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0041 HAYWARD ROAD - Health
41 Hayward Road Centerville P y A = 186 081 No. 4210 1/3 ORA 77 pro--% 10°10 0 a a a a i 1 I i' S <� C 10, NION V,TE-ALTH OF 7VIASSACHUSETTS 7 (T EXECU'TIVE OFFICE OF ENVIRONMENTAL AFFAIRS. F — EP,ARTII EI�tT OF:ENv-IRONMENTAII PR'QTECTIOI�T TITLE 5 OFFICIAL INSPECTION FORIA/11—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM. PART A CERTIFICATION `t 5 5 � Property Address: A_1 d y� Owner's Name - Owner's Addr !� -7 ( ' Date of Inspection: V� Name of Inspec (please prinij Company Nam f Mailing Address- Telephone Number: co . � CERTIFICATION IO�i STATEMENT 1 certify that I have per inspected the sewage disposal system at this address and,that the i�formation)repc`ed below is true, accurate and.complete as of the time of the inspection.The inspection was performed oasedTn myr" trainin-and experience.in the proper function and maintenance of on:site sewage disposal system I am a DEP •approved system inspector_ pursuant to Section 15.340 of Title 5'(3.10 CMR 15:000). ;The syst rn: 1passes Con na11y Passes eeds urther Evaluation by the.Local Approving-Authority Fails Isaspeotor's Signature:. Date:. /d$ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or. DEP)within 30 days of conpletins 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 oriainal should'be sent to the system owner and copies sent to the buyer,if applicable, and the approving authority. Notes and Comments ""`*This report only describes.conditions at the time of inspection•and under.the conditions:of use at that time.,This inspection does not address'how the system will perform in the future under-the same or different conditions of use. Title.5 Inspection Form 61*1 512 0 0 0 page 1 .• Page 2 of 11 . ,OFFICIAL INS.PECTION:F0RM:7 NOT FOR VOLUNTARY ASSESSMENTS: 1 SUBSURFACE SEWAGE:DISPOSAL SYSTEM INSPECTION FORIYI PART A CERTIFICATION (continued) Property Address Owner: Cr Date of I iecti.on: 7 ir.4ection'Summary: Check, A,B',C,D or E/ALWAYS complete.all of Section D A. vytem 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 15304 exist.Any failure criteria.not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components.as described in the"Conditional Pass'section need to.be replaced or repaired.The system, upon completion of the replacement or repair;as approved by the Board of Health..will pass. Answer yes,no or not determined(Y,NiND)in the ',for the following statements. If"not determined.'please explain. The septic tank:is metal and'over 2.0.years old, or the septic tank(whether metal or not):is structurally unsound, exhibits substantial infiltratiori or exfiltration or.iank failure is imminent:System will pass inspection if the existing tank is replaced with a.complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20.years old is available. . ND explain: Observation of sewage.backup or break out or high static.water level in,the distribution box due to broken or obstrucied'pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of B oard.of Health): broken pipe(s)are replaced obstruction is-removed distribution.box is leveled or replaced ND explain: The system required pumping more than:4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with..approval.of the.Board of.Health).: broken pipe(s),are replaced obstruction is;removed ND explain: Page 3 of 11 . . t OFFICIAL INSPECTION FORS -.NOT FOR VOLU3YTARY ASSESSMENTS SUBSURFACE SE VTAGE:DISP'OSAI` SYSTEM INSPE CTION-TORM PART_A CERTIFICATION(continued) Property Address: f ` Owner. 10 Date of6FApection: C. Further.l✓valuation 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. I. System will pass unless Board of Health determines in accordance with 310 CMR 15303(1)(b) that the system is not functioning in a manner which will protect:public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool orprivy is within_50 feet of a bordering vegetated wetland or a salt°marsh Z_ System will fail unless the Board of Health(and Public,Water ,Supplier,if any).determines that the system is functioning in z manner that.protects the public health,.safety.and environment: _ The system has a septic tank and.soiI absorption system(SAS)and the SASis.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 systen has a septic tank.and SASand the SAS is.within 50 fe�ef of aprivate:water supplywelL _ The system.has aseptic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water suppi_y.well**.Method used to determine.distance *This system passes ifth e welI water analysis;performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is.free from pollution from that facility and the presence of amn+onia nitrogen and nitrate nitrogen is equal to or lessthan 5 ppm,provided thatno other failure criteria are triggered. A copy of the analysis*must be attached to this-forte. 3. Other: 3 L Paae 4 of I 1 OFFICIAL:;IItiSPECTION::FORI NOT F.OR VOLUNTARY ASSESSNIENTS SUBSURFACYSE'WAGE DISPOSAL::.SYSTEM-INSPECTION.FORM PART A CERTIFICATION(continued) ProPety.r .Address: 'Owner:(::)-- Date of I pection:. �j7 Oc �0 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 liquidl.evel:in the distribution box above..outlet.invertdue 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 Required pumping more."than 4-times in.the'last year NOT due to clogged or obstructed pipe(s).Number of times pumped t p p . Any portion of the-SAS,cesspool or privy i.s..below nigh around 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 cesspcol.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. than 1.00 feetbut.r ater,than.50feet.�om a private water supply well with no acceptable-water quality analysis..[This system passes-if the.well water analysis, performed at..a DEP certified laboratory,for coliform.bacteria and.volatile organic compounds indicates that the.welI•is free from pollution from that.facility and the:presence•of ammonia nitrogen 2ndii nitrate nitrogen is equal.to or less than 5 ppm,.provided that no other failure criteria are triggered..A.copyof the analysi"s.must'be.Attached to this form.] AV (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in'310 CMR 15.303,the'refore•the system fails.The.system-owner should contact the Board of Health to determine:what wilt 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. 1.5,000 gpd. You must indicate'either":yes" or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a.surface drinking water-supply the system is within 200 feet.of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA) or a mapped Zone Il 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 ID shall upgrade the system iri accordance with 3:10 CMR 15.304.The system owner.,should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL.INSPECTION FORM-*NOT FOR V-6_bTiTAI�Y ASSESSMENTS SUBSURFACE'SEWAGE DISP.OSAT .SYSTE�VI INSPECTION FOR!Y1 TARTS CHECKLIST Property Address: Owner. _ Date of I spection: Check if the following have been done..-You must indicate"yes"or"no"as to each of the following: YVS -0 - . . Pumping.information was.provided by the owner, occapant, or Board of Health. Were any of the system components pumped out in the previous two weeks.? v Has the system received normal flows in the previous two week period? v 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 ? ` V _ Was the site inspected for signs of break out ? L _ Were all system components, excluding the SAS,.located on site? .6Z _ 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; 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'deterininedbased on: Yes no V/ 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 C_-MR 15.302(3)(b)j 5 } Page 6 of 11. QFFICIAL:INSPECTION FQ.RIYI NOT.FOR VOA UI T;A 'ASSESSMENTS SUBSURFAC'E`SEWAGE:DISP.OSAL- SYSTEM-INSPECTION FORM PART.C SYSTEM.-ItY- F.ORMATIOi d Property Add:resst Owner: Date;of. spection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):'. Number of bedrooms(actual).: DESIGN flow based on'310 CIviR 5.203 (fo example: 11:0 gpd x of bedrooms): Number.of current residents:. Does residence have a garbage grinder(yes or no): 0 u Is laundry on.a separate:sewage system(y or no):A& .[if ves separate inspection required] Laundry system inspecttailable r no}; 6 Seasonal use: (yes orna ;`y��2�j'f Water meter readings; if (last 2 years usage:(gpd)): ( � /Sump-pump (yes or no):Last date of occupancy:: C OMMERCIATJIND USTRIAL4/0 Type of.establishment:. Design.flow(based on 510 C1vIR I5.203): gpd Basis ofdesizn flow(seats/persons/sgft,etc.): Grease trap present(yes:or-no).: Industrial waste holdings tank present(yes-or no):_ Non-sanitary waste discharged to the.TitIe 5 system(yes or no):_ Water meter readings. if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping RecordsPp , Source of information: Was system pumped as part ofthe.inspecfion.( s or no): :d If yes,volume pumped: gallons—How was quantity pumped determined2 Reason,for pumping: TYPF SYSTEM reptic lank, distribution box,soil absorption system _Single cesspool _Overflow cesspool Privy _ _Shared system (yes:or no)(if yes, attach previous inspection records,.if any) _Innovative/Alternative technology-Attach a copy of the.current operation and maintenance contract(to be obtained from system'owner) _Tight tank _Attach a copy of the DEP approval —Other.(describe): Approximate age of all components, date installed(if known)and source of information: Were sewage odors..-detected when.arriving at the site (yes or nox-20 6 Page 7 of l l OFFICIAL INSPECTION FORM—NOT FOR*VOLUNTA.RY ASSESSMENTS SUBSURFACE SEWAGE-DISPOSAL`SYSTEM.INSPECTTON F:ORiY1. PART .0 . . SYSTFM.INFORM.ATTON (continued) Property Address: Owne. Date of. spectic o(� BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron .40 PVC_other(explain): Distance-from private water supply well or suction line: Comments (on condition'of joints,venting, evidence of leakage,'etc.): SEPTIC TANK: °�(locate on site plan) Depth below aradkvjC Material of construction:.—V60-ncrete metal fiberglass . Polyethylene- _other(explain) If tank is metal list age:— .Is age:confu-coed by a Certificate of Compliance(yes or no).`—(attach..a cosy of certificate) Dimensions: Sludge depth:�l/ Distance from top of sludge to bottom of outlet tee or baffle:. . Scum thickness: j� / Distance from top of scum to top:.of outlet tee or baffle`.. Z Distance from bottom of scum to bottom of outlet tge or baffle: How were dimensions.deternine.d -t.Aj'4 ga fJ '1 g�ax Comments (on pumping recorime dationli, inlet and outlet tee or baffle condition, structural integrity, Iiquid levels a related to outlet invert, evi ce of leakage, etc.): T L3// @.Q.Z/'rfV GREASE TRAPlocate on site plan} , Depth below grade:_ Material of construction:—concrete. metal— fiberglass__polyethylene—other (exol-ain): — Dimensions: Scum thickness: Distance from top of scurf to top of outlet tee or baffle: Distance from bottom of scum to bottom`of outlet tee orbaffle: Date oflast.pumping: Comments (on* pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,-evidence of leakage, etc.): Page 8 of 1.1 •OFFICIAL..INSPECTIO�FOI�I—Nfl I:FOIE;COI U�I?���'.ASSESS?�LE�i TS SUBSURFACE•SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C. S.YSTEMJ lFORMATION(continued) Property Address: 7. CyL� Owner: - Date of I ection: -7 TIGHT or HOLDING TANKA/(tank must be pumped at time of inspection)(loc.ate on,.site plan). Depth,below grade: Material of construction: concrete metal fiberglass polyethylenz other(explain)-. Dimensions: Capacity: Gallons Desi-n Flow: gallons/day Alain present.(yes.or no):. - Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments•(condition of alarm and float switches, etc.): DISTRIBUTION BOX: i✓ of present must be opened)(locate on site.plan) Depth of liquid level above outlet invert: Comments (note if box is-level and distribution to outlet. qual,.any evidence of solids carryover, any evidence of age into or out of bob, et . : ate' - aaw V ���r �" v a PUMP CHAMBER:: ocate on site plan)_ Pumps in working.order(yes or no): Alarms in working order(yes or no): C mments (note condition of Pump chamber, condition of pumps and appurtenances etc.): iou � -u� . Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE-SEV/-AGE:DISPOS-AkL:SYSTEM INSPECTION FORMI PART.0 SYSTEM INFO 'RiYIATION(continued) Property Address: Owner: Date of I pection: Q "� SOIL.ABSORPTION SYSTEM (SAS):Zlocate on site plan, excavation not required) If SAS'not located explain why: Typ Ieaching pits,number:_` -Ieaching chambers,number: deaching.galleries, number: leaching trenches,number, length: Ieaching 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; CESSPOOLS(cesspool must be pumped as part of inspection)(locate on site plan) Number and coniauration: Depth'—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: indication of.groundwater inflow (yes or no): . Comments (note condition-of soil, signs of hydraulic failure,.level of ponding, condition of vegetation, etc:): ' U PRIVY (locate on site plan) Materials of construction: Dimensions: Depth ofsolids: Comments (note condition of soil, sins of hydraulic failure, level of ponding, condition of vegetation, etc.):- I Page 10 of 1.1 OFFICIA.L:INSPECTION=FORlYS;=.-i0-T FORNOLIJNT.—AR-Y-ASSESSMENTS . SUBSURFACE SEWWAGE:-DISPOSAL SYS`I'E_NI.1. SPECTIO�i FOR 1 PART C- SYSTEM:ZNFORMAT1ON(continued). Property Address: Owner: Date of SKETCH OF SEWAGE DISPOSAL SYSTEM j Provide a sketch of the;sewage disposal system including ties to at least two.permanent reference landmarks or benchmarks. Locate all:wells within 100 feet.'Locate.where public water supply enters the building. 9 o 10 } Paae I 1 of I I OFFICIAL INSPEC f'ION FOR-1Y1 -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYS•TEM.INSPECTION'FORIM, PART C SYSTEM-INFOP-MATI ON(continued) Property Address: Owner: Date of I pection: . Alp ''j SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please.indicate (check)all methods used to determine the high ground water elevation: Obtained from system.design plans on record-If checked, date of design plan'reviewed: Observed site(abuttinc'property/observation hole within 150 feet of SAS) Checked with local Board cf I-lealth-.explain: Checked with.local excavators; installers- (attach documentation) Accessed USES'database-explain: You must describe how you established the high groundwater elevation: 11 i Permit Number: Date: Completed by: HIGH GROUND-WATER LEVEL COMPUTATION Site Location: / Lot No. Owner /C Address: Contractor: Gc -Address: ✓� l�P rLf6J'?� .✓Gt� Notes: �5/yel5 STEP 1. Measure depth to water table �y to nearest 1✓10 ft. .................................. ................................ ......... .Date month/day/year STEP .2 Using Water-Level.Range Zone and Index Weil Map.locate site and determine: a(A Appropriate index well.......................:........ !: .a.. ....• Water-level range zone ............................................... :..... STEP 3 Using.monthly report"Current Water Resources Conditions" determine current depth to water level for index well ............................. month/year STEP 4 Using Table of Water-level Adjustments for index well;(STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) y determine water-level adjustment ............................. . STEP 5 Estimate depth to high water by subtracting the water level adjustment (STEP 4) from measured depth to water levelat site (STEP 1) .......:...................................................................................................... . Figure 13.--Reproducible computation.form. 15 i ° ' T;ol e Town of Barnstable OF tHE Tp� Regulatory Services BAMSUBLE, Thomas F. Geiler,Director 9$ MASS. •�� Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This sep tic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the "Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. TOWM OF B,aNS'FABLE SEWAGIr� °_�> _ ASSES R'S MAP & LOT-- (� =NAME&PHONE N �`-27/" SEP —'1C TANK CAPACITY MOD I t 6W WJA1h1eJbm4,e,- ILEACHING FACILITY: (type) t (size) X' � x NO. OF BEDROOMS BUILDER OR OWNER m",/, PERMITDATE: 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 Aag 7 2—?10S— ID° b coi �ec . F i i ud L�GH7 0OVT I 77-7 'V 35 U ^ c.5 Rai., rrc^ a' T,t 4.'2:_. cou R r. VATCD 1 ouCIAA �� l z TO O 1 , 9 \S% uu)ER - of 13 �oQ 390 J ems. Of r ti ARNE H. �G� /o ARNE G\. a GJALA y H. ^I i12 C2 ev� No.h9 %d�, 1 , 31L N1 �� OJALA 90792 / N26:ia8 moo; NCj/NEc/�S AF'�FCIS E�p\���o_. �F �`��°j.,�� �• SUf'1/c�YJ S F �G/ Il lRy b90UT/j;;C�rC'T It/j'� AR N..: WALA� L,S.i P•E. DATE f:pFR COMMONWEALTH OF MASSACHUSETTS .�'� r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION r TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Owner's Name: Owner's Address: tie �3A, Date of Inspection: C� l� Name of Inspectgx.44please rint _•! ..,,Company.Name. e R r ;;,A co Mailing Address: Z. d 7 ^f C`7 Telephone Number: $`�"71'• __ t �o CERTIFICATION STATEMENT Z I certify that I have personally inspected'the sewage disposal system at this address and that th 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 DE.P approved system inspector pursuant Zo Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by t-ie Local Approving Authority UilsInspector's Signature: / �"— Date: ' If/os The system inspector shall submit a copy of this inspection report to the :pproving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address,how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 t Page 2 of l I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 7 Owner!( r Date of Inspection: ~- X-26 Inspection Summary: Check A,B,C,D or E./ALWAYS complete.all of Section D A. (System Passes: " V 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?;ndicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass section.need to be replaced or repaired. The system,upon completion of the replacement or repair; as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N.ND)in the for the following statements. If"not determined"please explain. Thelseptic tank is metal and over 20.years old" or the septic tank(whether metal or not):is structurally unsound;exhibits substantial infiltration cr exfiltratiori 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 f it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 yea_s old is available. ND explain:. Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass.inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping.more than'4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed N I' D explain: 2 Paee 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) 4/a, Property Address Owner- Date of Inspection: 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. G 1. System will pass unless Board2pf Health determines in accord2nce with 310 CMR 15.303(l)(b)that the system is not functioning in a planner which will protect publs health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within.30 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of 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 I of a public water supply. i The system has a septic'tank and SAS and the SAS is within 50 feet of a.private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform: bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. i i" 3. Other: c; yl 3 Page 4 of 11 OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY"ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEN1 INSPECTION FORM PART A. CERTIFICATION(continued) Property Address: Owner: Date of Inspection: ,.QC06- D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes N 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 1f 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 _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number > of times pumped IV 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 a/ water supply. Any portion of a cesspool or privy is within a Zone.l of a_public well. Any portion of a cesspool or privy is within 50 feet of a.private water supply well. greater Any portion of a cesspool or privy is less than 100 feet but seater than.5.0 feet.from a private water — P Y a .. supply well with no acceptable water,quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bac'eria and volatile organic compounds. indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen.and nitrate nitrogen is equal to or less than 5 ppra, provided that no other failure criteria are triggered. A.copy of the analysis must be attached to this form.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The;system owner should contact the Board of Health to determine what will be necessary to correct the faih:a;e. E. Large Systems: To be considered a large system the system must serve a facility with a design.flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"tor each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is.within 400 feet of a.surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 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. . ' 4 1 r Pase 5 of l l OFFICIAL.INSPECTION FORM-NOT. FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner Date of Inspection: a Check if the following have been done.You must indicate"yes"or."no"-as to each of the following: Yes —o Pumping.information was provided by the owner, occupant, o_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 ssite I _ 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 liqu_d, 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 j The size and location of the foil Absorption System (SAS)on the site has been determined based on: Yes no Existing information. For example, a plan at the Board of Health. l Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] I, i 5 - I Page 6 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION Property Address: ' / Owner Date of,nspec i6n ' FLOW CONDITIONS RESIDENTIAL Number of bedrooms(.design): plumber of bedrooms(actual): >_ DESIGN flow based on 310 CMR 15.203 (for example: 11.0 gpd x#of be,drooms):� ( Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system (y/s or no (�. .(if yes separate inspection required] Laundry system inspected(y s.or no):f'1 O Seasonal use: (yes or no)MV Water meter readings, if a,va�;ilable (last 2 years usage(gpd)):D��ZZ✓/G00 Od Sump pump(yes or no):/Z v / Last date of o.ccupancy:0ijA" COMMERCIAL/INDUSTRIAL N Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Titre 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): n GENERAL INFORMATION Pumping Records J Source of information: Was system pumped as part of the i spection(yes or no): If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: T/Y%E F SYSTEM epic tank, distribution box, soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system (yes or no)(if yes,attach previous inspection records,:f any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval € Other(describe): Approximate age of all components, date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): 6 l Page 7 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM:INFORMATION(continued) Property Address: j�► c Owner: A � -�� Date of Inspection: ' . - jo's- BUILDING SEWER locate on site lan c U ( P . )� Depth below grade: Materials of construction:_cast iron _40 PVC_other(explain): Distance from private water supply well;or suction line: Comments (on condition of joints, venting,evidence of leakage, etc.): SEPTIC TANK:ZI (loc ate on site plgti) Depth below grade - 6/. Material of construction:-4,,,66'ncrete__metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age con!;irmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: Distance from top of�sludge to bottom of outlet tee or baffle:. Scum thickness: /f Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom 9,f outlet tee or baffle: flow were'dimensions determined: Comments (on pumping recommend tions, i let and outlet tee or baffle condition,structural integrity, liquid levels related to outlet invert, evidence of leakage, etc.): L 4' GREASE TRAP,moi(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other" (explain): . Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of 16,1kage, etc.): t�1 l� 1 5 3 f 7 Page 8 of 11 OFFICTAL INSPECTION.FORM-NOT FOR VOf UNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: r C�� Owner: Date of Inspection:. TIGHT or HOLDING TANK:.(tank must be pumped at time of inspection)(locate on.site plan) Depth below grade: Material of construction: concrete metal fiberglass.__polyethylene other(explain): Dimensions:' Capacity: gallons Design Flow: gallons/day Alarm present.(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): 1 • DISTRIBUTION BOX: (if present must be opened)(locate on site.`.plan) Depth.of liquid level above outlet invertgvgQz� "� Comments(note if box is level and distribution to owlets equal, any evidence of solids carryover, any evidence of akage into or out of box,etc.):. ^Ae PUMP CHAMBER/, (locate on site plan). Pumps in working order(yes or no): Alarms in working order(.yes or no): Co ments(note condition of pump chamber,condition of u ps and appurtenances, etc.): 1 r` 1 y' i� r Page 9 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: C Owner: c Date of Inspection: , SOIL ABSORPTION SYSTEM (SAS):_'/ocate on site plan,excavation not required) If SAS not located explain why: f Tyt;/ leaching pits,number: leaching chambers,number: leaching galleries, number: leaching trenches, number, length: leaching fields,number, dimensions: overflow cesspool,number: _innovative/alternative system T)'pe/name of technology. Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil; condition of vegetation, C.)I A � 1/ X 4 CESSPOOLS/t (cesspool must be pumped as part of inspection)(Iccate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: 4 Dimensions of cesspool: Materials of construction: ' Indication of.groundwater inflow(yeskilr no): Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc:): PRIVY(locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs,of hydraulic failure, level of poreding,condition of vegetation, etc.): 9 a Pace 10 of I I OFFICIAL INSPECTION. FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: y Owner:` �� Date of Inspection: 7,g0U,� SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least permanent.reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public wate.4 supply enters the building. I .r()S is �� i � J i \e - 6C)o &Y4 y9 e El 0 ---------------- s 10 1W,M1 Page 1 I of I I OFFICIAL INSPECTION] FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEW XGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address— Owner: ' Date of'Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells ;. Estimated depth to ground water G7 'feet Please indicate (check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Healith-explain: Checked with.local excavators, installers-(attach documentation) Accessed USGS database-explaint'a You must describe how you established'the high ground water elevation: �5r ..5�- �r�t �' .LII�DS f i IF I J 11 .D 1 ' Permit Number: Date: Completed by: 3�✓C� v HIGH '—I ROUND-WATER LEVEL COMPUTATION Site Location: � rC�C ` Gr° �U� C, Lot No. Owner: /� ./i' d Q(� ` Address: Contractor: + Address: . Notes: STEP Me 1 � :V-`• Measure depth tc water table to nearest - e t 1/10 ft Dat- 7�7 0J : .. month/day/year STEP 2 Using Water-Level Rar-g= 'lone an - d Index, -<Well M - p �c l.. site and determine: g n. - - , . . ! , _. O APPropnaLeand >::,vell.................... R o \ B Water-level Orange -cne .........................".."... ..........""..."". STEP 3 Using monthly report. Current Water Resources.Cond-ions' I; determine curre.nt.depth tj water level for index nth/year STEP EP 4 Using Table of Water- ceel'Adjus tments for index well (STEP 2.4 'current depth to water level for index,well (STEP 3), - and.water-level zone (STEP 2B) - determine water-level I stment` . ....""....................................... a�T STEP b Estimate depth to high water G subtracting Y g the waiver- - level adjustment (STEP s; "sl•";5 from measured depth to vJ �er level at site (STEP ) ._.... ........... :':: `; :r: .................... fr A Rowe 13.--Reproducible computation fora. t t a 15 : q S l �D CI aA/Vie/` , n J I. ti� TOWN OF BARNSTABLE SEWAGE`S_ 'd'LL LA`GE_ ASSES OR'S MAP & LOT _ NAME&PHONE N rCt 7/ 1 SEPTIC TANK CAPACITY )U oc /y, Byj LEACHING FACILrIT: (type) ` f (size) l,2'K Z: X NO. OF BEDROOMS BUILDER OR OWNERLlh/1i _12 ,, 7 PERMITDATE: 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 l'1rfL V Trr e 7///2-7/05" r aERaF':Mi) COLA R-r. v.a V \ TREE Tel ``` ."\ 30 N r i5: Q 1.� S -,,`� _ 1� .. pig�\J�i E � _" „f• i S G/ U Pace 10 of 11 l OFFICIAL INSPECTI, N FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SELVAGE DISPOSAL SYSTEM-INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ' L i Owner:" Date of Inspection: .Q• _ '�QC00� SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building. i rG 1 03 /11nr, 1 0 10 i �i. TOWN OF BARNSTABLE LOCATION _ SEWAGE # 'II.LAGE ASSESSOR'S MAP & LOT NAME&PHONE N , - ! SEPTIC TANK CAPACITY )D I"A, iY- , /ytp/- LEACHING FACILITY: (type) (size) NO.OF BEDROOMS— BUILDERry I //� I OR OWNER(jh Am;J34 2,&,d1 PERMITDATE: 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 I I F D 0�� c�llon 5 t,� c F_13 1 4 I Do age Po► I Bituminous ent 1 Boot Romp tone Lowe \ Cana Stone •/ -%Pubs s,. � � � '• � ��e ry►'ewoy� Tank And-PChamtwr ump Meter Retain. lYo// _ — ` ` Lowe ILL _ ANO \moo , — Patio FL 00�_ � alrr, � F�,=11�- �'' I \ ' •\ 5' Wide Pier r Stanewo//s `'1+ P/anting Area _ ..., ����, � . ——�•`_,__.'_\' , — L , � � III 1\ \ \ �- \ � Salt Marsh SL a \ °� •; alp. ; I 1 11 ` of / I Lawn ► • 1 1 \ � °�. w 4' High Fence L I 2366 • Fps f; < \ Z A PROPOSED 0 01 IN c (CENTER BARNSTAE I a / COMMONWEALTH OF`1VIASSACHUSETTS x EXECUTIVE OFFICE OF ENVIRONMENTAL.AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION REVED CE• AUG 6 2002 TOWN OF BARNSTABLE TITLES HEALTH DEPT. OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY:AS . SSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: /1 Owner's Nam . �t C�4-5 Owner's Address: �7 9 Date of Inspection: O vZ- Name of Inspect • (please rint) P `�'�� L�bf °41 iVIAP ( � Company Name ' Mailing Address: 0• `>0 VPARCEL Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based.on my training and experience in the proper 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 Nee s Further Evaluation by the Local Approving Authority. a• Inspector's Signature: Date: G The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP..The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. , Notes and Comments � �� �� y /y � 6 ��C!/)�r.[.C1�, ****This report only describes conditions at.the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/20.00 page 1 v Page 2 of 1] OFFICIAL INSPECTION FORM—. NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 4,. Y;; ;.} PART A CERTIFICATION (continued) Property Address: Owner Date of ;nspection: SOU Inspection Summary: Check A,B;C;D or E/ALWAYS comp lete.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: B. System Conditionally Passes: nior 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,ti!ill pass. .. ;ti. M ....: Answer yes,no or not determined(Y,N;ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or.tank failure is imminent:System will pass inspection if the existing tank is`replaced with a complying septic.tank as approved by the Board of Health. *A metal septic tank,will pass inspection if it is sructurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pi.pe(s)or due.to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): . broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3:of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM'INSPECTION FORM PART A CERTIFICATION(continued) Property Address: ,p24 ao Owne • Date ofInspection: 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 C.MR 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 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 I of a public water supply. _ The system has a septic tank and SAS:and the SAS is within 50 feet of a private water supply.well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from.a, private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified.laboratory,for coliform bacteria and volatile organic compounds indicates that the well.is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL.INSPECTION FORM—NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE,'SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner. Date of Inspection: . pa D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes N9 l/. 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 '/Z day flow yP 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 ofa.public well. V Any portion of a cesspool or privy is within 50 feet of d.private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes-if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence:of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described,in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct`the failure. E: Large Systems: To be considered a large system the system mustserve a facility with a desigw low of 10 000:.gpd to 15,000 gpd. You.must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 490 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 questibn 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. 4 I Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Date of Inspection. 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.volume.s of water been introduced to the system recently or as part of this inspection? V _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) V — Was the facility or dwelling inspected for signs of sewage backup? _ 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.t 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: Ye no �/ 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 nacceptable) [310 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE`DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 9�, Owner ooAy- V Date of Inspection-, Oa FLOW CONDITIONS RESIDENTIAL ✓. Number of bedrooms(design):a. Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 for example: 11.0 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system es or no):;oZ&:[if yes separate inspection required] Laundry system inspected es or no): Seasonal use: (yes or no): p� / Water meter readings, if ay�iable(last 2 years usage(gpd)): Sump pump(yes or nq), Last date of occupancy: COMMERCIA`L/INDUSTRIAL "" Type of establishment Design flow(based on 310 CMR 15.203): . gpd Basis of design.flow(seats/persons/sgft,etc.): Grease trap.present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system (yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:. Was system pumped as p"ofnspec 'on(yes or 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) —Tight tank _Attach a copy'of the DEP approval Other(describe): � proximate'age of all components,date installed(if known)and source of information: � S. ih_, Were:sewage odors detected when arriving at the site(yes or no):,_/ 6 i Page 7 of 11 OFFICIAL INSPECTION FORM NOT FOR.VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM PART C SYSTEM-INFORMATION(continued) Property Address: � ( e4 OwneroA,fy Date of nspection: J BUILDING SEWER"(locate on site plan);®`" Depth below grade: Materials of construction:_cast iron 40 PVC.—other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓(locate on site pla ) Depth below grade. Material of construction:�ncrete_metal_fiberglass_polyethylene other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no):_(attach,a copy of certificate) i Dimensions: "5 'X Cv X �5 Sludge depth: /(„ Distance from top of sludge to bottom of outlet tee or baffle: Z.Z— Scum thickness: 0"� Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Comments(on pumping recomme datiet and outlet tee or baffle condition,structural integrity, liquid levels related to outlet invert,evidence of leaks e,etc.): , GREASE TRAPocate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of'leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: o 6 Owner: ,Pr' Date of Inspectio co� TIGHT or HOLDING TANK,;/ {tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions:' Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: �f present must be opened)(locate on site plan) Depth of liquid level above outlet invert: ' eve]and distribution to outlets a ual an evidence of solids carryover, an evidence of Comments(note if��x �s 1 � Y n'Y Y eakage into grout of b x ete.): PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms'in working order(.yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): I 8 f Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: fcy& 4 Owner a< Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): L/(rocate on site plan,excavation not required) If SAS not located explain why: Type eaching pits,,number: Teaching 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, CESSPOOL(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth'—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of.groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.): PRIVY`(locate on site plan) Materials of construction:. Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.): 9 1 Page 10 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: llauo� yge_/ P Y Owner - Date of Inspection: 00- SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the,sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. too I i 6. boo " 0 u 10 r Page l 1 of 1 l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: k ' Date.of Inspection: a SITE EXAM Slope Surface water Check cellar Shallow wells Estimated.depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation- Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) 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: 11 i Perm!Number: Date: Completed by:. _ HIGH GROUND-WAT E'R LEVEL COMPUTATION Site Location y��/ 1 i Lot N`o. /fit GP �Gi'ts�Z4f J.w•ner: �//�1� �% i� Address:. r" Contractor: Address: Notes:. STEP• 1 . Measure depth xo.water table �/ to nearest.1./10 it......_.......................... Date F711fl _. month/day%Year _ ST.El? 2 Using.Water-Level.Range Zone and Index WeII:N.a.p..locate site and determine: OAppro.priate.index well_.............._................_.....:....._....... —J• CWater-level-range zone ...............-........-....... STEP;Z;: Using-month ly.repart:"Current Y Water R.esources-Conditions" determine current•de.pth'to water level for•indez well ........................... 0 month/year I I STEP. A. Using,Table.of-Water-Ievel Adjustments for index well (STEP.2A6_current depth I to water•level for•index well (STEP 3y, and water-le.vel zone (STEP'2B) determine water-level adjustment ...................................:.........................................:.:.............. STEP: 5 Estimate depth to Ahigh water by subtracting th.e•water-; level adjustment-(STEP 4) from measured-.depth to.water level-at site.(STEP"1)..........................................:..................................................._................ Figure- 3:—k�'i2�r(�ti4o1��8 iOTi�ili�iliJi;form. `Belk a O dd _ Ft IVE9 FEB 11 20 1 �'NOFggq�� BORTOLOTTI CONSTRUCTION, INC. - ZAN%D , 45 INDUSTRY ROAD, MARSTONS MILLS, MA 02648 508-771-9399 508-428-8926 FAX: 508-428-9399 $ ,, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: GY ' Date Of Inspection 9 5q In pe ctor's Name::Ow er's am and Address: CERTIFICATION STATEMENT• I Certify that I have personally Inspected the Sewage Disposal System at this address and that the informa- tion reported below is true,accurate and complete as of the time of Inspection. The Inspectioin was perform- ed based on my Training and Experience in the Proper Function and Maintenance of On-Site Sewage Dis- posal Systems.Th ystem: Passes t' t Conditionall ass s Needs Fur r Ev u n By the Local Approving Authority Failure Inspector's Signature Date: I TheSystem Inspector all submit a copy of this Inspection Report to the Approving Authority with Thirty (30)Days of completing this Inspection. If the System is a Shared System or has a Design Flow of 10,000 gpd or greater,the Inspector and the System Owner shall submit the Report to the appropriate Regional Offie of the Department of Environmental Protection. The Original should be sent to the System Owner and copies sent to the Buyer,if applicable and the Approving Authority. JNSpE MARY: A) SYSTE PASSES: I have not found any Information which i ndicates that the System violates any of the fail- ure criteria as defined in 310 CMR 15.303. Any Failure Criteria not evaluated are indi- cated below. B) SYSTEM CONDITIONALLY PASSES: One or more System Components need to be Replaced or Repaired. The System,upon completion of the Replacement or Repair,Passes Inspection. Indicate yes,nor,or not determined(Y,N,OR ND). Describe bases of determination in all instances. if"not determined",explain why not. The Septic Tank is Metal,Cracked,Structurally Unsound,shows Substantial Infiltration or exfil- tration,or Tank Failure is iimminent. The System will Pass Inspection ifExisting Septic Tank is Replaced with a conforming Septic Tank as Approved by the Board Of Health. Sewage Backup or Breakout or High Static Water Level observed in the Distribution Box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven Distribution Box. The System will pass Inspection if(With Approval of the Board Of Health): -1 - 6 I . SUBSURFACE. A C SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced The System required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of The Board of Health) Broken pipe(Q hie replaced Obstruction is removed 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 the public health,safety and the environment. 1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: + Cesspool or privy is within 50 Feet of a surface water Cesspool.or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh. 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND.PUBLIC WATER SUPPLIER,IF APPROPRIATE.)DETERMINES THAT THE.SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT THE-PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:.. The system has a septic tank and soil absorption system and is within 100 Feet to a surface + water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is with a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 Feet but 50 Feet or more from a private water supply well, unless a well water attalysis,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from ; the facility and the presence of ammonia nitrogen and nitrate nitrogen'is equal to or less than 5 ppm• D)SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMIt=15.303. The basis for this determination is identified below.;, The Board of Health 1 should be contacted to determine what will be necessary to correct the failure. s Backup of sewage into facility or system component due to an overloaded or clogged.SAS or cesspool: Discharge or ponding'of elluent to the surface of the ground or surface waters Idue to,an,.. overloaded or clogged SAS or cesspool:.,. ,, y Ti, Statialiquid'level in the distribution box above'outlevinvert due to an overloaded or clog- ged SAS or cesspool. _ h Liquid depth id cesspool is less than G"below-inverfor available volume is less than 1/2 day flow. ; Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ -2- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (conlinucd) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 Feet of a private water supply well. Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private water supply well with no acceptable water quality analysis. if the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a large systen►in addition to the criteria above: The design flow ofya system is 10,000 gpd or greater(Large System)and the system is,a significant thieat to public health and safety and-the endirom.nent because one or more of the.following co ex►st F., h The system'is w61n 400 Feet of a'surface drin ing water supply 9 't The system is within 200 Feet of a tributary to a surfacedririking water supply` The system is located in a nitrogen sensitive area Interim Wellhead Protection Area (IWPAj or a mapped Zone 11 of a public water supply well: The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment•program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check If#w following have been done: Pumping information was requested of the owner,occupant,and Board of Health. ►None of the system components have been pumped for atleast two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As-built plans have been obtained and examined. Note if they are not available with•N/A. The facility or dwelling was inspected for signs of sewage back-up. he system does not receive iron-sanitary or industrial waste tlow The site was inspected for signs of breakout.; ,,•' system components,excluding,the Soil Absorption.System;,have been located on site. E The septic tank manholes were uncovered,opened,and•the.interior of the septic tank was in s ed for condition of baffles or'tees,material of construction;`dimensions,depth of liquid, epth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. t •' SUBSURFACE SEWAGE DISPOSAL'SYS'1'EM INSPECTION FORM PART B CIIECKLIST(continued) '�Thecility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION / FLOW CONDITIONS RESIDWNTIAL. /l Design Flow: .' . Ions Number of Bedrooms: Number of Current Residents: Garbage Grinder: Laundry Connected To System: Seasonal Use: Water Meter Readi ,if 'table: ---Last Date of Occu .CO MIrRCIA AND 1ST IAL, A)O.. ` "'I*of Establishment: ti Deal Flow: aallonstda Grease Trap Present:g4 y p (yes or no) Industrial Waste Holding Tank Present: Non-SaWlary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) _ Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: d.P />> 44�42�� System Ptunped as part of inspection. If yes,volume pumped: gallons Reason for pumping TYPEJAF,SYSTEM: _ V Septic TauldDistribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(if yes,attach previous inspection records;if any) Other(explain): - PROXIMATE AGE of,all c9mponents,date installed(if known)and source of,information: Sewage odors detected when arriving at the site: -4- r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: ► (,i09, Depth below grade: Material of Construction:/concrete metal FRP Other (explain) Dimisions:___ .6'k�' Sludge Deptl►: _ Scum Tckness:�" Distance from top of sludge to bottom of outlet tee or bafile:_�6 Distance from bottom of scum to bottom of outlet tee or bathe: Comments: (recommendation for pumping,condition of inlet and outlet tees or alYles,depth of liquid 1 rel in relation t outlet invert structu al integrity,evidence of leakage, etc. GREASE TRAP: Depth Below Grade: __Material of Construction: concrete metal.. FRP Other vv (explain) — — — Dimensions: Scuin"I'liickncss.,:-" Distance from top of scum to top of outict lee or balTle: Comments: (recommendation for pumping,condition of iiil'et anii'outlet`tees or baffles;,depth'of liquid level in relation to outlet invert,structural integrily;,evidence of leakage:Pic.) TIGHT OR HOLDING TANK: Depth Below Grade: Material of Construction:..___concrete_n►etal_—FRP_Other(explain) Dimensions: Capacity;Alarm Level: gallons Design Floc l;allons/day __ _ Comments: (condition of inlet tee, condiliuu of alarm and float switches, etc.) DISTRIBUTION BOX: ✓ Depth of liquid level above outlet invert: Comments: (note' level and.distribulion is equal, evidence of solids carry-over,evidence of leakage into or out of box,etc. , JJ pia n PUMP CHAMBER:_~. -- Pump 1s'ia`woiktng order. omments: (n le coed' ' n f pum han►ber, condition of Int�ipsa�n( urtena ce's, etc.) C` + 12 i ' d 5 •k1 i Ili.• + .. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL.ABSORPTION SYSTEM(SAS): V-' (Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: Leaching pits,number:Leaching chambers, number: Leaching galleries,number: Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number: Co nits:(note condition of i ,s' of hydraulic failure level f pond' g, ndition of, egeta 'on, etc. CESSPOOLS:= Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: I Dimensions of Cesspool: Materials of construction: Indication of groundwater, Wow(cesspool must be pumped as part of inspection) Comments: (note condition of soilk,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY: Materials of construction:y Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) r }, t. -6- a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM \\ PART C \ SYSTEM INFORMATION (conlinucd) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benclimarks. Locate all wells w'ltun 100 Feet. QY f 1 i i 1 Y r I �16 1 1 1 �_ �j DEPTH TO GROUNDWATER: i Depth to groundwater: /S Feet Method of Determination or Approximation: nyq . . / A�eo c ur u nn Mp -7- r 362-4541 939 main street rt 6a , yarmouth port mass 02675 down cape eftgineefh7g civil engineers&land surveyors structural design Arne H.Ojala P.E.,R.L.S. land court Richard R.Fairbank P.E. surveys May 27, 1988 site planning Town of Barnstable Board of Health sewage system designs 367 Main Street Hyannis, MA 02601 inspections RE: 41. Haywood Road, Centerville D.C.E. plan #87-392 Greater Harwich Construction permits To Whom It May Concern: On Thursday, May 26, 1988, Down Cape Engineering inspected the septic system on lot 41 Haywood Road, Centerville, and found the installation to be in accordance with the Barnstable Board of Health variances granted 4/11/88. The septic tank is 27 feet from the extreme high water mark, and the 4-foot diameter pump chamber is 30 feet from the extreme high water mark. Please refer to the attached as-built plan, Down Cape Engineering's plan #87-392, dated 5/27/88, last revision date 3/23/88. Respectfully,. Arne H. Ojala, P.E., R.L.S. inspected by: Arne H. Ojala AHO:amg I attachment cc: Barnstable Conservation Commission Robert Our Company � r j TOWN OF 3 L._NSTABLE LOCATION f �CSEGE # '? VILLAGE � .tl/ ASSESSOR'S MAP & LOT "0 INSTALLER'S NAME 6z PHONE NO. , ,' (11Y � SEPTIC TANK CAPACITY I LEACHING FACILITY:(type) (size) r NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: J. DATE COMPLIANCE ISSUED: Ltr- 6 VARIANCE GRANTED: Yes No i L'I o T. \ 0urLEr DENIAiZON \ �� J \ N •.:''-t---D.+"ii..� __. -. ,.•• �- � `.���`��\. � .;`! C.f5,--1Yl ER6►a:i�p] `i ~�;wYO �// \'. 1 t 7 T,H.2— CouRTOA - ._! l A) \ o ON 13 doe 10 �\1N OF ARNE H. yGM ixo ARNE � . .a OJALA y H. CIVIL OJALA I No.30792 1 N2948 moo, jl/�/Ec/�5 �,�'�FCIS E E�\����: \��F `_Ss4%��•�f 1 ivi Ey fir\ ff N6 q 0-0 DATE APPR ARnI N. CUALA TOWIN LOCATION J40 GE # c, VIL .AGE �'�C 1 12� :Vl ASSESSOR'S MAP & LOT 4 INSTA'LLER'S NAME & PHONE NO. �6 ®0� SEPTIC TANK CAPACITY. LEACHING FACILITY:(type) (size) ) _ e NO. OF BEDROOMS v PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: A'191 ! ATE COMRLIANCE ISSUED: Awl VARIANCE GRANTED: Yes No ' SEWAGE - N0•l0 C A T 10N VILLAGE I N S T A LLER'S NAME i ADDRESS 6 U I L D E R 0R OWNER DATE PERMIT ISSUED DAT E C.0_MPLIANCE ISSUED f � f 6' e� � ) L � �0 a No.�r ..__...1.- � ,.�` ��.�' FEs.... `-_l . THE COMMONWEALTH OF MASSACHUSETTS i BOARD OF HEALTH ......../..ate...................OF..... ............ ---------•---------....-------.....----........... � Appliratiun for Mipmal Works Towitrudion 11amit lf -145, Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at ..._...... �_ ... � �/� ------------------------------------- -•-•••••............__................... Location-Address or Lot No. ...................Gt/«� x�_ sly.............................................. ....... .......................................... Owner Address a ! ...U�.................................................... ........ /Ic..............---------------•------------..-........ ......... pq Installer Address V Type of Building Size Lot...o?-4U2Q ....Sq. feet Dwelling—No. of Bedrooms.............. .......................Expansion Attic Wei Garbage Grinder (/W aa Other—T ype of Buildin g ............................ No. of persons.....------------------..... Showers ( ) — Cafeteria QOther fixtures -...-----------------•-----------•------•••-------------••-....................................................... W Design Flow...................................-.5:...gallons per person per day. Total daily flow...........:3.m.......................gallons. 9 Septic Tank—Liquid capacity.Z.O.0 ..gallons Length...?d?4 . Width:-'`t�_.l-01.".. Diameter:..-...—.--... Depth..*..,.".. Disposal Trench—N Width...In........... Total Length....,Q......... Total leaching area._��7.......sq. ft. 3 Seepage-Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box (K Dosing tank ( ) Percolation Test Results Performed by...Zrvrti ..�s. ..... sr1s � -y------------- Date::.: ..7 o p `' �7 Depth grbi nd g 1 Test Pit No. 1.....a-.....minutes per inch Depth of Test Pit.../©$........ D th to Test Pit No. 2._._..--..minutesi per inch Depthh, of Test Pit.....l..Z...... Depth to ground j.zc --•3-�-�--r�St,.c O Description of Soi1..: slk� r._ `"' "� - s'. ',. ._ .: 3CG-....3 ....; ?.rx ..: r/t�rc..�sr«rs 49.. � � •�-1 � `� {:+tea=��•-----••�'�„•;� W ..:�I...d�..}....fT ...V1�Z,,&QLy...... �c ,tlJ,�7 . u ~� ... ... ... lae...Cs1:��r.. i .�St� ................... fl�l Ut' j0. �J21G 4 J' A U Nature of Repairs or Alterations—Answer when pi l ERTIFY riTt .�.��s s,. ��m YST€I�JI �A ..INSTALL�(� ..... Agreement:------••--•---••------•----.....-•-•------•---------•------•--------P�i�-'S- NCE l O PLAN- •--------•-��6%� - kCCORDA The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLZ 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 bard of health. ... a ...... .._.. . l ... tf.....Application Approved By...... . p. ............. ..... .__ o .. Date Application Disapproved for the following reasons:......................... ----•-•-••----------------------------------------------------------_.. ........................................•---...�...-----...--•--..._......---•--•---.........---.......------............._......-------------------------•--••------............Date ............ PermitNo..... .........= �'� ............... Issued....................................................... Date r - -- --- -- ---- --- - --- ----- -- ----- -- THE COMMONWEALTH OF MASSACHUSETTS t BOARD OF HEALTH OUA/!I., . • 6fi!� /U' 1 ENGINEER MUST SUPERVISE OF. .. . . . Tt°sI LATION ANI� CERTIFY IN I lG h (Irrtifiratr of (hum l t r -�T= 9 WAS INSTALLED THIS IS TO CE��IF &the Ind wage Disposal sy%aan7*Zon%McTQ"�-or Repaired ( ) bY.................................. . . .. .......... ...............................•..---•••-----..............•---••.........--•-•-..........._......-- nstall at.... ` '� 11 .i,�.C_._ _... y1� J � :fll! .Y .V1 .............................................................. has been installed in accordance with the provisions of T T F 5 h State Sanitary Code as - i . in the application for Disposal Works Construction Permit No..V. �..�........ . dated......l . ................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTE THAT THE SYSTEM WI L F NCTION SATISFACTORY. s................. .a DATE....... AW9.................................................. Inspector.. r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................/V( OF................. . k .................... Tntifirate of Toutpliattrr THIS IS TO CEUIFY, Th the Ind d rage Disposal System constructed or Repair by . . . ........................... ................................. ......... ..................................................................... 4L-1 nst 11 at.............../...!......... ....... - .1.....RVII-A64................................................................ has been installed in accordance with the provisions of T67W-1 5 h State Sanitary Code as in the application for Disposal Works Construction Permit No-a----/------ ..... dated..... E�------------------ THE ISSUAN�E OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTE THAT THE SYSTEM WILL FVINCTION SATISFACTORY. DATE........;-1 4 ; Inspector....................................................... ......... ------------------ ....... - ------------------------ ------------------- ------- ------ -------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD e"-= HEALTH of .....OF......... ................. N FEE Disposal Works TondrWiatt Vernfit Permission is hereby granted-r-h, ... -------------------- ............................................................................... to Construct. or epair Vah'i0v ua Sewage Di stem atNo�........41..... ... t S.reet........................................... ........... as shown on the application for Disposal•IYorks Construction Permit No Dated..... A 4? . ...w. .. . ............. ............................ .. ....1-4--.)................................................... DATE..............lz9---.2------ .................................... Board of Health �.:;OMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _.._... 7. ;"w..................OF........ L- ..................................... Applira#dun for Diupuiittl Workii Toutitrurtiun rrniit te Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal . System at: ........... -- -----Tavl� c......-•-•---•---••............................................................................ , Location-Address or Lot No. . / ...... � Owner Address ... ... -••-•-•............................ ........ .............................................................. Instal ler Address Type of Building Size Lot...r2.4.3.-7o.. ._..Sq. feet ., Dwelling—No. of Bedrooms.............. ......................Expansion Attic (A4 Garbage Grinder aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures .........---•-•--•-••....---•--••--••--••-•-•--••-••--...........-••----•--.......-•--------...•-••-••-•---....-•..................................... WDesign Flow.................................. .a..gallons per person per day. Total daily flow......... E_3.:ct.......................gallons. Wtj Septic Tank—Liquid capacity..AR llons. Length-_-`�cs�'. Width_.A4--1Q'. Diameter---------------- Depth. _''-?.".. x c� -Disposal Trench—No. ..... eAV6*Width...A?........... Total Length_... ....... Total leaching area-_as7......sq. ft. 3 Seepage-Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( K) Dosing tank (' ) Percolation Test Results Performed by----2:1_, ... AA -%EEf! �r2«r%n ............ Date._...`'. /./ (0 6 4 w. }D� Test Pit No. 1......91.....minutes per inch Depth of Test Plt../Pa........ Depth to ground w a `t. Test Pit No. 2.......�..minutes per inch Depth of Test Pit.....Z.3�...... Depth to ground TM J C"a-_ c�.�•T Y ��. .51 ° i.�j_.. u"c1�._�. D�.!?�:F.. �3?Ra�1 "� ...q� ctl:3� O Description of Soil... e� u c 'CtSQ ���i � � ct r ga r, Si/fti �E�._t�� .... .W I-�O P .y « ` . ._. �........... v r T7r ./!0.`�,.�, q�l 4 ` 'v7r •e?q`i 1�c.r E.? r ¢ .vJ Nof30fl��J<v� U � ..._ �........... ...... a 1......? ....... n w1. n Q . .................................................... ...........................-.................................................. V 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 AITLZ 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 bard of health. � � ✓vJ.� ..................ned...0..- Application Approved •-•................•--.......----- ---•-•....-B ..... 0. ..... _ .. �1 `�/tT-•. .... Date Application Disapproved for the following reasons:.............•.........................---------...---••-•........--•---••-•-•............................-- ......................................:.:........................•-.....-----•-----------......_........................._...--------•--•---•................._..........-•-----••--......------........ pprr 7 i Date Permit No.....A_..r�� .... Issued................•-•••....... ' ---•- ----••--- ---^.. � Date ........................... P�p4TMEt0�` TOWN OF BARNSTABLE OFFICE OF i DAH73TABLt MAGI BOARD OF HEALTH %639. a YtiY w� 367 MAIN STREET HYANNIS, MASS. 02601 Sewage Permit # Applicant : V)Ajekaj SHI)C,K Proposed Installer: fi_�Q�j61?-r oU l?J The plan for the on-site sewage disposal system at tf 1PAYWiW wi�1n {t�addC�la� off' mneQ) Fib D,Wv5or 'c � �,✓JLC�� has been approved with the condition that the design engineer must be on-site and supervise installation as well as certify in writing that the system was installed in strict accordance to the approved plan. 9 � 111"h 7 Approved Date cc � �D��nl e_AA� ojG N66 eelW� L �J✓H M �T i �� -'"-P-'� ,�;--� V�G I A r�.F� IZE�tl�1'r�.���o� �,�.►J�t31.�. or ors wLt 0� r �� � _I' { � �� i. r- --p�1N1P G�I�M TU EE �&•CED Z�` �{?� �' �, � Sri / Q rTEST H 0 L. IOGS F N G I N CEP, S..A. WILSON , R8, �+ to WIT�Ess_ .IZR�I p�a�.1I�t1► ... LOCUS LATE. _ `� / ► I4 7 �- �' PERC. RATS- ° MIN,, INCtf O } \ LOCUS MAP 5CALE: 1"=Z000T. �' --�-- 30" ;F O CNN . E SAWN SAN Po5'j'oaTL:E DENDiZQN \ _- qe ram,, s �v 08s.G- .10 •SILL. ��i1,$ �� G. MUNICIPAL WA R I -,rAVAILA$t,.� . _V�tAL� \ ----- Q I I� .Z 3.�'IP5 PITCH=V4'g/i`rT'. UNLESS 01THEINOE NOTEb. / �\ ti � -76 4.:LESICiN LUADIN/q ALL PF-ECAST UN)T5AASH0._.E1-!LQ--44, / '5. PIPE JOINTS SHALL, BE � I�WTER"t ICxM"1: 10g KATieR P-NGoo WreKVD V4ELL -r5N - $q / rat... 3,4 0Ng5-rf?Ut..,Tl0N DETAILS To BE )N AC.COFS?,ANC.E N IT►-k / . � � ``,,...-- �•-' die ` � \ (-r:M. I ) .�o�E ,�,, 6, ' 1.'" F:r ADJ. = 1.eta' MASS, ENV►kONlv11~.N�AL CG�D�TITLE :. t 7 ]3E USED FOR �'I�C�PE bL LINEWORK 5TA1<IN D 51-�OUL.D NOT J -we3 y �. �- 4 1 FL.00Z> Iry 5 u RANCE RATS- MAP Z oO0 I 001(o G T 1 ` . MIN, gRouNp COVFR OVeR ALL. SEWAGE �ACILj1-F,S: ig"oAKO p . _ E,X15TIT lq 5EPTIC sy5TE,M To BE DISCZNNP-CT'EU ,.. Coc_LA?'Sits AND tv d 1 =k F't L LaED A r 0„ OILk_ 0c ,,. ,' o, f ^-, FILL.. 5t- OLALD CONSIST' 0F' CL N SAND. , c RE .s.-ToBEMou�p �V�w!b�/ 11. CA-rcH LAStr A 3ENEATIt PARKING /AREA TO 'Be SiH r uEa T.H. - Gcyx.A RT.. A NJ E-) _:�FiF Cr= RFC;rRA2�0 `!v DRA I N FIRST FLOUR CL NoRTt 1 . _. _ Cc•I•cov��c) PV.C� I�Ir}E P ,As c>w �'o OF" SyST�tvl CELLAR EL. O tN O ,o a�.q5 - • i cry 4 _. Z 5�x , T3c�x o 0 in \ 1O HEAvN 1 � uM o o a V. S p'rIG 'TANK CHAMB —1 Z.79 C7 ao 4' eo I� Z.1py 1 6v 14.5.5 � oo � � o 0CIO 30 Ml�K ELEv. 14-.40 o�'ap° c5 eel c To r ZG�� 31 3 '� WASHED SToNje �� -a L)ER q DESIGN CALCULATIONS �DUL. � _ -- ----_ ._ DER ^. 3 &1✓D Roo MS . GPD/13 R = 3 30 G P D rQ SEPTiG TANK '33o CPD x C I,5 GAL. us Eo GALLON 'TANK L.EA r-H I N G ICJ w�S - U I LT o >� . t3ATTOM:_1T ')L= 113� ( t O s ITE AND SAC3 'L. 1�1 A55ESSOR5 MAP I?G ._ LOT . D -r 041 HAY ooD _ROA , Ak A = z4 390 ± t, —(�LEACR P i z (h X 4) `S. �1tTN 3' � S?' ►J� .4Rc�AiJP CE 7 TIER/I LL , MASS. �, 171 _FOR E4��N OF S o GRfEAT-ER_ HAR W IGH CONSTfRUCTIO A -V o AEL FlIA ga ; Q� AFiNE � H. G7OLVYI GcE'. rairJG� / /C1 •, clvIl i� oJat_A �^ 91 No. 30792 c� #26348 c � 11 ,� 1 civic iivt�s q� �o �4 u� ;;may, SCALr.E - 2C� T : . NIAFZ, Iq$8 �i , CIs E ;<� fc�;1E �, '' II WARD. of H.EACr+i Ls1ND SUR�/�yORS FS NG�� at tk I\^,MA 5,IS$g- v• - - i BAKNSTA,BI-W MA. P'1'E, 6A y.ARMOUTH3�;OR7� lit , A R Nilf CiJAt..A, ,5., P,E. :DATE AppR7VeD DATE d *$7-39 . .. ..