HomeMy WebLinkAbout0023 KALMIA WAY - Health 23 KALMIA WAY, CENTERVILLE
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r
A
23 Kalmia Way fro,
Property Addresst
Sandra Storm ;
Owner Owner's Name -ry
information is •
required for every Centerville ✓ Ma 02632 5-10-17
page. City/Town State Zip Code Date of Inspection -
1
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
`oe23L
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Matthew Gilfoy
use the return Name of Inspector
key.
B&B Excavation
Company Name
374 Route 130
Company Address
Sandwich Ma 02563
City/Town State Zip Code
(508)477-0653 S113640
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
5-10-17
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° 23 Kalmia Way
M
Property Address
Sandra Storm
Owner Owner's Name
information is required for every Centerville Ma 02632 5-10-17
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System was in working at time of inspection.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M
23 Kalmia Way
Property Address
Sandra Storm
Owner Owner's Name
information is required for every Centerville Ma 02632 5-10-17
page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
23 Kalmia Way
Property Address
Sandra Storm
Owner Owner's Name
information is Centerville Ma 02632 5-10-17
required for every
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) stem S Failure Criteria Applicable to All S Y Pp stems:Y
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 Y2 day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 23 Kalmia Way
Property Address
Sandra Storm
Owner Owner's Name
information is Centerville Ma 02632 5-10-17
required for every
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c�M 23 Kalmia Way
Property Address
Sandra Storm
Owner Owner's Name
information is required for every Centerville Ma 02632 5-10-17
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?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (Actual) _3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330gpd
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 23 Kalmia Way
Property Address
Sandra Storm
Owner Owner's Name
information is required for every Centerville Ma 02632 5-10-17
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry'system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonal use? ® Yes ❑ No
Water meter readings, if available (last 2 years usage (gpd)): See below
Detail:
2016- 126,000gallons 2015- 149,000gallons
Sump pump? ❑ Yes ® No
Last date of occupancy: CurrentDate
Commercial/Industrial Flow Conditions:
Type of Establishment: NA
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available: —
t5ins L•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° 23 Kalmia Way
M
Property Address
Sandra Storm
Owner Owner's Name
information is required for every Centerville Ma 02632 5-10-17
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Last pump date unknown per 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) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
o wM 23 Kalmia Way
Property Address
Sandra Storm
Owner Owner's Name
information is required for every Centerville Ma 02632 5-10-17
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Unknown due to lack of records
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 18"feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: Town
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
6"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gallons
Sludge depth: 3
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c,
M 23 Kalmia Way
Property Address
Sandra Storm
Owner Owner's Name
information is required for every Centerville Ma 02632 5-10-17
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle 33"
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 16"
How were dimensions determined? Measured _
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank was in working order at time of inspection with liquid level equal to outlet invert. Tank is not in
need of pumping at this time but should be pumped every two years for maintenance.
Grease Trap (locate on site plan):
Depth below grade: NA
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
15ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M
23 Kalmia Way
Property Address
Sandra Storm
Owner Owner's Name
information is required for every Centerville Ma 02632 5-10-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: NA
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
23 Kalmia Way
'M
Property Address
Sandra Storm
Owner Owner's Name
information is Centerville Ma 02632 5-10-17
required for every
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
11
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 was in working order at time of inspection with no sign of past backup or carry over.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
NA
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why: t
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
o° 23 Kalmia Way
Property Address
Sandra Storm
Owner Owner's Name
information is required for every Centerville Ma 02632 5-10-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: (1) 6'x6'
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system.
Type/name of technology.-
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation,'etc.):
Leaching was in working order at time of inspection. No high staining, damp soils or lush vegetation
were present. Pit had 3" of standing water.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration NA
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 -Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
'M
23 Kalmia Way
Property Address
Sandra Storm
Owner Owner's Name
information is required for every Centerville Ma 02632 5-10-17
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction: NA
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 23 Kalmia Way
Property Address
Sandra Storm
Owner Owner's Name
information is required for every Centerville Ma 02632 5-10-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
REAR
B
A
A1-31' B1-224'
A2-36' 82-33'6" (D
A3-586"B3-32'
0
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
7M
23 Kalmia Way
Property Address
Sandra Storm
Owner Owner's Name
information is required for every Centerville Ma 02632 5-10-17
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: >15'
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health - explain:
A previous inspection report shows greater that 15' to water
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Info on file with BOH.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
23 Kalmia Way
M
Property Address
Sandra Storm
Owner Owner's Name
information is required for every Centerville Ma 02632 5-10-17
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
E Inspection Summary: A, B, C, D, or E checked
E Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
I
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
TOWN OF BARNSTABLE '
L�X-- , ION93 A 4� Z Al 41 SEWAGE #
VILLAGE ���"/''�tC./lo,, .��'�'�� ASSESSOR'S MAP & LOT .,
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY lG�GtG7
LEACHING FAXILI TY: (type)
�� "F (size)
NO.OF BEDROOMS ✓ '" _
BUILDER OR OWNER
PERMTTDATE: 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 Le ping Facility(If any wetlands exist ,
within 300 fee I ility) Feet
�. Furnished b ��
a
r
DAM .147 9 9
PROPERTY ADDRESS:_2'3 Katrn-ia Wdy
Centerville ,Mass .
02632 ,
On the above date, I Inspected the septic system at the above address.
This system consists of the following:
1 . 1-1000 gallon .septic tan14.
2 . 1-Distribution box . >�y
3 . 1-1000 gallon precast .leaching pit . , �fW VF0 �\
Based bn my Ineoactlon, I cerffly the following con,, tilo��:B o a
4. This is.. a title five septic' 5ystem';`(1 V8 Code ) 1999
5 �_. "-t r0wru
a� OF F
6. •S'eptic tank was pumped- as part of inspection . ff
Neavy .scum ,solids layers were present .
SIGNATUR!7,7 /O
Name; J . P.Ka-co mber JRJL :• i ' ,'
Company: J. P.Macorgber b � on"Ync ,
Address•
Phone:__�S48J_7�-.7338_______
•• 1
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER '& SON; INC. - ,
Yanks-Co"pooIPLsachllelds , .
.Pump+d 4 Instilled
' Town Sewer Connections
P.O. Box 66' Centerville, MA 02632.0066
7 7.5.3 3 3-8 7 7 5-6412
i
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON)1SA 02108 (617)292-5500
TRUDY COKE
Secretary
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
PropairtyAddreu: 23 Kalmia Way Center villeNameofowr,wVincent Taber
Data of Inspection:1/27/99
Ma s s .Address of owner: 2 3 K a a m i n p Name of inspector:(Please Print) Joseph P.Macomber J r . Centerville ,Mass . 02632
1 em a DEP oved system Inspector to Section 15.340 of Tide 5(310 CMR 15.000)
Company Name: J.T.M a c o m b e r & Son Inc .
Mailing Address: R n Y 66 M A n t a r v i 1 1 a ,M a s c _ 02632
Telephone Number: 598 445 5 3338
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 inspection. The Inspection was performed based on my training and experience In the proper function and
maintenance of on-site se age disposal systems. The system:
140,00 Conditionally Passes
_ Needs Further Evaluation By the local Approving Authority
Fails
inspectors Signature. Dats:
The System Inspe r shall aubmlt a copy of this Inspection report to the Approving Authority(Board of Health or DEP)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 ofrEnvironmental Protectlon. The original should*be sent to Vse
system owner•and copies sent to the buyer,if applicable, and the approving authority. .
NOTES AND CONIMENTS
revised 9/2/98 Page Iof11
'10 Printed on Recycled Paper
i
SUBSURFACE SEWAGE DISPOSAL•SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
property Address: 23 Kalmia Way Centerville ,Mass .
Owner. Vincent Taber
Daft Of kwPOcf'On: 1/27/99
INSPECTION SUMMARY: Check A, B, C, o/ A
lave not found any information which indicates that any of the failure conditions described In 310 CMR 16.303 exist. Any failure
criteria not evaluated are Indicated below.
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system,upon
completion of the replacement or repair,as approved by the Board of Health,will pass.
Indicate 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 complying septic tank as
approved by the Board of Health.
Nd 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).
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(sY. The vystem wilhpess--
Inspection if(with approval of the Board of Health): - --
broken pipe(s)are replaced
obstruction is removed
revised 9/2/98 Page 2ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
PropertyAddross; 23 Kalmia Way Centerville ;Mass .
owner: Vincent Taber
Date of kupec6m: 1/2 7/9 9
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
/1 - 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 W ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING W A MANNER WHICH WLLLPROIECT THE PUBLIC KE LLTHAND SAFETY AND THE ENMIRONMENTs
Cesspool or privy Is within 60 feet of 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 AND SAFETY AND THE 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 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 60 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 collform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonla nitrogen and nitrate nitrogen is equal to or less
than 6 ppm. Method used to determine distance A44 (approximation not valid).-
3) OTHER
A)lk
revised Page 9 2 983of11
/ /
i
_1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
PropertyAddress:23 Kalmia Way Centerville ,Mass .
Owner Vincent Taber
Date of Inspection: 1/2 7/9 9
D. SYSTEM FAILS:
VuYou st Indicate either"Yes"or"No" to each of the following:
I have determined that one or more of the following failure conditions exist as described 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 the failure.
Yes No
_ Backup of•towage into 4acility"or•9etem component-due t to an overloaded or-clegged-GAS•orceaspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liqu vel in t e distr ution Dove outlet invert due to an overloaded or clogged SAS or cesspool.
,�
Liquid depth in Dees s ess an 6"tielow 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 Q.
�. Any portion of the Soil Absorption System,cesspool or privy Is below the high groundwater elevation.
rY 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 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
•"coliform bacteria,volatile organic-compounds, ammonia nitrogen•and nitrate nitrogen. -
E LARGE SYSTEM FAILS:
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:
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:
Yes No
� the system is within 400 feet of a surface drinking water supply
the system•is-within 200 fSet of*4FibuteryAoa-OuFfaoe•drkgapg•water•oupply•••• - --• -- •• _._
AZf the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area:IWPA)or a mapped Zone 11 of a public
water supply well)
The owner or operator of any such system shall upgrade the system In accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 Page 4of11
f
I
f
,
i
i SUBSURFACE SEWAGE DISPOSAI,SYSTEM INSPECTiON FORM
PART B
CHECKLIST
PropertyAddress:23 Kalmia Way Centerville ,Mass .
Owner: Vincent Taber
Date of Inspection: 1/2 7/9 9
Check if the following have been done:You must Indicate either"Yes" or"No" as to each of the following:
Yes No
-i,•/ Pumping information was provided by the owner,occupant,or Board of Health.
-None of the system compoaants.wara2twn puwgmd4opatleast,two•aweekaaadtbe'aystam hasbaeoaeceiaiagensmW Aow
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,. u�inp;tlt SoU Absorptlon.rSysl�wmR,bays 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 orr the site has been determined based on:-
_ Existing information. For example, 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)
115.302(3)(b))
The facility owaar.(and.wxAq =UAf differaat froouownerl.ww&punddad with Infogmat oa:on*ha spar rnnin*a^"^^ ^f
SubSurface Disposal Systems.
I
revised 9/2/98 Page 5of11
I i
1
9.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 23 Kalmia Way Centerville.,Mass .
owner: Vincent Taber
Date of Inspection: 1/2 7/9 9
FLOW CONDITIONS
RESIDENTIAL:
Design flow: l/D g.p.d./bedro M.
Number of bedrooms(d sign): Number of bedrooms(actual):
Total DESIGN flow
Number of current residents:
Garbage grinder(yes or no):N?
Laundry(separate system) (yes or if yes,sepamtelnspection•required --.
Laundry system inspected (yes or o
Seasonal use(yes or no):-,A /�Water meter readings,if available(last two year's usage(gpd): 9 7 �7Sump Pump(yes or no):�/9' f ' Y 4 D40 / 0.0POW
Last date of occupancy:_
COMMERCIAL/W DUSTRIAL•
Type of establishment: Ald
Design flow: j1h agj (Based on 16.203)
Basis of design flow
Grease trap present:(yes or no)
Industrial Waste Holding Tank present:(yes or no)_&,*
Non-sanitary waste discharged to the Tilts 6 system:(yes or no)�
Water meter readings,if available: �/ -
Last date of occupancy:—N2
OTHER:(Describe) 4!
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection:(yes or no)..70s y
If yes,volume pumped: gallons
Reason for pumping:
TYPE OF,&YSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
_A9D Overflow cesspool
"Oly Privy
Shared system(yes or no) (if yes, attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank IJ4 Copy of DEP Approval
Other
APF%OXIMATE AGE of all components, date Installed{if known)-and source of4mformation:
&wage odors detected when arriving at the site:.(yes or no) Aeo
revised 9/2/98 Page 6of11
SUBSURFACE SEWAGE DISPOS/1L SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PropertyAddr-s: 23 Kalmia Way Centerville ,Mass .
Ownw: Vincent Taber
Data of Inspection: 1/2 7/9 9
BUILDING SEWER:
(Locate on site plan)
ti
Depth below grade:
Material of construction:_cast Iron PVC_other(explain)
Distance from rivate water supply well or suction line 1��"
Diameter
Comments:(condition of Joints,venting,evidence of leakage,-etc.)
Joints appeartight - No Pvid,-nrn of leakage -
SEPTIC TANK:
(locate on site plan)
Depth below grade:
Material of construction: concrete_metal_Fiberglass _Polyethylene_other explain)
If tank Is install,,liist aJJJJge,,,,/d/ Js.ago.confirmed by Certificate of Complianc (Yes/No)
Dimension,:. ��O' e/&
Sludge depth:-
Distance from top of gludge to bottom of outlet tee orbaftie: A�_
Scum thickness: Q
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to botto of outlet tee or baffle:__2L
How dimensions were determined:
Comments:
(recommendation for pumpin,y,condition of inlet and outlet toes or-baffles,depth of liquid level in relation to outlet invert, structuralintegrity,
evidence of leakage,etc.) Yump tank every 2-3 years : Inlet & outlet tees are in
place ThP tank is striirturn1 1 y enttnd Tank QhntTQ no oui loan ,
of inakaso
GREASE TRAP:,d�aVe—
(locate on sit*plan)
Depth below grade:
Material of construction. oncrote et4'/FiberglaszA)6Polyethylene/L4other(explain)
Alld
Dimensions:
Scum thicknoss:
Distance from top of scum to top of outlet too or baffle:—AY
Distance from bottom of scum to bottom of outlet tee or baffle: 4
Date of last pumping:Al4
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 leakage,etc.)
Grease trap is not present .
revised 9/2/98 Pa&t7of11
SUBSURFACE SEWAGE DISPOSAL,SYSTEIM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PropertyAddress:23 Kalmia Way Centerville ,Mass .
Owner: Vincent Taber
Date of i"Pection: 1/2 7/9 9
TIGHT OR HOLDING TANK (Tank must be pumped prior to, or at time of,inspection)
(locate on site plan)
Depth below grade:
Material of constructionJ41—, concrete/kgtneta 4Fiberglasa��Polyethylen*i'dother(explain)
Dimensions:
Capacity: /L49 gallons
Design flow: gallons/day
Alarm present
Alarm level:Alarm in working order:Yes&!&NojV
Date of previous pumping:A_
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
'light or holdini7tanks are not ,-event
DISTRIBUTION BOX:Z
(locate on site plan)
Depth of liquid level above outlet Invert: NO
Comments:
(note-if level and distribution is equal,evidenoe of solids carryover,evidence of leakage into or out of box, etc.) - --
Distribution box has one lateral ;Niu ovidiappe of selida—ear y e
No evidpnrp of 1 eairag into Qr- ei t a€ the—bei .
PUMP CHAMBER:� 41'e-
(locate on site plan)
Pumps in working order:(Yes or No)- L
22±Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
revised 9/2/98 Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 23 Kalmia Way Centerville ,Mass .
Owner Vincent Taber
Date of kmPwt on:1/2 7/9 9 1^
SOIL ABSORPTION SYSTEM(SAS)-Izad �l�
(locate on site plan,if possible:excavation not required,lollation may be approximated by non-Intrusive methods)
If not located,explain:
Type:
leaching pits,number:_
leaching chambers,number•
leaching galleries,number:�
leaching trenches,number,length: D
leaching fields,number,dime on
overflow cesspool,number:
Alternative system:
Name of Technology:
Comments:
tnote condition of soil,signs of hydraulic failure,level of ponding, damp soil,condition of vegetation, etc.)
oamy sand to medium fine sand : No signs of hydraulic failure o
nnndi no TAT aeto below the- 1pver-t plpe, Sei I i A
Her-Vegetation is normal .
CESSPOOLS:
(locate on site plan)
Number and configuration:
Depth top of liquid to inlet invert: i
Depth of solids layer: IVq
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater: AIR
Inflow(cesspool must be pumped as part of inspection)
Cesspools are not pregPnt
Comments:
(note condition of soil,signs of hydraulic failure,-level of pending,condition of.vegetation, etc.)
esspoo s are not nrPSPnt _
PRiVY:&NG
Ilocate on site plan)
Materjals of constructi n: Jl//9 Dimensions:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation;etc.)
Privy is not present ,
revised 9/2/98 page 9orii
• F � -Y r. .a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PropercyAddross:23 Kalmia Way Centerville ,Mass .
owner: Vincent Taber
Date of lnepection: 1/2 7/9 9
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes Into house)
i
\ 3° f,
revised 9/2/98 Page 10of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART tr
SYSTEM INFORMATION(continued)
PropertyAddress: 23 Kalmia Way Center vi1le ,.Mass .
Owner: Vincent Taber
Date of hspecti°n:1/2 7/9 9
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date wabsite visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep _
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
i
Estimated Depth to Groundwater41EII-Feet
Please indicate all the methods used to determine High Groundwater Elevation:
/Obtained from Design Plans on record
1/ bserved.Site(Abutting propert bservation hole,basement sump etc.)
determined from local conditions
Checked with local Board of health
/Checked FEMA Maps
✓Checked pumping records
Checked local excavators,installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
Used Water Contours Ma.p
Gahrety & Miller Model
12/16/94
revised 9/2/98 Page 11of11
a•.nnrw.-nrr��•n-zrnrmrm.nnr+.rtrnxrerarrvs.-rs.sra�n*•nnn m-rn•.0 r�+�.�s-n a�r•r.-.--.tRn�...�-.r'.�
TOWN OF Barnstable BOARD OF HEALTH
SUBSURFACE SEWAGE DISPOSAL SYSTF,M INSPECTION FORM - PART D •- CERTIFICATION 1
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 23 Kalmia Way Centerville ,Mass .
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER' s NAME Vincent Taber
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J.P.Macomber� & So-I Inc .
COMPANY ADDRESS Box 66 Centerville ,Mass. 02632
Street Town or City State LIP
COMPANY TELEPHONE ( 508 1 775 - 3338 FAX ( 508 ) 790 _ 1578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate, and
complete as of the time of .,inspection , The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one: yy
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15. 303 . Any failure
criteria not evaluated .are as stated in the FAILURE CRITERIA section of
this form.
System FAILED*
The inspection which I have con icted has found that 'the system fails to
protect the public health and the environment in accordance with Title
5 , 310 CMR 15 . 303, and as specifically noted on PART C - FAILURE
CRITERIA of \this inspection form .
-
Inspector Signature Date A
One copy of this ertification must be provided to the OWNER, the BUYER
( where applicable ) and the 130ARD OF HEAL1111.
* If the inspection FAILED, the owner or.".operator shall u d
he
within one year of the date of the inspection, unless allowed ortrequiredm
otherwise as provided in 3.10 CMR 16 . 305 ,
partd.doc
No. %Z:1 ..7 .� FIc$.....��...........�
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
.............. .(A7?'4............0F........ .P' et.T- -------------•------.......................
Applira#ilan for Bhipoii al Workri Tomitrnrtion lirrmit
Application is hereby made for a Permit to Construct ( t1l"or Repair ( ) an Individual Sewage Disposal
ystem at:
................_..............�ZA_,_ .JA.....-•- `' e._...._.._.......��T . ....---- .........
S!!l_.:---•.............................. f_.', . ............ ..........
caner . _...Address
1.4 j� Installer Address
UType of Building it Size Lot.... 0 W.1......Sq. feet
_t Dwelling—No, of Bedrooms...............J__---------.-------------Expansion Attic ( ) Garbage Grinder ( )
pa., Other—Type of Building ............................ No. of persons..........................-- Showers ( ) — Cafeteria ( )
Q' Other fixtures ---------------------------•-•-- -
W Design Flow...................ST..................gallons per person per day. Total daily flow.........................3.30........gallons.
WSeptic Tank—Liquid capacity.tPQQ.gallons Length................ Width-----------_--- Diameter--.--.-------.-- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.--_------I------- Diameter.........--1?------ Depth below inlet.....--.&....... Total leaching area..... Q...sq. ft.
z Other Distribution box Dosing tank ( )
Percolation Test Results Performed by.......13A X.'1� -:._.f". �....................... Date.....`... S...........
Test Pit No. 1------�--minutes per inch Depth of Test Pit-----------0T-.. Depth to ground water-.-.--- ............
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
•-------•---------------------------• .......................................................................................................................
0 Description of Soil....................................................................--•---••---------•--------•-------------------••--------------•-....---•---•-••-----...............
...............................................C.L.B.14A......aim..........�Aj.x?..............................................................................................
W ----•-•------------------------------------•----------•--------------•......•--•--••------------••------------------------------...-------••---------•------•----•----------•-----------.....-----------
UNature 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 Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by the board of health. G
lk
Signed - � � ............................................... ........ral 1.
Application Approved By ................
^' ....... "' ---.............--------------------------------------------------- ...
Date
Application Disapproved for the following reasons: ................ ............ . --------------------. ------. . . ------- -- -------.......--------------.
-----.---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ........................................
Dare
Permit No. ----- . ..�._74/—-- Issued
----------------------------
Date
s
i'
THE COMMONWEALTH OF MASSACHUSETTS
i_ BOARD ROF HEALTH
Appliratiun for Disposal Varks Tunntrurtiun rprutit
Application is hereby made for' a Permit to Construct ( _�or Repair ( ) an Individual Sewage Disposal
System at: e
:..., . #... tl 1'u it'd`a /leir.�� .
....................................................__................... ............._._....______............. I...._..... ............
! Ad
.p L ati ss No.
�..:. ... _:................................. ' ' ............... 'f ........................._..
wner Address
a --_•-•..--• ------------------------------------I...-----..._-------- --T.... ._.................................................-----
•/ Installer Address
d Type of Building .r. Size Lot...._ ....$P t-----Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
'04 4 Other—T e of Building No. of persons............................ Showers — Cafeteria
d Other fixtures .---••----------- ------ --- ----•- .�.�--------..........------
W Design Flow..................`0- . ...............gallons per person per day. Total daily flow.......................... ........
Septic Tank—Liqaid caPacitY._:'V!?Q.gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
PT.
Seepage Pit No_____________________ Diameter....___..__ "..... Depth below inlet........:6�'....... Total leaching area.....�Q...sq. ft.
Z Other Distribution box Dosing tank ( )
'-' Percolation Test Results Performed by-------- 1 ` ? __. L' ._........ _:`----"
---•----------. Date--------- -"---------------------.
,tea Test Pit No. I........ _minutes per inch Depth of Test Pit----------- _._ Depth to ground water___-_ ""`---_---__.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
04 •-•-•-•-•---••••--.....--••-----••--••---•--•-•--.•----••-•••••......-•-•---•......................................•----------•---••••--...................--
0AwDescription of Soil-------------- ----------•---------------------------------------------------------------------------------------------------------------------.--------.---
W U€r. _..._X`'M ...........
/y R ...
W
.......................................................... .............................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
•-------•-----------------•-•---••---•-----•--r----------•------------•-----....------......----.........--••-------------------------------•-------------------------------------------------------•---
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliant has been issued by the board of health.
Signed - ` . ' ` ( - d u
�' ................._... .... ------ --- -�. ....... �
Application Approved B 4 [ .`�!%�-'` ... 17••.-
PP PP Y ............... -'w'�..-.. Date...
Date
Application Disapproved for the following reasons- ------------------------------------------------------------------------- ......--............----------------------------
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------ -- ---- ---
Date
Permit No. ..... - -----.. -y.. Issued
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
- ,,d OF
(fQrtifirate of Qlaraptianre
THIS IS TO CERTIFY, That the In ividual Sewage Disposal System constructed ( � ) or Repaired ( )
by --------------- .= 1�. . .......--........ ---------
Installer "
at .......... --d-T .... ....� �. M/ ............... .
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. --...---,{-rram�. -e�.-rr,,.�� dated ---------------------=--------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE`CONSTRIJE6AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE....................... ... ..... ................................... ................... Inspector ..----... .--------- .-----..........------------- -- . ...------. --------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................I=1 ' OF............ 1: �.i'a;�s t /,\42J L ��-
.................................................................
No.... .----.
(� FEE.. -•--------------•
/ Disposal 1vorkii 00111nn#rudiun Vandt
Permission is hereby granted............ �_h . -•--•-••••--•-•---...-•-.._._..-•-...---•----•--•--•-••-••..................•......
to Construct ) or Repair ( ) an I vid Se�rage D> pos System
"Street Zlo '__. ._..
as shown on the application for Disposal Works Constrttefion Permit No.... _. Dated.........................:................
................................. ---------------------------------------------------
/ r � Board of Health
DATE / __Bc:ard
/------------------------.....
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS -
S`Q TOWN OF BARNSTABLE O
LOCATION i"o+4 .7c��H,,.c� W� � SEWAGE # 7 �
VILLAGE r S�;'kESSOR'S MAP & LOT
INSTALLER'S NAME Si PHONE NO.
SEPTIC TANK CAPACITY 1, aC► t�9�t Il o�..S
LEACHING FACILITY.(type) (l/.n&v , (size) �;,0114
NO. OF BEDROOMS PRIVATE WELL O PUBLIC WATER
BUILDER OR OWNER �`)�:/>i ✓LIa' Le.
DATE PERMIT ISSUED:
DATE COLIPLIANCE ISSUED: — ,�
VARIANCE GRANTED: Yes No
3 363-10
�Jl�ll-�( 3 T3t�TZ1�bN�
110 V 341
EPi'lc TA�1k = 33ov (r?G % • d�rj c6.RD. ,y6. M di'
Usk- 100x--,� GAL—
d
POSAL PIT - USt_ I000 GAL �- x
P
Icy Sir )c Z.S + 3-75 G.P.D. r .-.dt3 f vl
8a►�o�K Atzt=�_ EA""A l
=s.PD. r N�. w
o
' TOTAL -DG-St6W d•25 G , �
i-oTp l_ Dal L-�- Flew = P.D. m •'' "33D 6.
PEZCOL T1OLJ OISTE ("tt� ZhtttJ 02 LESS,.
OF
p`T r}
`�c�; RICHARD ' tr i,
r A.
No. :r i
Bi1XT R � Ak ,
CIS
w t
-ram-; P a2-1I Top F'u —
u K ��..
EL: 4,
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4"PPP- 1>6T. IW. GAL. ZI,g
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i I DSO x1 ( T-An1K
GAL. 2-1 Z Z1•�
PN :A
a s i - WITa I e'
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STONE EL----24
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tvarE� r - ScA1_C 11I 1yATt I2-i-
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i !uF:F?Lt�l�l Cc��nL�IS W I•t•I•� '"I"4-1` �IDC.t_t►-•►� ��'
�At.ID `7E'Z"l`.�ACIG '~'[Q:.JI�:Ert/Ii:I•••;�S DF TNT LC� •-7
'To ov- 'BA-rz4 '1P1- tLZ ANU ;i l4or Lo,4Am%6. I t
,�,JtTti4tN t,��Ey r1.��� GAIN
ATE +'• i 1 4 =\. .�G. (/ Y ,� �.t, ,'�+,,,d J L.
. i
REGISt'C-IZ�D LA Wo 5Uevayoiz
TI-ll� C7I_A►�-1 (�,-, t-!OT L'•A��C-_'O U�•� pe.,J - OSTEfL�/i�� o /�rCASS�
>•l i Lam,C_, U�-,C:L-, TO
NOTES:
1. ANDERSEN 400 SERIES CLAD WI OWS HP LOW-E GLAZIN U 8 +
AND GRILLES BETWEEN GLASS, C NFIRM GRILLE TYPE WITH EXISTING NDO
2. INSULATE EXPOSED WALL AN CEILING C TIES WITH AFT FACED _U
BATT INSULATION
3. INSTALL TRIM SYLES TO MATCH EXISTING
4. REINFORCE BASEMENT BEAMS BELOW NEW POSTS IN KITCHEN WALL WITH 9 1/4" LVL f /
EACH SIDE OF EXISTING HEADER. ATTACH WITH 3/8" LAG BOLTS 16" OC
z
3-9 1/4"LVL WITH 3 - 2X6 Idi;
EX BR Posrs. BOSOTON
EX LIVING/DINING EX. FAM RM
No.8=
BATH MO: REMOVE EXISTING
REMOVE TOEKICK HEATER
FIXTU 1ES AND CLOSET.
REMO EXISTING FLOOR REMOVE PORTION OF EXISTING �-
FINIS REPLACE
WALL
WALL
FINISI ES IN AREAS RECEIVING
NEW IL E OR OTHER WORK.
PATC I CEILING AS NEEDED
FTE I STALLATION OF NEW PAD OUT EXISTING WALL WITH
A
AFT 2X6 FRAMING FOR RELOCATION
OF PLUMBING LINES NEW DOOR TO GARAGE:
INSULATED FIRE RATED METAL
DOOR
MED B 2'-7" NEW WOOD STEPS
EX DOOR
2'-4 1/2" HANDRAIL 36"H KITCHEN DEMO:
MUDSET TILE SHOWER OR( ink EX GARAGE REMOVE CABINETS, FLOORING,
O ON COPPER OR MEMBR PAN WALL FINISHES, AND LOWER
NEW NITY,COUNTER, SINKS EX 112 I FLAT CEILING. SAVE
AND I RORS GLASS WALL PANELS AND KITCHEN APPLIANCES FOR REUSE. PREP
DOOR THIGH +/- BATH WD FLR
WALLS AND FLOOR FOR NEW
-- NEW OR EXTENDED EXISTING ref w/ I CABINET AND APPLIANCES.
EX FRAMING. FINISH WITH E i REVISE PLUMBING AND
icemkr I dual fuel lO CUT OPENING IN EXISTING WALL ELECTRICAL FOR NEW
BACKER BOARD IN ARE TO I APPLIANCE LAYOUT.
CLOSET range O FOR RECESSING MICROWAVE/
RECEIVE TILE, BLUEBD D mw/ex. EXHAUST FAN. INSTALL 2X4
PLASTER ON REMAINDE
3-0^ HEIGHT J — — — — � hood FRAMED BOX WITH 5/8"-X GWB
/ I FINISH ON GARAGE SIDE.
VERIFY WITH
TUB FRAME 36X60 TUB WITH
BATH MANUFACTURERS SUPPLIED I / sink i INFILL EXISTING DOOR OPENING.
TILE FL ,- r--I- FINISH WITH 5/8"-X GWB ON
FOAM BASE AND FRAME W L / 3 2 l i GARAGE SIDE
SUPPORT � � �
TILE SU OUND " A EX open above I w
TUB TILE BA ER B RD / I INSTALL TOEKICK HEATER U
CLOSET /
C N
/ m
PAD WALL 12" DEEP, 2" HIGH, �
TOP WITH STONE SHE L / CX13 �_ T
L
PROVIDE TEMPERED GLAZING IN C34 > Y c
WINDOW SASH OR CHANGE EPLACE EXISTING WI DOW CTR32010 U N U
SASH INFILL
ALL ABOVE NEWS DARE progress 5.25.18
TRANSOM AND AT JAMBS AS permit 5.31.18
NEEDED. TRIM TO MATCH
EXISTING HOUSE