HomeMy WebLinkAbout0018 CATS PAW WAY - Health 18 Cats Paw Way
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Commonwealth of Massachusetts
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W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments /
18 Cats Paw Way, Centerville
iGgM
Property Address a '
Don and Laurel Proto
Owner Owner's Name ,TI
information is 6
required for every - �w/tdj�� MA 02649 _August 7, 2015 �:
page. City/Town State Zip Code Date of Inspection ;mow
1-31
e-0
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms
on the computer, S/ ���
use only the tab 1. Inspector:
key to move your
cursor-do not David B. Mason
use the return Name of Inspector
key.
David B.Mason
r� Company Name
4 Glacier Path
Company Address
East Sandwich MA 02537
City/Town State Zip Code
508-367-1617 S1287
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
August 7, 2015
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 is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
""This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
�agp -V/
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
18 Cats Paw Way, Centerville
Property Address
Don and Laurel Proto
Owner Owner's Name
information is Mash pee MA 02649 August 7, 2015
required for every p 9
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The observations noted in this report represent the condition of the system only on this date of
inspection and the information contained herein does not guarantee the continued operation of the
system.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or 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):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
u v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
18 Cats Paw Way, Centerville
Property Address
Don and Laurel Proto
Owner Owner's Name
information is Mash pee MA 02649 August 7 2015
required for every p 9
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ 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):
brokenpipe(s) are re laced Y N ND (Explain
� N ❑ ❑ ❑ below):
obstruction i❑ s 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):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 18 Cats Paw Way, Centerville
Property Address
Don and Laurel Proto
Owner Owner's Name
information is Mash pee MA 02649 August 7, 2015
required for every p 9
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
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 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.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/day flow
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
18 Cats Paw Way, Centerville
Property Address
Don and Laurel Proto
Owner Owner's Name
information is Mash pee MA 02649 August 7, 2015
required for every p g
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°wM 18 Cats Paw Way, Centerville
Property Address
Don and Laurel Proto
Owner Owner's Name
information is Mash pee MA 02649 August 7, 2015
required for every p g
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
, M 18 Cats Paw Way, Centerville
Property Address
Don and Laurel Proto
Owner Owner's Name
information is Mash pee MA 02649 August 7, 2015
required for every p g
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d Yes
9 ( Y 9 (gp ))�
Detail:
2013; 72,000 gallons and 2012; 39,000 gallons. Note; one meter for property
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ® No
Industrial waste holding tank present? ❑ Yes ® No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°wM 18 Cats Paw Way, Centerville
Property Address
Don and Laurel Proto
Owner Owner's Name
information is Mash pee MA 02649 August 7, 2015
required for every p 9
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Board of Health
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1500
gallons
How was quantity pumped determined? sight glass on pump truck
Reason for pumping: Required to observe tank
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) 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):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 18 Cats Paw Way, Centerville
Property Address
Don and Laurel Proto
Owner Owner's Name
information is Mash pee MA 02649 August 7, 2015
required for every p 9
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
4 Years
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 10+feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 2
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 Typical
Sludge depth:
7"
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
18 Cats Paw Way, Centerville
Property Address
Don and Laurel Proto
Owner Owner's Name
information is Mash pee MA 02649 August 7, 2015
required for every p _ 9
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
40"
Scum thickness
6"
Distance from top of scum to top of outlet tee or baffle
3"
Distance from bottom of scum to bottom of outlet tee or baffle
10"
How were dimensions determined? Scour Stick
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Effluent level with outlet invert. Tank required pumping due to excessive material in the tank and
needed to pump to observe components and tees in the tank. Tank is 19 inches below grade and
risers are within 9" of grade.
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
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
18 Cats Paw Way, Centerville
Property Address
Don and Laurel Proto
Owner Owner's Name
information is Mash pee MA 02649 August 7 2015
required for every p g
page. City/Town. State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c�M 18 Cats Paw Way, Centerville
Property Address
Don and Laurel Proto
Owner Owner's Name
information is Mash pee MA 02649 August 7, 2015
required for every p g
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert effluent level with 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.):
No evidence of solids carryover. distribution box is 36 inches below grade and risers are on d-box
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 18 Cats Paw Way, Centerville
Property Address
Don and Laurel Proto
Owner Owner's Name
information is Mash pee MA 02649 August 7, 2015
required for every p 9
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 2
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
2-500 gallon chambers with 4' stone. No signs of hydraulic failure or ponding.
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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 18 Cats Paw Way, Centerville
Property Address
Don and Laurel Proto
Owner Owner's Name
information is ee Mash
required for every P MA 02649 August 7, 2015
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 18 Cats Paw Way, Centerville
Property Address
Don and Laurel Proto
Owner Owner's Name
information is Mash pee MA 02649 August 7, 2015
required for every p 9
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
'M 18 Cats Paw Way, Centerville
Property Address
Don and Laurel Proto
Owner Owner's Name
information is Mash pee MA 02649 August 7, 2015
required for every p 9
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: None at 12'
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: 8/20/20111
Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
Groundwater Contour Map
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Groundwater Contour Map. Viewed engineer plan on file with the Health Department.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 18 Cats Paw Way, Centerville
Property Address
Don and Laurel Proto
Owner Owner's Name
information is Mash pee MA 02649 Au
required for every p gust 7, 2015
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Assessing As-Built Cards Page 1 of 2
i
TOWN OF BARNSTABLE
LOCATION "0' C-47f SEWAGE#
VILLAGE C� ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY X So o t9 4e-,,'
LEACHING FACILITY:(type) (size) l 3 X sT J'X o't
NO.OF BEDROOMS 3
OWNER
PERMIT DATE: -a 6// COMPLIANCE DATE:
Separation Distance Between the: ,yioN.,gr Xa
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) .111, Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY
i
i
45
0 t
0 50
0
http://town.bamstable.ma.us/Assessing/HMdisplay.asp?mappar=192111&seq=2 7/31/2015
YOU WISH TO OPEN A BUSINESS?
For Your Intorn-iation: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOU NQME'in townr [which you
must do by M.G.L.- it does not give you permission tooperate'.)
`mot i5J-'. {
operate.)J You must first obtain the ne.ce.�ssary signatures on this form at. -)O ran a"iim 5t , Hyannis.
Take Ihe required b�� Iahti�feel foram to the. Town Clerk's Office, 1st. FI. 3671viain St., Hyannis, MAC?2GO1 (Town Hall) and g�f7thej.B 1,Sin 1. fffri�ic<�te that is
rcu ir
k n, DATE: �� Fill in please.
A'. APPLICANT'S YOUR NAME S: �!
BUSINESS YOUR HOME ADDRESS: C _ Ir r �� t _ ta1 • 4z. "- '
f
TELEPHONE # Home Telephone Number b `
NAME OF CORPORATION:. :. :
NAME OF NEW BUSINESS. j'c?N LN ivy sc.Ja A .V TYPE OF BUSINESS /�Ivc Sc
IS THIS A HOME OCCUPATIONS YES NO C
ADDRESS OF BUSINESS C S �� '�- ��G 1 -✓v r�'�.��r 6�'171 MAP/PARCEL NUMBER (Assessing]
When starting a new business there are several things you must do in order to be in compliance with the rules and.regulations of'the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth
Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town.
1. BUILDING COMMISSIONER'S OFFI MUST COMPLY WITH HOME OCCUPATION
This individu I h_ rSe n nform o� telpAr uirem nts that ertain to this e of RU -
q p type business. RULES AND REGULATIONS. FAILURE TO
! �' OMPLY MAY RESULT IN FINES.
Auth eFz�d Si atu e
COMMENTS , `
% o Av
2. BOARD OF ALTH
.This individual ha be yn n r ed pe r re, is that pertain to this type of busines�
uthorized Si ature*
COMMENTS:
3. CONSUMER AFFAIRS(LICENSING AUTHORITY)
This individual has feery((nformed of t he censi g requirementshat pertain to this type of business.
Authorized Signature**
COMMENTS:
Date:5 /t7 / 13
TOWN OF BARNSTABLE ficQ; *rt�
TOXIC AND HAZARDOUS MATERIALS ON-SITE
NAME OF BUSINESS: Cd rcnr Z4n•c1 Sal- ;,
BUSINESS LOCATION: C -s w w0,1 INVENTORY
MAILING ADDRESS: "� -'111;k r TOTAL AMOUNT:
TELEPHONE NUMBER: 7 7�1 - �-6 7 - '2 6
CONTACT PERSON: p o_ oz c �dZ /
EMERGENCY CONTACT TELEP ONE NUMBER: 508 w 367 7� "'�MSDS ON SITE?
TYPE OF BUSINESS: 2- Aw �Sc/} f�.�-+.�g
INFORMATION/RECOMMENDATIONS: Fire District:
Waste Transportation: Last shipment of hazardous waste:
Name of Hauler: Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The board of health and the Public Health Division have determined that the following products exhibit toxic or
hazardous characteristics and must be registered regardless of volume.
Observed / Maximum Observed / Maximum
Q Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive
❑ NEW ❑ USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
❑ NEW ❑ USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers)
Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED j
Miscellaneous petroleum products: grease,
Photochemicals (Developer)
lubricants, gear oil ❑ NEW ❑ USED
Degreasers for engines and metal Printing ink
Degreasers for driveways &garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Miscellaneous Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt& roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (including carbon tetrachloride)
❑ NEW ❑ USED Any other products with "poison" labels
(including chloroform, formaldehyde,
Paint&varnish removers, deglossers hydrochloric acid, other acids)
Miscellaneous. Flammables Other products not listed which you feel
Floor&furniture strippers may be toxic or hazardous (please list):
Metal polishes j" Jg't ( (o/�j " vLsU /i/V{�
Laundry soil &stain removers
(including bleach)
Spot removers &cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Windshield wash
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS App s Signature Staff's Initials
r
,�
No. qV¢ I�� ��� Fee r
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Application for Xh6pogar 6pgtem Comaruction Vermtt
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) LJ Complete Sy/em ❑Individual Components
Location Address or Lot No. ei4�"` /d� lf*'514y Owner's Name,Address,and Tel.No.
®e/.� �04OT�
p CI�Nl '
Assessor's Map/Parcel
Installer's Name Address,and Tel.No. Des' ner's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder ( )
Other Type of Building lyE No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 3 3 o gpd Design flow provided 3 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 thi o d of He th.
Sign Date CP
Application Approved by Date
Application Disapproved by: Date
for the following reasons
Permit No. ®'`�� Date Issued
.. � •-, �, � _ ..:.,,�, .,.. _,,.. ..�..... ;+tip.,.. ,
1 3 "°�`• - fit
2
No.
r� .. Fee Mi.
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE,,MASSACHUSETTS Yes
ZIPPYication for �Dtgpogal *pgtem Construction Vermit
Application fgva4ermit to Construct( ) Repair( ) Upgrade( ) Abandon( ) 2 Complete System ❑Individual Components
Location Address or Lot No.,"� (=`o4l �/ G�/�y 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.
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) 3 3 gpd Design flow provided 3-/ 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)
t
I
i" 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 thi oard of He lth.
Sign G Date
Application Approved by l DateCj ^ ( I
Application Disapproved by: Date pp
for the following reasons
Permit No. O' 6[ Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
-- BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (!/< Upgraded ( )
Abandoned( )by
at G.q7✓ ',,f AV low has been constructed i accordance p
with the`prowi�sions of Title 5 and the for Disposal System Construction Permit No. dated
Installer�Ylj7«�06`l/ DesignerQJ�101 ,0 ,Pe,4 �Y'
#bedrooms 3 Approved design flow gpd
i
The issuance of this permit shall not be construed as a guarantee that the system will u cti• s signed.
--
Date t. Inspector
1
'No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
&5poga1 ,pgtem Cougtruction Vermit
Permission is hereby granted to Construct ( ) Repair (Upgrade ( ) Abandon ( )
System located at G i01� �iC�� !?ice % G i✓1;
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this permit.
Date ^ " Approved by lf�
I
Town of Barnstable
Regulatory Services
Thomas F_Geiler,Director
8 Public Health Division
K
" . Thomas M Kfto,Dtreetor
200Maiffi Street Hyannis,MA 02601
Office: 50$ 62 644 fax: 508-790-6304
SewageJPerm1t#-20--"—o Assessor's Map/Parcel
Installer_ _219mer Certifleation Form
Designer: f staller: --Ti �Cmrvp
Address: FA 1 M GWWAddress:
�,ACHH
on "� ` 'l was issued a permit to install a
(date) . i cr
s�rtic system at C*iG based on a design drawn by
ICU dates
( �) - ,
I ce ufy that the septic system rahren above was installed substantially according to
the de&M winch may include ininor Wrovod changes such as lateral relocation of the
distribution box andler septic tarnk. Stripout (if required) was inspected and &c soils
were found satisfactory.
I certify that the mptic system refereed above was installed with;major changes(i.e.
greater d=10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with Mate&Local Pt -lotions. Plan mvis►on or
certified as-built by designer to follow. Stripout(if re- -acted and the soils
w ound satisfactory. .ETA Of
DAVID
t&Ucr sSignature) MASON
g no.toss
� r
;;�'$ Sip .-
PLE"E RET1W TO-A& WILLlELTAB f_�� ��V i ii.
RECEWED BY TM—MNSTABLE PUBf.f
TH&M You,
q.inffi c Wrial ftm*c
Town of Barnstable pit
Department of Regulatory Services
a n„gn a,.E.: Public Health Division Date AvA. 17. 2011
y NA9.4
639, `0� 200 Main Street,Hyannis MA 02601
Date Scheduled / Time Fee Pd.—
Soil Suitability
Assessment for Se a Disposal
m
Perfored By__D J �. �'`�W y�� Witnessed By:
LOCATION&GENERAL INFORMATION
Location Address I� `, ' Owner's Name
Address t
Assessor's Map/Parcel: �2 ',VI ` Engineer's Name
NEW CONSTRUCTION REPAIR io/ Telephone#
Land Use Slopes(%) Surface Stones
Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well 11
Drainage Way ft Property Line ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
I
I
I
I
( I #Z
1 �
Parent material(geologic)_Dy/W L:�H ep(h to Bedrock /C /
Depth to Groundwater: Standing Water in Hole:�- Weeping from Pit Face All
Estimated Seasonal High Groundwater r 6-� /
DETERMINATION FOR SEASONAL HIGH WATER TABLE
Method Used:
Depth Observed standing in obs.hole: in. Depth to soil mottles: in.
Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft.
Index Well# Reading Dale: Index Well level Adj.factor Adj.Groundwater Level
PERCOLATION TEST Date Time
Observation
Hole# ! Time at 9"
Depth of Pere I Time at 6" -
Start Pre-soak Time @ Time(9"-6")
End Pre-soak
RateMinllnch z RA411'I �h
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N)
Original: Public Health Division Observation Hole Data To Be Completed on Back-----------
***If percolation test is to be conducted within 100'of wetland,you must first notify the
Barnstable Conservation Division at least one(1)week prior to beginning.
Q:\S EPTIC\PERCFORM.DOC
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%Gravel
14
t �
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%Graven
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency%Graven
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency%Graven
Flood Insurance Rate Mao: 1/
Above 500 year flood boundary No , Yes
/ f�
Within 500vear boundary No V Yes
Within 100 year Flood boundary No Yes
Depth _
Depth of Naturallv Occurring Pervious Material
Does at least four feet of naturally occurring pervi u mat rial exist in all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the depth of naturally occurring pervi its material?
Certification
l certify that on b (date)I have passed the soil evaluator examination approved by the
Department of Env ental Protec irom tion and that the above analysis was performed by me consistent with
the required training,exp ise a d ex enence described in 310 CMR 15.0((17. t
Signature Date V oil
yr ,
1 �
Q:\S E PTIC\PERCFORM.DOC
a
TOWN OF BARNSTABLE
LOCATION f�` �T� ®�K �''�� SEWAGE#
VILLAGE ' ASSESSOR'S MAP&PARCEL "-Z
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS 3
OWNER ,0 0 ,-?vfo
PERMIT DATE: ep".Z 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
O
O
yob 5r oz
00��
F
LO�C A ION SEWAGE PERMIT NO.
V'; G 2^ ��
VILLAGE
INSTALLER'S NAME & ADDRESS
BUKDER OR 0 NER
DATE FOERMIT ISSUED
DAT E COMPLIANCE ISSUED _,S- _ 7 7
�6
� � � d ���/
ASSESSORS MAP : LOGS—
PARCEL:
NOTES:
TEST HOLE
-
`� SO I L EVALUATOR: I AYI 1) The installation shall comply with Title V and Town of Barnstable Board of
FLOOD ZONE r._ /� ' WITNESS : Health Regulations.
l
REFERENCE: ;el DATE : T '� 2) The installer shall verify the location of utilities, sewer inverts and septic
- - components p g
prior to installation and setting base elevations.
PERCOLATION RATE: ..z !
C�� - ----- 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8"per foot. The first
..._..........
�?�, / /�G� f �„// , �� ve' '�Q 1l%{• �0 5 two feet out of the d=box to the leaching shall be level.
/ -- -- - ----- TH- I TH-2 4) This plan is not to be utilized for property line determination nor any other
5 0 purpose other than the proposed system installation.
Liz 5) All septic components must meet Title V specifications.
6) Parking shall not be constructed over H10 septic components.
434 7) The property is bounded by property corners and property lines.
�0419 8) The property owner shall review design considerations to approve of total
LOCATION MAP Gi 2�`� b t7 C j design flow and number of bedrooms to be considered for design. Receipt
` Z, of payment for the plan and installation based on the plan shall be deemed
' approval of the design flow by the owner.
/ G2 w rt t,�Gti / pp
Zvk 9) The existing leaching or cesspools shall be pumped and filled with material
Lrlpl ,c � '''� ►' per Title V abandonment procedures. Those within the proposed SAS shall
be removed along with contaminated soil and replaced with clean sand per
Title V specs.
10)System components to be 10 feet from water line. Sewer lines crossing the
water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if
applicable. The proposed SAS is being installed below the water service
C SYSTEM S T E NI DESIGN line. The line is to be sleeved as aforementioned and maintained in place.
SEPT I
d 11) If a garbage grinder exists it is to be removed and is the responsibility of the
\� 9� owner to ensure such.
f� FLOW ESTIMATE 12)The installer is to take caution in excavation around the gas line if such
exists.
f
l X� BEDROOMS AT 110 GAL/DAY/BEDROOM - ?J'� GAL/DAY 13)The installer shall verify the location, quantity and elevation of the sewer
lines exitingthe dwellingprior to the installation.
d�e— —_ SEPTIC TANK 14)The installer is to determine if other sewer lines exiting the structure exist
_ and if so, to be re-plumbed or tied into the septic tank.
aGAL/DAY x 2 DAYS GAL
USE ICE GALLON SEPT I C TANK
ACT AUD�-
w►a.
I L ABSORPTION SYSTEM
SIDE DE AREA: X IjJ�- �1 i 0�=Mq
- , - �-
BOTTOM AREA.
g� °
� .� � � � .� Z �, � DAVI .��
t7_ �G Ac7 l D -- N
-- -� EPTIC SYSTEM SECTION _. ru�a 'T
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/�� GAL �`(�j9j?
, . � l._��,� .,�� w,+ � � �.1•. _tip , . I f. �,�
SEPTIC TANK _ VIt� l
h 1K _ 41 I:, Wye
SITE AND SEWAGE PLAN
_ o LOCAT I ON : 1 . PTwG '_PAV4 WAY
.J
PREPARED FOR : 1ti �ctowl:�- 6&Fn
M ` .c I
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SCALE: '
.,�-�..._. _ DAV I D B . MASON T2,, : DATE: 1
z ) DBC ENVIRONMENJfAL DESIGNS
W '� D EAST SANDWICH . MA
ATE HEALTH AGENT
W ( 508 ) 833- 2177
y �