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HomeMy WebLinkAbout0295 GREEN DUNES DRIVE - Health 295 Green Dunes Drive Centerville A=245 - 029 BMEACPJ No.2-153LOR UPC 1?.534 samd com • Made In USA 1 ' 9 13 Commonwealth of Massachusetts o7�5_ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GM 295 Green Dunes Drive 6"a Property Address Pria Elizabeth Harmon Owner Owner's Name Q? information is � /��required for every Ma 02647 7/13/2016 page. Cityrrown State Zip Code Date of Inspection W m m Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection my Company Name 74 Beldan Ln. Centerville Ma 02632 Cityrrown State Zip Code 774-2484850 smjonestitle5@gmail.com SI4522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority �7/13/2016 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 9 / D r i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 295 Green Dunes Drive - Property Address Pria Elizabeth Harmon Owner Owner's Name information is p required for every y West H annis ort Ma 02647 7/13/2016 page. City(rown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The dwelling located at 295 Green Dunes Drive is served by a Title V septic system consisting of a 1000 gallon septic tank and a 1000 gallon precast leaching pit. The system was found to be in proper working condition at the time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ .ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 295 Green Dunes Drive Property Address Pria Elizabeth Harmon Owner Owner's Name information is required for every West Hy p annis ort Ma 02647 7/13/2016 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ 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 t5ins•3/13 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 295 Green Dunes Drive Property Address Pria Elizabeth Harmon Owner Owner's Name information is p required for every y west H annis ort Ma 02647 7/13/2016 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/day flow t5ins•3/13 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 M "p 295 Green Dunes Drive Property Address Pria Elizabeth Harmon Owner Owner's Name information is required for every West Hy p annis ort Ma 02647 7/13/2016 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-3/13 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 295 Green Dunes Drive Property Address Pria Elizabeth Harmon Owner Owner's Name information is required for every West HY P annis ort Ma 02647 7/13/2016 page. Citylrown 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): 4 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 gpd t5ins-3/13 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 295 Green Dunes Drive Property Address Pria Elizabeth Harmon Owner Owner's Name information is required for every West Hy p annis ort Ma 02647 7/13/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 11/2105pate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 295 Green Dunes Drive Property Address Pria Elizabeth Harmon Owner Owner's Name information is required for every West Hyannisport Ma 02647 7/13/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for um in : P P 9 Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments z 295 Green Dunes Drive Property Address Pria Elizabeth Harmon Owner Owner's Name information is required for every West Hy p annis ort Ma 02647 7/13/2016 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: system installed 1974 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1 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.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): Depth below grade: 10"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: 1000 gallons Sludge depth: 6" t5ins•3/13 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 wM 295 Green Dunes Drive Property Address Pria Elizabeth Harmon Owner Owner's Name information is required for every West Hy p annis ort Ma 02647 7/13/2016 page. Citylrown 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 3" 3" Scum thickness 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 10" How were dimensions determined?rmined. opened covers, took measurements Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Water level was even with outlet invert, tank was structurally sound and not leaking. Outlet tee was intact. Tank does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3113 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 M 295 Green Dunes Drive Property Address Pria Elizabeth Harmon Owner Owner's Name information is required for every West Hy p annis ort Ma 02647 7/13/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 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 295 Green Dunes Drive Property Address Pria Elizabeth Harmon Owner Owner's Name information is required for every West Hy p annis ort Ma 02647 7/13/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert N/A 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.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ` 295 Green Dunes Drive Property Address Pria Elizabeth Harmon Owner Owner's Name information is required for every West Hy p annis ort Ma 02647 7/13/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1x1000 ❑ 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.): Leach pit was dry with a stain line approx 1.5'from the bottom Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 295 Green Dunes Drive Property Address Pria Elizabeth Harmon Owner Owner's Name information is required for every West Hy p annis ort Ma 02647 7/13/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 295 Green Dunes Drive Property Address Pria Elizabeth Harmon Owner Owner's Name information is required for every West Hy p annis ort Ma 02647 7/13/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately co � 2 3 � � z 2� 5-5 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 " a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 295 Green Dunes Drive Property Address Pria Elizabeth Harmon Owner Owner's Name information is required for every West Hy p annis ort Ma 02647 7/13/2016 page. Cityrrown 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: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: 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: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 295 Green Dunes Drive Property Address Pria Elizabeth Harmon Owner Owners Name information is required for every West Hy p annis ort Ma 02647 7/13/2016 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 J Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments '(0 295 Green Dunes Property Address Philip Conway Owner Owner's Name information is required for every � t Ce �V� Ma 02672 09/13/2013 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: (� key to move your cursor-do not Michael T Bisienere use the return key. Name of Inspector Cape Septic Inspections �I Company Name 624 Old Barnstable Rd Company Address Mashpee Ma. 02649 City/Town State Zip Code 508-280-3356 S13938 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 i -soection. T§ ins tion was performed based on my training and experience in the proper function and maQntenance 4f on.iite sewage disposal systems. I am a DEP approved system inspector pursuant Xooection M340 Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fail ::i.: f.,n -t ❑ Needs Further Evaluation by the Local Approving Authority .77 a k..,1 rr9"s Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. UI D 1 1511 017t5ins•3/13 Title 5 Official Inspection Form:Sub a Sewage Disposal System•Pag Commonwealth of Massachusetts w Title 5 Official Inspection Form x Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 295 Green Dunes Property Address Philip Conway Owner Owner's Name information is required for every West Hyannis Port Ma 02672 09/13/2013 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The house has three 1000 gallon septic tanks and each tank has a leaching pit B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 295 Green Dunes Property Address Philip Conway Owner Owners Name information is required for every West Hyannis Port Ma 02672 09/13/2013 page. City(rown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ 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 16.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt.marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'l 295 Green Dunes Property Address Philip Conway Owner Owner's Name information is required for every west Hyannis Port Ma 02672 09/13/2013 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °� •'' 295 Green Dunes Property Address Philip Conway Owner Owner's Name information is required for every West Hyannis Port Ma 02672 09/13/2013 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•3/13 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 295 Green Dunes Property Address Philip Conway Owner Owner's Name information is required for every West Hyannis Port Ma 02672 09/13/2013 page. Citylrown 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): n/a Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a t5ins-3113 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 295 Green Dunes Property Address Philip Conway Owner Owner's Name information is required for every West Hyannis Port Ma 02672 09/13/2013 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ® Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: 2012 95000 gallons used 2011 59000 gallons used Sump pump? ❑ Yes ® No Last date of occupancy: weekends Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 295 Green Dunes Property Address Philip Conway Owner Owner's Name information is required for every West Hyannis Port Ma 02672 09/13/2013 page. Cityfrown 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: 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): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form A s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 295 Green Dunes Property Address Philip Conway Owner Owners Name information is required for every West Hyannis Port Ma 02672 09/13/2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: (1) 10" (2) 16" (3) 16" 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): Depth below grade: (1) 6" (2) 12" (3) 12" 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: Standard 1000 gallon „ Sludge depth: <2 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' 295 Green Dunes Property Address Philip Conway Owner Owner's Name information is required for every West Hyannis Port Ma 02672 09/13/2013 page. City/Town 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 23" Scum thickness 2" ' Distance from top of scum to top of outlet tee or baffle 10" Distance from bottom of scum to bottom of outlet tee or baffle 20 How were dimensions determined? field instruments Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): all three tanks should be pumped soon Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •'� 295 Green Dunes Property Address Philip Conway Owner Owners Name information is required for every West Hyannis Port Ma 02672 09/13/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 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 295 Green Dunes Property Address Philip Conway Owner Owner's Name information is y required for every west Hyannis Port Ma 02672 09/13/2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0"on system ( 1 )2 and 3 do not have d-boxes 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.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 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 295 Green Dunes Property Address Philip Conway Owner Owner's Name information is required for every West Hyannis Port Ma 02672 09/13/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 3 one for eachtank ❑ 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.): Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Vk Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 295 Green Dunes Property Address Philip Conway Owner Owner's Name information is required for every West Hyannis Port Ma 02672 09/13/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 295 Green Dunes Property Address Philip Conway Owner Owner's Name information is required for every West Hyannis Port Ma 02672 09/13/2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately - � _ 39 C2 �- _2 . - � - �� � A/ 1 r � y � y 3. 03 13 5-3 = 3 La: G _ (; - /2- G - ' y2 0( t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 295 Green Dunes Property Address Philip Conway Owner Owner's Name information is West required for every Hyannis Port Ma 02672 09/13/2013 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: 16 plus feet 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: I augared a hole in a dry leaching pit Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,.•' 295 Green Dunes Property Address Philip Conway Owner Owners Name information is required for every West Hyannis Port Ma 02672 09/13/2013 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information— Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 AsBuilt Page 1 of 1 LO ATION SEWAGE PERMIT NO. VILLAGE IN TTA LL III, ME i ADDRESS BA1ttIW R Olt OWN E R 7 DATE P RMIT ISSUED 4 DATE C0MPLIANCi.. I.S-SUE-D s.s SU 1 S 1 http://issgl2/intranet/propdata/prebuilt.aspx?mappar=245029&seq=1 9/6/2013 AsBuilt Page 1 of 1 TOWN OF BARNSTABLE LOCATION r r•v» �lJ�w, �- SEWAGE 7 VILLAGE SOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. ,,,,i �j�• � SEPTIC TANK CAPACITY t`iN ! Grin Gr C LEACHING FACILITY:(type) / (size) �� �L NO.OF BEDROOMS / OWNER PERMIT DATE; Ik 7-D 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) ,,r'•' feet Edge of Wetland and Leaching Facility(if any wetlands exist within 300 feet of leaching facility) /rY feet FURNISHED BY ♦f rai W f 1 , J6 d http://issgl2/intranet/propdata/prebuilt.aspx?mappar=245029&seq=2 9/6/2013 NO. 90 r,17� THE COMMONWEALTH OF MASSACHUSETTS FEE ' BOARD OF HEALTH OF al"k 11 APPLICATION FOR DISP05XL SYSTEM CONSTRUCTIO RMIT Application for a Permit to Construct ( ) Repair ( Upgrade ( ) Abandon ( ) - ❑Complete System ndividual Components .a 9 S rimed► tip- //�- v .,Lcf,� e-d Loc Owner's Nrarne Map Parcel# Address Lot#�3�✓ /d y/, �yJ jG J Telephone# instal r;fame Designer's Addess Address Telephone# Telephone# Type of Building: -J+hCT Lot Size Sq.feet Dwelling—No.of Bedrooms Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min.required) gpd Calculated design flow gpd Design flow provided gpd Plan: Date Number of sheets Revision Date Title Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator/ Date of Evaluation CR TION OF REPAIRS OR ALTERATIO S �-o hc-e Y it , T r'°-V v ,e A c d1 H GJ The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLES and furtWagto#ace the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date 411-5 1/--7--0 Inspections FORM t - APPLICATION FOt3-DSCP—® �' DEP APPROVED FORM 5/96 No. C? � THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF `HEALTH OFF APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTIONXERMIT Application for a Permit to Construct ( ) Repair (+) Upgrade ( ) Abandon ( ) - [-]Complete System El Individual Components �Locaii;on � Owner's Name /�✓'!I`/ Map`/Parcel#'/ (I' I V Address l 7 /� //, / Lot#/ f Telephone# Installer'g Name Designer's Name / Address Address �TTeelephone# Telephone# Type of Building: /! -►�I�.-�r-r Lot Size Sq.feet Dwelling—No.of Bedrooms Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min.required) gpd Calculated design flow gpd Design flow provided gpd Plan: Date Number of sheets Revision Date Title Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF R PAIRS OR ALTERATIONS f -dp/arf,r ,.G'�r� /9 o,Ar IS/ a The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further ogre,,es not to place the system in operation until c Certificate of Compliance has been issued by fhe Board of Health: Signed =' Date 4�/53� Ins Pections ' ' 7- FORM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 - No. : �00 L(7 THE COMMONWEALTH OF MASSACHUSETTS FEE A� "` / tG���►�;� ors BOARD OF H E A LT H CERTIFICATE OF COMPLIANCE Description of Work: ®,4h-dtvidual Component(s) ❑Complete System The undersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired(graded( ),Abandoned( ) at has been installed in accordance with the provisions of 310 CMF, 15.00 (Title 5) and the approved design plans/as-built plans relating to application N,o.. � �" dated I!- 7-06 Approved Design Flow (gpd) Installer � `- At Installer [��y )�` s"� /'�; q "I d" o' �J a/ Designer: nj/01- Inspector !1_ �''v/li�( n� �/Vmlzq 'te V r The issuance of this certificate shall not be construed as a guarantee thattthe/system will function as designed. r l FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 No. THE COMMONWEALTH OF MASSACHUSETTS FEE jr�at+ 1/r BOARD OF HEALTH DISPOSAL SYSTEM CONSTRAUCTION PERMIT Permission is hereby granted to Construct ( ) Repair Upgrade ( ) Abandon ( ) an individual sewage disposal system at DX, gvt!W,*/ej � as described + r �f in the application for Disposal System Construction Permit No. ;:k)0 `( �,dated �(" 5-0(1 Provided: Construction shall be completed within three years of the date of this permit.All local conditions must be met. ' Date 0 Board of Health FORM 2 - DSCP DEP APPROVED FORM 5/96 FORM 1255 (REV 5/96) H&W HOBBS&WARREN TM PUBLISHERS- BOSTON TOWN OF BARNSTABLE LOCATION ?J %•�.., JJ��s� /�- SEWAGE 7 Vl LAGE a S SSOR'S MAP&PARCEL {INSTALLER'S NAME&PHONE NO. 1Sr�� SEPTIC TANK CAPACITY a/e G" c LEACHING FACILITY:(type) �0�aY 'eyj-40 (size) JOV �I NO.OF BEDROOMS OWNER PERMIT DATE: /,k 7-p COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility feet Private Water Supply Well and Leaching Facility(if any wells exist on site or within 200 feet of leaching facility) feet. Edge of Wetland and Leaching Facility(if any wetlands exist within 300 feet of leaching facility). feet FURNISHED BY �irO I , CPOG v _4 ' C7 No......... Fles..... .... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OY HEALTH. ........... ........OF......... P4 .. t',t✓YJ!,Z..�.... Allp iratiun for Disposal Works Tonutruriiun Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal S st at: &a cxxv... v v e .........RA........................ .....-------••-•------•--•----•------•--------••••---..._...-----------._....._•---------•--....._ L,of ation-Address or Lot No. P..P..� ...... w ------------------------ ---- caner Address a1�.�.(�.c.4......i .... a�� "........................................ �:e. �.�3 r►:r:�f +N . ...►nc�!'_.......---- Installer Address 7 d Type of Building / Size Lot____________________________Sq. feet Dwelling o. of Bedrooms.______.'.__________________________Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixture = ----------------------------------------------•-••-----•--•••-----•-••---••-••-•••-•••••-•-••.....•••-••...._..-••-...-•-•-••--•---•-•--- W Design Flow__ ..................6-____ ions per person per day. Total daily flow.............................................gallons. WSeptic Tank Liquid capacity/__-_ allons Length________________ Width................ Diameter................ Depth................ x Disposal Trench—No_ ___________________ WidthLing' __._._.._._.. Total Length...... Total leaching area__.__ii_��___........sq. ft. Seepage Pit No---------- Diameter....... ..... Depth below inlet__.___.__ Total leaching area___i� /sq. ft. Z Other Distribution box ( ) D tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ L� Test Pit No. 2................minutes er inch Depth of Test Pit.................... Depth to ground water........................ a -------- ------------------••---- .....................................--• ..._-- -••-•- • Description of Soil - .-- ----- ----•• ••...•--.......XZA. .� -1."4 -- ------—•--•---•---------------------------------------•-----------•------•---- W x -------------------------------------------------------------------------------------------------•-•----------------------------------------------------------•-••---•---•----•---_----- -----------•-- U Nature of RepairsCr Alteration Answer when applicable--------L.Q_0®___.S.•9_-1+....... ......�k(....___._.. ------------------------------------------------------------------------------------------------------------------------------- -------------- Agreement: The undersigned agrees to install the aforedescribed. Individual Sewage Disposal System in accordance with the provisions of iIT I.;,,. 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. Sign -•-----------------------•---------------------------............. Application Approved BY /� `/ � 1 .G" . :a� D..... Date Application Disapproved for the following reasons_____________________________________________________________________ ......--•-•--------•-__ _____________ ...........................••-•••-----•-._...__.....-------•......_.._..---•--•••--•-•-••----••-_...._._..__...-----------------------------------------------------------------------•-••-••--•--..__... Date Permit No...................................................... Issued-----5 `_ Date v 7f ), No.- ---. .3Z Fi$............... ...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............1..-.�FZ�l.YP........0F.........2444-14.. .................................................. Appliration for Disposal Works Tonstrur#iun thrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .... •-......... ....................... - •-•. ----•-•------•------•---•-------•--•-----------•------------•-----.....--•--------...__--•---..... Location-Address or Lot No. ....m ... m'*.�.....P h- 11. �-^'.w,�Y..---...--•-......---- ............................................. ••••••-•. -. --.•.•-••••---•-'-•- -••--•----•---•...............•--............. Owner Address W 11 l ( f ` r..._.....•••-•--•-••...................... ................F`l..4. ��+ ti..,�;.,s...m,•- c ry 1 . .............................. ....:.: 1 f 14 = ........... Installer Address dType of Building' Size Lot----------------------------Sq. feet U Dwelling "o. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building No. of persons............................ Showers W YP g ---------•------------------ P ( ) — Cafeteria ( ) Other fixtures�-----------------------------•----------------- --------------- W Design Flow....................... .....) _jj _:g llons per person per day. Total daily flow............................................gallons. WSeptic Tank_�Liquid capacity.. 1 .gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No�-------•_------•-•_ Width....:............... Total Length..................... Total leaching area_.__.__ ........sq. ft. 3 Seepage Pit No..................... Diameter..«...A__..... 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................._-__-_. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ = s . ... F--.. •-• .............. o � � .In,• - - - -•---e----....--•.............Descri Description of Soil..--- 'y W UNature of Repairs or Alterations—Answer when applicable.......1_-q 0 A....c_n L �:_pt,(_-.7 A —X _8�__X.io c , 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. SignA..................................................................................... ••--•--••••-•.......----..«..._ J' Da/'tp, Application Approved By.......... _ ,. r ----- �..r/j� _ Date Application Disapproved for the following reasons_____________________________________________________________________________________________...................... -•---------•--•-----••-••-•---•--------•-----•------••--......---•--•---•••.......--•................•--•---•-------•------•----•---•-•----•--•......•-•---•-••••--•-----•-----••----•--••---------••-- ,,/ Date PermitNo......................................................... Issued..= Da THE COMMONWEALTH OF MASSACHUSETTS BOARD - HEALTH ........ .... ....OF. . 1.......... .................................... nrtif irat a of f�vrutph aurr THIS S K E�� 'Y, T atf the Individual Sewage Disposal System constructed (r Repaired ( ) by- ... ! ... :A .-------- -- f ..-- -=-- -•----. y/ /Installer ) at . •. ••--------------- has been installed in accordance with le provisions of T i L 5 of The State Sanitary, s described in the application for Disposal Works Construction Permit No._ ._.__._4.__-�-.�:--........ dated_.... ____`_._ .'_7__ r........... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.........� .���....... ` ....................................... Inspector-----.. •-------------------.............----•----- THE COMMONWEALTH OF MASSACHUSETTS BOARD Or7 .HEALTH ram,....... O F.......... ................................... k .......•.... FEE �i��rrr�ttl r _ -,,I�n�#r1t.L�ilan rruti� �1 Permission is hereby/granted.,.. d'... .+... ................... .... ........................... ... f.._.. ................ to Construct ( jepair (,�((ff n Individu Sewage oral Sys ' " I at No. f,` ... � .. _. ....':... ` r-- .. ..._. Street as shown on the application for Disposal Works Construction Permit�o.._«.: _'_«�__ i��' _ Dated........---�-----•--•---...7�---- ....�.. � -------- ----- f DATE....................... ........................................................ Board of Heal FORM 1255 HOBBS & WARREN. INC., PUBLISHERS - LO ATION _ SEWAGE PERMIT NO. in. ' V.ILL E I N -TALL R'S M E i ADDRESS B=U+r R OR OWNER v v DATE P RMIT ISSUED lT 7 DAT E COMPLIA-NCE, y1:S-SU:E:D I - , � __._.,.: �� �i ' ��r i _.-- 1 � i � � � �D E a'` � _ �� �'�