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0 YOU WISH TO OPEN A BUSINESS? G 7 I710k
For Your Information: Business certificates (cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which
you must do by M.G.L.-it does not give you permission o usiness Certificates are available at the Town Clerk's Office, 1"FL., 367
Main Street, Hyannis, MA 02601 (Town Hall)
, 1 DATE:
Fill in please:
APPLICANT'S YOUR NAME:
FN BUSINESS YOUR HOME AD RES.S: !O C
TELEPHONE # Home Telephone Number7Z 6 -S6 Q`
NAME OF NEW BUSINESS �!� TYPE 13.F BUSINESS_
IS THIS A HOME OGCUPATION?? !�- YES NO
; o
YES: :
ADDRESS OF BUSINESS MAP/PARCEL NUMBER
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 COMMWuhorized
ER'S OFFICE
This individualenkin e of any permit requirements that pertain to this type of business.
Azd
e tore*
MMENTS: R�
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i
2. BOARD OF HEALTH
This individual h be n info of th rm-it requirements that pertain to this type of business.
Authorize nature*
COMMENTS:
3. CONSUMER AFFAIRS LICENSING AUTHO )
This individual ha.. n info r dof the n r. u' ements that pertain to this type of business.
Authorized Signature**
COMMENTS:
y'
Date: 7/ j / lac
TOWN OF BARNSTABLE
TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY
NAME OF BUSINESS: `) AAA �f s Z1�1� ��--,e
BUSINESS LOCATION: Cx11 -c Dr. Cam' _e-rI/ We m-4- 1U3ZINVENTORY
MAILING ADDRESS: I u ®r• • l� 01A , 02d33ZZJOTAL AMOUNT:
TELEPHONE NUMBER:
CONTACT PERSON. ...
EMERGENCY CONTACT TELEPHONE NU BER: MSDS ON SITE?
TYPEOFBUSINESS: -�`''-�S��-De
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 materials use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health and the Public Health Division have determined that the following products exhibit toxic
or hazardous characteristics and must be registered regardless of volume.
Observed/Maximum Observed/Maximum
Antifreeze (for gasoline or coolant systems) Misc. 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 US D (insecticides, herbicides, rodenticides)
Gasoline, Photochemicals (Fixers)
Diesel Fuel, kerosene, #2 heating oil NEW USED
-- -- ---- --- _Misc..-petro.l.eum_pCoducts:_grease, Phot_ochemicals (Developer)
lubricants, gear oil NEW USED v
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 Misc. 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 (inc. carbon tetrachloride)
NEW USED Any other products with "poison" labels
Paint & varnish removers, deglossers (including chloroform, formaldehyde,
Misc. Flammables hydrochloric acid, other acids)
Floor & furniture strippers Other products not listed which you feel
Metal polishes may be toxic or hazardous (please list):
Laundry soil & stain removers 6��-cJ<
(including bleach)
Spot removers &cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Windshield wash
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION RECEIVE®
Property Address: 10 Cyrus Drive MAY 2 3 2002
Centerville,MA 02632
Owner's Name: Jason Michonski TOWN OF BARNSTABLE
Owner's Address:PO Box 2087 HEALTH DEPT.
Cotuit,MA 02635
Date of Inspection:05/07/02 `T 4V I
Name of Inspector: (please print)Janet E.DuPont
Company Name:Wind River Environmental
Mailing Address: 120 Great Western Road MAPl Z
South Dennis,MA 02660
Telephone Number: 508-760-4827 PARCEL
CERTIFICATION STATEMENT LOT
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true,accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5
(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: LDate: OZ—
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of
Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a
design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the
appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to
the buyer,if applicable,and the approving authority.
Notes and Comments: While this system passes title V regulations at the time of inspection,the leach
field is approximately'/2 full even though it was installed in 1998. This could be due to soil conditions
surrounding the leaching area. I would suggest also that the owner consider eliminating the extra
driveway and parking area as the leaching system may not be constructed to hold up to such activity.I
would also suggest adding a filter to the outlet of tank to prevent future contamination of SAS by solids.
****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.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 10 Cyrus Drive
Owner:Jason Michonski_
Date of Inspection: 05/07/02
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_X_ I have not found any information which indicates that any of the failure criteria described in 310
CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced
or repaired.The system,upon completion of the replacement or repair,as approved by the Board of
Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"
please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is
structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board
of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to
broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass
inspection if(with approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 10 Cyrus Drive
Owner.Jason Michonski
Date of Inspection:05/07/02
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require Rirther evaluation by the Board of Health in order to determine if
the system is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(l)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines
that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet
of a surface water supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 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:
f -
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 10 Cyrus Drive
Owner:Jason Michonski
Date of Inspection: 05/07/02
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or`no"to each of the following for all inspections:
Yes No
_X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or
cesspool
X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an
overloaded or clogged SAS or cesspool
_X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged
SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day
flow
_X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed
pipe(s).Number of times pumped
_X_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
_X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply.
X_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private
water supply well with no acceptable water quality analysis. (This system passes if the well
water analysis,performed at a DEP certified laboratory,for coliform bacteria and
volatile organic compounds indicates that the well is free from pollution from that
facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis
must be attached to this form.)
_No_(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist
as described in 310 CMR 15.303,therefore the system fails.The system owner should contact
the Board of Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to
15,000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
— _ the system is within 400 feet of a surface drinking water supply
— _ the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or
a mapped Zone lI of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or
answered"yes"in Section D above the large system 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.
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 10 Cyrus Drive
Owner:Jason Michonski
Date of Inspection: 05/07/02
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
X_ _ Pumping information was provided by the owner,occupant,or Board of Health
X_ Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period?
X Has large volume of water been introduced to the system recently or as part of this inspection?
_X_ _ Were as built plans of the system obtained and examined?(If not available note as N/A)
_X_ _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out?
X _ Were all system components,excluding the SAS,located on site?
_X_ _ 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?
X_ _ Was the facility owner(and occupants if different from owner)provided with information on
the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined
based on:
Yes No
X_ _ 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(3)(b)]
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 10 Cyrus Drive
Owner:Jason Michonski
Date of Inspection: 05/07/02
FLOW CONDITIONS
RESIDENTIAL
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
Number of current residents:_2_
Does residence have a garbage grinder(yes or no):No
Is laundry on a separate sewage system(yes or no):No [if yes separate inspection required]
Laundry system inspected(yes or no):_
Seasonal use:(yes or no):No
Water meter readings,if available(last 2 years usage(gpd)):_2000-50,000 gal. 2001- 112,000 gal.
Sump pump(yes or no):No
Last date of occupancy:Current
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): opd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records 4/17/98 6/10/98 9/6/2000
Source of information:Town of Barnstable treatment plant
Was system pumped as part of the inspection(yes or no):no
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract
(to be obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if known)and source of information: Tank and D-box
approx. 15 yr-20 years Leaching installed in 1998 per Barnstable BOH
Were sewage odors detected when arriving at the site(yes or no):No
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 10 Cyrus Drive
Owner:Jason Michonski
Date of Inspection:05/07/02
BUILDING SEWER(locate on site plan)
Depth below grade:2.5'
Materials of construction:_cast iron _X_40 PVC_other(explain):
Distance from private water supply well or suction line:more than 10'
Comments(on condition of joints,venting,evidence of leakage,etc.): No evidence of back-up seen,no
signs of leakage_
SEPTIC TANK:_X_(locate on site plan)
Depth below grade:6"_
Material of construction:_X_concrete_metal_fiberglass_polyethylene
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a
copy of certificate)
Dimensions: 1000 gallon
Sludge depth:6"
Distance from top of sludge to bottom of outlet tee or baffle:2'
Scum thickness: 34"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 7"
How were dimensions determined:_probe_
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 appeared sound,concrete baffles,
no signs of leakage,liquid at invert of outlet.
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,
liquid levels as related to outlet invert,evidence of leakage,etc.):
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 10 Cyrus Drive
Owner:Jason Michonski
Date of Inspection: 05/07/02
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:_X_(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:Liquid at 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.):D-box appeared sound with no signs of leakage into or out of
box,water levels in box appear to have been constant and at outlet level.
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
f
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 10 Cyrus Drive
Owner:Jason Michonski
Date of Inspection:05/07/02_
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:_
X leaching chambers,number:3 chambers called"maximizers",surrounded by stone
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.):No signs of hydraulic failure on ground surface, top of stone level at 29"below surface,
did hit leachate with probe 9"below that. Due to concern over water level I ran a sewer camera from the
D-box into the maximizer and found them to be at least'/2 full. Observed water flowing freely through
system and into leaching.
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: (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.):
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 10 Cyrus Drive
Owner:Jason Michonski
Date of Inspection: 05/07/02
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. �;� �--- G� RUS ---�
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C
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 10 Cyrus Drive
Owner:Jason Michonski
Date of Inspection: 05/07/02
SITE EXAM
Slope -level ground
Surface water-none
Check cellar-dry
Shallow wells-none found
Estimated depth to ground water 17.3+feet from bottom of SAS
Please indicate(check)all methods used to determine the high ground water elevation:
_Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
_X_Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
X Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Data on file at Barnstable board of health shows site elevation at about 68'A.S.L.
Assumed bottom of leaching=29"+48"=6.4'below surface= 61.6 A.S.L.
Groundwater per map on file Barnstable BOH dated June 1992 shows groundwater in that area at 35'
A.S.L.
Groundwater in that area monitored by well SDW 252
Adjustment per Barnstable BOH for that area in June 1992 was 9.3'
61.6(bottom of SAS)—35'+9.3' = 17.3'
.��INE Town of Barnstable
Department of Health, Safety, and Environmental Services
BAMSTABU,
� Public Health Division
��DN1�a P.O. Box 534, Hyannis MA 02601
Office: 508-790-6265 Thomas A.McKean,RS,CHO
FAX: 508-790-6304 Director of Public Health
April 1, 1998
Mr. Bob Trask
C/o Lisa Hanson
Realty Executives
Harwich East Center
Juct. 137 & 39
East Harwich, MA 02645
ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL
CODE, TITLE 5.
The septic system owned by you located at 10 Cyrus Drive, Centerville was inspected on
March 24, 1998, by Troy Williams, a Massachusetts licensed septic inspector.
The inspection of your septic system showed that your system has failed under the
guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• The wastewater effluent liquid depth in the leaching pit was less than six(6")
inches below the invert and there was a back-up of sewage into the facility or system
component due to an overloaded or clogged leaching pit.
You are directed to hire a licensed Town of Barnstable septic system installer to submit a
sketch diagram of a proposed system to the Town of Barnstable Health Division Office
(Town Hall, 367 Main Street, Hyannis)that will bring the septic system into compliance
with 310 CMR 15.00, The State Environmental Code, Title 5 within(30)thirty days of
receipt of this notice.
You are also directed to bring the septic system into compliance within sixty (60) days of
receipt of this order letter.
You are further directed to maintain the system by hiring a licensed septage hauler to
pump the septic system to prevent discharge of sewage or effluent into the buildings, onto
the surface of the ground, or in to surface waters.
l
Any person aggrieved by any order issued by the local approval authority may appeal to
any court of competent jurisdiction as provided for by the laws of the Commonwealth.
PER ORDER OF THE BOARD OF HEALTH
j
Thomas A. McKean,
Agent of the Board of Health
q\health\dbfiles\title5 i.doc
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111�4—C &
TROY WILLIAMS X0
SEPTIC INSPECTIONS ><2
H �
Certified by MA Department of Environmental Protection 3-55-1300
19 Hummel Drive �4
South Dennis, MA 02660
COMMONWEALTH OF MASSACHUSETTS
�r9
A�q Z9 4
EXECUTIVE OFFICE OF ENVIRONMENTA AIRS' �c<`
DEPARTMENT OF ENVIRONMENTAL PR _ > ON_ IRV
ONE WINTER STREET. BOSTON. MA 02108 617.292-5500 -
WILLIAM F.WELD Governor TRUDY CORE
Secretary
ARGEO PAUL CELLUCCI
Lt.Govemor DAVID B.STRUHS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioncr
PART A
CERTIFICATION
Property Address: '0 C Y''`�S 0". C,_„ 4- "� f G Address of Owner:CIS.000) �IIL
iK1 k
Date of Inspection: 3 1.2e/ 1S8 (If different)
Name of Inspector: Troy W 1 11 i a m S Or.s o"
I am a DEP approved system inspector pursuant to Section 1S.340 of Title S (310 C EX. t v� C s
Company Name- Troy .Wi11ialils Septic Inspections
MailingAddress: 19 HIIMMpl DriVa_ SOrtthDPnniS MA 02660Telephone Number: f n R 1_ ) 185-1300 37 3yCERTIFICATION STATEMENT "w"�+� M �zG`/S
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 inspection: The inspection was performed based on my training an\ experience in the proper fikion and
maintenance of on-site sewage disposal systems. The system:
_ Passes
_ Conditionally Passes
_Needs Further Evaluation By the Local Approving Authority
I[ Fails
Inspector's Signature: Date: 2 1.2
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, 8, C, or D:
A) SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
61 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.
Indicate yes, no, or not determined (Y, N,or ND). Describe basis of determination in all instances. If'not determined', explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
tr..t..a o�/lsit�t
�, P•q• 1 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Addr 10 Cyrus Drive,Centerville,MA ess: Bob Trask
Owner: March 24, 1998
Date of Inspection:
B] SYSTEM CONDITIONALLY PASSES (continued) A1119
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
CJ FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N//9
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND 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, It APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply.or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid).
3) OTHER
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 10 Cyrus Drive,Centerville,MA
Owner: Bob Trask
Date of Inspection: March 24, 1998
DI SYSTEM FAILS:
You m st indicate ei;,.er "Yes" or "No" as to each of the following:
1 have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
_ Backup of sewage into facility or system component due to an 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.
IY6 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
L -- L ►o:t
_ Liquid depth in c4es4peel•is less than 6" below invert or available volume is less than 112 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped _.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
/✓119 Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
N19 Any portion of a cesspool or privy is within a Zone I of a public well.
N/� Any portion of a cesspool or privy is within 50 feet of a private water.supply well.
N 9 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. 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.
El LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revis*d 04/25/97) p•n• 1 ^� ^
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM
PART B
CHECKLIST
10 Cyrus Drive, Centerville,MA
Property Address: Bob Trask
Owner: March 24, 1998
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes, No
Pumping information was provided by the owner, occupant, or Board of Health.
�L _ None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into.the system recently or
as part of this inspection.
/yam/ As built plans have been obtained and examined. Note if they are not available with WA.
_ The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
_ All system components, excluding the Soil Absorption System, have been located on the site.
✓ _ 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 Soil Absorption System on the site has been determined based on:
_ The facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of
/ Sub-Surface Disposal System.
_ Existing information. Ex. Plan at B.O.H.
�L _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) (15.302(3)(b))
(r.v1..d 04/25/97)
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 10 Cyrus Drive,Centerville,MA
Owner: Bob Trask
Date of Inspection: March 24, 1998
RESIDENTIAL: FLOW CONDITIONS
Design flow: 3-70 e.p.d./bedroom for S.A.S.
Number of bedrooms: 3
Number of current residents:
Garbage grinder (yes or no):_ZVo
Laundry connected to system (yes or no): y=S
Seasonal use (yes or no):L/-
Water meter readings, if available (last two (2) year usage (gpd): �j 7= �/ yu o
Sum Pump �'4 ��°
P P (Yes or no): a, r 96 4
Last date of occupancy: 6 U e d .
COMMERCIAUINDUSTRIAL• N/4
Type of establishment:
Design flow: ¢allons/day
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:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source/of information: / n/1U V Yti a ✓.G r h TL Cw✓0. . 11- I /- 4 T ' rh C�0. /L ✓G c.�
System pumpedras pan of inspection. (yes or no) A/o
If yes, volume pumped: Gallons
Reason for pumping:
TYPE QF SYSTEM
Septic tank/diatr4yd6ew-be,Jsoil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information:
1—; I � C-e/��6X. l 57Y, , o
Sewage odors detected when arriving at the site: (yes or no) /vO
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 10 Cyrus Drive, Centerville,MA
Owner: Bob Trask
Date of Inspection: March 24, 1998
BUILDING SEWER: N
(Locate on site plan)
Depth below grade:
Material of construction: _cast iron _ 40 PVC _• other (explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:_
(locate on site plan)
Depth below grade:
Material of construction: Zoncrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance (Yes/No)
Dimensions:_
Sludge depth: ---
Distance from top of sludge to bottom of outlet tee or baffler/L
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: /u� /w a./ 4- L, 4 ,L«
How dimensions were determined: __ A—a 16e.
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, etc.)(f t` �4-
l� J✓� Ih 01-J� - n�
iCA
- � I f1 S � � vL /uca v IL Acf �cc r ti c //
a. u �,o l� o f s•, �—
GREASE TRAP:-/L9 w o✓h y o r d�v S. s d b< e- 5 /Q
(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:
(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, etc.)
(rwio.d 04/25/97) •
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 10 Cyrus Drive,Centerville,MA
Owner: Bob Trask
Date of Inspection:March 24, 1998
TIGHT OR HOLDING TANK: AJ//q (Tank must be pumped prior to, or 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 level: Alarm in working order Yes; No
Date of previous pumping: — —
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
(locate on site plan)
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, etc.)
PUMP CHAMBER:A//�/g
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms in working order (Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(r—iud 04/25/91)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 10 Cyrus Drive, Centerville,MA
Owner: Bob Trask
Date of Inspection:March 24, 1998
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:
Type:
leaching pits, number:v hh z 6 L .o
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:�_
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure�,/level oflpondiing, condition of vegetation, etc.)
G v` t f J r' Gw.r p�./ ti cJ` --�- 2
CESSPOOLS: A///,
(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 (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY: JI,1119
(locate on site plan)
Materials of construction:
Depth of solids: Dimensions:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(r.v1..d 04/25/97)
P•4. ! of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 10 Cyrus Drive, Centerville,MA
Owner: Bob Trask
Date of Inspection: MarCh 24, 1998
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
i
1,3c�c.lti_
33 '
a
/Uu.0�aIlu ti
3�
(r—i..d 04/25/97)
P.q• 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 10 Cyrus Drive,Centerville,MA
Owner: Bob Trask
Date of Inspection: March 24, 1998
Depth to Groundwater= Feet adjusted high groundwater level
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
V/Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how you establishedthe High Groundwater Elevation. Must be completed)
5 7 h a l-c U
L)��.
P.p• 10 of 10
No. Z ] Fee$5 0 . 0 0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
ZIppYtcation for Migpogal *pgtem Comaruction Vermtt
Application for a Permit to Construct( )Repair(x)o Upgrade( )Abandon( ) ❑Complete System El Individual Components
Location Address or Lot No. 10 Cyrus Drive Owner's Name,Address and Tel.No. 7 6 0—5 8 91
Assessor'sMap/Parcel Centerville, MA Robert Trask 10 Cyrus Drive
41 -hfl
Centerville, MA 0263
Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No.
W E Robinson Septic Sry
PO Box 1089 , Centerville, MA 0263
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(no
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil sand
Nature of Repairs or Alterations(Answer when applicable) Title 5 Leaching consisting of
D—bx, and three stonepacked maximizers.
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of H lth.
Signed w Date
Application Approved by e Date
Application Disapproved for the following reasons
Permit No. 177 oo,— Z C 3 Date Issued y 07--%pr,
TOWN OF BARNSTABLE
LOCATIbN,> V C / y S Z SEWAGE #
VILLAGE:; c:�— T• ASSESSOR'S MAP&LOT 1
INSTALLER'S NAME&PHONE NO. o' t—
SEPTIC:TANK CAPACITY 16 6-e
LEACHING FACILITY: (type) .,ya-.a /moo ' (size)
NO.OFBEDROOMS
BUILDEk OR OWNER Q
PERMIT;DATE: COMPLIANCE DATE:
Separatioh.-Mlance Between the:
Maximum;-Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private,Water'Supply Well and Leaching Facility (If any wells exist
on site<or.mithin 200 feet of leaching facility) Feet.
Edge ofWetland and Leaching Facility(If any wetlands exist
within:3W feet of leaching facility) Feet
Furnished'tiy;
1
I
No. — Fee$50.00
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01pplication for �Wgoml *p!tem Construction Permit
Application for a Permit to Construct( )Repair(x.,�Upgrade( )Abandon( ) ❑Complete System El Individual Components
Location Address or Lot No. 10 Cyrus Drive Owner's Name,Address and Tel.No. 7 6 0—5 8 91
Assessor'sMap/Parcel Centerville, MA Robert Trask 10 Cyrus Drive
Centerville, MA 0263
Installer's Name,Address,and Tel.No. 7 7 5.-8 7 7 6 Designer's Name,Address and Tel.No.
W E Robinson Septic Sry
PO Box 1089, Centerville, MA 0263
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder(nq
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S. 1
Description of Soil sand
s
~ Nature of Repairs or Alterations(Answer when applicable) Title 5 Leaching sonsisting of
D-bx, and three stonevacked maximizers.
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this B and of He lth.
Signed Date L),rF q
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued y 07--
—————————————THE COMMONWEALTH OF MASSACHUSETTS
Trask r'-�; ; --,BARNSTAB,L-E, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( x:� Upgraded( )
Abandoned( )by
at 10 Cyrus Drive, Centerville has been constructed in accord nce
with the provisions of Title 5 and the for Disposal System Construction Permit No. '/3 dated 41— 9
Installer W E Robinson Sept Sry Designer
The issuance of this permit steal of be construed as a guarantee that the system 'll function as designed.
Date Inspector
- -----------------------------------------
No.
Fee $50.00
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS
Trask
Mi5po5al *pgtem Con,5truction Permit
Permission is hereby granted to Construct( )Repair( x)Upgrade( )Abandon( )
System located at 10 Cyrus Drive
Centerville, MA
Installers W E Robinsda Septic Sry
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 p it.
Date: Approved by 6 f• +rl
i
r n
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
I, William E. Robinson, Sr. ,hereby certify that the application for disposal works
construction permit signed by me dated '/v— F" 9- � , concerning the
property located at 10 Cyrus Drive, Centerville, meets all of the
following criteria:
VThere are no wetlands within 100 feet of the proposed leaching facility.
here are no private wells within 150 feet of the proposed septic system.
There is no increase in flow and/or change in use proposed.
here are no variances requested or needed.
* If the proposed leaching facility will be located with 250 feet of any wetlands,the bottom of the
proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S. map)
B)Observed Groundwater Table Evaluation(according to Health Division well map)
SIGNED: ! DATE 4).— f 4'
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 20-1998
(Attach a sketch plan of the proposed system. Also if:the.licensed installer posesses a certified plot plan,
this plan should be submitted).
{� ,,.�.
_ .__ - o��
. j
i —.
a
—`
—�_
j
(�':
TOWN OF BARNSTABLE
LOCATION / 1/ R f7, SEWAGE # �
/7 /
VILLAG ^—i• ASSESSOR'S MAP & LdT
INSTALLER'S NAME&PHONE NO. ,lRo i.- s cb c—
SEPTIC TANK CAPACITY /6ev---Q
LEACHING FACILITY: (type) 14-12-6 /�"/�X'S (size) //1.1 l— r
NO.OF BEDROOMS
BUILDER OR OWNER �/ � l�2
PERMTTDATE: 7-9 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
,�
E�" �
i � I
�, ,�� � �<
�___
�...� . � �
S
�/ j
�j
TROY WILLIAMS r �,
SEPTIC INSPECTIONS A0ZIA
Certified by MA Department of Environmental Protection f � (508) 760-1819
40 Old Bass River Road
South Dennis,MA 02660 '� °t"' 6 !
CormXrnMeatth of MassacfxueM
Executive Office of ErnArormerttal Affairs O� U
Department of U
• Environmental Protection
o.Cla t W
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: %0 C.1 r 0 S Dr. CLh�w✓ ��t . Address of Owner. U h /�r1 C- /,/o�a
Date of Inspection: 31119 (If different)
Name of 1 C;r
nspector.— oy w� ! I uvi.•s /vo J�o l%e ; l l
Company Name,Address &rid Telephone Number:
se- to✓ Dal yU
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 inspection..The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
-Zpasses
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signatur� Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B,C, or D:
A] ,SYSTEM PASSES:
V I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria no(evaluated are indicated below.
HI SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon eornpletion of the replacemem or repair,
passes inspection.
Indicate yrs, no, or not determined fY, N, or ND). Describe basis of determination in all Instances. If'"determined', explain why rot)
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: /0 Cyry s
Owner. X,/. �
Date of Inspection:
B] SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
_. The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
CI FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: W19
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank ano soli absorption system and is within 100 feet to a surface water supply or tributary- to a
surface water supply.
The ss•stem ha, a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a well water analysis 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.
11 SYSTEM FAILS:N/"g
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Backup of sewage into faciliry or system component due to an 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
—,sed ei1S/9Sj 2
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: U C y 0 S
Owner. M CIL c Do H I
Date of Inspection: 3 IO2
D] SYSTEM FAILS (continued):
Static liquid level in the distribution box above outlet invert due to an overloaded or dogged SAS or cesspool.
Liquid depth in cesspool is less than 6'below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to dogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of.a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. 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.
El LARGE SYSTEM FAILS: /\/14
The following criteria apply to large systems in addition to the criteria above:
The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety
and the environment because one or more of the following conditions exist:
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 (1WPA) or a mapped Zone 11 of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
I
revised 0/15/95) 3
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKUST
Property Address: /r7 G y rQ s
Owner.
Date of Inspection:
Check'if the following have been done:
✓Pumping information-was requested of the owner, occupant, and Board of Health.
,None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
As built plans have been obtained and examined. Note if they are not available with WA.
The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow
jZ'The site was inspected for signs of breakout.
ZAII system components, excluding the Soil Absorption System, have been located on the site.
/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 Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
/
The facility ovvne, lamed occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
evised 8/15/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: /O C r S
Owner.
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow:-33O gallons
Number of bedrooms: 3
Number of current residents:
Garbage grinder(yes or no):�/o
Laundry connected to system (yes or no): 5
Seasonal use (yes or no):_/o
Water meter readings, if available:
Ov
Ck-
Last date of occupancy: V rn��, ot�o�r✓y lclr—.
C OMMERCIAUI NDUSTRIAL: IV(14
Hype of establishment:
Design flow: aallons/day
Grease trap present: (yes or no)_
industrial Waste Holding Tank present: (yes or no)_
,4on-sanitary waste discharged to the Title S system: (yes or no)_
.water meter readings, if available:
..ast date of occupancy:
OTHER: (Describe)
ast date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
�l q D✓ ✓�% ti y �-c c.v 1 C L, 1 16"*rv, S
System pumped as pan of inspection: (yes or no)_ZJO
If yes, volume pumped rallons
Reason for pumping:
1YP� SYSTEM i
Septic tank/dictrib-iliop bau,/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) and source of information: 4b u,c
-+ Cr"/-- ' . / y'?v.
',ewage odors detected when arriving at the site. (yes or no)
rcviscd B/1S/9S1 S
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: /d C-y r-J S
Owner. M C_ oo
Date of Inspection: /C ' ��6
SEPTIC TANK:,
(locate on site plan)
Depth below grade:
Material of construction: _zconcrete _metal _FRP—other(explain)
Dimensions:_ S 1 - 't /y00 ��
Sludge depth: /r
Distance from top of sludge to bottom of outlet tee or baffle: a
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: aA)t-1-,
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffl s, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) C o c 4�L A- o� o_
r ✓ .uc r r. n -
/Du v G u 41 4
LJ `r � n / 6a''��V. �Qrtl1 htiS Gt.K�- (,out✓ -fvr /b�.�/.. , r� 4,�c..cSS ,
GREASE TRAP:4Vjy
locate on site plan)
Depth below grade:
.Material of construction: _concrete _metal _FRP —other(explain)
Dimensions:
,cum thickness:
Distance from top of scum to top of outlet tee or baffle:
-)tstance from bottom 01 «o— 1- honor- or ou!te! tee or barne
Comments:
recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
niegrity, evidence of leakage. etc.)
cv,5e-d 8;1S/951 6
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued,
Property Address: I V C y r tJ S
Owner. /LI ti 4 00 C a l C
Date of Inspection: 3/a
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade:
Material of construction: _concrete_metal_FRP other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
locate on site plan)
Depth of liquid level above outlet invert:
Comments:
note if level and distribution 15 a ual, evidence of solid carryover, evidence of leakage into or out of box, etc.)
PUMP CHAMBER:_Y_e4
'locate on site plan)
Pumps in working order:(yes or no)
omments:
note Condition of pump chamber, condition of pumps and appurtenances, etc.)
revised 8/15/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: /0
Owner. /4 C'C_ po u /
Date of Inspection:
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:
T ype:
leaching pits, number:_
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number: OH c. C>rc✓
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
1, e.- U
r. t—V
CESSPOOLS: A(67
,locate on site plan)
yumber and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
materials of construction:
ndication of groundwater:
inflow (cesspool must be pumped as part of inspection)
omments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
locate on site plan)
materials of construction: Dimensions:
)epth of solids:
omments: (note condition of soil, signs of hydraulic.failure, level of ponding, condition of vegetation, etc.)
revised B/1S/9S 8
TOWN OF BA NSTABLE
LCICATION 16 C(g 2'J S 4�2- SEWAGE#
VILLAGE e ASSESSOR'S MAP& LOT .
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 166 V �i
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by �:W ('� �`"^�' _: : �� �h-/
` �^-
33 / ® o2y �
n
3
tO C:\4ruS tv' c
i
r:
No./a/ ........ F�$...d�L. ........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEA TH
.................. oF.....
Apphratiou fiar 13ispagal 19orkii Tonstrurfivtt Vrrutit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individuual Sewage Disposal
System at....... - ._.._ _.... !1 1/ 2 �S
cat''o Ad ss t o.
.................. ..� ........... ...... .or Lot N ... ..-........................_..
w � .. s,
................ ............... . . . .......... ..............,..... ..... .... .. . ...... ....._..........-----........._
.... .... . ..... .
Installer
� Address
Type of B ' ding Size Lot...l�� ...._Sq. feet
Dwelling—No. of Bedrooms....... ..................................Expansion Attic ( ) GWrbage Grinder ( )
aOther—Type of Building __ . .............. No. of persons__________.._.___...._. Showers ( ) — Cafeteria ( )
Other fixtures .................I..................
W Design Flow________________________J_0............gallons per person per day. Total daily flow................ ---------_...........gallons.
WSeptic Tank—Liquid capacit/M_gallons .Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Wifll Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No_____________________ Diameter..6..__ _ epth below inlet.................... Total leaching area__i�e ....sq. ft.
Z Other Distribution box ( ) sing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_-_-_-__.._-__________.-
f14 Test Pit No. 2................ibinutes per inch Depth of Test Pit.................... Depth to ground water........................
9 -- •-•- - . . ............
O Description of Soil......... .:.. .............
W
x ------------------------------------------ .............................................----•••--------------•------------•---•--••--•-----•----------.__-•----•--•----•----•---•-------•••••-...--•--
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 Article XI of the State Sanitary Code he undersig further agrees not to place the system in
operation until a Certificate of Compliance has been is by the�qa o h lth.
Sign --•-- ..�/ ---- ----•-•-----•-••--•-•--•--•-- ............. ..................
Date
Application Approved By_'______ ._
ate
7 .
Application Disapproved for the following reasons-----------------------------Y---------•---------•--•-••••---••--•--••••--•--••--•-•---•-•--------_•----
--••••-•-._._..••-•---•-••-••--------••--------------------•••••--------•---•-•_..._.-.--•-•---••-•---•-----•-----•-----•-••----•-----.•--•...-------•----------•---••-•--•-•--•----•--__...•----_..._..
Date
PermitNo......................................................... Issued............................................-...........
Date
No./,/Z......... F�$...�7 ,..`-- .......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD.,,®®F HEALTH
d
t`, ,.' .im�'-•„j�..Aw.�. ..... ..........OF.... f .✓.�kT': .,�,1 1-+:_....
Appliration for lisposal Modii tonotrurtion Vrrufit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
........... . a 1'. ,.... . y ............... . -- ......,. ... �.... �. ... ..........
• .�Location Address �/ p ��fr or Lot No.
.................rir .....`X' �. i .2,..... ............... .. / t,,•°X_- ^s9-- ..,� L:. ° .. ..............................
• on�ol f � _4 I" ..
a .....................__, ..:1.."3l i t ►7.._................._. ._..,:. .. �, -nal.,;.............................................................t ll �
.... ..,r........
L� "Installer Address
T e of Btttldin
U yp g , ;. Size Lot.... .r'_f'::�'.....Sq. feet
�-, Dwelling—No. of Bedrooms.,.....j...,;.,,.. --•-•.............Expansion Attic ( ) Garbage Grinder
Other—TBuilding
( )
p-, e.of Buildin yp g _._;::"�_._:_j^��_°�1_:� No. of persons..............:„� ._._..._. Showers ( ) — Cafeteria ( )
al Other fixtures .................
W Design Flow......................... � ........--..gallons per person per day. Total daily flow............... Y?..._..................gallons.
WSeptic Tank—Liquid capacity_":<.0 _gallons Length................ Width................ Diameter................ Depth................
xDisposal Trench—No.................... Width;:._............... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter ; ,,,,Depth below inlet.................... Total leaching area..:_ eT.r .....sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
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 ground water........................
.................--••---------.•-•-------------------------------•---•------------------.-...---•---•-----------------.-------
O ,� � .�w
Description of Soil........ � �`
U .........................................................................................................................................................................................................
W
UNature 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 Article XI of the State Sanitary Code;;Ahe undersig3c4 further agrees not to place the system in
iif�
operation until a Certificate of Compliance has been is s}� by the hqa ofhealth.
Signed ..... k.A ?
i Date
Application Approved By_: 9""" i ` ' L° ;;r�r y'" ? ..
ate
Application Disapproved for the following reasons--------------•------------- ------------------...----------------- .....-•••-••••........
,,........•------•-•----•---•-••--•---•-•---•••••••••-----••-•--•••-----•-•••••-•-•--
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
9
�i BOARD .OF HEALTH
s `" 4
.�. � �� 'gam fi L
4"':: .y. ✓.: .r...................OF i d. ......... -" .............. ...............................
T'i�
Terfift6tr of Tome aurr
THIS,IS`TO CERTIFY, ,tat the Individual Sewage Disposal System constructed ( or Repaired ( )
L � � s "` , p y ,�
by.............{ i}j:.rj'1 ./ �r< �C i rth r}J ---. -- --- ..... ._. ,�. ..:!4:.:'_�. •.&'... F ....
Jhst lde
has been installed in accordance with the provisions of Article XI o ` he State Sanitary Code as described in the
application for Disposal Works Construction Permit No--------------g'' _______-__- dated..... '.. _._°:�G�;E7'HAT
. ...THE ISSUANCE OF THIS CERTIFICATE SHALL NOT EE CONSTRUED ASA G ARANT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........�..�a9'.Z-� ------------------------------------------- Inspector.......2..-LIV..........................................................
THE COMMONWEALTH OF MASSACHUSETTS
1
x`f BOARD ,OF HEALT�4
d r OF ...................................................
No.... ! -•- ... �� rFEE ..............
�i��o��l ork� C�on,��u �an rrnti� -
r
Permission, is is hereby granted................... r���`�--''•--••---�' ='=-<_ '�...�: "_- ..........................................................
to Construct ( ),or Repair ( ) an/Individual Sewage/ ispos6l System , f�
............. ,t. ,
as shown,on the application or Disposal Works Construction jrmit N
l Dated.G.S,�,"
.lJ.. ...•7•••.---.............._-Boar ofalt h ,
DATE-------------------------------------------------------- ---------------------- C .'4')
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS -