. .�' w.ea.K7 b5 �� 'av % EAte'•-/ Zd=QE aG Ada 3 -- pP'� . ... . --J5,000 s.F k 40'F=A0wT S.S. zx mm `� I��4s• z '• a5� � _ - d 1 5 a � s 1 y • cz-� g b•4 1 8 0 CPA ps 40 / fir• -7 p o ; Isilt L_oT -7 3-17 o0o S. Frs 7r } ! '< 1471f 148+ �, ioa rn WA-MIZ LOCAMOM P&C CLAW CA?Lb Av6uST 21. 19-73 ' H*LD AS eDnE F..1s'rLAtiDs 0Av1D Qaux6, bAQwl- (I t •VnA6.d to NaCQ�lAT7ou CtvA b.ICt1aN oeteweea.•tt.�9b2 / L GEND1ece EXISTING SPO ELEVATIO � ,10 S C�F�Tf EOr `PLOT PLAN EXISTING CON OUR - -.0Lo.T FINISHED SPO1� ELEVATION •�1 C/►PNCR0.5. n rzP. FINISHED CONTOUR 0 'r� C'7 E/✓TT�ti%� MORS y I IN APPROVEDs BOARD OF HEALTH F°r'T "•SIOMAL� My15eb: C4./ / 3 S DATE AGENT •+�,.� SCALE, I "=4D' DATEI 1 2,_ Fr Ire 1 rr— LDREDGE ENG/NEERJNG CQ JN KA N/ CLIENT I CERTIFY THAT THE PROPOSED EGISTERE REGISTERED JOB NO FrZ233 BUILDING SHOWN ON THIS PLAN CIVIL ;' 'LAND CONFORMS TO THE .ZONING LAWS ! ENGINEER URVE R OR•BY' �� M OF 'BARNS LE, ASS. 712_:M-AI N;sTREET. CH. By J.R•E_ a!•v7.a3 MYANNIS' }MASS = •Z .l�13— it ' IsHimTS OF DATE G LAND SURVEYOR .�;;.; i _�r J` 'T-t �"-S`r � � 't'°`°a�" � ary '• `..•..T k z�u� k���'c; s -:- '' ���. r �' �, --�di i- "r�n"a" k ''�-s' �.,�sv-°ts ��:-t..'c�Y :r �'��• 3:''�: r fis.�x `� �e xr : 1 � a r*.. - c _� 1 - . '" ,r .'a.+ + :;;� x r`s+��MCa�YF�� '�''�"�.:�'"��$."THE�COMMONW6i4L't•t yr,.:lnnoon.'�`.� -::, r` t�sv'v�' £ c✓�a'.g -_ �r 1 ...;. Y � t..x_'S. `� .'r" .'i2. ��,c-� �t �v � Y.+^$ ,� �r �y ri"mat d�i*zy�•�# y � ,ur,.3` �Nc�.:a'C"F sv��z� � #w .�, � x,�_�,h ��-�"�' ,� - � y�`' �i Y � ,x .k ..sae ,✓ :a- �f"°fi `W.E ,€`-w_•;a .,.a 0ARO 6OF HEALTH `` :r,. y� "`kr r 2��ro., "'`"'� �, •.,xr ��i� t � 'C �_` K�� j�,���.s �s��x" '1 r �,§� � ;d,, $.y 3rr�t:-"��' •,. � * `�'�`•'F r. i' :ur � �" ,� a�'a1*.��� '� # ,R v '.�' s' t r s„ i�' .yam„ � ,,.,'v �'"§+� �'�.,. �`�� :..Y'r•�"`.. �. %.. y/('.a���..�'* .�y -+�c�s',�<� r s �-. •9`Y,,. �� h�." �_`+� '14''� Y�..��k�a'.�Afi� ? s ,g'�'a� #t"���...::.....«.. .,�r�� •��.��. 7".�a ��.R S'� ,} �' ANQ ...«. ���"�' �„.�, ,,�`� Y �`'�� .P.; .` ;i'9..�a;�': :t�v's�.x �. ,� �i,si_:€&.�.,� �.•g L s i;�`�,• �.w•- r6t^.. ,� a:R •'3. a�-:;ur"�' �'. z••,. -_ems` e� 3,. fi �' �,'' F . "� `� -�Ata,t�azrl nrl;�.�nn��liiftgri Pxitttf� �•;r lVZ SEPTIC PUMPING AND INSTALLATION 350 Main St. • W. Yarmouth, MA 02673 • 775-2800 Heating rl<Plumbing,Fire Sprinklers SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Ct4 PA) Address of property 10_';� GAf-i^c��-\ C ccr 1,�1 (.` . C�� �� ,ll� MA 13 Owners name �j� h n k.�n, CAp�i1/ C2ci5� Date of Inspection Y PAR# PART A CHECKLIST Check if the following have been done , I Pumping information was requested of the owner , occupant, and Board of Health. AX$j%,!9iM- the system components have been pumpe and the system has been receiving normal fl rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. y As built plans have been obtained and examined. Note if they are rz: t available with N/A The facility or dwelling was inspected for signs of sewage back-up. V The site was inspected for signs of breakout . = All system components , excluding the SAS, have been.: located-or the site. t✓The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions , depth of liquid, depth of / sludge, depth of scum. The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner (and occupants , if different from o ^e provided with information on the proper maintenance 'D IBC. Cb d� O al) ocr T � a '4 .9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential number of bedrooms number of current residents _,_:_ .garbage grinder, yes or ( 0 laundry connected to s stem, Ce6lor no >` seasonal use, yes or (h If nonresidential , calculated flow: Water meter readings , if available : Last date of occupancy GENERAL INFORMATION Pumping records and source o - information : System pumped as part of inspection , yes or no if yes, volume pumped Reason for pumping: f pe 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) Other (explain) Approximate age of all components . Date installed if known. Source of information: ' Sewage odors detected when arriving at the site, yes or Cnoi v SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK, /fs ( locate on site plan) depth below grade, a'�1f / material of construction, 1---concrete metal FRP other(explain) dimensions t l?e r dy5T— sludge depth distance from top of sludge to bottom of outlet tee or baffle 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 Comments (recommendation for pumping, condition of inlet and outlet tees or baffles depth of liquid level in relation to outlet invert , structural integrity, evidence of leakage, recommendations for repairs , etc. ) / "' �f.�. ��� ; o:•i�-i i ��r__.�� �/�..-fir C�� r.� `7�4.�4i . o c✓ �..?rJ.�4 •..7(!(6i:C.•.� �/l/St CDU'(:'C.. ..�' (d•^f� �� JCai� DISTRIBUTION BOXt ;'fS ( locate on site plan) 0 depth of liquid level above outlet invert Comments , (note if level and distribution is equal , evidence of solids carryover , evidence of leakage into or out of box , recommendation for repairs , etc. ) J O.A �i•�f t�{�LL S NF.G�S` �o yJc' ,�i��/�CiDo �` �� PUMP CHAMBER (locate on site plan) Pumps in working order , yes or no Commentse , (note condition of pump chamber , of pumps and appurtenances , recommendations for maintenance or repairs , etc . ) :j SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION. FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS).: ( locate on site plan, if possible ; excavation not required, but may be approximated by non-intrusive methods ) If. not determined to be present , explain : eaching pits and number leaching c a ers an number ` leaching galleries and number leaching trenches , number , length leaching fields , number , dimensions overflow cesspool , number Comments, (note condition of soil , signs of hydraulic failure , level of ponding, condition of vegetation recommendations for maintenance or repairs , etc . ) i CESSPOOLS ( 1 o c a t e. o n site plan ) : -- - -- -----___---__.----_—__-�_- number and configuration depth-top of liquid to inlet invert ""— depth of solids layer dimensions of cesspool materials of construction — indication of groundwater inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil , signs of hydraulic failure , level of ponding, condition of vegetation , recommendations for maintenance or repairs , etc . ) PRIVY: ' ( locate on site plan) materials of construction dimensions depth of solids Comments: -- (note condition of soil , signs of hydraulic failure , level of ponding, condition of vegetation , recommendations for maintenance or repairs , etc . ) r'? so SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks I locate all wells within 100 ' � C I DEPTH TO GROUNDWATER k,j L•1 L c v�r 1 f C,;Ld depth to groundwater method of determination of approximations SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes , no, or not determined (Y, N, or ND) . Describe basis of determination in all instances . If "not determined" , explain why not A/ Backup of sewage into facility? ,P1 Discharge or ponding of effluent to the surface of the ground or surface waters? ",r Static liquid level in the distribution box above outlet invert? OP/7— Liquid depth in <6" below invert or available volume< 112 da flow? Required pumping 4 times or more in the last year? number of times pumped Al Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? is any portion of the SAS , cesspool or privy , below the high groundwater elevation? W within 50 feet of a surface water? within 100 feet of a surface water supply or tributary to a surface water supply? within a Zone I of a public well? within 50 feet of a private water supply well? less than 100 feet but greater the 50 feet from a private water suppl well with no acceptable water quality analysis? If the well has been analyzed to be acceptable , attach copy of well water analysis for coliform bacteria , volatile organic compounds , ammonia nitrogen and nitrate nitrogen . C—VN 7 r SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector Company Name A & B Canco Company Address 350 Main Street , West Yarmouth MA 02673 Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection . The inspection was performed and any recommendations regarding upgrade , maintenance and repair are consistent with my training and experience in the proper function and maintenance of on-site sewage disposal systems . Check one: I have not found any information which indicates that the system fail to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . I' have determined that the system fails to protect public health and the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. NOTES A & B Canco has had no control over the use and/or routine maintenance of the septic system. Circumstances such as a recent pumping Will- significantly alter evaluation results . No guarantee or warranty is hereby given , express or implied , as to the evaluation . THE ISSUANCE OF THIS INSPECTION FORM SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY If you have any questions , please call me at 508-775-2800 between 8 : 30 am rind 4 : 30 pm, Monday through Friday . Inspector ' s Signature �,r�f,;1_�= � -.t..;__. - Date � Original to system owner r REcE���O Copies to : OCT 6 ao 1990 , Buyer ( if applicable ) sup Approving authority °� , LO--eAT10 Ir/ SEWAGE PERMIT NO. `idIILAG #, IN A L 'S NAME i ADDRESS 6 I —,D E R qlll OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED r�, r h �� �� '�� � 3 .. a ry ��' THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF H A TH Y. /BL!� . .....................OF.......�j.a!!.. ._.._...----....................................... f ' AVV traliou for Disposal Works Ta nstrurtion Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ............nt.,----—----------- -------------------------------------------------------------------------------------------------- ,oc4tion-Address Lot No. ........ ..................................• ..Owner -------------- .........Address Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) `4 Other—T e of Building ............... No. of persons............................. Showers — Cafeteria a Other fixtures ---------------------------------•-•--------•. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid'capacity............gallons Length................ Width................ Diameter----............ Depth................ 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.---.................--. Test Pit No. 2................minutes per inch Depth of Test Pit.--................. Depth to ground water........................ P1 •-------•---------•-•-••-•----•.................................................•---•---•-•-..---••-......................................................... 0 Description of Soil..........................................•............................................................................................................................. ----------------•-....--------------------------------------------------------------------------------•----- . --- ------•.VY J..................... U Nature of Repairs or Alterations—A wer w n a li le ------1 f , ...y b ........ --------------5.04.----------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'TT1:i4. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued by the board of health. igned .......................................-........................................... _._.. Application Approved B . 1 ea� Date ...... Application Disa oved the flowing reasons:--..-........................................................................................................ ......................... ......... ......... ......... .---------------------------------------------------------------------------------------------------------------------- Date PermitNo......................................................- Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS r BOAR® /OF !-i ALTH 1 Appliratiun for Dhipouttl Works Tonstrtirtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at .......1/ d �1, .. ( 1 --•....... .......................•-----------•........ ..................._........_......------ L cation-Address or Lot No. / .......................................... ............-•--••••--------•-•-----•.....•----......-••-----•----•--..................._---_..... Owner Address________________•......•.------. Installer Address Type of Building Size Lot............................Sq. feet ,., Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e 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......_.....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........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P+ •••••--••-••-•---•-•-•-----•-•-•---•---•---•............................•-•--------•......_ ................................................................ 0 Description of Soil........................................................................................................................................................................ x U ------ ------------- •------ •------------------------------•-----•----------------------------•-------•---.-•--- --------•---------------•---------------•---------------------- -------------------------------- W ------------------------ --- `� ....axn Answer _- r --......................................................---- ��.�--44. -:----.....--------------------._...---.--..._....----------------�-----.-.--.----------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of I I`T ,% p 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 board of health. Signed./.............................................................•-•--•--•---•-••••-• ----••-=�• �..------- - y // �Da te Y Application Approved B � , - -•.................•--- .................... Application Disapproved for the following reasons------------------•-----•---------------------------•---------------------------------•--••Date .•....-------- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH, ..... j :Z1?i!...........I.,........OF.....19&,,"W/Ttt!1i 1{ ....... Tertifiratr of Tontpliana THIS IS TO CERTFIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( w)' by............ ` P•;1= -� '� ... =_'------ -. .......... ...... ...................................................................................... -- 1I taller 11 ,(__has•been installed in accordance with the provisions of TITI,": j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No._ .. _:__« jf................ dated_...- .Z:........._._.__.._.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS,A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. r DATE..................................... ...................... Inspector?=..........................Z�....--...---.........----•----........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... r'' No......- --•••....... FEE..... ............... ioottl urk ,)Wontrttrtuan rrintt Permission is hereby granted::�:����� "&� • -••- ---...••---•--•--•-----••..---•••......-•--- ----------•------------------------.........------.........--••-•••--_-•--- to Construct ( ) or Repair'(, }'/all I ividual Sew=age-Disposal stem t' at No.••...'',6..p••....h f11, c= ��, .....................................................c ?z/,��t.�i fit' / . ............................................ --•-••------•-•----------••- Street as shown on the application for Disposal Works Construction Permit No:/ Dated ./1/.....k.Z............. �f �. Board of Health DATE..... -;:-------•-----•---•---. ................. ; FORM 1255 HOBBS & WARREN, INC., PUBLISHERS 7-1 ,f THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH .................OF.......................................................................................... Appliratiou for Dwvoiial Workii Tome rur#inn ".truth Application is hereby made for a,Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System : ) •-• -------•-- ................................... ... ............ Lac tion-Address or Lot,No. 'e.,�n.. .. .��±�.-..... .4.Ya.IQ ......... . .......... ••--•-•- 1.�6►�►r,���{-----.5..P�.e���------M o--r-�-........:�_.��.. o Owne J -- Ad ress W o •-- :� ........ = - --- ------- - -- ....�t� .:C'.. �t..c�. E�. .. Installer Address Type of Building Size Lotl. ..0.0.0........Sq. f t Dwelling—No. of Bedrooms..........3------_-------------------Expansion Attic (A!o) Garbage Grinder ) per, Other—Type of Building ............................ No. of persons........................ Showers ( ) — Cafeteria ( ) Q' Other fixtures --------------• •---------.•.-• - W Design Flow..-. ........1 5-------------gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............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 ( ) 0-4 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...................----. Pd ..-- --•-•--•------••--•-----••-•------••--•••--••--•.............••••-•••...............•--...--•......................................................... O Description of Soil------ -•-- ......k_Q.q P_-+V-P..1AA•1-•-•-•••••..)•J_11e-.....i, hIIBC......Sm-n►d-............................... W c., ••••----•---•--•--•---•---•....•••-----------------,--•-•-----------•-•--•-•--••----.......-•--------.......--•---------•-••••------••------•-----•-•---•-----••-----••---•-•-•----•-•-••••-•--•-••------ w -•---------•---------------••-------------------......----------•---•-----•---.....---••••-••-••-------•---------------......•--------•-•-•---------•-•-•••-•-••------•-----------------•.............. VNature of Repairs or Alterations—Answer when applicable............................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT E 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 bo r of health. • S ned .... . ..'--- -------------- Application Approved By-----...• •-•••-. •t------•--.••-••-•-----•-•......................•---••••... //..DatS!J�-•.•••-- Application Disapproved r the- ollowing reasons:-.,-.,----------------------------------------------------------------------------------------•-•--••-----••-- ............•-•-••••--•-••---•---••--••-••-•-•-•---•-----••---••••--••---•••--•--••-•...-•••--`••--•------••-••--------•-•-------------••-••----•-•-----------•---••---------------•------•-•--•-•----- Date PermitNo......................................................... Issued-....................................................... Date 41, Nn........°: P FEB................._--..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................... .................OF.-....-..-..-.-.... .-.-.-.-.......... Appliratiou for Disposal Works C oustrurtiuu ramit Application is hereby made for-a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System a 'CrOXV.. 4 err rmoff Loca ion-Address f or Lot•No. jllo......�._ar...g. h�.�.r�.,.� .._. ... . .......... ...... i- �ti�!a..�� s P..r.n.�,�a �r�-----°-...11 A- ,,� Owner Add ess 7 a -• _.. ..._ ..._ Installer Address 3 Type of Building Size Lot_. ,,_9_*_�+_......Sq. feet" V Dwelling—No. of Bedrooms___________:__________________________Expansion Attic (NO) Garbage Grinder (49 Other—Type e of Building ____________________p-1 yp g ___.____ No. of persons__::___., ,________________ Showers ( ) — Cafeteria ( ) Q' Other fixtures. -------------------------------------•--------------- ................ ............................=-•-_•••••-••-••-....•-•-• W Design Flow..... . _.......... ..........gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............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........................ Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a --=----------------------- ••--•-----------=- O Description of Soil ..An.IS 'Cl xH =`#" ! .S!�t t tt------W 1-C------5.-�." x w ------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable................................................................................................ -------------------------------------------------------------------------------------------•-_---•-•--•-•-•-••--••-------•----------••-----•--•--••-••--•-----=•--•-•------•-••-•---•••-•--•--•...••••-• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha been issue by the boa of health. • D ApplicationApproved By................. •• .�.-- -----------•-------------•---------------------------•-•--- •••. ....... /ilowing Date Application Disapproved� the reasons-----------------------------------•-----------------------------------------------------------------.....•----- -•..............••--...._...--•••-•-•••---••••••--•-•--•-•--••---•••---•••---•-•-••-----•••---•-•-•••••-..___...__.._._...-•••---••••------••------•-•---•-•-•---•-•--- - s Date PermitNo.............:........................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................................OF..............................................................-.................. ..._ rrtifiratr of Tuutpliaurr T I T Ij/fi hat the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by----•....... .. .. . ....,.............. •------- a ---------••------•-•-••---_____----•-•--______________------•---•----••------------------------ Inst er at.......... •• ............... -•-••_••-- � ----------------------•------------------------------------ has been ins alled in accordance w,j 1 the provisions of," l� _ham State Sanitary `o in the application for Disposal Works Construction Permit i o_____________________________._____._._. dated__-. __ -_-___..__.._.._._._.__._.___._______ THE ISSUA CE F THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WIL TION SATISFACTORY. DATE.....& __ •--••-•- •--•-------------------••-•-••-------------------- Inspector..... ----•-------- ............................................................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................OF.................................................................................... / No... ................. FEE........................ Disposal r uutrurtiuu rrutit Permission is 'T y'granted...... ---•-•-• ... ---- .•.-----•---•-•..................................................... to Construct _ Repair ( n idu evf�ag f°lisposal s -•• at No.. ('� ... ---------- n Street as shown on th7appl' tion for Dis osal Works Con ction Permit No �" ated__________________________________________ foard of Health DATEf - ----------•-•-------•----- FORM 1255 HOBBS & WARREN. INC., PUBLISHERS hkSTE +:L t lAn,P_Jtl_G. vr*►1 rca QHnAA i4.J.i r.I ),I D _ ' • rG 1 r�nn a oF °rf= v Li=ss 4 J<spc� cPC Z, o S; erLA4 j J S - P r= - W a �. fi P vAT-vam La Ca E / �✓ 1 y o� /d 3 J 5,ocac, 5.F �. D 1 , a Wl I OQ l�fT M eL 1 �t3c, w 2s* •• o ,5 w t. .q L ei' 3 I, lo .5 1. $6.4 O S S . .. x s s. r• :, r L Ise+ V a � su . ,wIlTE�1. LOLAMOW PE-L PLAN OA*b At14y5T 1-1, 1 V 7 3 - HOLD I Ep[aE c,F..tom,-Lltw,C onvic aou, S'. _, - 4T'hfjL6 CO N4SQUAT70 wJ C1.71.A4A ICSICA IJ l L GEND EXISTING 8P0 EIEVATIO � ,�0"" `� C-E MI)r PLOT PLAN EXISTING CON OUR --- 0 -- -� � ' �� L�?T -7 Ci4�,✓ci2.o.V/3 rzo. FINISHED SP0 ELEVATION FINI SHED CONTOUR .O MQRs - IN APPROVED .BOARD OF : .HEALTH . A pNo:ra A s �rfseb: dL/ -7/ 3 NALtii'_ DATE AGENT S SCALES I "=4D� DATE.1 I2, LDREDGE ENGINEERING Ca IN K N. � A CLIENT I CERTIFY THAT THE PROPOSED EGISTERE RE 3 L%q j00 "O. 3 BUILDING SHOWN ON THIS PLAN CIVIL LAND CONFORMS TO THE ZONING LAWS DR BY: `�} ENGINEER SURVEYOR --------- OF BARNS LE , ASS. 4E dt <J .` 7.e3. 712 MAIN STREET : CH. BY1 :.._ 14 13 a'L , H YA N N I S, MASS. SHEET_L. OF-,.'' DATE G. LAND SURVEYOR I 1110TE /F E/TNL�R THE SEPT7C TAN�C,.OR" 20 FT. MIIIC.... �'E�4.GX/iVG' P/T. .4RE JJORE• 7WA."/ /2"BE40tV f . ' /O f7: M/N �"- GR.4 OEM A 24�O/•4 M E.TER CONCR E T.� CO vE.4' '. SWAL L BE B I?OCIGR T TO 4RA O.E.(14,V EXTRA ' q'PYE` PIPZ CONCRETE NEA vY CAST /RON C o i/ER Sf/A L L .!3E US EO' HL CoOYERS M/ T rr. IF/N ,DR/VEIVA Y . ( O 2� CONC,eE•TE' A . . ir- G1�Ao COVER CL EAN SAN LAP010 LEYELCA /RON P/PE /' f.�L! 0 v o GNIMtiIE( a o a e Qlr //g -.J�e" M/N.P/TtX GitL y o, o • • • a e4' yYASHFO 572�NE. D/ST. • PE/t r7:... SCPT/C`. TAN/C , s f • . . • . • t d BOX o r o f1 8 � r , • � r e f • .•EFFECT/✓C t • sp 314 ' r_lo�� ; � �flc�-t��..iG • ° i • •� DE.oTN,' • • ' • v o it�ASh►ED STaXE P17 Sk3'SreeE r a r •. • • • ► t 0'e o e ` cF r IEAc,r1{ PREC.AS T SEEPAGE !Nf/CR"1'•�L Ef�AT/DAYS �Z` 'L x 2 5 S(S.5 G/D ' ° ►• ' • • , . • ... • • • 'o P17 -Oq E4u/V. . a >=L -71.0 INYERT.AT'..O!//GD/N6 FT. 1 .1; `J7: PIAM. Z+ FT O//�l M. C SEE TABULATION, JNLET':SEPTK' Ti4NK 83.y FT Prrc.,4PA�rr ( �-7 S Co'. /P`, M ; 82: OtlTLET"SEPT/C TANK //VLET O/STR14VT/ON BOX 60-o FT SECT/ON_OF GROuNO: ITER TAeLE,; 0V7ZAETDI3TRfA&rWONBQX .S.OWA GE. OLSF�OSA L SY7&M S lNL6r LPrACN/NG. P/T -T7.o IcT T,gBULr1TlON L-RACHI ma Ja/r . SCAE FT L DES/GN CRITERIA N[IM 8ER OF BEDROOMS 3 DIMENSION C _FT. M� ti ritRQAGE D/SPO:SA1-UNIT NOW E SOIL LOG ` T4TAL EST/MATED F�OH/ 33o Gac./oAV SOf[. TEST 0/ SOIL 7ES7'#2 SD/L TEST IS(UMBER QF LEACNING PITS 1 f`E[EY. !`-ELFY, DATE GF soli- TEST . SLOELEAGHING PER PIT 22Co Sq FT CLLiS JACaS i (�4M RESULTS WI.TNESSFD dY BOTTOM LH1CH/NG PER P/T ( 1.3 FT d-! - .,o,� PERC04 AT/ON RATE, / LDS MJN�//NGN Tor44 LEACHING AREA 3'-'`� SO FT. �7 F-3EJlCOLAT/ON RATES 2 2 O M/N.//NCH RESERVEGEACNIN6AREA 33`? SQ. FT., FINE Qi=� ��1` T>=`"T �.[= P- 1 SS OF Mq� � n �r ,tiAns' 18 - 13L WHITE LD /T^ Cr4-P% v C2..USay /;-,p . 3, AL yc al S, r '�°WI �1 o CA �' CRSE I ,� .298740 a No.10951b O`Q EL DREDGE EMr-I ME�RING CO,I/YC. 4NosTg o� E N T. �� � L= ��.0 712 MA/ S sutt`� ��s`°_ ��' .[R . N06R0vNo yrATER ENCOUNTFREo CL/ENT: AfflA DRTE GROUND WATER AT ELE(/. ✓OB NO! SHE,ET?OF z-