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0040 GLENEAGLE DRIVE - Health
40 Gleneagle 0z.,Ive Centerville. A= 1 91-163 /// SMEAD No.2-153LOR UPC 12SU amaad-com • Made In USA FYI 0� I�IipMA�N�11Cfl�i SFI �DfSR PWQM CFWIRED SOII¢CING e, YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 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 to-operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall)and get the Business Certificate that is required by law. DATE: f l Fill in please: #'e,'F I',`'hk;7�ti ? , �, APPLICANT'S' YOUR NAME/S: a�� 1 1,1 htris1�! f,� € k ' BUSINESS-_ ,_ 2�1rrriF YOUR HOME ADDRESS: I.101Q�n �, €� 3 ,ct a.Ir rl�sO "�CO Q Vr S J TELEPHONE # Home Telephone Number �1. rrr',}'f'rrd�€+t a .: '. a:, NAME,OF=CORPORATION. -'° NAME OF NEW BUSINESS "' �tiJ w € t TYPE OF BUSINESS IS THIS,A.HOME OCCUPATiow, _YES NO 17 ADDRESS OF BUSINESSc ;N5 A�'' MAP PARCEL NUMBER + " Assessor / (. g)' 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 CO MISSIO R'S OFFI E 1\ MUST COMPLY WITH HOME OCCUPATION This individu I h ee infer�4oferA requirements that pertain to this type of businessRULES AND REGULATIONS, FAILURE TO t i * COMPLY MAY Rr=SULT IN FINES'. Au on atu g r COMMENTVd i 2. BOARD OF ALTH This individual has been informed of the permit requirements that pertain to this type of business. Authorized Signature** ' MUST COMPLY WITH ALL COMMENTS: AZARDOUS MATERIALS REGULATIONS 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature* COMMENTS: TOWN OF BARNSTABLE Date:-51 / TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: -n BUSINESS LOCATION: @ . INVENTORY MAILING ADDRESS: TOTAL AMOUNT. TELEPHONE NUMBER: CONTACT PERSON: ,9 C' EMERGENCY CONTACT TELEPHONE N MBER: 5o —!6j!jq0 MSDS ON SITE? TYPE OF BUSINESS: s INFORMATION / RECOMMEN IONS: 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 re uires 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) 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 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 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 Applicant's Signature Staff's Initials TOWN OF BARNSTABLE. LOCATION _!�¢2 . SEWAGE# 't0 0- VILLAGE Cet rL')ZJ-4LLJ--'"ASSESSOR'S MAP&PARCEL F l l— l f63 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY ��C o���� fc�a-C•�Z !�/O LEACHING FACILITY. (type) (size) i I.3 �� e NO.OF BEDROOMS 1(. 44-1-�� °N�1 Ui C�OC� OWNER 1 PERMIT DATE: �--7 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) N t4--• Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY C nJygs �s�g -tr I �dQN ail yi DAB. 6 0• 71d` U LOCATION SEWAGE PERMIT NO. L,' 5 2 CLem VILLAGE ecgTk--12 V I LLS I N S T A LLER'S NAME i ADDRESS pcoig lYYla" ©U 1e. a I Kt CC, P_D, B U I L D E R OR OWN ER 'DATE PERMIT ISSUED DATE COMPLIANCE ISSUED i L r - A. 24M 6.' 8- To TK 41 �000 a- ToTA44IK 94 m GAT ,e.- -ro'V'fix 3J ' C7 'O"raox f3 -l'o'� Rox 4S� No. V ? Fee— � THE COMMONWEALTH OF MASSACHUSETTS Entered in compute" r: PUBLIC HEALTH DIVISION -TOWEL 1 ARNSTABLE, MASSACHUSETTS Yes Rpplitatiou for �i�tl"at *pstem Construction Permit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System Rfndividual Components Location Address or Lot No. k/d W�s (P C'0-0- Owner's N e,Address,and Tel.No. ��C�nl�itl�e 'l )sr�rc�- tic�3-fen /P Dr Assessor's Map/Parcel -3 e /. Installer's Na e, dress and T 1.No. / signer's e Address and Tel.No Q o�nne ,p Type of Building: q � Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) :J,7[� gpd Design flow provided y� gpd Plan Date ') )D— Number of sheets , Revision Date Title /'r U� ' a2 Size of Septic Tankx%s�71.i�q /Gld 7�2.0 Type of S.A.S. %1• ' �L 1C , (o ' 16-H3o /-A'' Description of Soil Nature of Repairs or Alterations(Answer whenapplicable) 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 Environmen a and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Sign Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. no /,::L— Date Issued No. V- �.V rJ Fee V C) THE COMMONWEAfI.T Entered in computer: Yes J PUBLIC HEALTH DIVISION - TOWN-GF=BARNSTABLE, MASSACHUSETTS m. application for h�) Upgrade �sa' *pstem Construction Permit Application for a Permit to Construct( ) Repair ( ) Abandon( ) ❑Complete System R11ndividual Components ' Location Address or Lot No. y0 e_ Q U-t ale Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 1 g/ �/y 3 e� tt �'P i % 1 y0s}to3X I r N,aln�,t�ddress and Tgl.N�o� n r7�l �5°f�/ Designer's Dame,Address,and Tel.No. Ve, crce r oa675 Type of Building: p Dwelling No.of Bedrooms 3 Lot Size �f sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) t Other Fixtures 4. Design Flow(min.required) , .30 'gpd Design flow provided �7 � gpd Plan Date OLuz0 9,�Oi 1 Number of sheets J Revision Date Title 1 oe',-2le/'U//��Size of Septic Tank Typeof S.A.S._/_/3,iU X c�S ��. lv ,(.gacI Description of Soil /6-H o /4I d� ' Nature of Repairs or Alterations(Answer when applicable) 14 a0 „ ;n it•3 X a S'�X 1.1,� ��c�+�c ccA-ect--- ! Date last inspected: Agreement: s 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 Environment I e and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signe Date i a Application Approved by Date -`- 7 ff Application Disapproved by Date for the following reasons Permit No. nQ / :;L— 23) 7 Date Issued / , 4^ 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 &Z4/dmt, .1. c- at V6(rtan ecLce f e Dr, Qen 4E r-thl'__ has been constructed in accordance r� t with the provisions o//f Title 5 and the for Disposal System Construction Permit No •. �of--�;� ated Installer1^f6J (� rUC�`(�C16'1,_3�n G. Designer Lj- #bedrooms 3 \ Approved design flow _ gpd The issuance of this permit shall rot be%6n trued_as a guarantee that the system will functio desi` ed. Date9 / ��- Inspector ------------------------------ _ -•- --- -----_----- - - -- - - - - --------------- ------------ No. .-)� — J D"? Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS MIsposal *pstem Construction Permit Permission is hereby granted toConstruct( ) Repair Upgrade( ) Abandon( ) System located at 7 V e�.91 e_ F" r 'i and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this pe it. Ili C Date J��```�, Approved by ~------- , f MAY-10-2012 10:42 From:BORTOLOTTI CONST 5084289399 To:15087906304 P.1/1 FROM :daxjm cape engirmring inc., FAX NO. ;ISW3629980 May. 10 2M2 10:39AM Pt �,t�b�''d'�L11 fr•j1 +g..1`a�,�b�,��1Li$�'�l'4 'l'leomm r.C'ei ex tPu'�ctui e M.H. w! �a�iai ."'Ytm>!Oh Duvi-sst�at, �`��?� � '1'<tu�naR 1VJ(�,S�,rcan,lluR'a:L-1 u,• vlo Maim Strocd, ftyra,mmiN M 112601 ()fpiGj` 'eol WA-4644 FA' 1f►S�'1!�0 5Jt14 'k 1 r� �- c?r�1 d. - 1�7 A,,, ensues "Ibn l�atrW /91 1 ��oe.ma - tt _ ��w�a�e�pe;rumi>i# . � - Da+ai , aslr" cf.)uW�. � •� 1 / �'ebe�tnl�ri:m: ©d�7�1�� _�eau��Q� �, OJ D. � �J rl+itledross: 7 ! Lin kilt- �4c� ese. _ f dY — oil �, w_.. ` JI IZWL�to t$Vl �. se�rEsc sy�lattt ax, i �G!.r.P,.at. ✓(� I)agcd en a doLcila a dru'rvn l,y t, a n d d. j dxtc�9_. y o� / T ;:e,t't;fy tbar th,;arptiu, systrin raf�ti juned ahuvo wLq int�.11ed si.,bstortlally aw-UrCU� r11.e deli , avl�ic nay iur;lilrve rqin.ua Ez' Prnveal c,Loa ,es uiYchi u� letcrol relurritin�l �� tlle disrtrf butiou lynx huc1/%x 9Nptir.trjok. _ I' r.;mr.ify theft the 'n..icy qgLtu (rjjrc,Twcc3 ;Lbnvti w-e in!;idled'xi'Lh uasl nr cLau�;e� (a.e. - t*,raEoi'rJtan 10' ja4.,TAi leiYivB nf-tFe $AS nr =y voxm,c4d r(,loc.,,j-Lju of any c OrJl�uutJ�,t r)f the 8 C s stern)lFilr i;,aouvrelmoe wi'il�Sttve &j„o al PV1911100%13. I`hln TUVi inn Or I.ki,rlie (n q deaigwu to filluw a OF wasp DANIEAA. JAI. .a hn 4d$02 1?crsiiyl 'ti h"igpr�tiarc�) x17r�ri(i,iZet' r.CC) _C)11! �'1��`�_;.�°�. , 1��_,., ?�F ...?his-.>w.-��• �'1� Lib+�S X a r.��r n > �� t� QT�T ` ? r Rj4C.F,jyM, ;X' r, fJna"f1J!irOtlt;J�14eIQA7trCtm•d�irrui�raKorm 9.2t U��aa 1, �) urf e, o�✓ Town of Barnstable Departznpit of Regulatory Services / ' � nnarlerAetz, 4 Public Health Divisiol, Date 'P � 200 Main Street, Hyannis MA 02601 00 pate Scheduled_ / /Q�Tit-le Feerdl. `oil Suitability Assessnient joy° See >ESP 115al 1'crPonn d.➢y:lyw �- _ N �'�i Witnessed By.; IL0 CATION & GE NEI RAL I[NFORTVDITION Location Address /1 (_ / /I ` Ve Owner's Name 3 ar. Ce-A �/� e�r�—✓ ✓•I M Address Assessor's Map/Parcel: /9/ � Cngincor's Numc C O>� C"CJ NEW / Tele hone If Owl J W CONSTRUCTION RBPr\1R � p 1. / Land Use Slopes(%) Surface Shines Distance's From: Open Water Body ` rt Possible Wet_Are4 ft Drinking Water Well ft Draihn.ge Way Ft Property Line A0 Ft 011ler ft h SKJl{ITCH, (Street came,dimensions of lot,exact locations of lest.hales Bc perc tests, locale%yrdwids.1n pionhidly la Boles) VZE 4 tv I d Q 1, OV �1✓ "' J __ w f i Purcnt math al(gcologtc) 0�7Tu 514- Depth Iq Qucbucl '36® Depth to Groundwater: Standing Watcr in Hole: �O C_� ' Weeping I'l'un1 Pit Pope Estimated Seasaual High Groundwater DIETEB.I1ENA7CJLON I[,OR SEASONAL HIGH WA.71'EM11 TABLE Method Used: Depth Observed standing in obs. bole: In. Deplla 10 Soil alutil..m; Depth to 5veeping Frain side ofobs.hole: _ III, ClrttulldWular Ad�uslment„e _F[. lndeX Well ff Reading Date: Index Well IeYnl _ _ AdL1,Awtor Aq),droUlIdWllteP UVLd IP ERCOLA7Cl[ON 71'1CS".Q' Observation Holc ff �,--- Tinle tit 9" Depth of Perc Thrip Q1 G" SlarCPCe-soak Time @ 0 O A O� _ Time(9"-0") End Pro-soak 10S 0S Rate Min./Incli ICZ-1-3 TRI Site Suitability Assessmunt: Site Pessed_ Sit.G-Failed: Additional Testing Needed(YIN) Original: Public Health Division Observation Hole Data To Be Coinpteted on Flack_ *""If VC Colatiom test is to be conducted wiLl.A z 100' op vvefland, you ritiuxst drslt uotity ILIAC. .13arnstable Conservation Y)ivisioti at least 011C (1) weclr prior to beginuh-Ag. Q:\SCPTIC\PCRCF,ORN9.DOC DIICICP.O][ SV�If��T�i''�']ION lFlf®J['E ~ .. Depth from Soil Horizon LOG S Hole #�_ •�Surface(in.) Soil Texture ;Soil Color (USDA).. Soil• Other .(Munsell) Mottling (Structure,Stoncs; Boulders, Con ista c ru el Depth from soil HorizonEf LOG Surface(in.) Soil Texture Soil Color Hole Sol! (Munsell) Mottling (Structure,Ier Stones, Boulders. O m L /0 ' Z/ C psis e c %Gravel DREPOBSERVAT-TONHOLE LOG Depth(rani Soil 1'-torizon Hole # Surface(in.} Soil Texture (USDA) Soil Color Soil (Munsell Other Mottling (ptruclure,Stones,Boulders. Consistency 9"a Orwell 7-- Depth ONIJ from Soil Horizon OL-E �'®�ic aa��# ` Surface(in ) Soil Texture Sail Color Soil (USDA) (Munsell) Mottlln Other g (Structure,,S(one5� Boulders, COnsistencV 9y pra�el ^ —� - - IC qgd Ynsn_urance Rate myar Above 500 year flood boundary No Yes Within 500 year boundary No Yes. Within 100 year flood boundary No� Ye5 ll�d ll� of 1`rTtotunrilly 0—couarrjnRpgivx_aus Material Does at least four feet of naturally occurring pervious materlal e aA'e xist in all areas °bserved thlaughout the a proposed for the soil absor ption system. �� 1f not, what is the dePtll of naturally occurring pervious m�� �I�rt11f9c�U110n , I certify that on�& (date)I have passed the soil evnJuator examination approved by the DepartmgntofEnvJronmeltal.�'rotection and that the above anal .sis was performed the required training, expertise and experience descriUcd in �10 C11� 15.017, by me consistent with Signature t Datb Q,1$RPT1CU'ERCF'0RM.D0C Town of Barnstable Barnstable tikxftA Regulatory Services Department ' each + BARNSCABLE �A Public Health Division m 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 70083230000251783173 9/09/2010 April Barselow 40 Gleneagle Drive Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 40 Gleneagle Drive, Centerville MA was last inspected on June 21, 2010, by Patrick M O'Connell, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool. You are ordered to repair or replace the septic system within Sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH s eXV5, ;CHO Agent of the Board of Health Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �w 40 Gleneagle Drive Property Address April Barselow Owner Owner's Name information is Centerville MA 02632 June 21, 2010 required for every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the I _. computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name 189 Cammett Road Company Address Marstons Mllls MA 02648 Cityrrown State Zip Code 508.428.1779 S1 12855 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 C� le 5(310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes ® Fails c= ❑ Needs Further Evaluation by the Local Approving Authority a I-u June 21, 2010 Job# 10-157 Ins ector's Signatur Date m 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. t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Dispo Sys le •P ge of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �. 40 Gleneagle Drive — Property Address April Barselow Owner Owner's Name information is Centerville MA 02632 June 21, 2010 required for every page. Cityrrown 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 CM 15.303 or in 310 CM 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. 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): 15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 40 Gleneagle Drive Property Address April Barselow Owner Owner's Name information is Centerville MA 02632 June 21, 2010 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Gleneagle Drive Property Address April Barselow Owner Owner's Name information is required for Centerville MA 02632 June 21, 2010 every page. CityTrown 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 1.00 feet of a surface ovater 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 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 15ins•09l08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Gleneagle Drive — Property Address April Barselow — Owner Owner's Name information is Centerville MA 02632 June 21, 2010 required for — every page. Cityrrown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Gleneagle Drive _ Property Address April Barselow Owner Owner's Name information is Centerville MA 02632 June 21, 2010 required for every page. Cityrrown 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-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Gleneagle Drive Property Address April Barselow Owner Owner's Name information is Centerville MA 02632 June 21, 2010 required for every page. City/Town State Zip Code Date of Inspection — D. System Information Description: 5 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 157,000 gal. = 9 ( Y 9 (gpd)): 215 gpd. _ Detail: Sump pump? ❑ Yes ® No Currently Last date of occupancy: Occupied. 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: 15ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Gleneagle Drive Property Address April Barselow Owner Owner's Name information is required for Centerville' MA 02632 June 21, 2010 - every page. City/Town 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: Tank pumped 3 years ago. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) 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): l5ins-09/08 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Gleneagle Drive Property Address April Barselow Owner Owner's Name information is Centerville MA 02632 June 21, 2010 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Overflow pit installed in 1994 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 3' _ Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): 3' _ Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.5' long x 5.2'wide- 1000 gal. 511 Sludge depth: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Gleneagle Drive Property Address April Barselow Owner Owner's Name information is required for Centerville MA 02632 June 21, 2010 every page. Cityrrown 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 4" 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 Measured How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level was found at bottom of outlet invert, baffles were intact. 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 l5ins-09f08 Title 5 official Inspection Form Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Gleneagle Drive — Property Address April Barselow Owner Owner's Name information is Centerville MA 02632 June 21, 2010 — required for every 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 El metal ❑ fiberglass ❑ polyethylene ❑ other(expla.in): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ElYes ElNo 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Gleneagle Drive Property Address April Barselow — Owner Owner's Name information is Centerville MA 02632 June 21, 2010 required for every page. Cityrrown 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 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: l5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Gleneagle Drive Property Address April Barselow Owner Owner's Name information is required for Centerville MA 02632 June 21, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: Two 6x6 pits in series. ❑ leaching chambers number: ❑ leaching galleries number: — ❑ leaching trenches number, length: — ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: — Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Overflow pit was full to top in hydraulic failure. — 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-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 40 Gleneagle Drive — Property Address April Barselow Owner Owner's Name information is Centerville MA 02632 June 21, 2010 required for every 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.): 15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 cd 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments " 40 Glenea le Drive_ -- Property Address April—__Barselo`^i -- Owner Owner's Name MA 02632 __ June 21, 2010 information is Centerville _ __________ required for Cily�rown State Zip Code Date of Inspection every page. D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two pia water supply reference enters the building. Check one of the boxess or benchmarks. Locate l wells belowWithin 100 feet. Locate where publicpp Y ❑ hand-sketch in the area below ❑ drawing attached separately Glenea le Drive 23 41 40 53 9 49 r Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Gleneagle Drive — Property Address April Barselow Owner Owner's Name information is Centerville MA 02632 June 21, 2010 required for every 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: N/A — feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next pager. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16.)f 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y 40 Glenea le Drive Property Address April Barselow Owner Owner's Name information is Centerville MA 02632 June 21, 2010 required for State Zip Code Date of Inspection every page. City/Town 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 t5ins•09108 No............. Fs$.............................. BernstableCpnSerVatjMOSPSM"On+tHE COMMONWEALTH OF MASSACHUSETTS @_BOARD OF HEALTH Signed Date TOWN OF BARNSTABLE Appliration for Biopw3al Work.6 (famitrnrtion 1hrmit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: r w . Location-Address or Lot No. Cam..----------- ddr6w wner „ es. a svr�tt8 It]stalIer Address d Type of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms.............�_.--_---_..-_-_--.---_-Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) a'' Other fixtures ------------------------------- - - W Design Flow.................. . per person per day. Total daily flow----------�_r�_.�--___--__-. .........gallons. WSeptic Tank—Liquid capa6tv/0J9—__gallons Length................ Width----_-.-__-___. Diameter---------------- Depth................ 15. x Disposal Trench—No. ....... .......... Width....._.7_._------ Total Length---- `�...._... Total leaching area....................sq. ft. Seepage Pit No--------J-------- Diameter.....AQ_°------ Depth below inlet...... ....... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-------------------------------------------------------------------------- Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water...................... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_..................... P+ -------------•-------------------------------------------------------•-•----------------•-----------..................................... --... ...-----.------ ODescription of Soil........................................................................................................................................................................ x U w x -------•---•-----------------------------------••-------------------._..._...-----------•---------------------------A----------------------------.---...-------------,-------- ................ U Nature of Repairs or Alterations—Answer when applicable.-..� ------A-------------7- .........LC4eAA1 . Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance �ben su by e bard of health. Signed ------- --------- ----- ....................� Dace ApplicationApproved By .. ..... ---f' ------ ----------------------------------------------------------------- f � . -------------- Date Application Disapproved for the following reason-- ------------------------------------------------------------------------------------------------------------------------------------ ......... .................................... .. .................. .... . ...... ...... ..._.. Permit No. Issued t?.: "./ --✓ �".._ Dace No.. .....-....... Fss....................... THE COMMONWEALTH OF MASSACHUSETTS ���'�� .� ►S�vN� BOARD OF HEALTH TOWN OF BARNSTABLE , pphratinn for Diripwial Work.5 Tomitrnr#inn ramit Application is hereby made for a Permit to Construct ( ) 'or Repair (.< an Individual Sewage Disposal System at: ............................................ -----------•----•----•-•---------------------------------------•--•------•-- Location-i\ddress or Lot No. �.OvIi �1� :�.•� ,�� l r2.-i vy c �l ...---•-•-•- ..------------------------------- ------ -- . -•----•-----•---••---------•--•---••-•-- ----------...--•--•••••----...---..........--•-......._. Owner Address- W ...... � :/ l'20 �/1 1141 l.t_j a � _ .......-- Installer Address Q Type of Building Size Lot............................Sq. feet U Dwelling— No. of Bedrooms.............`3-------_..-------------Expansion Attic ( ) Garbage Grinder ( ) `4 Other—Type T e of Building No. of ersons----------------_-.----.-. Showers 0.1 YP g ---------------------------- P ( ) — Cafeteria ( ) a' Other fixtures --_---..--_.. .............. •- d ---------------------------------------------------- ---------------------------•------•-----•------------------- W Design Flow.................... -----_---..gallons per person per day. Total daily flow....-.--.-�.'�.. ......................gallons. WSeptic Tank—Liquid capacity/ 9---gallons Length._............. Width---------------- Diameter................ Depth.............. x Disposal Trench—No. ....... .......... Width..___..7--------- Total Length----Wig........ Total leaching area-_-_--.-_------_--sq. ft. Seepage Pit No----------/-------- Diameter----.Zo.._..... Depth below inlet.....//.......... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date.....................---------•------- ,aa Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water.._------.---._._--.---- (% Test Pit No. 2................minutes per inch Depth of Test Pit--.-----_-_-_._---. Depth to ground water_-_---. -..---------. 9 --•--------•-----------•--------•----- ...................................................................................................................... 0 Description of Soil--------------------------------------------------------------------------------------------------------------------------------------- ............................... w x --------24- £,i U Nature of Repairs or Alterations—Answer when applicable ............ r -.� f lL at(L QcD i y =................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance,has b en?sue d by t e board of health. I Signed �:�-r--------- -- ----------- ---------�--`- Dare Application Approved r ._. .. /.---- ------------------------------------------ Dce Application Disapproved for the following reafonf- --------------------_.........._---------------------------------------------------------------------------....._----------------- .......- .................... ._. ..............._------------------------------------------------------------------------------------......--------------------------- --------------------------------------. Permit No. ..��....,�.........��'a._...'tF Issued Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE CErtifira E of 01-111ompliartrP THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( / ) � J `l"G'G_ /Y7"7. Cat.,*J S; 1�e-rourJ. by _..... - - ---------- Installer at .. - .... - --------- ------------------- .:.r rv...�`- ------------- has been installed in accordance with the provisions of TIT L 5 of The State Environmental-Code as described 'n the application for Disposal Works Construction Permit No. - PP P - ,F .... dated �. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT�EONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.... . ----------- ------- ----. .. -- --------- --------- Inspector ----------------------------------------------------------------•---------- THE COMMONWEALTH OF MASSACHUSETTS jl �I BOARD OF HEALTH / (p TOWN OF BARNSTABLE No..l. FEE .�f�.`...... Mspimal Worb Tnntrurtinrt Vantit Permission is hereby granted................�Q L4 1"5 C%G' �j,� N c..i7b v--+ ---....... ..-1.5-2 . Construct ( ) or Repair (64 an Individual Sewage Disposal System as shown on the application for Disposal Works Construction Per `t t - _- Dated-----�"A.. --,....�� 1/ � --------------------- Board of Health DATE-----------------••--------...........-----�`-�- J FORM 36508 HOBBS&WARREN.INC..PUBLISHERS TOWN OF BARNSTABLE LC-CATION d/e �,�,,'Qe, SEWAGE VILLAGR�&'/e/l( A6 V ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO.60F SEPTIC TANK CAPACITY C�DO UEACHING FACILITY:(type .% /'q��if2S C �`J (size) ?fO: OF BEDROOMS PRIVATE WELL PUBLI��WATE�R . BUILDER O OWNER��jQt- S�tC� C.c� :0ATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: 40 VARIANCE GRANTED: Yes No t_. Ic/o 23 ` y/ Vol , S3 S f .......................... JHE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH )3,qPNTT1q6Lr=.- .........OF..................................................................... --------------------- Appliraftan for Uhipasal Works Tom4rurthin Frrutit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: /-oT S2, 6L 04 E F4&LE ORLVE ................................................................................................. .................... .............................................................. Local,iiq -A dr Co L 0 A,q poeMSS15T 7 00 1A1AX141AZ-'r0V Tl-!-'Ot . .............................................. ....................................................................... i.............. 'w 'fr ..Ra6art......B., 11C..............................GT _xa.. ...................................d................................:S.......... Installer Address jC��49......Sq. feet Type of Building Size Lot .................... Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder ( ) Pk Other—Type of Building ............................ No. of persons............................ Showers Cafeteria ( ) P4Other fixtures ...................................................................................................................................................... Design Flow...........................5 ..........gallons per person pr day. Total daily flow_._.._.......__...._..2,1.0...........gallons. J.4�qd.gallons 1-6 to 14 / P4 Septic Tank—Liquid capacity ... L .......... Width.4-t......... Diameter................ Depth4`-V&.. Disposal Trench—No. .................... Width-....---............ Total Length........7---------- Total leaching area--------------------sq. f t. Seepage Pit No...._. .............. Diameter.��'Le?....... Depth below inlet-.4.............. Total leaching area.;ZAI�......sq. ft. Z Other Distribution box Dosin tank kr aoc Percolation Test Results Performed byl.wr_ ....... .................................................... Date..��Jjq Zpz (I ............................... Test Pit No. 1494:�---minutesperinch Depth of Test Pit-1 Depth to ground water..Ab Wmst ...... ................... Test Pit No. 2.4.VOminutes per inch Depth of Test Pit-lU..,...... Depth to ground water-6 .U/4rlsoe. .............................................;i;:.......�;7.................................................................................................. 0 Description of Soil......��kE7-qtj IKE-.DIU tvi 0 ChfiRrE 644jo '91, Z_0.4 " ........................................................................................... .............................................................. SURS,oil ........... .................................................... ..................................----------............................................................................................... 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 TITLE 5 of the State Sanitary Code— The undersigned further agrees place the system in operation until'a"Certificate of Compliance has�been is�ey the board of health Signed... ................................................................................ ........................... -------Z Vauyl Application Approved By....... -------------------------------- ----------- Da e Application Disapproved for the following reasons:.............................................................................................................. ......................................................................................................................................................................................................... Date PermitNo......................................................... T. .............................................. Date No.---- :3 f ..� ./THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ,r 4 wl"I ...OF..... }4iq"!� sTiq_q .............................. ........ ...... . ............................................. App iration for B4fV" om1 Vorkg Tonstrnrtinn ramit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: �+ v Locatii -A�d�Iress rIAIA o-yj of No. ........... ... __..._`....-----...... ...---.......Yei ...-----•-- --•-••-----------------•--........-•----. •-----............... �......._... ... Owner Address W Installer Address £ ^I Q Type of Building Size Lot--- ..:�_�.�......Sq. feet Dwelling—No. of Bedrooms............`3...............:............Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ..................:......... No. of persons------------_............... Showers ( ) — Cafeteria ( ) a' Other fixtures ... ................... W Design Flow........................* :........_:__gallons per person er day. Total daily flow__._____.___.____..__. ___._.___ lons. WSeptic Tank—Liquid capacity-.__:__ .gallons Length... Width______ - . .. Diameter________________ Depth.-4.._..�_..... x Disposal Trench—�o..................... Width..�.�...._.__.. Total Length......._._....... Total leaching area....................sq. ft. Seepage Pit No.....::.............. Diameter.__---__.__..:...... Depth below inlet....:__............. Total leaching area.---:---.-_--.....sq. ft. Z Other Distribution box ( Y%) Dosing,tank tt Percolation Test Results Performed by. �� : _........................ .................... Date.. . q hou ,� Test Pit No. 1 PP_.�,_.minutes per inch Depth of Test Pit.__ r'�.__..._... Depth to ground water._�L. q plf �is'1 7 r -'14 ^.. P74 a f=, Test Pit No. 2.._.:r...._ minutes per inch Depth of Test Pit... ......_._.... Depth to ground water......:..:.............. EOe Description of Sl �---- ..--- ...... .... . Soev?il �� f� ..+M��� � �� '.�-----.----- W -------------•--...----...------------------------------------------------------------------......------------------------------------............------------------------------------------------------ VNature of Repairs or Alterations—Answer when applicable................................................................................................ --------•--------------------------------------------------------------------•---------------------•------------------------------------------•-----------------------••------------------••---......... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE: 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. - Signed................ ----------.............................. ......................... --------------------•-•------- 4.1 Application Approved By....... ............. � e Date =7 Application Disapproved for the following reasons---------------------•----------•------------------------------•-----------------•-------....................... -----------------------------•------------------------------••-----•---•--•---------------...------------'--....----------------------------------------------------......-------------------•---------- Date PermitNo._.:................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF.................................................................................... Clun#if iratr of Tomplinnrr THIS IS CERTIFY, That the Individual Sewage Disposal System constructed ( �or Repaired ( ) by........... ...........0! .......................•-•--•-------------------------......-•--------••-•---------•----------------------------........-•----................ C I taller > at................... 9�--•.... ...... =- ........................................................ has been installed in accordance with the provisions of TITLY' 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No---- '.._ .9............. dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE A GUARANTEE THAT THE SYSTEM 1NIl/# #UNCTION SATISFACTORY. DA T ....................................................... Inspector............ --- ....... --`---------------------------.........--------........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ✓ ..........................................O F..................................................................................... No......................... FEE........................ Dispood Morb Tofiiitr uan "permit Permission is hereby granted-------- ....---•---------------•-••--'---••----------------------•--•----•------.._......------•-----------.......................... to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo............................................................................................................................................................................................... Street as shown on the application for Disposal Works Construction Permit No..................... 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Y Y :�G .4 k xt7 i Y k v , .' ,. o....x ., ,. f yr t£ ti� "4Y ; OFFICE+ FILE?G7�t'J� .�s'KET�iH ` ` { 'GG,:.b f rf f drt '.., 4 4 4:. � K 5 /!+/ f PLAN REF i LAND:II .i k z t f �r �. ID f'41L��ib,..�...' r I :, p � < ,' 5 7 r'FOR MASS i �, " ., n r r r � f #�' •[4`f;�r.ty{ d x w,? `' tQ. �`��J•lrC3L..� ' P t r Y "'r s },,. s r Y }..,, 1. r9.'. �i ,-..i w, S y .a.. f �l-,�Ills `7 i # 0POSE©.:.. .._ m j` GATE � � =•7 L � �;- ���, A� z;, 11, } �: .oT 4 6 I c 1 " : ,�fW tNN6 BHgWN,ARE.IN FEET ASOVE a aR._sWEETSEftoAtt ,a�1 r °.w ",, :A '' e x M' �� .,i 97 SEA STEET.,D + rx �w.ij�s`�a .,r� T7dS.T\)M • - 3.r + r �.. i �.. ~, -, m �' ' �; 14 r s .. ,. DATE -' QQ A S r.'. a« x•. t`. . �.�r fii.. ei lir - ^"« d +' %>: FF` \-�'Y i ti ':';: " ' } y�,4, •er=`. a a - r a L3, ENT �aaY- -_5 BOARD OF HEALTH RE.V. 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NGVD tiYeQuaquet ACCESS COVERS TO WITHIN 6" OF FIN. GRADE 1. DATUM IS Lake PROVIDE INSPECTION PORTS TO TOP FOUND. EL 65.8' WITHIN 3" OF FINISH GRADE 2. MUNICIPAL WATER IS EXISTING \ MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER SYSTEM 65.0' 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. � o PRECAST H-10 4. DESIGN LOADING FOR ALL PROPOSED PRECAST RISERS (TrP.) / UNITS TO BE AASHO H-10 o° � �o ed,o/p`� 2'0 62.4' 4"OSCH40 PVC ' /� \ PIPES LEVEL 1ST 2 5. PIPE JOINTS TO BE MADE WATERTIGHT. dray o c 61.0 10" EXISTING 14" 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE TEE SEPTIC TANK** TEE 1 0'f* WITH 310 CMR 15.000 (TITLE V.) 72' 000000000 6" MIN. SUMP 60.62'GAS BAFFLE::` o Oo °o° 12" MIN INT. DIM. 7. THIS PLAN IS FOR PROPOSED WORK ONLY ANDu60.8 60.65' 0.92' 59.70' NOT TO BE USED FOR LOT LINE STAKING OR ANY \o� 4' LIQ. LEVEL (ACME OR EQUAL) OTHER PURPOSE. (16) H-20 HIGH CAPACITY INFILTRATORS 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. o ePd d e (NO STONE PROPOSED) 9. COMPONENTS NOT TO BE BACKFILLED OR. ° qv; Grec orsh 6" CRUSHED STONE OR MECHANICAL CONCEALED WITHOUT INSPECTION BY BOARD OF orn COMPACTION. (15.221 [2]) 25' X 11.3 X 1.6' high overall dimensions w e � 4 4.6' 26t' HEALTH AND PERMISSION OBTAINED FROM BOARD a ( 1 % SLOPE) ( 1 % SLOPE) OF HEALTH. k 10. CONTRACTOR SHALL BE RESPONSIBLE FOR LOCUS MAP LEACHING CALLING DIGSAFE (1-888-344-7233) AND FOUNDATION EXIST. SEPTIC TANK 18' D' BOX 5' FACILITY VERIFYING THE LOCATION OF ALL UNDERGROUND & NOT TO SCALE **INSTALLER SHALL CONFIRM MINIMUM SEPTIC TANK SIZE AT BOTTOM TH 1 EL. 55.1' OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF 1000 GALLONS AND ITS SUITABILITY FOR RE-USE. REPLACE WORK. *THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS WITH 1500 GALLON SEPTIC TANK APPROPRIATE TO SITE G-W ESTIMATED AT EL. 33'f ASSESSORS MAP 191 PARCEL 163 PER TOWN MAP 11. ANY UNSUITABLE MATERIAL ENCOUNTERED PRIOR TO INSTALLING ANY PORTION, OF SEPTIC SYSTEM CONDITIONS IF NOT SUITABLE SHALL BE REMOVED 5' BENEATH AND AROUND THE PROPOSED LEACHING FACILITY. 12. EXISTING LEACHING FACILITY SHALL BE PUMPED AND REMOVED OR PUMPED AND FILLED WITH CLEAN VARIANCES FOR SEPTIC SYSTEM REPAIRS WHICH MAY BE SAND. IMMEDIATELY GRANTED BY THE BOARD OF HEALTH AGENT OR BY HEALTH INSPECTOR PAPERWORK 'AND HEARING REDUCTION PROPOSALS APPROVED BY THE BOARD OF HEALTH REVISED DURING A PUBLIC HEARING HELD ON AUG. 4, 2009 SYSTEM DESIGN. 3) FAILED SYSTEMS ONLY SOIL ABSORPTION SYSTEM INSTALLATIONS PROPOSED MORE THAN THREE FEET BELOW GARBAGE DISPOSER IS NOT ALLOWED GRADE WITH PROPER VENTING (PIPED TO THE ATMOSPHERE) AND WITH H-20 LOADING, BUT IN NO CASE SHALL THE SAS DESIGN FLOW: 3 BEDROOMS ® 110 GPD = 330 GPD BE LOCATED MORE THAN SIX FEET BELOW GRADE. USE A 330 GPD DESIGN FLOW 145 23 a SEPTIC TANK: 330 GPD (2) = 660 " 65.23 M.64.99 RE-USE EXISTING SEPTIC TANK PAVED DRIVE / 64 LEACHING: I ` .24 91 �� ' Q. 71 4.73 SFAF x 6.25' LENGTH = 29.56 SF PER Q .ffiT3 65.41 HIGH CAPACITY INFILTRATOR UNIT TEST HOLE LOGS 1,. 31 HOOP HOUSE 330 GPD/0.74 GPD/SF = 445.9 SF LEACHING �V 5.01 (STORAGE) REVD v GARAGE 65 3 ENGINEER: ARNE H. OJALA, PE, PLS o W w w )(64. / 27 445.9 SF/29.56 SF/UNIT = 15.1 UNITS WITNESS: D. DESMARAIS, RS 65.24 EXISTING DECK TH 2 9 THEREFORE, USE GRAVELLESS SYSTEM OF (16) APRIL 27, 2012 , X DATE: � DWELLING H-20 HIGH CAPACITY UNITS IN FIELD TOP FNDN. _ / CONFIGURATION OF 4 ROWS OF 4 UNITS PERC. RATE < 2 MIN/INCH V 5825 ELEV. 65.8' x 2 TH 1 SHE 6 4 CLASS I SOILS p# 13621 16 UNITS x 29.5 SF = 472 SF > 445.9 SF © 46 6P 0 472 SF (0.74) = 349 GPD (OK) 65 ELEV. z ELEV. � // 1 65.97 12" - 18" a.79 0" 65.1' p" 65.1' LOT 52 / / �\ 6 OAKS PROP. VENT WITH CHARCOAL FILTER MA 15,249f SF 5 AND BUGSCREEN (FINAL PLACEMENT BY APPROVED DATE BOARD OF HEALTH A A , / 64.60 GARDEN CONTRACTOR WITH HOMEOWNER LS i S 64.4 CONSULTATION) 1 oYR 2/1 1 oYR 2 164 41 \ TITLE 5 SITE PLAN 6" 6" 1� p `� 61 OF B B ' \, 64 64.03 LS Ls 57 48:63 64 �� 40 GLENEAGLE DRIVE ' 63.43 CENTERVILLE 30" 10YR 5/4 62.6' 30" 10YR 5/4 62.6' ' 1 45.2,3' PREPARED FOR BORTOLOTTI CONSTRICTION/ PERC [ATTENCH MARK - CORN. OF CONC. WALL BARSELOW STEPS TO WALKOUT ELEV. = 65.1 MCS MCS _ APRIL 27, 2012 l 0YR 5/6 10YR 5/6 ��OFM off 508-362-4541 H 0 A4,18s FPf� - A � fax 508-362-9880 qcy GANIELA. tiN, ( downcape.com GRAVEL GRAVEL CJAf._L �. clAllA A. down cape engineering, iac. No.40U8 z ? 40 C)?t'� i e civil engineers 120 55.1 120 55.1 �� � . �� land surveyors NO GROUNDWATER ENCOUNTERED Scale: 1 = 20 -Z�-`1- til � �;, � ` 939 Main Street ( R to 6A) 0 10 20 30 40 50 FEET DATE DANIEL A. '6JALA, P.E., P.L.S. YARMOUTHPORT MA 02675 12-089