Loading...
HomeMy WebLinkAbout0405 LAKESIDE DRIVE WEST - Health �405 Lakeside Drive�� �,t✓� MMI Centerville P _ A = 232 022 D ,. .' .\ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL (PROTECTION • TITLE s OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A g CERTIFICATION Prokrty Address•t tli i : Owner's Name: Owner's Address: , Date of Inspection: Name of Inspector.(please print) Co,mpanyName: William E. Robinson Septic Service Mailing Address: P O Box 3 089 Centerville, MA Telephone Number.. (,508) 775=&77-6 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 S ton 15.340 ofTitle 5(310 CMR 15.000). The system: Passes Conditionally Passes s Needs Further Evaluation by the Local Approving AuthotTnty O Fails Inspector's Signature: Date: '7 g y The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Healthy DEP)within 30 days of completing this inspection.If the system is a shared system or has a design#low of 10,1)0 �'y gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional:office of iWc DEP.The original should be sent to the system owner and copies-sent to the buyer,if applicable,and the appr@ng M . authority. , Notes and Comments """This report only describes conditions at the time of inspection and under the conditions of use at that time_This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I �6 D Page 2 of l l r . s OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address Owner. Date of Inspection: , f Inspection Summary: Check A,B,C,D or E/ALWAYS complete sll ofSectioa D A.� Sys�te Passes: I have not found ' 15.303 or in 310 CMR 15.304 exist information failure criteria of evaluated are indicatcates that any of the failure ed below described m 310 CMR Comments: B. System Conditionally Passes: t N One or more system components as described in the"Conditional Pass"repaired.The system,upon completion of the repla r repay as section,need to be replaced or cement o 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 strut unsound,exhibits substantial infiltration or exftltration or tank failure is imminent S ) structurally existing tank is replaced with a complying tank as yswm will pass inspection if the 'A metal septic tank will pass inspecti ifi�sst structurally approved sound,not eak leaking and i Board fa 1CertiCteate 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 tv obstructed Pipe(s)or due to a broken,settled or uneven distribution box.S broken or, approval of Board of Health); System will Pass inspection if(with-, broken pipe(s)are replaced 7 obstruction is removed distnUtion box is Ievded or replaced ND explain: The system required ection if a Pumping more than 4 tip a Pass ins with Yeardte to broken or obsrs�ed P�(s).The system will p ( . approval oftlte Board ofHeaith): y broken pipe(s)are replaced obsmxtian is 2T`l WVW ND explain: -' 5 , Page 3 of i l OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE-SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART A CERTIFICATION(continued) Property Address: ac�s Owner: Date of Inspection: .: G Further Evaluation is Required by the Board of Health: Conditions-exist which require 11i Cher 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 CNIR 15.303(i)(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. A _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more front a private water supply well•• Method used to determine distance "This system passes if the well water analysis.performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 y Page 4 of I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE-SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: v (Q '162- c-c v.L�jelzl i Lie- Owner: �z7i'VN Date of Inspection: Q 7 D. System Failure Criteria applicable to all systems: You must indicate'yes'or"no"to each of the following for all inspections: Yes No _ ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above-outlet invert due to an overloaded or clogged SAS or _cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Numbcr 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 100feet of a surface water supply or tributary to a surface water supply. _ An portion of a cesspool or privy is within a Zone I of a public well. ��'"Any y portion of a cesspool or privy is within 50 feet of a private water supply well. y portion of a cesspool or privy is less than 100 feet but greater than 50 feet Gom a private waver 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 t nitrogen and nitrate nitrogen is equal to or less than S ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails. 1 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.I5,000 gpd- You must indicate either"y- 'or"no"to each of the following: (nic following criteria apply to large systems in addition to the criteria above) Yes no die 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 an itrogcn sensitive area(interim Wellhead Protection Area—I WPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E die system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator ofany 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 o%vner should contact the appropriate regional office of the Department. 4 Page 5 of 1] OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: �151G� CQ�I V�WQS-�— knAcx-V� 1 Owner. 7J t;'r\ K-(,v{"U `JCL. Date of Inspection: O Check if the following have been done.You trust 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? v 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 t Were as built plans of the system obtained and examined?(if they were not available note as NIA) Was the facility or dwelling inspected for signs of sewage back up? T 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: . Yes - _� Existing information.For example,a plan at the Board of Health. _ Determined in the Held(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 , Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:L�o"5 `>1 ttiE! �5 - Can U) 1 16— Owner:_:1 'M VC L' S Date of Inspection: KC1W 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): . Number of current residents:�-X Does residence have a garbage grinder(yes br no): AA Is laundry on a separate sewage system�(y�e�s or no):� jif yes separate inspection required) Laundry system inspected(yes or no): 'tl' Seasonal use:(yes or no):,PJ Water meter readings,if available(last 2 years usage(gpd)): ac)o g 1 CA,00 0 Sump pump(yes or no): Last date.of occupancy. c,,,•c, �--- COMMERCIAL4MUSTRiAL Type of establishment: Design flow(based on 310 CUR 15.203): Basis of design flow(seats/persons/sgNctc.): Grease trap present(yes or no):— Industrial waste holding tank present(yes or no):_ Nbn•sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no):�Lf If yes,volume pumped:MoD allons--How was quantity pumped determined? Reason for pumping: j�,,SAb. ,r T g- TYP OF SYSTEM eptic 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: 1 I j � - �----- f e-ea,�-is - Were sewage odors detected when arriving at the site(yes or no): � 6 i I'a�c 7 of 1 1 OFFICIAL INSPECTION FOR 1—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORi1I PART C r SYSTEM INFORA ATION(continued) . Property Address: qo5 Owner: Y\ rUK-0S Date of Inspection: 7r '�_ �, BUILDING SEWER(locate on site plait) Depdt below grade. / Materials of construction:_cast iron L. PVC_other(explaur): Distance from private water supply well or suction lute: Comrttcnis(on condition of juints,venting,evidence of leakage,ctc.): s tr SEPTIC TANK: ✓(locate on site plan) Depth below grade: ell Material of construction:%.,Concrete_metal fiberglass_polyethylene _othcr(explain) If tank is metal list age:_ Is age con finned•by a Certificate of Compliance(ycs or no): certificate) —(attach a cope 'of 1 Dimcnsions: Sludge depth: Distance from top of sludge to bottom of outlet lee or baffle: Scum thickness: Distance from top of scum to top of outlet ice or baffle: Distance from bottom of stunt to bottom of outlet tee or batlle: -- Ilosv were dimensions dc(ennincd: Comments(on pumping recommendations,inlet and outlet ice or bathe condition,structural tnlcrrtty, liquid levels as related to outlet invert,evidence of leakage,etc.): P � f c FlC T C);- a.�. I{� ��✓✓� 6.f` �'✓f!i Jy1+'s/f" 't- Ertl aj*4,f C O✓"..$ ,t,lL e �r UREASE TPAII:_lo at on site plan) Depth below grade: Material of construction:,concrete_metal_fiberglass---}rolycolylene`other (explain): Dimensions: Scum Ihickncss: Distance Gorr top of scum to top of outlet ice or baffle: Distance front bottom of scum to bottom ofoutiet tee or baffle: Date of last pumping: Conunenls(on pumping recommendations,utlet and outlet tee or baffle eunditio;t,structural integrity,liquid levels as related to outlet inycn,et•idencc of leakage,ctc.): 8ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SENYAGE DISPOSAL SYSTEM INSPECTION I-ORM PART C SYSTEM INFORKIATION(con(inued) arty AddressM05 La -D6 ter. J i t} Cc,s of Inspection: 2 Ir, d—,Q S 41T or HOLDING TANK:Atplr must be pumped at time of inspection)(locate on site plan) th below grade: trial of construction:_concrete metal fiberglass_yulyc►hylene o►her(explain): tensions: acity: gallons ign Flow: gallons/day nu present(yes or no): rm level: Alarm in working order(yes or no): c of last pumping: _ > Tuncats(condition of alanu and float switches,ctc.): - I STIUBUTION BOX: (if present must be opcncd)(locate on site plan) pth of liquid level above outlet invert: !� nunents(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of kagc into gr out of box,ctc.): w-4lc �,C��.,I JAIP CIIA11IBER: .AJ/(I'ocatc on site plan) nips in working order(yes or no): arms in working order(yes or no):— ►nunents(note condition of pump chamber,condition of pumps and appurtenances,ctc.): Page 9 off1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Properly l V%1l� Owner: 5_i Y-v\ �46XL)k_06- Date of Inspection: 7 41bL C,S �• 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: ,leaching trenches,number,length: � leaching fields,number,dimensions: I v K 1 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.): AC.-;- CESSPOOLS: jcess ooI must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer. Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: /V(10 t�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 Page 10 of 17 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:L+05��Si (7i N v it 2_ Owner:<i`\, S Date of Inspection: S SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or beachmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. c c - 1 r " r✓ � r �Q , .- J y x d 2.� ►�r, J )3 , �? r Q'- 3 y'' 10 gage 1 I of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:40 cr7 - {e_ I JCS+ Owner. `,S'L M ° S - Date.of Inspection: g SITE EXAM, Slope •/ Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-if checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS_) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe ho�wr^you established the high ground waterelevation: — �1Pdati. Oe t7t f 1 S ccA. I�l,s iY1eC . O�SI?i.£ G riCa► 11 - COMMONWEALTH OF MASSACHUSETTS e ExECUT1VE OFFICE OF ENVIRONMENTAL AFFAIRS . DEPARTMENT OF ENVIRONMENTAL PROTECTION- .- 4; @1 e 11 Z005 TOWN'OF BARNSTABLE HEALTH DEPT. ' TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Z3� Property Address: 405 Lakeside Drive WEst O�- Centerville Owner's Name: Jim Karukas Owner's Address: Date of inspection: Name of Inspector:(please print) Wi 1 1 i am _ •Robi nson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville, MA Telephone Number: (508) 775-8776 CERTIFICATION STATEMENT I certify that 1 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 Sec on 15340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails v Inspector's Signature: Date: �J 1 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 approrcing authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page i Page 2 of l 1 # u e OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 405 Lakeside Drive West Centerville Owner: Jim Karukas Date of Inspection: Inspection mmary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sy em 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 Passe One or more system comp nents as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon compit tion 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 an, over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infi lion or exfiltration or tank failure is imminent.System will pass inspection if the - existing tank is replaced with a c mplying septic tank as approved by the Board of Health. •A metal septic tank will pass i pection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less th n 20 years old is available. ND explain: Observation of sewag backup or break out or high static water level in the distribution box due tabroken or _ obstructed pipes)or due to roken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Heal broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system requ' d pumping more than 4 times a year due to broken or obswKlcd pgre(s).The system will pass inspection if(with a proval of the Board of Health): i broken pipe(s)are replaced obstruction is removed ND explain: lain: Page 3 of 11 A OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 405 Lakeside Drive West Centerville Owner: Jim Karukas Date of Inspection: . --CS C. F her Evaluation is Required by the Board of.Health: C ditions exist which require further evaluation by the Board of Health in order to determine if the system is failing t protect public health,safety or the environment. L Sys( m will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the syste is not functioning in a manner which will protect public health,safety,and the environment: — C sspool or privy is within 50 feet of a surface water — C sspool or privy is within 50 feet of a bordering vegetated.wetland or a salt marsh 2. System ill fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is fui ictioning in a manner that protects the public health,safety and environment'. _ Th system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface ater supply or tributary to a surface water supply. _ Th system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. _ T system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. e system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more front a privat water supply well** Method used to determine distance '•T s system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bact ria and volatile organic compounds indicates that the well is free from pollution from that facility and the resence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other fa' ure criteria are triggered.A copy of the analysis must be attached to this form. Other: 3 r - L Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 405 Lakeside Dr West Centerville Owner: Jim Karukas Date of Inspection: .-S-1 9 °- D. System Failure Criteria applicable to all systems: You mu indicate"yes"or"no"to each of the following for all inspections: Yes No ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or logged SAS or cesspool _ tatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or sspool L quid depth in cesspool is less than 6"below invert or available volume is less th in'h day flow R quired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number o times pumped y portion of the SAS,cesspool or privy is below high ground water elevation. y portion of cesspool or privy is within 100-feet of a surface water supply or tributary to a surface w ter supply. y portion of a cesspool or.privy is within a Zone 1 of a.public well. _ y portion of a cesspool or privy is within 50 feet of a private water supply well. y portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water s pply well with no acceptable water quality analysis. (This system passes if tare well water analysis, p rformed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds i dicates that the well is free.from pollution from that facility and the presence of ammonia itrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria re triggered.A copy of the analysis must be attached to this form.) (Ye /No)The system fails. 1 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. Lar Systems:To be co sidered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd- You m st indicate either"yes"or"no"to each of the following: (Tlte f lowing criteria apply to large systems in addition to the criteria above) Yes o 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 We Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you h ve 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 faded.The vwtter or operates of any large system considered a significa t threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. he system owner should contact the appropriate regional office of the Department. 4 Page S of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 405 Lakeside Dr West Cen ervi e Owner: Jim Karukas Date of Inspection: V Check if the following have been done.You must indicate`yes"or no as to each of the following: Yes No P mping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks? as 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? V _ 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 CIAR 15.302(3)(b)) 5 Page 6 of 11 w . OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 405 Lakeside Dr West Centerville Owner: Jim Karukas Date of Inspection: A—l 1^65 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):, _ Number of bedrooms(actual): DESIGN flow based on 310 CMR I .203(for example: 110 gpd x li of bedrooms):G Number of current residents: ` Does residence have a garbage der(yes or no):-4- Is laundry on a separate sewage system(yes or no):/10[if yes separate inspection required] Laundry system inspected(yes or no): U L Seasonal use:(yes or no): ;9/0 Water meter readings,if avail ble(last 2 years usage(gpd)): 2004 — 87 , 000 Sump pump(yes or no): ✓ y — 8b, 000 Last date of occupancy: =(51 C'O ER NDUSTRIAL Type of establi ent: Design flow( ed on 310 CMR 15.203): gpd Basis of desi flow(seats/persons/sgft,etc.): Grease trap p esent(yes or no):_ Industrial w to holding tank present(yes or no):_ Non-sani waste discharged to the Title 5 system(yes or no):_ Water mete readings,if available: Last date o occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part f the inspection(yes or no): If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: _ TYP 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) _Tigbt tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all o nts, ate installed(if known)and source of information: PP com g l � 9�� Were sewage odors detected when arriving at the site(yes or no): 6 I Page 7 of I I OFFICIAL INSPECTION FOI01—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORI11 PART C SYSTEM INFORII'IATION(continued) Property Address: 405 Lakeside Dr West Centerville Owner: Jim Karukas Date of Inspection: T G 5 BUILDING SEWE (locate on site plan) Dcpat below grad Materials of con ruction:_cast iron _40 PVC_cater(explaut): Distance Gont rivate water supply well or suction line: Comments(on condition ofjuutts,venting,evidence of leakage,etc.): SEPTIC TANK: 1/(locate . oil site plan) Depth below grade: Material of eonstruc4 _concrete metal fiberglass_polyethylene _othcr(explain) If tank is metal list age:_ Is age conftrnned•by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 3r g Sludge depth: o Distance Goin lop of sludge to bufto—of outlet Ice or baffle:_�'] Scum thickness: -1 ' Distance from top of scum to lop of outlet tee or baffle: Distance frorn bottom of scum to bottom of outlet ice or baffle: _ Ilow were dimcnsions determined: © ?/ 6A i, �t_S Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): IQ CREASE TRAP: cane on site plan) - Dcpan below grade: Material of construe on:_concrete metal fiberglass__Itolyeatylene_other (explain): _ Dimensions: Scum thickness: Distance from i p of scum to top of outlet Ice or baffle: Distance Gom ollom of scum to bottom of outlet tee or baffle: Date of last p mping: Conunents( n pumping recontnnendations, inlet and outlet ice or baffle condilio:t,structural integrity, liquid levels as related t outlet invert,evidence of leakage,etc.): c 7 r L 'age 8 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F01 1 PART C SYSTEM INFORMATION(continued) Properly Address: 405 Lakeside Dr West Centerville Owner:_Tim K;;rlikas Date of Inspection: j d 5--0 TIGHT or HOLDING T K: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of eonstructio : concrete_metal_fiberglass_polyethylene other(explaut): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(ye or no): Alarm level: Alann in working order(ycs or no):_ Date of last purr ing: Comments(condition of alann and float switches,etc.): DISTIUBUTION D l/orpicscnimustbeOa.— opcncd)(locate on site plan) Depth of liquid level above outlet invert: Conunents(note if box is level and distribution to owlets equal,any evidence of solids carryover,any evidence of - leakage into or out of box,etc.): t PUMP CH4nof tale on site plan) Pumps in wr no):— Alarnts in or no):—Comments ump chamber,condition of pumps and appurtenances,etc.): • Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:405 Lakeside Dr West Centerville Owner: Jim Karukas Date of Inspection: 3-1 f —6 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation'not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: le ing galleries,number: aching trenches,number,length: leaching fields,number,dimensions: iJ'-36 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.): J ' CESSPOO/lar: sspool must be pumped as part of inspection)(locate on site plan) Number an lion: _ Depth—top to inlet invert: Depth of sor.Depth of scr:Dimensionspool:Materials oction: Indication odwater inflow(yes or no): Comments ndition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): _ PRIVY: (lo ate on site plan) Materials of co struction: Dimensions: Depth of sol' s: Comments note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of I l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 405 Lakeside Dr West Centerville Owner: Jim Karukas Date of Inspection: --E T—P6 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. J - 0 1 �J 10 l Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 405 Lakeside Dr West Centerville Owner. Jim Karukas Date of Inspection: 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: 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: ® S - l 11 Town of Barnstable aAtwErtest.� t Department of Health, Safety, and Environmental Services Mom t639.. Public Health Division � 367 Main Street, Hyannis MA 02601 Office: 508-790-6265 Thomas A.McKean FAX: 508-775-3344 Director of Public Health September 25, 1995 Leo Berg 405 Lakeside Drive West Centerville, MA 02632 ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned by you located at 405 Lakeside Drive West, Centerville was inspected on August 31, 1995 by Robert Bortolotti a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Static liquid level in the distribution box above outlet invert You are directed to hire a licensed Town of Barnstable septic system installer to submit a sketch diagram of a proposed system to the Town of Barnstable Health Division Office (Town Hall, 367 Main Street, Hyannis) that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code, Title 5 within (14) fourteen days of receipt of this notice. You are also directed to bring the septic system into compliance within thirty (30) days of receipt of this order letter. You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings, onto the surface of the ground, or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH A. McKean, R.S., C.H.O. Agent of the Board of Health [Installer letter] Sl TO: —3�Q �� R (Date)5 1 6 3 2- ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. 7���1 � The septic system owned by you located atd � 1'�-� l�Q 2��'. inspected on F5"by 79ch a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 5310 CMR 15.00)due to the following: _ You are directed to hire a licensed Town of Barnstable septic system installer to submit a sketch diagram of a proposed system to the Town of Barnstable Health Division Office (Town Hall, 367 main Street, Hyannis) that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code, Title 5 within (14) fourteen days of receipt of this notice. You are also directed to bring the septic system into compliance within thirty (30) days of receipt of this order letter. You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings, onto the surface of the ground, or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH a Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health Town of Barnstable BORTOLOTTI CONSTRUCTION, INC. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address Prop Data of Inspec Map arcel Owner z32 Zae sF PART A — CHECKLIST . ,� 1to CHECK IF THE FOLLOWING HAVE BEEN DONE: PUMPING INFORMATION.WAS REQUESTED OF THE OWNER,OCCUPANT,AND BOARD OF HEALTH. c NONE OF THE SYSTEM COMPONENTS HAVE BEEN PUMPED FOR AT LEAST TWO WEEKS AND THE$YSTE RECEIVING NORMAL FLOW RATES DURING THAT PERIOD. LARGE COLUMES OF WATER HAVE NOT BEEN I O 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. HE FACILITY OR DWELLING WAS INSPECTED FOR SIGNS OF SEWAGE BACK-UP. ---THE SITE WAS INSPECTED FOR SIGNS OF BREAKOUT. ✓ALL SYSTEM COMPONENTS,EXCLUDING THE SAS,HAVE BEEN LOCATED ON THE SITE. E 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. C___THE SIB AND LOCATION OF THE SAS ON THE SITE HAS BEEN DETERMINED BASED ON EXISTING INFORMATION OR APPROXIMATED BY NON-INTRUSIVE METHODS. HE FACILrrYOWNER(AND OCCUPANTS,IF DIFFERENT FROM OWNER)WERE PROVIDED WITH INFORMATION ON THE PROPER MAINTENANCE OF SSDS. PART B — SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL _ No of Bedrooms No of Current Residents Garbage Grinder Laundry Connected to System 49S Seasonal Use�,� NON RESIDENTIAL• Calculated flow .WATER METER READINGS,IF AVAILABLE: GALLONS I ng:R®cgrds and Source,of Information: ' r SYSTEM,PUMPED AS PART OF INSPECTION? A14 IF YES,VOLUME PUMPED = GALS Reason for,Pumping: TYPE OF SYS Septic,'tank /distribution box/soil absorption system Single Cesspool- Overflow Cesspool Privy Shared systemx(ffyes,attach previous inspection records, if any) Other(e�cplain) Appro mate age of ail comporter�ts. Date installed,if known. Source of Information. a. `. SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE? SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM c PART B — SYSTEM INFORMATION (Continued) SEPTIC, Depth below grade: �> Dimensions: Material of construction: Concrete Metal FRP Other} Sludge Depth Distance from top of sludge to bottom of outlet tee or baffle Scum Thickness !/ Distance from Top of Scum to top of outlet tee or baffle 'O,'?7 e Distance from bottom of Scum to bottom of outlet tee or baffle Comments: DI TRIBUTI N BOX: DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT Comments: t ` PUMP HAMBER• -Pumps in working order? Comments: ` SOIL ABSORPTI N° YYTEM SAS IF NOT PRESENT,EXPLAIN: TYPE: 4 Comments: CESSPOOLS: Number and configuration Depth=top of:liquid=to'inlet Invert"` Depth of solids layer Depth of scum layer Dimension of.cesspool"' Materials of construction Indication of groundwater.inflow(cesspool must be pumped) ti:r Comments: PRIVY: Materials of,construction . Dimensionst Depth of solids Comments: W SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SMTEM INFORMATION (Continued) SKETCH OF`$EWAGE'DISPOSAL SYSTEM: INCLUDE TIES+TOFAT LEAST;TWO PERMANENT REFERENCES,LANDMARKS OR BENCHMARKS. LOCATE ALL WELIA,jrTHIN 100' e ' 0x)T- of ° �, II "N OEPTHjrTOO� ' DEPTH TO GROUNDWATER METH04,QFp �yATlt OR`ARPROAMATION. s "r s �v`�Ls�a j4 �;.�.z��ry?���dG✓ I''` �� �o �il��4�! �/'�G�® ,Y '3;'� i } Ilk 4 i.}..�' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C — FAILURE CRITERIA (Indicate Y-yes N-no ND—not determined.Describe basis of determination.If`not determined',explain why not) /Y Backup of Sewage into Facility? Discharge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the districution box above outlet invert? Liquid depth in cesspool, 6"below invert or available volume, 1/2 day flow? Required pumping 4 times or more in the last year? Number of times pumped Septic tank`is metal?cracked?structurally unsound?substantial infiltration?substantial exfiftration? tank fatlune imminent? Is any.,,portion of the SAS,cesspool or privy, below the high groundwater elevation? Wdhln 50 feet of a surface water? Within 100 feet of a surface water supply or tributary to a surface water supply? Within a Zone I of a public well? Al Within 50 feet of a private water supply well? Within 501eet of a bordering vegetated wetland or salt marsh (cesspools&privies only, not the SAS)? 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,amonia nitrogen and nitrate nitrogen. PART D — CERTIFICATION INSPECTOR: ROBERT J.BORTOLOTTI ADDRESS: 765 WAKEBY ROAD,MARSTONS MILLS COMPANY: BORTOLOTTI CONSTRUCTION INC. MA 02648 (508) 771-9399 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 RECOMMENDATION 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: I HAVE NOT FOUND ANY INFORMATION WHICH INDICATES THAT THE SYSTEM FAILS TO ADEQUATELY PROTECT PUBLIC HEALTH OR THE ENVIRONMENT AS DEFINED IN 310 CMF 15.303. ANY FAILURE CRITERIA NOT EVALUATED ARE AS r/- STATED IN THE'FAILURE CRITERIA"SECTION OF THIS FORM. —,I-HAVE-DETERMINED THAT THE SYSTEM FAILS TO PROTECT PUBLIC HEALTH AND THE ENVIRONMENT AS DEFINED IN 310 CMR 15.303. THE BASIS FOR THIS DETERMINATION IS PROVIDED IN THE"FAILURE CRITERIA'SECTION OF THIS FORM. INSPECTOR'S SIGNATURE: LUDATE: �_ ClGINAL.T0.SYSTEM OWNER,COPIES:BUYER('rf applicable),APPROVING AUTHORITY t 'f,.a`'�y`4v� 9����A.'.'" 1 y.�. tr 1a�.'r.•�, %y i n £ u rf s i��`+Kr���a.aY'+�o�'�#s t.:i .r. k.>'.`.'�i.�rY�j�ti.tk sa.,r": 3 ';;?�i s• 1t t v'.-M.�. � i��t�.t�xas��X."1A'�1�:„.�.^,a,.29•F�/�s�(�r,M ki1,��4�,'�4'.,",uY.'�+3��°'S.dr��4k,fi�a�.�."��tE"F�1 Ar�4t#7P 5 �3 7 x!"{RG^`''ia?Y:�:.'' �.`�$4��,,G.'.�,.11a.�.��.'''' �?�RN�,� 1 ''t.? >;£,Fi�!kC..�:YY�F ra. `l� ^/+q�4y�i ati�,1��q.'ik`wr,+:�tt 9°�'+�{6°awxte`�s�- .g1�.tF♦+.Y 9��u '"F-`t' % 0 5r ;� ...,..,b,,r $. ,x ,�;. $ y t. �,Y w ray Po ✓t d h"3 '`< ��.: ,,f. f .a 7 Y' ...a*i ri$4"�! "y�':^-. 4 rL 7� '4 u.�4 �r.Eht"rr.-G :•fr t #i 1' i' ;t,.- `- ._:ri" a x r o ,n �I 1. Town of Barnstable Department of Health, Safety, and Environmental Services • BA6N$TABM &61 Public Health Division Gg9. � 367 Main Street, Hyannis MA 02601 Office: 508-790-6265 Thomas A.McKean FAX: 508-775-3344 Director of Public Health September 25, 1995 Leo Berg 405 Lakeside Drive West + Centerville, MA 02632 ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned by you located at 405 Lakeside Drive West, Centerville was inspected on August 31, 1995 by Robert Bortolotti a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Static liquid level in the distribution bog above outlet invert You are directed to hire a licensed Town of Barnstable septic system installer to submit a sketch diagram of a proposed system to the Town of Barnstable Health Division Office (Town Hall, 367 Main Street, Hyannis) that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code, Title 5 within (14) fourteen days of receipt of this notice. You are also directed to bring the septic system into compliance within thirty (30) days of receipt of this order letter. You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings, onto the surface of the ground, or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH A. McKean, R.S., C.H.O. / Agent of the Board of Health -Selo �- 3 0—%5' • �(��s� 6� ►L41�o� �� t�e G5 Uc �,,U co kt,* eCP e." I � c co N�i`F g� TOWN OF BARNSTABLE LOCATION ^^�nnO� �'l�/ S`Gz� Q� �(/EV SEWAGE# VILLAGE c �! '�'�//�l 1414 ASSESSOR'S MAP&LOT z3Z��u INSTALLER'S NAME&PHONE NO. 'ee'rta41 eA C//1f6V,_ SEPTIC TANK CAPACITY 4600 &e. LEACHING FACILITY: (type) Fl, c4— —(size) /s X 36 ` 1 NO.OF BEDROOMS 3 BUILDER OR OWNER era PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well 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 lot IN /9)-33 �oh� Qi-; y' 03-)9 i L)e ' I r � i No.Jsi Fee 30 - THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppfication for �Digooal *p5tem Construction Permit Application is hereby made for a Permit to Construct( )or Repair(Pan On-site Sewage Disposal System at: LocatioUdre r Lot N Owner's e, and Tel.af v ( L_1_ N _ Insta Name,Address d Tel.No. Designer's Name,Address and Tel.No. "A f7 ri B G/Z—�i—0 Type of Building: Dwelling No.of Bedrooms Garbage Grinder AJ'V 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 Description of Soil Nature of Repairs or Alterations(Answer when applicable) 1 A Date last inspected: Agreement: The undersigned agrees to ensure the construction ' of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code a�o not to place the system in operation until a Certifi- cate of Compliance has been issued by this Boar f H falth. Signed Date 9 �� Application Approved by Application Disapproved for the following reasons Permit No. � - /2 a 6 Date Issued 07i 4 i THE COMMONWEALTH OF MASSACHUSETTS r �• . PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZIPPlicatcou for Migogal *pgtem Cougtruction Permit Application is Hereby made for a Permit to Construct( )or Repair(P<an On-site Sewage Disposal System at: Location Address,or Lot No. / Owner's Name,Address and Tel.N y� p 2_. ME'D F/lg.4 QAa,f L Ill 1. Instal Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 0/t7VL07T_7 +�1.TT/T�/c.T 11 u�J U Ulm ,, C-t wJ J J'. Type of Building: Dwelling No.of Bedrooms Garbage Grinder Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures -Design Flow 3 �' gallons per day. Calculated daily flow "Z64 y gallons. Plan Date Number of sheets Revision Date Title Description of Soil i Nature of Repairs or Alterations(Answer when applicable) 5 riOw /9 Date last inspected: Agreement: The undersigned agrees to ensure the construction l of the afore described on-site sewage disposal system in accordance with the provisions of Title 5'of the Environmental Code a not to place the system in operation until a Certifi- cate of Compliance has been issued by this Boar/�f H lth. Signed >// �•.�,,K.---- Date Application Approved by ( t Application Disapproved for the following masons Permit No. ` % �' (0 Date Issued 737 o THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of Compliance 0 - THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced( 64/on by OOP t..01 r/U.!�!1 QN ^J for d L /9 v E a v& ay C. has been constructe in ac rdance with the provisions of Title 5 and the for Disposal System Construction Permit No. 9 "/ )P-h dated / Use of this system is conditioned on compliance with the provisions set forth below: ya_. �.��.-rr-_ __.— _vi'�.��.�a���a.�:its.�I4.o:�►i.ILi'MLf.'i:Ti`:C+-'C7C.�.r——.� m�.�1.ra...-r No. 9 3-. �,�-� Z Z -z?Z Z Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migpogal *pgtem Congtructfou Permit Permission is hereby granted to D 2-x—U t-U_'77 L4,k) 1-4- /mow `ul°J to construct( )repair( plan On-site Sewage System located at 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. All construction must be completed within two years of the date below. 114 r Date: �� ,L �.Sf Approved by s pea s vile n Q �avm, a } ak l i t , tg"- F:x. j ,5't ... x4' me= s: - s-cF •r ':i•v x4 Yfi£ ' a s`'-5� y p e r is oW ,^f tip.., y. i x rn ;.y~k";k-`Sy, ?"-ra U 3f a} �' „x e2j r� " �k4�.kf- r1 p'- :< :.�:rs:,. ,� J'{:+ :+,, x' ri',i• ft:. .Y ..M�^'•,-- ns�=��'>D��.,},>a,.i.>.'.-.r.,x�"p;`.�4,r:�f StY�}•a.k:,.�s',,g.t'+','¢""�,!,W�'<�..'.rdips`*-„,q�.n,"3?'�r.�.c t-'T..;,...x:C��ri.y'..r..P+.. 4--.-�..Y^'.+r.,1,Y'�,.r..'.,skau a�.:p.u,+.N'"o-�.�r�-'t�aS 't'�Y'ia�y1,fi:�'vy,a':,sti;�,.-Y�..dt�'.s"r. Al ix ,V, gY � �y vA !Y '�-.^i._rs:'wk=/,;t•§a,p`S-F..i,t�rit<.*-?:;x n i nF.-.�ecr:,::,'i v,4.,',,",'*'g�`3 d.y..,.:#.aJ xpt dra'.ra•T;�t,:;�l'_,';,.`a ra e { `'t rti1y`ltk� '•„Yfr,''j(.5,s"�7,•s''"v,p E.�'�*;>.s ��,�n•Y.; .rr•i as.4:'? ..i�:r< ` �• " s +'-1 '�'n ,r.- n... *''S:=.iNS' ..>•,.r. , .--.: *r 5, +la+'�'isi. ,5u} p �+'e } M �,.. - t x} ;'ww- vt.-� i�- •F'iC $..•�` 1 �t`'^c:�r c k "�1._.- �.w�+7,c�n`� va�'K,,�.aF;'d n.::-T.�4 1J k� �.t a�'..,`. - J . .,.*2 .. # -p, -.... y�. -_r �...,.,. a :-.� ! f '`w:t-r.�s, sF` ry�Te rp i :.S s*.4`a. :,;5 `'K.�'N��,,�'° v .*�3r..�; ��a ,�., t �. �h ,� - F a�a,A��x� �>,� � *�'." T'f G�`A'S�6&Cr �'"',e,X"k' ->•fR ;€,� '� t r"� ,ac,. � f•4i f �..'� '�* f �' a 7 s ''° �" w �" ,.wx".,„�..• .ey,x`p,¢:ra - }-.r S3'� '' '' *Y'.?f .;;4 ,�''=p 1,�'a;A -Yw -fi-*d 'z`.HAM Y i`,ay'z rz ? i'F° "•'r -,�R,w vk $+ 8 �r . ,+c �ti sY M<, ."-e-.r�.`t•.t ....:4Yy,,. ". Y"4 m.�l 'SG. :F." t y:" $ t,.Z _ '�C°i.,y -sL q :-`i .,, ?+3r�' F;.��i"kS?F `''•''-.,�,"�;tz•` 'r'`Y s'�..,a t ai:s�' S�F *°a, x ; f.� w.•. w � �: }" �r," ',�s- "3��_..i''�„l x .tea.'#Fh��,,���o �"�''4+:'..c� .� -+S F -,a •,.*` 't i �'� " ±= �' +� � 5� ".•- apt "tv z t '-�' �, s if x a'{., �s- Y• ! }ir, "' ?+ � ^4 wp';rf t j r� a R„t r'a r fiG`r f "''c > ;. yr=::±°fa;`"'�rk "q,r '��,.:J�w�Nt"`�s,•�+�� �1 p �� "+� �rS{'sx d�'`�a�,yiv� ,t` �'r Y�,+r? r;= �" � v,.,, »'r r#i+, � ��* *� •y 6•,.,, 5 t „'�*-fit�'�'�#�;,y���t���F....;sPmS3 �$.�k�,,,��'�'���'�b�j���'�a b ,`n'a.5T'n..y t4a �:i ",,;f.+' n 1 �:.� �'t 1.��k j �.•v� ,' s-: t� 2;qt}:•. �r jr r �xCERT ON OF SKETCH AND APPLICATION FOR A DISPOSAL * WORIS'�CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANSI ;e X nIv T`q 7' r F ,,,�+ �."�} •,�''Sw3F le��,{.Gs+Y"e F4 ,s,4$'� R '" ,r< °4Gn,R^ apt t� -� y 'su'xz.� 10, A,p �:a..�� J l":.. k I'C RS*.syii' - F ::fP 1 k :Y k t• ¢. „c 'C r I: Y .+' :•:? fi �t d > -:a.a: • � Y i, sr'� y} -€ hereby certify that the appltcatton for dts o S "'A�W' S'�i< W'L. r t � p sal works K•4 r'`' 41 �'�d PAY.-g4.-�, t e ra t ::'; y�^ i 4 -.c {.r-f 4Y"'-*`rr z,. 'r" R r- Y•�'h'k Sjfy.+7'.Y e. i... ;,�; Y b ;;. ,: �. k construction permit signed by me dated / '` r r r���� �� �, conce"Hung the »A'k%t. K „f �a }property located at3 } ro} s 5 > , r iZt f meets all of the F 'following criteria L,t • There are no wetlands within 300 feet of the proposed septic system There are no private wells within 150 feet of the proposed septic system The observed groundwater table is 14 feet or greater below the bottom of the leaching facility `�• There is no in in flow and/or change in use proposed �There.are no variances requested or needed. SIGNED DATE: l y LICENSED SEPTIC SYS INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed in staller posesses a certified plot plan, `this plan should be submitted]. r k �{ a 4x, -'�"'' hg' X r« ✓ .J& 48a�3c+.` :: `` 9u},?x w, aa:? «.,ig•-' �r{y? }' t ysv t7a ,, c. 'h y. i.. x 6 .R ter.*y �"` a;3 .at<- t E_ r. ter :.1�,:u' {rF` n ,'i<,3 .� •g,v �. ,�"a' rrk ui,:, >'S•�� 4 'rd..`,� � ,:�:wu. -, ,+`� `t rB. 2 �,s ` .^ �' a aL• . .57M, M.;� ?e"•: x'+drp__r�.r$t`-a. w✓• �•,..,�.{„?.,;ys� ., ,} �''k't'�f v, r=..? a y x r; 44.E 5 `#`;k.;,.:u,: s,�'r' & 4 .� ,; .•. ta,p,.-....r ',;..z .Ad 5...°',j. -� _s ,,, a ,rt .•,Y::,sy s-...',. ;t s �.': e N, y �-,�. vY".. ^3�,="j'. r.,�.� �,-. .yrg,�� •.'` ^.z,s,���, � �.a ��,�''4 r�' ::n�; �i�S*!-x`., dam', �•s e�.e�.'�t�h_...:y; 4.Sft;k.;i:��d-��` �.�y.'`fi�.. �.'�•`?;"�...' � .«�.. xl '�` ''.- s' .T __.r;: '4t j '-, t• ..J>:.,�A u'at^ vr's�t .a.5r,7.;: d` y� '�.e. L r if',ti,r� 7A,-, rk ',st - " it^ Xp ? ;. {f``aka'•' h. }^;y. :.9' g `7 k" v� ' • ,�k .n . n�. .. ar is F •� - sx` '. r x , �tf � y.r :...ni ��y 5F .,-a'.r. -ek .,,>;.':�T.r.,. ��., •�wkr �� �' 'x.r M k ::t:r� ON TOWN OF BARNSTABL.E r, LOCATION /� ?P� SEWAGE# ASSES R'S MAP '&/LOT C��2 i F—'�S NAME&PHONE NOZ#-)r471d�QVW 66ns l SEPTIC TANK CAPACITY GYsJI r2 V4Qo 7,G —J/L5-/,26Y LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR'OWNER�' PERMITDATE: COMPLIANCE DATE: 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 facili / Feet �Furnished by c D�9 i' (6rif'1/Y.r C�4iOO —ZA/C. 6'(3 I � ' l ' `A, ,,`.,e._.....—•- C.v �.�e�� S P 1-,-� Ltv�. � -two g-�o�Y ��G�� �,,.� �-� �c1�.ems, �e r, 15 1 9 � c�,.�,. LI I Public health Division Town of Barnstable �5 PO Box 534 4edV--rCr Hyannis,Massachusetts 02601 f Fax(508)775-3344 AA , 2 �•. "d v,�p Phone(508)790-6265 SvbSpwi¢+ f f � �