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HomeMy WebLinkAbout0007 HITCHING POST LANE - Health 7 Hitching Post Lane Centerville P A - 173 030 UPC 12534 ' No.2153LOR HASTINGS,MN Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 5 7 Hitching Post Lane Sri !� Property Address Carla Delazari Q Owner Owner's Name information is Centerville MA 02632 April 16, 2008 required for p every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:When filling out A. General Information forms on the computer, use 1. Inspector: only the tab key to move your David D. Coughanowr cursor-do not Name of Inspector use the return :? key. Eco-Tech Environmental =3 Company Name i 43 Triangle Circle Company Address -;.i c3 ` Sandwich MA E02563 — City/Town State :2=Zip Code:2,7� 508 364-0894 1328 Telephone Number License Number r- B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority LM4 (L• A,5 April 16, 2008 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5-2921.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Hitching Post Lane Property Address Carla Delazari Owner Owner's Name information is Centerville MA 02632 April 16 2008 required for p r every page. CityTTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E I always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed t5-2921.doc•06/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 1 1 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 7 Hitching Post Lane Property Address Carla Delazari Owner Owner's Name information is Centerville MA 02632 Aril 16, 2008 required for _ P every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally 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 pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. t5-2921.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 7 Hitching Post Lane Property Address Carla Delazari Owner Owner's Name information is required for Centerville MA 02632 April 16 2008 every page. Cityrrown 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 passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/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: ❑ ® 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. 15-2921.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 7 Hitching Post Lane Property Address Carla Delazari Owner Owner's Name information is Centerville MA 02632 April 16, 2008 required for P every page. Cityrrown 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 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5-2921.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 7 Hitching Post Lane M Property Address Carla Delazari Owner Owner's Name information is required for Centerville MA 02632 April 16 2008 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? SAS also evaluated ® ❑ Were all system components, excluding the SAS, located on site? Inlet only ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. Location confirmed Determined in the field (if any of the failure criteria related to Part C is at issue size not ® ® approximation of distance is unacceptable) [310 CMR 15.302(5)] t5-2921.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 7 Hitching Post Lane Property Address Carla Delazad Owner Owner's Name information is Centerville MA 02632 April 16, 2008 required for p every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3(assessor's) DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd Number of current residents: 16 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 241 gpd 9 ( Y 9 (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: currentDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): t5-2921.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M s 7 Hitching Post Lane Property Address Carla Delazari Owner Owner's Name information is required for Centerville MA 02632 April 16, 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract to be obtained from system owner ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Age: 4+years. Certificate of Compliance issued 811812003 (Board of Health permit#2003-374) Were sewage odors detected when arriving at the site? ❑ Yes ® No t5-2921.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 Hitching Post Lane Property Address Carla Delazari Owner Owner's Name information is Centerville MA 02632 April 16, 2008 required for p i every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 1 feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): No evidence of leakage or backup into dwelling was observed. Septic Tank (locate on site plan): Depth below grade: 0.25 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) I If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.5 ft x 5 ft x 5 ft(1000 gallon) Sludge depth: 8 in Distance from top of sludge to bottom of outlet tee or baffle n.d. Scum thickness 6.in Distance from top of scum to top of outlet tee or baffle n.d. Distance from bottom of scum to bottom of outlet tee or baffle n.d. How were dimensions determined? Design Plan t5-2921.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 7 Hitching Post Lane Property Address Carla Delazari Owner Owner's Name information is required for Centerville MA 02632 April 16 2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping is recommended at this time and maintenance pumping is recommended every two years. Tank appears structurally sound and functioning as intended. No evidence of leakage in or out was observed. Outlet cover is under handicap ramp and not accessible for inspection. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): t5-2921.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Hitching Post Lane Property Address Carla Delazari Owner Owner's Name information is Centerville MA 02632 April 16, 2008 required for p 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 Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert At outlet inverts Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box appears structurally sound with no evidence of leakage in or out. Some solids in sump. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5-2921.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 7 Hitching Post Lane Property Address Carla Delazari Owner Owner's Name information is required for Centerville MA 02632 April 16, 2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: 1 ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1- 15ftx30ft ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soils above leaching field appeared unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. An observation hole was dug into leaching field stone and no effluent contact staining was observed in the stone or overlying soils. Standing effluent was observed in the bottom 2 inches of the stone. t5-2921.doc 08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Hitching Post Lane Property Address Carla Delazari Owner Owner's Name information is required for Centerville MA 02632 April 16, 2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No 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.): t5-2921.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 Hitching Post Lane Property Address Carla Delazari Owner Owner's Name information is required for Centerville MA 02632 April 16 2008 every page. City/Town 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 public water supply enters the building. HITCHING POST LANE L_OCATIONS A B 1 25 ft 31.5 ft J 2 26 Ft 39 Ft 0 W ry 3 = EXISTING L DWELLING O ' ` A 6 W / SEPTIC o l-1 TANK o D-BDX 2 LEACH 2 co FIELD NOT TO SCALE t5-2921.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 115 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Hitching Post Lane Property Address Carla Delazari Owner Owner's Name information is Centerville MA 02632 Aril 16, 2008 required for _ p every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to ground water: 10.5 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 8/11/2003 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Approved design plan on file with the Board of Health shows bottom of system to be 6.92 feet above the adjusted groundwater elevation. t5-2921.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 �- 2ua3-37`l �� � O iM1...ti r. v f { I } 1 o c_c e_SS \Vi W I i i { f -�10� 0 2 t 6 OD , p TOWN OF BARNSTABLE LOCATION / Pmri SEWAGE #20D:3 -3 23;e VILLAGE Or4 ✓7 l d ��' ASSESSOR'S MAP & LOT 3'01A INSTALLER'S NAME&PHONE NO.� e NET r Sg F 7 I r 1.3 C� SEPTIC TANK CAPACITY FX S i /s .® C--9 „✓ LEACHING FACIL=: (type) Gf 4 c X NO.OF BEDROOMS BUILDER OR OWNER C 2 �i� 1f r-A 2 PERMITDATE: Y-1% 03 COMPLIANCE DATE: �'I 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 t3sq C-if A r 43 C a.,b 37 BE 3 X -3? 14 Fee } THE COMMONWEALTH OF MASSACHUSETTS Entered-in copputer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0(pplication for Miopaar *p5tem Congtruction Permit Application for a Permit to Construct( )Repair(el Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. . � ner's Name,Addres}and Te5Nog y Assessor's Map/Parcel l ` 3 0 ,3 a Installer's Name,Address,and Tel.40. Designer's Name,Address and Tel.No. 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 gallons per day. Calculated daily flow 25 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 4000 AFX is ri Type of S.A.S. ® 5 6 r e Description of Soil Nature of Repairs or Alterations(Answer when applicable) 4.--'� �err cs T �+—.4 �D®0 '�jc3.✓C/ Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has v this Board f Health S _" Date r re O Application Approved by Date 1k 6 k Application Disapproved for the following reasons Permit No. oZ0 3 -- `7y Date Issued e3 . i � 'Fee s 0 THE`COMMONWEALTH OF MASSACHUSETTS Entered`mputsr-• les' �ii ,i PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 21ppfication for XDigpoga1 *pgtem Congtruction Permit Application for a Permit to Construct( )Repair(el-upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. — ' / ner's Name,Address and Tel, f �i /r92,g Assessor's Map/Parcel ��g Q 1A O Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 19 12-e-,y of U--5 T e a Y-F 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 gallons per day. Calculated daily flow gallons. I Plan Date Number of sheets Revision Date Title 7 r I Size of Septic Tank /ad)0 C 1l i57 R, Type of S.A.S. l �X 3G1 1 Description of Soil Nature of Repairs or Alterations(Answer when applicable) /a � a X 30 Date last inspected: x Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has e� 'sued- y 's Board f Health. r a}. I S ned — Date f1l y �J Application Approved by Date a Application Disapproved for the following reasons Permit No.. S "7L.1 Date Issued !! cj THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (,Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( ) Abandoned( )by 4 ?— p II' at 7 � c 1`aa►.J % w �. r� ✓ ✓/ll has been constructed in accordance with the provisions of Title-5-and the for Disposal System Construction Permit No.Z003-37q dated�C -Installer A Designer E 2 The issuance of this permit shall not be construed as a guarantee that the system MIL/tion 8s •esig= Date 0 3 Inspector No. Doc) --37� ------------------------Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 1wigo0al *pgtem Congtruction Permit Permission is hereby granted�torConstruct(� )Repair( «�Upgrade( )Abandon( ) System located at f +t'�z�ti �I S N' -'q' and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this pe t. Date: Approved by i 'F i f COMMONWEALTH OF MASSACHUSETTS r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON. MA 02108 617-292-5500 WILLIAM F.WELD Governor TRUDY COXE Secretary ARGEO PAUL CELLUCCI - DAVID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION Property Address: 7 Hitching Post Ln, Centervil"ress of Owner: Joseph Mayne Date of Inspection: i �L- X-9 -7 (If different) Name of Inspector: Wm E Robinson Sr I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (3 -M 15.000) Company Name: 6Im E Robinson Septic Service Mailing Address: PO Box 1 089 , C ent er vi 1 1 p� LIA 02632 Telephone Number,, 5 0 8 7 7 5-R 7 7 D73 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and tha elow is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: e, Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: 1�j L I Date: / - The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, Or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. VMEO- Any failure criteria not evaluated are indicated below. NTS: B] YSTEM 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. Indicat yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (reviaad 04/25/97) Page 1 of 10 DEP on the World Wide Web: http:Nwww.magnet.state.ma.us/dep ej Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 7 Hitching Post Ln, Centerville Owner: Mayne Date of Inspection: �.. B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] URTHER 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 FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that he well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or t less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 7 Hitching Post Ln, Centerville Owner: Mayne Date of Inspection: D]{ STEM FAILS: You m st indicate ei;,,er "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct he failure. Yes o Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2"day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. 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] RGE SYSTEM FAILS: You ust indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: jequi 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) ner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program ents of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 7 Hitching Post Ln, Centerville Owner: Mayne Date of Inspection: y ;L-g,_q 7 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes i No Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. _✓ _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. r — Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)) (revised 04/25/97) Page 4 of 10 i Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 7 Hitching Post Ln, Centerville Owner: Mayne Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: V V0 g.p.d./bedroom for S.A.S. Number of bedrooms:3—'1 Number of current residents: 9- Garbage grinder (yes or no):A-0 Laundry connected to system (yes or no):�'3 Seasonal use (yes or no): A- O Water meter readings, if available (last two (2) year usage (gpd): 1995 — 116, 000g Sump Pump (yes or no): /L- 1 9 9 6 — 81 , 000g as of 6/97 — 36, 000g Last date of occupancy: C MERCIAUINDUSTRIAL: Type f establishment: Design ow: gallons/day Grease t p present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sani ary waste discharged to the Title 5 system: (yes or no)_ Water ter readings, if available: Last d e of occupancy: OTHER: (Describe) Last da f occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no) ,5 If yes, volume pumped: 6.O gallons Reason for pumping: c Cj v s TYPE OF STEM 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) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: A J:= Sewage odors detected when arriving at the site: (yes or no) (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 7 Hitching Post Ln, Centervirll&3 Owner: Mayne Date of Inspection: j 1 BUILDI G SEWER: (Locate o site plan) Depth bel w grade: Material f construction: _cast iron _40 PVC _other (explain) Distance rom private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: (locate on bite plan) e � Depth below grade: 1 / — — — Material of construction: concrete metal Fiberglass Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: Sludge depth: e!> t' Distance from top of sludge to bottom of outlet tee or baffle: 7 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:/d-! How dimensions were determined: h 'v Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,.evidence of�aka�,e, etc.) E e� G EASE TRAP: (loc to on site plan) Dept below grade: Mater al of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dim nsions: Scu thickness: Di ance from top of scum to top of outlet tee or baffle: D' tance from bottom of scum to bottom of outlet tee or baffle: ate of last pumping: mments: (r commendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural in egrity, evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 7 Hitching Post Ln, Centerville Owner: Mayne Date of Inspection: j�L— '2—(j -1 TW HT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (lo to on site plan) Dept below grade: Mate al of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dim nsions: Cap city: gallons De gn flow: gallons/day Alar level: Alarm in working order _ Yes; _ No Date f previous pumping: Com ents: (condi ion of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_✓ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUM CHAMBER:_ (locate on site plan) Pumps in working order: (Yes or No) Alarm in working order (Yes or No) Com ents: (not condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 7 Hitching Post Ln, Centerville Owner: Mayne Date of Inspection: f —;Z— 00 -7 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number: leaching galleries, number: leaching trenches; number length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) a 3 10G A;�IeIJ y� �d �, e.� ,b t A/off--O 417'0 k 5 //deb `of w2 r C SPOOLS: _ (loc to on site plan) Num er and configuration: Dept -top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dime sions of cesspool: Materi Is of construction: Indica ion of groundwater: inflow (cesspool must be pumped as part of inspection) Co ents: (note ondition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate n site plan) Mate ials of construction: Dimensions: De h of solids _ Com ents: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 7 Hitching Post Ln, Centerville Owner: Mayne Date of Inspection: j .a SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) lt> � - e � C Y t j L ) S J (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 7 Hitching Post Ln, Centerville Owner: Mayne Date of Inspection: /;L—,7--ems 7 a,. �p Depth to Groundwater b Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record V/Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) (revised 04/25/97) Page 10 of 10 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 7 Hitching Post Lane Centerville, MA 02632 Owner's Name: Deb Kenney Owner's Address: Same Date of Inspection: June 28, 2001 �EC�1VEp Name of Inspector (Please Print) James M. Ford 'Company Nadi e. _JamesM Ford �UL O 6 2'04 Mailing'Address:' O�rvllle4MA 02655-0049 Paa�el1 30roWNoF6NpEp?ABLE Telephone Number: (508)862-9400 HEAL 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: t ✓ Passes Conditionally Passes N Further Evaluation by the Local Approving Authority F ils Inspector's Signature: Date: June 30, 2001 The system inspector shall subm 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 .........................._........_ ..__..._ .......__..._.._._...._..._. ***This report only describes;conditions at the time Of,inspection and under the conditions Ouse 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 Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A . CERTIFICATION (continued) Property Address: 7 Hitching Post Lane Centerville, MA Owner: Deb Kenney Date of Inspection: June 28, 2001 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or n m letion of,the replacement or-re air as a roved b the. of Health will ass. re aired.,:The system,upon co PP y P Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"riot determined",'please "explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or.exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken"or obstructed pipe(§).'The system will ass ins echon if with a royal of the Board Health _P..._.- _. p_ .__... . PP ) broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of i l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ' CERTIFICATION (continued) Property Address: 7 Hitching Post Lane -- ... .. Centerville. MA Owner: Deb Kenney Date of Inspection: June 28, 2001 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail'unless the Board of Health(and'Public Water Supplier;if any)!determiaes that'the system"is functioning in a manner that protects the public health,safety_and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100;feet'of a surface;water supply or tributary to a surface water supply. _ The system has a septic tank'and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,pert rmed at a DBP 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 I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART A. CERTIFICATION (continued) Property Address: 7 Hitching Post Lane , Centerville. MA Owner: Deb Kenney - Date of Inspection: June 28, 2001 D. System Failure Criteria applicable to all systems: You must indicate either"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'/z 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. ✓ 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 .1 OW feet;but greater than 50,feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at.a,DEP.certified.laboratory,for coliform bacteria,and.volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 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 Page 5 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B :CHECKLIST Property Address: 7 Hitching Post Lane•- _...__....__ _.. _-.___._._.._. Centerville. MA Owner: Deb Kenney _...__ Date of Inspection: June 28, 2001 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ Were as built plans of the system obtained and examined?(If they were not available.note as.N/A) ✓ Was the facilityor dwelling i8spect'ed for signs'ofsewage backup r. ✓' Was,the site inspected:for signs of break outi` -✓' " 'Were all system'components;excluding-the SAS;located on site? ✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes 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 unacceptable) [310 CMR 15.302(3)(b)]. 5 j r , Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM,INSPECTION FORM PART C. SYSTEM IN.FORMATION Property Address: 7 Hitching Post Lane Centerville, AM Owner: Deb Kenney Date of Inspection: June 28, 2001 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 4 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No - [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): 2060-65,000 gals.; 1999-41,000 gals. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/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: New system, never pumped-per owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? _ Reason for pumping: TYPE OF SYSTEM ✓ 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.,(W 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: 1997-per as built card .. . . ... .... .. . . Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 7 Hitching Post Lane— Centerville: MA Owner: Deb Kenney Date of Inspection: June 28, 2001 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 grade: S" Material of construction: ✓ concrete _metal _fiberglass ._polyethylene . _.. _other(explain) If tank is metal list age:._, . . . -Is.age confirmed by_a_Certificate.of Compliance(yes or no)::.' (attach a copy of certificate) = Dimensions: 1000 gal. Sludge depth: 1" _ Distance from top of sludge.to.bottom.of outlet.tee or baffle: Scum thickness: 1" 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: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): The baffles were present. Stairs were covering the outlet cover. Scum and sludge were minimal. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: s.'Distance from:top ofs'cum`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 baf)le condition,structural integrity;:liquid levels as related to outlet invert,evidence of leakage,etc.): .7 Page 8 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ,SYSTEM INEORM:ATION (continued) Property Address: 7 Hitching Post Lane Centerville, AM Owner: Deb Kenney Date of Inspection: June 28, 2001 TIGHT or HOLDING TANK: None (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.): �DLSTRIBIJTION: BOX ✓ (if present must be opened)(locate on site,plan) _ ... .._ . . .__ ._.. ----- _.._.. . ._-... Depth of liquid level above outlet invert: Even 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.): The D-box was level, and there were no signs of solids or leakage. There were no signs of back-up or failure from the leach field. The outlet invert was 20"below grade. PUMP CHAMBER: None (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.): 8 Page 9 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM'INFORMATION (continued) Property Address: 7 Hitching Post Lane.. .. `r` `" ':r. r•" Centerville, MA Owner: Deb Kenney Date of Inspection: June 28, 2001 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: 3-H2O Max's(11'x 30'x 2)-per design plans leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,.number: . . Innovative/alternative-system . Type/name..of.technology:,._ Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): The leach field was not dug up:=>-There were'rio"signs offailure'i&the'D boz.' The:bottom to'Qiade:was'approximately 44': CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet inv ert: Depth of solids layer: Depth of scum'Jayer: Dimensions of cesspool: Materials of constructiou: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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 i Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS -SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM,INFORMATION (continued) Property Address: 7 Hitching Post Lane „ . Centerville. AM f Owner: Deb Kenney Date of Inspection: June 28, 2001 Map: 173 Parcel: 030 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. Aa- 3y f6a- ti-7 Ila A3- 3(D 59 3 10 Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 7 Hitching Post Lane Centerville. MA . Owner: Deb Kenney Date of Inspection: June 28, 2001 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater 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: 1977 Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: r. You must describe how y66'established the high ground water elevation: The bottom of the'leach field to grade was approximately 44': A test hole was done when the system was installed, and water was observed at 8'. Using the Cape Cod Commission Technical Bulletin,the high groundwater adjustment for this site(SDW 252, Zone A. 5/01)was 1.2'. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,written or implied, relating to the system, the inspection and/or this report. 11 TOWN OF BARNSTABLE LCKATION 1���,'►S POs`T' SEWAGE /�1 ' �7 VII.I.AGE C2,nTt/V►�t� ASSESSOR'S MAP & LOT' ?3 030 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 10rn C-41 LEACHING FACILITY: (type) 3' MAXS (size) L� NO,OF BEDROOMS_ 3 BUILDER OR OWNER �tnne . PERmrrDATE: 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 _ _ A ' `a Al- aSr p aco 3Iq 3a- y-7 AS- 3(� 3 ``'' TOWN OF BARNSTABLE L .00 9-AT ON '-7 i-n j Pas SEWAGE # 97- VII.LAGE a/J " ASSESSOR'S MAP & LOT L ZLV INSTALLER'S NAME&PHONE NO.,I.J t ll i s in tf,466 r w on SEPTIC TANK CAPACITY 1000 LEACHING FACILITY: (type) /1�Ak P✓t7/2e:',S (size) t' e NO.OF BEDROOMS 3 BUILDER OR OWNER lnj` Ol C PERMITDATE: COMPLIANCE DATE: 1a13/J-2 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �r�c.k ��' �lo�f . � - . . �-F��- s ^� ® t .. Fk ��X I� No. Fee 5$ 0.0 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. - Yes ..a PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Rpprication for Migaar *p6tem Cow5truction Permit Application for a Permit to Construct( )Repair(XX)Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. 7 Hitching Post R-& Owner's Name,Address and Tel.No. 4 2 8—8 9 0 4 Assessor'sMap/Parcel Centerville, MA L 4 Joseph Mayne V- Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. Wm E Robinson Sr Septic Sry PO Box 1089 Centerville MA 0263 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder(no) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil sand Nature of Repairs or Alterations(Answer when applicable) Title 5 Leaching consisting of 3 H-20 stonepacked infiltrators. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by th' B ud,of H h. Signed L14 Date Application Approved b — i Date r 7 Application Disapproved for the following reasons Permit No. -+P' Date Issued No. / OF� t Fee $rJ 0.0 0 _.` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes r = PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ;tea-•-�.... 4 application for Migpogat*pgtpm Construction Vermit Application for a Permit to Construct( )Repair(XN Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 7 Hitching Post 14 Owner's Name,Address and Tel.No. 4 2 8—8 9 0 4 Assessor'sMap/Pazcel Centerville, MA. L 4) Joseph Mayne / `7 V- LS Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 775-8776 Wm `E Robinson Sr Septic Sry %� PO BOX 1089, Centerville, MA 0263 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(no) _. Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons,pp day- Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title ..' Size of Septic Tank Type of S.A.S. rrg Description,of Soil sand Nature of Repairs or Alterations(Answer when applicable) Title 5 Leachingconsistin of 3 H-20 stonepackdd infiltrators. Date last inspected. Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss ed by th• B d of H h. Signed t Dated Application Approved b - Date Application Disapproved for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS — ,, ,,,:.. BARNSTABLE, MASSACHUSETTS Mayne Certifi to of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constrict (5-..)�tepa�ed ( X)Upgraded( ) Abandoned( )by ii at 7 Hitching Post Rd Centerville has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated /f—:7,$9'� Installer Wm E Robinson Sr Spt Sry Designer The issuance of this permit shall not be construed as a guarantee that the sys will fsun t as designed. f Date 2-— 3- 7 `7 Inspector%-,&A f• A�rC.�..,, I / 0Q. f No. � -----$——————--—--———-------Fee 150.00 pis THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mayne Miopooar *pztem Construction 3permit Permission is hereby granted to Construct( )Repair(X)g Upgrade( )Abandon( ) � System located at 7 Hitching Post Rd Centerville, MA Installer: Wm E Robinson$Sr Septic Sry and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must becompleted-witgin three years of the date of this it. Date: i�` sue''' Approved b8 NaTLCE,-, Thi&Farn l&Ta Be�Usk Fo>- 'Repair OfFailed Septk Systems-Only.. y.. CERTIFICATION OF SYCETCIFE ANRAPPLACATION FOR A DI OAL W-Q S-C TRUCTIGN PE 1IT(H UT L hereby certify that-the applicatimfor dispos works co riperntitsignecLby mf dated=//-XS—g 7 ,_cancernirsg the 1-4 property located at___ 'f HitehintBestA Centerville, M --a#ft-of the faUo-wing-criteria_ * e-ar e-no-wetlands-witlrirr 1W€eet of the proposed-leaehtagfacihty. * ere are-no-privatewells within-l5@-feet of the proposed-septicsystem. were-is-rrv-urcrease-irrftowan&orcharrge-in-use-proposed. *dare are.no-variances-requestecLor-.needed. * Ifthe-proposecLleachfii fkfliity vaUbe-l-ocatecl=wittr2S(I feet_of-any wetrandi tFw—bottom-of the proposed l-eaching fcTity wffLn�i be-located Tess-ter fourteen Ffot}het abave-tfit-maXirrAum-Rusted groundwater table elevatier- Please-complete-the-following: 4 Top of aunct:E)evatiorL(accordingfQtfie l;ilgineering_DLvisiG.i= -map_)_ 1 ObservedGoundwater Table—Evaluation-(according_to>meal-tFi-MisfmwelLmap)-S 1, 6 — StfrA>1✓D DATE L r tc -sEPTtC7SYs i IMTHF--TCLWNOE-M xx&rAarF-KMMER 60 (Attach-a-sketch-plan-ofthe proposed-system. Also.-if the licensed mstallerposesses-a-certifiect-pletplan, this-plan-should be-submitted} :t r �., 1 NjG S I I -�' i �� ��� �IQP ti TOWN OF BAKNS'1Al3LE L: -- J t OCATION -7 / Iich SEWAGE # (o 7$> VIL AGE Ge/I�" ASSESSOR'S MAP&LOT.i LZLD:)d '.:INSTALLER'S NAME&PHONE NO. L;Jd/fA1n ZRo60300 _77$4776 ,SBPTIC TANK CAPACITY 000 ;;LEACHING FACILITY: (type) _3 /1�Ak r�12e�,S (size) a f ',?Z`(O.' OF BEDROOMS .::!BUILDER OR OWNER 9A ye) - ,:pERMTTDATE: /l I o 4, l COMPLIANCE DATE:.I a/,3/9 7 {� S¢paration Distance Between the: Feet :'Miximum,Adjusted Groundwater Table and Bottom of Leaching Facility :.Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet ge of Wetland and Leaching Facility(If any wetlands exist <`within 300 feet of leaching facility) Feet .:`Furnished by ;t. LAO .I kFTi . .. ........ ...t. '.s'*.., fi Mre r .'C'„'.•;f71�'7 i,-n r ,�.r'a '.'� ,. .. ,,✓•E '...: ."r�.7+*Rr .7^'�,-w--e.....,Frne^ "" tom_n' .ryK.1 h •nY• v,.,: �y z.+°4 .,.q w.�,a. •�yP'��STD TOWN OF BARNSTABLE BAR-WC Ordinance or Regulation WARNING NOTICE Name of Offender/Manager 01�/U`ICC A1,9 '/ '40 .Address of Offender 17 1LL ITC1flpJ6 P49,5K 4Ay€ MV/MB Reg.# Village/State/Zip 64A Business Name am/pm, on 20 Business Address Signature of Enforcing Of it er` Village/State/Zip Location of Offense 11� /��`t'`r;� t �►�r'7'. '` Enforcing Dept/Division Offense. V(VLA rJQt t QF /Vi/iQl Facts Assa&r6D RvAk5 /3or7 �°- "A�r.S &Aatle P&CAr of 04.444/ d r This will serve only as a warning. At this time no legal action has been taken. It is the goal of Town agencies .to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the. Town. WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT. TOWN OF BARNSTABLE BAR Ordinance or Regulation WARNING NOTICE Name of Offender/Manager Olt'It YQ1164"`Itd Address of Offender f7 1-117Mlr,16 FOS7- t 4AyC MV/MB Reg.# Village/State/Zip PA Business Name am/pm; on 20_ Business Address _ ` Signature of Enforcing Of i,cer Village/State/Zip Location of Offense Enforcing Dept/Division Offense VICU"T'lor t Ok eyilIMA, Facts A� y&r 0 g ,4e!) , /30-7'it_5 0/ 0 4L4�--'i r This will serve only as a warning. At this time no legal action has been taken. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT. A$SESSOP S MAP NO. PARCEL LO. CAT'ION S.EWA C E PERMIT NO. VILLAGE e 6HrE INSTALLER'S NAME i ADDRESS B U I L D E R OR OWN ER DA T E P E R M I T 15SU E D DATE COMPLIANCE ISSUED T � Aouxf, �10406�mv lo ' - .. a r . 4� p 4s, F o o 3 VVV, CA � ZOVVA : v.J ASSESSORS MAP JT NOTES: PARCEL : (�'�D TEST HOLE LOGS 1) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH FLOOD ZONE : 1lOtj N>��O SOIL EVALUATOR :b. Mje_yeje HIS PLAN, 1995 MASSACHUSETTS TITLE V & TOWN OF �- WITNESS : NOT- U t .� 'EAg BOARD OF HEALTH REGULATIONS. �AUE � NIt` 'r,J REFERENCE: DATE : L I 3 L �� 2) THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES, �1. Sr PERCOLATION RAT : r SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO © INSTALLATION. c� c��ss r SOIL ; o,7 y Pd TH- I Et. Lr 2j TH-2 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION t,0Arh�u ONLY, AND SHALL NOT BE USED FOR PROPERTY LINE ., It`�1 SR-4 loyg ' DETERMINATION. t l Wf} —4'U3 4) ALL PIPING TO BE 4" SCHEDULE 40 @ 1/8 "/ FOOT. (UNLESS owj LOCATION MAP N.T.S. /�,, R- Jo V9 101L SPECIFIED OTHERWISE) C ) S`TJ 45,(�� NIA 5) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A MGDfVl.� GARBAGE DISPOSAL. (� qo'lU 6) SEPTIC TANKS AND DISTRIBUTION .BOXES (WHEN INSTALLED) S I cr- MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON LOAIA, 1�Y 7� A BASE OF 6"OF CRUSHED STONE. zo r Qrr c g� .XovvrJ P►?�w w �. w rso'o� r SEPTIC SYSTEM DESIGN �ta wet! !5_._w !.✓�._._� o v ...... tD _dQ ►e a tit �i"R, 0231i/zr�S FLOW ESTIMATE bo ( I ' W _2BEDROOMS -AT 116 GAL/DAY/BEDROOM GAL/DAY Lour 3<- � Zv Ff�"' -SEPTIC TANK 3 3 0 GAL/DAY x 2 DAYS GAL I USED OOGALLON SEPTIC TANK I IF 11.E0 �RM�Fly b 61 vNDyr � 51 SOIL ABSORPTION SYSTEM 30 I To - E� sc 3 0 \ S dAREA: _ y_ I DE N A BOTTOM AREA: 30 K 15 k O� (q1'0 J� Pton o J ° �$ _-S`'EPT I C SYSTEM SECTION � 330gpb o �J I ►._._ 7 �� �� Z �t✓e 1 € 2 3/ ''Dov6le G �1 �As //� _�� U 5 Pc� vrt Bn Fr"t,� `t 1/6 . /2 24 U �� D„BOX ( �3 ovroF d.b ems/ 1�, ,+ Double 5 R&PmoUtYL rt / GAL 7 b GV 4's4ec�1)6il•t -� ,►� aa�.��csf E(,, I{5,1v2 oR , _ Zox�S SEPTIC TANK t 1�t.1nt� l _/ -yS62- (+ ✓i�T � ,27 30 Lx/� ` `ro P o F C I L"-Y ><<S7�Nll - -- n 38.70 SITE AND SEWAGE PLAN \tiZ A OF MASS,q D R N v LOCATION : 7 fllre_"fl A 57- Z}IA/� con U/M.. 1 FG �� PREPARED FOR : �STE. � 0 O 7- � DARKEN M. MEYER, SCALE ge �c � C ,. ER R.S. scv�.l 04�3 VINE STREET DATE : DUXBURY, MA 02332 W W i°; �-2 (01-71 - � DATE HEALTH AGENT (781) 585-0293