Loading...
HomeMy WebLinkAbout0106 HEADWATERS ROAD - Health 06 Headwaters Road Centerville A= 228 - 184 a. No. 4210 1/3 ORA Pendaflexe 10% i x a � y 1 1 TOWN OF BARNSTABLE ` LOCATION 6�a, }M !&J SEWAGE# E f VILLAGE �^ �,F-i7 \ ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. � SEPTIC TANK CAPACITY � e 'f ("no LEACHING FACILITY:(type) (size) NO.OF BE ROOMS OWNER PERMIT DATE: 1 COMPLIANCE DATE`�/9 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 ��t)n� ,� Q � ; � � No. / /! I Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftPliLation for MispoSal 6pBtem Cvnstruttion Vertnit Application for a Permit to Construct( ) Repair(,/Upgrade( ) Abandon( ) ❑Complete System 6individual Components Location Address or Lot No. k 6(o Owner's N Address,and Tel.No. Assessor's Map/Parcel aa.k-I %`1 � -t� �kA, GOyr,�Ac. Installer's .ame,Address,and Tel.No. Designer's Name,Address,and Tel.No. Sc-v��rtr� tk3 U�,6 yG.r� Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank 106 Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) p \C,CR_ �,�t C,�r C�m\ Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. r Signed Date S-/q / Application Approved by Date Application Disapproved by Date for the following reasons Permit No. —txQ 77 Date Issued No.C I / Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Zipplica(tion for Disposal 6pstem Construction permit Application for a Permit to Construct( ) Repair(✓Upgrade( ) Abandon( ) [:]Complete System k6individualComponents r Location Address or Lot No. Owner's Nary,,Address,and Tel.No. ' Assessor's Map/Parcelaa Installer's Name,Address,and Tel.No. r Designer's Name,Address,and Tel.No. ktvc,ty. Mc. S G L� Type of Building: 4 Dwelling No.of Bedrooms Lot Size t ! sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures q.. Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank E'`/<< S ( ©6 Q Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) ` 0 p \C,CQ Fv-v- .er 'O NN Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. j Signed _ DateSJq / Q. Application Approved by Date �� Application Disapproved by Date for the following reasons s / Permit No. / Date Issued / -- - _- ---------------------- 1 THE COMMONWEALTH OF MASSACHUSETTS C� BARNSTABLE MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( ) Abandoned( )by y%~ at , C�( V�',C_ri,o.S-akc a j C. V t`e has been constructed in accordance - i with the provisions of Title 5 and the for Disposal System Construction Permit No--- ' � dated 51-1 / Installer [p �`^ �cY�n�. Designer #bedrooms Approved design flow gpd The issuance of this permit shall note a construed as a guarantee that the system will funct o as designed. �C7 Date Inspector --- - --------------------------------------------------------------------------=------ =---=----------=--------- _ No. l-2 /3, Fee ,,-0 C) THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS "''� _ MiSp08a1 6pstetn Construction permit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( ) System located at C c, d C-Vi ll e- and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this p rmit. Date /nl 1 —7 Approved by� /f, i Commonweal h of Massachusetts lugTitle 5 fficial Inspection Form Subsurface Sewa ge Disposal System Form -Not for Voluntary Assessments 106 Headwater Road Property Address Nuttall Owner Owner's Name information is required for Centerville MA 02632, October 2, 2009 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your Patrick M. O'C nnell cursor-do not Name of Inspector use the return key. Septic Ins ecti n Services Co. Company Name VAQ 189 Cammett Road Company Address Marstons Mills MA 02648 _ Cityrrown State Zip Code 508-428-1779 SI 12855 _ Telephone Number License Number B. Certification 1 certify that I have personally inspected the sewage disposal system at this address end that o information reported below is true, accurate and complete as of the time of the inspection. The-Mspec bn was performed bas d on my training and experience in the proper function and mi4hf nance awn sites sewage disposal sy tems. I am a DEP approved system inspector pursuant taection 15.340 of� Title 5(310 CMR 15.000). The system: ® Passes L ❑ Conditionally Passes ❑ Fails: w ❑ Needs Further Evaluation by the Local Approving Authority 0- M October 2, 2009 _ Inspector's Signatur Date The system insp ctor shall submit a copy of this inspection report to the Approving Authority(Board of Health or DE )within 30 days of completing this inspection. If the system is a shared system or has a design flov f of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the app opriate regional office of the DEP. The original should be sent to the system owner' and copies sent Io the buyer, if applicable, and the approving authority. ****This report only escribes; conditions at the time of inspection and under the conditions of usje at that time. Thii i inspection does not address how the system will perform in the future under the same or dill irent conditions of use. 09-200 Nudall.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of,15 5. Commonweal' of Massachusetts Title 5 fficial Inspection Form Subsurface So ova a Disposal System Form -Not for Voluntary Assessments °f 106 Headwater Ro ad Property Address Nuttall Owner Owner's Name information is required for Centerville MA 02632 October 2, 2009 every page. Cityfrown State Zip Code Date of Inspection B. Certificati n (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not f and 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: Tank is not in need of pumping at this time, leaching it was empty with no sidewall stains. B) System Condit onally Passes: ❑. One or more system components as described in the"Conditional Pass" section need to be replaced or -epaired. The system, upon completion of the replacement or repair, as approved by the Board o Health, will pass. Answer yes, no r 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 se tic tank will pass irrsoiktion if it is stru.cturaMy sound, not leaking and if a Certificate of Complian a 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 bstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspect on if(with approval of Board of Health): ❑ brok n pipe(s) are replaced ❑ obst action is removed 09-200 Nuttall.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealt of Massachusetts Title 5 fficial Inspection Form Subsurface Sewa a Disposal System Form -Not for Voluntary Assessments "( 106 Headwater Road Property Address Nuttall Owner Owner's Name information is Centerville MA 02632 October 2 2009 required for , every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) B) System Cc nditionally Passes(cont.): ❑ 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 ass inspection if(with approval of the Board of Health): ❑ bro en pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Ev2 luation 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 i 3 failing to protect public health, safety or the environment. 1. System ill pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b that the:system is.nbt,functioning in.a manner which will protect public health, safety and he environment: ❑ Ces spool or privy is within 50 feet of a surface water ❑ Ces pool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System ill fail unless the Board of Health (and Public Water Supplier, if any) determines hat the system is functioning in a manner that protects the public health, safety and nvironment: ❑ The ystem has a septic tank and soil absorption system (SAS) and the SAS is within 100 eet 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 supr ly. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supr ly well. 09.200 Nuttall.doc•0&0S Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealt of Massachusetts Title 5 fficial Inspection Form Subsurface Sews a Disposal System Form -Not for Voluntary Assessments 106 Headwater Road Property Address Nuttall Owner Owner's Name information is required for Centerville MA 02632 October 2, 2009 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 asses if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm provided that no other failure criteria are triggered. A copy of the analysis must be attached to this 'orm. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indic ite"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than_day flow ❑ ® 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. 09-200 Nuttall.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonweal t of Massachusetts Title 5 fficial Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments rr 106 Headwater Road Property Address Nuttall Owner Owner's Name information is required for Centerville MA 02632 October 2, 2009 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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 0,000 gpd to 15,000 gpd. For large systerr s, 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 answ Bred"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 he Department. 09-200 Nuttall.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 or 15 Commonwealt of Massachusetts Title 5 isficial Inspection Form Subsurface Sewa Disposal System Form - Not for Voluntary Assessments '( 106 Headwater Road Property Address Nuttall Owner Owner's Name information is Centerville MA 02632 October 2 2009 required for , every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the foll wing 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? ® El 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 Iodation of the Sail 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)] 09-200 Nuttall.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealt of Massachusetts Title 5 fficial Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y< 106 Headwater Road Property Address Nuttall Owner Owner's Name information is required for Centerville MA 02632 October 2, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System In ormation Residential FI w Conditions: Number of bed oms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of curr nt residents: 1 — Does residence have a garbage grinder? ❑ Yes ® No I Is laundry on a eparate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): — Sump pump? ❑ Yes ® No Last date of occupancy: CurrentlyOccupied. Commercial/Inclustrial 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: — Last date of OCCL pancy/use: Date Other(describe) — 09-200 Nuttall.doc-M06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealt of Massachusetts L Title 5 fficial Inspection Form Subsurface Sewa a Disposal System Form - Not for Voluntary Assessments r'0 106 Headwater Road Pro party a Address p Nuttall Owner Owner's Name information is Centerville MA 02632 October 2 2009 required for , every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Rec rds: Source of infor ation: Tank pumped two.years ago. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ hared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and aintenance contract(to be obtained from system owner) ❑ right tank. Attach a copy of the DEP approval. ❑ Dther(describe): Approximate age of all components, date installed (if known) and source of information: Compliance date: 11/15/84 Were sewage od rs detected when arriving at the site? ❑ Yes ® No 09-200 Nuttall.doc•0=6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonweait of Massachusetts Title 5 fficial Inspection Form Subsurface Sewa a Disposal System Form - Not for Voluntary Assessments y 106 Headwater Road Property Address Nuttall Owner Owner's Name information is required for Centerville MA 02632 October 2, 2009 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Building Sew (locate on site plan): 1' Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(lo ate on site plan): Depth below grade: 8"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) If tank is metal, I st age: years Is age confirmec by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 8.5' long x 5.2'wide- 1000 gal. Sludge depth: 3" Distance from to 3 of sludge to bottom of outlet tee or baffle 27" Scum thickness 1" 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 13" How were dimensions determined? Measured 09-200 Nuttall.doc•08M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of,15 Commonwealt of Massachusetts Title 5 fficial Inspection Form Subsurface Sewa a Disposal System Form -Not for Voluntary Assessments "( 106 Headwater Road Property Address Nuttall Owner Owner's Name information is required for Centerville MA 02632 October 2, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on 3umping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level wa found at bottom of outlet invert, tees are intact and clear. Tank is not in need of pumping at this time. Grease Trap(locate on site plan): Depth below gr de: 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 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 gra e: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): 09-200 Nuttall.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonweal h of Massachuse tts Title 5 fficial Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 106 Headwater Road Property Address Nuttall Owner Owner's Name information is Centerville required for MA 02632 October 2, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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 Distribution B (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 011 - Comments (note, if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No solids or higt stains. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 09-200 Nuttall.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealt of Massachusetts Title 5 fficial Inspection Form Subsurface Sewa a Disposal System Form -Not for Voluntary Assessments 106 Headwater Road Property Address Nuttall Owner Owner's Name information is Centerville MA 02632 October 2 2009 required for , every page. Cityfrown State Zip Code Date of Inspection D. System In ormation (cont.) Comments(not B condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: it. ® I aching pits number: One 6x6 p — ❑ leaching chambers number: ❑ leaching galleries number: — ❑ leaching trenches number, length: — ❑ leaching fields number, dimensions:❑ overflow cesspool number: — ❑ ir novative/alternative system Type/name of technology: — Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): Leaching it had no standing water and no sidewall stains. 09-200 Nuttall.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 e Commonwealth of Massachusetts Title 5 Official Inspection Form i; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 106 Headwater Rc ad Property Address Nuttall Owner Owner's Name information is required for Centerville MA 02632 October 2, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System I formation (cont.) Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and cc infiguration Depth—top of iquid to inlet invert Depth of solids layer Depth of scum ayer Dimensions of cesspool Materials of coristruction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate or 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.): 09-200 Nuttall.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonweal h of Massachusetts w Title 5 fficial Inspection Form Subsurface Sew ge Disposal System Form - Not for Voluntary Assessments 106 Headwater Rc ad Property Address Nuttall Owner Owner's Name information is required for Centerville MA 02632 October 2, 2009 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 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 F ublic water supply enters the building. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , , , . . . . . . . . . . 39 19 60 42 Water Service Headwater Drive • Commonweal h of Massachusetts Title 5 fficial Inspection Form Subsurface Sew a Disposal System Form -Not for Voluntary Assessments �• 106 Headwater Rc ad Property Address Nuttall Owner Owner's Name information is required for Centerville MA 02632 October 2, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow w lls Estimated depth20+feet to ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Ob ained from system design plans on record If c ecked, date of design plan reviewed: Date ❑ Ob erved 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: US S to o map and town GIS. You must describe how you established the high ground water elevation: Town roundwa er contour map shows water below el. 15 and to o map shows property at el. 50. 09-200 Nuttall.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 1 TOWN OF BARNSTABLE LOCATION IND ��JVJCT-er -VILLAGE fi-Q kv-- ASSESSOR'S MAP&PARCEL E'+ff*L+9R'S NAME&PHONE NOric� o�►u-`� ���75 SEPTIC TANK CAPACITY 16064�7 5 ' LEACHING FACILITY:(type) i�i� (size) / NO.OF BEDROOMS OWNER /4,0, PERMIT DATE: C-0 i' DATE Zr V 04ph/ 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) 11 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY \ \ 4 \ \ \ \ 4 \ \ \ \ 4 L \ \ L 4 \ 4 \ 4 4 \ \ \ \ f f f J f f f f f J ! f f f f J f ! f J f f f J f ! f- J f f J ! f f f J f f f J f I f f f J J f f f f f f J f f ! { F f { ! F ! J { f F J f J f J J f f f ! f f f f f ! f f ! f f 39 y ' f f f f f f J f f f J Jlfff , lJJ 19 60 m 4 Water Service Headwater Drive -LO CAT IONI�6 SEWAGE PERMIT NO. VILLAGE C-c- ✓-- e v :�\ I N S T A LL F71t'S NA i ADDRESS d U I L D E R OR OWNER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED � � -a r°Nc � ,:� a, ,s `f� LA C A T ION SEWAGE PERMIT NO. E I N S T A LLER'S ME & ADDRESS BUILDER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED �� `� o rv-( 39 `� 0 e `� 7 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH _........... IQ w�V.............--OF................ �.RN..A..LA6��_................................... Allp ir�a#ion fnr Roposal Works Tnntrnrtinn ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal eystem at cation-Address 11� or I of No. t ' ///���,{t� � / y nn '' Address .._....._IS..NteS�`�............... .....MRf.1.t mem....11Q/ MA."111,r....AA '1j Installer Address U Type of Building Size Lot.V4.0.00_.#'.....Sq. feet �-, Dwelling—No. of Bedrooms...................3.....................Expansion Attic ( ) Garbage Grinder (4-0 04 04 Other—T e of Building No. of persons____________________________ Showers — Cafeteria a Other fixtures --------------------------------------------•- W Design Flow..............X$, .........._........gallons per person per day. Total daily flow.............�.�........_...........gallons. WSeptic Tank—Liquid capacity/044..gallons Length....... Width....../-/.... Diameter________________ Depth•_-�__--_.. x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area.__....-......_.....sq. ft. Seepage Pit No-------I----------- Diameter.........f_...... Depth below inlet........L....... Total leaching area..,y2!�......sq. ft. Z Other Distribution box (,) Dosing tank �) F" Percolation Test Result Performed by...._..__i 9A g-It._.t—. /Y..C=-----------------•-•-------. Date_.__.•..�1�5._ �f�...... ) Test Pit No. 1........ ninutes per inch Depth of Test Pit....... qy"-.. Depth to ground water---AAOT....Ea►rovn,"t-aad ;To Test Pit No. 2................minutes per inch Depth of Test Pit..._-------_______.. Depth to ground water-.-_-______--___---_--__ 04 •--•-••--•--•----•--- -•.................................. .--------- -•-------- •-•--... ........... --.............. -•.........•-------------- ----------------- ODescription of Soil...............5&d'.-- &4.............•-•--•--•--•-------------------------------------------------------------------------------------•---------------- x W x --•••------------------------------------•---•--•••...•-------------•-•----•-•---------••---•--•-•-•-----•-•••-------•------------•---••------•--•-•-•--•-••••--••-•-•--•••••-•----•-•••--......._--.--- U Nature of Repairs or Alterations—Answer when applicable---------------------------------------_........................................................ ----------------------------------------------------------•--...... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITU 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 he b of health. Signed �'+� -----------------_-•--- ....r7 Date Application Approved By..... .:`� ---------------------------------------- Date ` Application Disapproved for the following reasons-----------------------------------------------------•----------------------------------------------------•--•-- --------------------------------------------•---------------•--------------...------------•---------------•-••---•---•-----•-•-•---•-------••-••--••-••--••••-----•-•-----•--••---•-•-••- Date Permit No.......... f Issued ` " Date Py`, No.... --------------- ..................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......... W.,ek...................OF:..... c . -:4 ►�(.�.. Applirution for Disposal Works Tontrurtion amit 'App�icatton'is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ............ F1W.:afCf.. ................................................ ............................................7...................................................... Lo.jinn-Address a . .1_ ----------•-------•------•-------... t`1 �a s v H a use°C� r t....... �.� s....- ... Address O ner 1� 11 aW e uy�w_ n .�i .....-----•--......manses!r!_..H1.115.... --••-------------•--•.......--•-........••••••-•••--••-••--•--•••............-•--••......••-••-•• •-•-•• •--- Installer Address Type of Building Size Lot.-aW feet Dwelling—No. of Bedrooms...............-�.........._.................Expansion Attic ( ) Garbage Grinder ( ) a Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures Design Flow-------------:�-5-----.....---- g P P P Y Y W _.._..____gallons per person per day. Total daily flow............33.Q..................... lons. WSeptic Tank—Liquid capacity.-I2GO..gallons Length..... ------- Width-______`:1�..... Diameter________________ Depth.. ? '....... x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area..._...._..._...-.--sq. ft. Seepage Pit No.........I.......... Diameter..........:_...... Depth below inlet...........60....... Total leaching area...2 .....sq, ft. Z Other Distribution box Dosing tank ( ) 0-4 W Percolation Test Results Performed by__--__-___-&,tx_t4 f.t•.. �1!........................... Date......!!/ g Test Pit No. I......L_.Z..minutes per inch Depth of Test _... Depth to ground water_.�14f..P.h.4Qy.KP� Pri Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ M •... --•.•--••••--------•-•--••-••-•-•.......---••••••••-•--••••-•--•--•.......--•••••-•--••-•••..............•--•---••.............•..........••••......-- O Description of Soil---••-------..`�<z- la.vl.........:.......................................----------•---------- ------------ x W VNature of Repairs or Alterations—Answer when applicable............................................................................................... -----------------------•--•,-•-------•-••••--••--••----•-•------•-•--•-••--•••-•••--...••-•------•••-•-••-•--•-••--•-•-----------•----•-••-•••----•-••-•-----•-•---••-•••----•-........................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been is d y e card of healh. Signed-•---•• . .•••• .....----••......••---•... 6 - Date ApplicationApproved BY.......A ------•---------------••--•-----....-•--------•----•-----------........------........ Date Application Disapproved for the following reasons:... .......................................................................................................... •-•-•------------------------------------••--•------••----------...---•--••-------------------••-•-------••--••••....-•••-•--••-••-•-----•-•-••-••••-•••••----•....................................... Date Permit No.......... "`r .9 __..------- .. Issued ----- Date THE COMMONWEALTH OF MASSACHUSETTS -y- BOARD OF HEALTH ....................OF........` .s.1 . wnrtifiratr of Toutplitanrr THIS IS TO CERTIFY, That the Individual age * pos 1, em constructed ( ) or Repaired ( ) by _ . -.- .. -:.._..._. �7 staller at -•••••--••-----•••--••---•---•--•--•-•-•---•-----••-•••- has been installed in accordance with the provisions of TITI 5 of The 5tate Sanitary Code as described in the application for Disposal Works Construction Permit No............:............................ dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SA ISFACTORY. DATE ........................ Inspector...............-<---"-----`-----------•----------••---•---------•-----••----•-••-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF'sHEAUTH v L- I No......'..............•-•• FEE.... •.••••ff-Irwmotion rrntit Permissio is hereby granted•.......................... .. to Co c ) or air ( ) Indivi 1 Se a al ystem at No�"�" / - C.phtJG ,B. Street 'r^X as shown on the application for Disposal Works Construction Permit No.._._...•..........._ Dated..__ ......... > / r ...........-•----•-----.................................................................. -•••••••- " L� / Board of Health DATE.......................----------------------- ................................. FORM 1255 A. M. SULKIN, INC., BOSTON 5 , IAll 1,7.'17 tx 4hit Is � � +��af.(.� �1✓�� l �• ,�' �,.{ter/!� a/I � J�� Z7 7 ol �' / / f G,Q L . / X //✓�! s1 y,•�^ - k d Wr R1 4,1 /its' fs /A�U /A7' tX � ,�_ `mac. •�`/i �`�� � 17.1 IL 00 � �- f s f / ,, /v©cam- �. fir! ', . Misr /VVI 4:r# g. ' • ���l�� �.47-ems. �. , /love" A.tom. .14>-'- IAI A . f�,E'e,--Z2"7-W 7Z /14/01 f/rtl. ZI Ica , `6 ." �4 " _�.� . .tom 7' '�' �,, ', ' - .r'�����';, •,+ t �e,��.,--=•-�:�`� -