HomeMy WebLinkAbout0049 LARCH LANE - Health f 49,LrarchLane,-,
Centerville.
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i
Commonwealth .& Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form .-Not for Voluntary Assessments
.� 49 Larch In.
1M
_5 Property Address
Mary McGaughy
Owner Owner's Name
information is required for every Centerville Ma 02632 3-9-13
page. City/Town State Zip Code. Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness.checklist at the end of the form.
Important:When filling out forms A. General Information
.
on the computer,
use only the tab _.
1. Inspector:
key to move your
-
cursor-do not Matthew Gilfoy
use the return key. Name of Inspector
B & B Excavation,Inc.
Company Name
14 Teaberry Lane
Company Address
Forestdale MA: _02644
City/Town State Zip Code
508-477-0653 S113640
Telephone Number License.Number
B. Certification
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 15000). The system:
® Passes. ❑ Conditionally Passes ❑ Fails
Needs Further Evaluation,by the Local Approving Authority
}
Inspecy,
s Signature Date tir
The s stem inspector shall submit a co of this inspection report-to the A -n
Y p copy ppit:"ving Aut&ity(Gard
of Health or:DEP)within 30 days of completing this inspection. If the system ls�a shared Vstet.&
has a design-flow of 10,000 gpd or greater, the inspector and the system owner shall submit thq
report to the appropriate regional office of the DEP. The original should be sent to the syVem 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. -
2A)l I
t5ins•11/10 p Title 5 Official Inspection F&ibsurfaceSewage Disposal System•Page 1 of 17
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
49 Larch In.
Property Address
Mary McGaughy
Owner Owner's Name
information is required for every Centerville Ma 02632 3-9-13
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:
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
49 Larch In.
Property Address
Mary McGaughy
Owner Owner's Name
information is required for every Centerville Ma 02632 3-9-13
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 49 Larch In.
Property Address
Mary McGaughy
Owner Owner's Name
information is required for every Centerville Ma 02632 3-9-13
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) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No" to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Yz day flow
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 49 Larch In.
Property Address
Mary McGaughy
Owner Owner's Name
information is required for every Centerville Ma 02632 3-9-13
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.
t5ins•11/10 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
°M 49 Larch In.
Property Address
Mary McGaughy
Owner Owner's Name
information is required for every. Centerville Ma 02632 3-9-13
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 -
El ® 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
IN El
available note as N/A
® _ ❑
Was the facility or dwelling inspected for.signs of sewage back up?
1Z El 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): . 330
t5ins•11/10 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
49 Larch In.
Property Address
Mary McGaughy
Owner Owner's Name
information is required for every Centerville Ma 02632 3-9-13
page. CitylTown 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? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
2011-145.21 gpd 2012-161.64 gpd
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 49 Larch In.
Property Address
Mary McGaughy
Owner Owner's Name
information is required for every Centerville Ma 02632 3-9-13
page. City/Town 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:
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•11/10 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
;M 49 Larch In.
Property Address
Mary McGaughy
Owner Owner's Name
information is required for every Centerville Ma 02632 3-9-13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
2006
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
2'6"
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: >20
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
At time of inspection building sewer appeared to be in working order no sign of leakage or blockage.
Septic Tank(locate on site plan):
Depth below grade:. 1
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 gal
Sludge depth:
3"
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
4 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
49 Larch In.
Property Address
Mary McGaughy
Owner Owner's Name
information is required for every Centerville Ma 02632 3-9-13
page. City/Town 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
36"
Scum thickness 6
Distance from top of scum to top of outlet tee or baffle
3"
Distance from bottom of scum to bottom of outlet tee or baffle 911
How were dimensions determined? scour stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
At time of inspection septic tank appears to be structurally sound. No sign of back-up.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
49 Larch In.
Property Address
Mary McGaughy
Owner Owner's Name
information is required for every Centerville Ma 02632 3-9-13
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:
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
l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
N W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
49 Larch In.
Property Address
Mary McGaughy
Owner Owner's Name
information is required for every Centerville Ma 02632 3-9-13
page. Cityrrown 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
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.):
At time of inspection d-box appears to be in good condition.
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.):
11
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11/10 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
�M 49 Larch In.
Property Address
Mary McGaughy
Owner Owner's Name
information is required for every Centerville Ma 02632 3-9-13
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number:
2
❑ 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.):
At time of inspection leaching was dry and appears to be in working condition. no sign of backup.
Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
GSM 49 Larch In.
Property Address
Mary McGaughy
Owner Owner's Name
information is required for every Centerville Ma 02632 3-9-13
page. City/Town 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:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
49 Larch In.
M
Property Address
Mary McGaughy
Owner Owner's Name
information is required for every Centerville Ma 02632 3-9-13
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
6
A
O
O
AI- i3°� '
A2' 11'q"
^3- s1 fo
A11{- 51° 0
A S- 63 c%"
IL.
dy- 42: S'
(3 S
- ►12 3
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
49 Larch In.
Property Address
Mary McGaughy
Owner Owner's Name
information is required for every Centerville Ma 02632 3-9-13
page. City/Town 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: >10'
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:
taken from COC dated 2/9/06
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Listed above.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 49 Larch In.
Property Address
Mary McGaughy
Owner Owner's Name
information is required for every Centerville Ma 02632 3-9-13
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® 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
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
TOWN OF BARNSTABLE
LOCATION �`� -(Q/Ch �n SEWAGE # 0
VILLAGE
"" "` " ASSESSOR'S MAP & LOT
_
INSTALLER'S NAME&PHONE NO.�f eve&Q cn7 qia? qo; ,R
SEPTIC TANK CAPACITY o UU g``
LEACHING FACILITY: (type) �`ot�SC� (size) 13 X o1S
NO.OF BEDROOMS 3
BUELDER OR OWNER M /"C C 8,-Q U
PERMITDATE: •/9/k COMPLIANCE DA : 0-A
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility ADS- 10 Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) /V d Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) �Q Feet
Furnished by
3
P
i
y s7
a _ 31.9
y �
�A3
i
No. J Fee �U
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
es
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZIPPYication for ]3igpo5 f,P9;tern Conelruction Permit
Application for a Permit to Construct( , )Repair(,-<Up;ade( )Abandon( ) ❑Complete System 2<vidual Components
Location Address or Lot No. / �I c' / Owner's Name,Address and Tel.No./
Assessor'sMap/Parcel iQl _0Q� t..MOOv� A/t '�A�y
Installer's Name,Address,and Tel.No. 5-0 it (4 �5 'fV —A-6 Designer's Name_,Address and Tel.No.
c. ,;qx ��� 0 3 -386
Type of Building:
Dwelling No.of Bedrooms_� Lot Size , sq.ft. Garbage Grinder(.GP
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design.Flow ? gallons per day. Calculated daily flow 7 3 gallons.
Plan Date Z O 6 Number of sheets Revision Date
Title
Size of Septic Tank _EX low S 'r/ r• ?. Type of S.A.S. Z •Sbo,1a( �ti- ►4ti1
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) IA.tti l zd &mA e_/�-
Z-J-0 0,yw. C a..+.G L r1 �'� Jrylrw. t&o. 7,.r 'I- �/?*w X Z`15 leA e- t 21LP-e a 1,
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with.the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by s oard of Health.
Signed Date 2--9 Zo oi.
Application Approved by Date a`k`0 6
Application Disapproved for Me following reasons
Permit No. Date Issued
44
No. d �Ll b zl Fee (/()
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
2pplicatiou for ;h5poal Wreum Conn;truction permit
✓ Application for a Permit to Construct( , )Repair(grade( )Abandon( ) ❑Complete System 2'1itdividual Components
Location Address or Lot No. r��01 L L ! t4 Owner's Name,Address
and Tel./No.
/� ova oo
Assessor's Map/Parcel 7 L ` � f(T A^ 2 N e y
- - y
Installer's
y,Name,Address,and Tel.No. So c c) ZF.('-(,v S Designer's Name,Address and Tel.No.
/ C
Type of Building:
Dwelling No.of Bedrooms Lot Sizell,, lq� sq,ft. Garbage Grinder(_OU
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures 4
Design Flow :3 7 O gallons per day. Calculated daily flow ? T 3 gallons.
Plan Date - z /L /o b Number of sheets / Revision Date
Title
Size of Septic Tank X /D 00 S A/ T. T, Type of S.A.S. Z - So y a ( c�_5
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) ir emi/k t-f ;/vej 1 e c (, w; �✓
Z — S O y ga l C I- rA p , 1 '� L I74�s ,/ c Zf C X ?'G✓ X Z /-a c 4 tree-,G j(+
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with,the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this oard of Health.
Signed JCI Date 2 - 9 - 2 b d(o
Application Approved by .)„ �i�/_ 0< Date k- 0 6
Application Disapproved for the following reasons
Permit No. �2O()�� - q�„ Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired(v)Upgraded( )
Abandoned( )by
at oL-1 c.Pi L /p h ,., v,'//� has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.2641, -PA dated
Installer !! Designer g(e,. 2 • 5.
The issuance of this permit shall nd`t be construed as a guarantee that the s st mewill'funct o as designed.
Date ra`'�1.1 Inspectors-.-�_.
_V_
No. �2 00 6` U L/f Fee
THE COMMONWEALTH OF MASSACHUSETTS
r g� oo6-001 PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
=igpogaf *proem Con!9tructiou 3permit
Permission is hereby granted to Construct( )Repair(✓Upgrade( )Abandon( )
System located at `f 2 ./A l �T/r���//" /R-
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to '
comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of thi's,permit.
- 7
Date:_ 2` !�' Approved by ,l�,I C
C1
Town of Barnstable
Regulatory Services
Thomas F. Geiler,Director
• saxxsreei.e,
MASS. g' Public Health Division
03;9.
eel° Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer& Designer Certification Form
Date: 7./10 D6 Sewage Permit#c 3 4- 0 L�4 Assessor's Map\Parcel /0-04-007
Designer: i
g (ems,. _. �arrcw� ,,,�5 Installer: C IS ►-t �rf >es
Address: q L a&I, ApJC 414 Address: Gk 7 L 3
V400J toK1 1f41%13 4�6 0Uy y" � +eri�� o2 0)-
On 0&vQ_k&0 AQ,_i was issued a permit to install a
(date) (installer)
septic system at l.a.rr.(.L Lo, Comte rv,*1te based on a design drawn by
(address)
G (e�. F• ffa.rr i ng a,.�•S. dated -Z L41'I.
(designer)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow.
�A or
N �n
( staller's Signa ) Tco
. 1070
9F �o I
qA'/TAFt\V"'
esigner s nature) (Affix Designer's Stamp Here)
P -RETURN TQ�,;.;�ARNSTABLE PUBLIC HEALTH DIVISION CERTIFICATE OF
. E WILL.,,, BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE
, a efBY THE Ph SUABLE PUBLIC HEALTH DIVISION. THANK YOU
Q:Health/Septic/Designer Certification Form 3-26-04.doc
- x:a:,n F .�`'k_i'4 4 ,?S'" ,r•x -Lr#!•i— �'�'�y.{[r, .' '? 'a„-Yr` `. M -5,[�•e*
Notice: This Form Is To Be Used For the Repair Of Failed -`+h
Septic Systems Only
PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM
I, (Yffti �•{{p•���r•5 �'�T S,hereby certify that the engineered plan signed by me
dated Z'(�— ?veto ,concerning the property located at
°! L a.� LH , �CK f2✓'v+'/le meets all of the
following criteria:
• Two soil evaluations excavated for detailed examination(no hand augering)and two
percolation tests shall be conducted.
.• This failed system is connected to a residential dwelling only. There are no commercial or
business uses associated with the dwelling.
• The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes
per inch.
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
• The bottom of the proposed leaching facility will be located do less than five feet above the
maximum adjusted groundwater table elevation. [Adjust the groundwater table using the
Frimptor method when applicable]
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information) 3 o f
B) G.W. Elevation +adjustment for high G.W. _ Co4y
DIFFERENCE-BETWEEN A and B
SIGNED : DATE: Z ZrJo
NOTICE
Based upon the above information, a repair permit will be issued f .�.5 ooms
maximum. No additional bedrooms are authorized in the future wi ngineered septic system
plans.
gASeptic\percexemp.doc
ASSESSOR'S MAP N0. — `�\ PARCEL i �/
LOCATION SEWAGE PERMIT NO of
_ILLAGE
INSTA LLER'S NAME A ADDRESS
QR UILDER OR OWN ER
L
DATE PERMIT ISSUED.
DATE COMPLIANCE ISSUED �����
�r.'.reA`y�
f
q ✓ '6
THE COMMONWEALTH OF MASSACHUSETTS
G BOAR® OF HEALTH #
--------- ..P..v✓..V---OF......, 3 .% N .: - _z. ............
Appliratiuu for Uhipjauttl Works Tuuitrurtiurt rami
Application is hereby made for a Permit to Construct ( <or Repair ( ) an Individual Se e Disposal o
System at: VJ 5£ • I "t
.. -
Location-Address or Lot No.
..� - --- - -•-•------------- .............
Owner Address
W
Type of Building Installer.................... Address Size Lot__j_7j.. ._` _y._Sq. feet
,., Dwelling—No. of Bedrooms..............._ __..........__..__.Expansion Attic ��j- Garbage Grinder '
aType g 2 t s cl� p ( ) — Cafeteria {�Other—T e of Building L_________________�_. .. No. of ersons__...__..�___._.__..._.._ Showers
a Other fixtures ------------------------------------•--•-....---•
W Design Flow............................'-.5.K..!F---gallons per person,per day. Total daily flow........... Cp........_......._..gallons.
WSeptic Tank—Liquid capacity.�000.gallons Length_-_ '_._._ WidthA.-.!_"-.. Diameter_______-•___--_- Depth..' .-_...._..
x Disposal Trench—No..................... Width_._...D_.._......... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.........I.......... Diameter.....o.'¢------- Depth below inlet......3 _. Total leaching area... p.!Lsq. ft.
Z Other Distribution box ( 'Y*5" Dosing tank,(/)' _ II _
Percolation Test Results Per by. Y_........%_-�`..:���'Z!__..____-_ ."�-C.:...___ Date..__.._�.`L -_''/,&
Test Pit No. 1.....-......_._minutes per inch Depth of Test Pit---- AJ....___ Depth to ground water___-
LL, Test Pit No. 2.... ....minutes per inch Depth of Test Pit---- Depth to ground water-_1_�- _f
---•----•--•----------------------•----------------------------.....------------•-------••---------•......................................
7_ � ..�a...-�. .._.'.� ✓� L iN---�&--i O Description of Soil........... j" ....... . Z _.. ---
EZS
W -------------------------`�" ' '-----•.`x --- ���� `� � ,.�-....
�-------------•-------------....
U Nature of Repairs or Alterations—Answer when applicable................................................................................................
---------------------•---.....--------------------------------------------------------•--_...-•---•••-----•-••---•••-------•-••••--••----•------------•-----------------•-••---.................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TL ITI 12 5 of the State Sanitary Code—The undersign urther agrees not to place the system in
operation until a Certificate of Compliance has been issy�d`by gh oard f lealth.
D t
Application Approved By.......................... .. . ..... ..... -----------z---�-� --�•g6-
Date
Application Disapproved for the f ollowi reasons--------------------------------------------------------------•-------------•--•------••----••-•--..............
......... ......••-----•------------•-•-----------.......•-•----•-•-•-•------------•--•................................................
% Date
Permit No.................. �.-•-�q--------- Issued----------••-------. . ------
Date
No................-....... Fps..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
ApplirFation for Rspos a1 Works Tonstrurtiun Permit
Application is hereby made for a Permit to Construct (V_J�or Repair ( ) an Individual Sewage Disposal
System at:
..-... :..d_%...... .... :, . c ..,-;�Location-Address
__or Lot No.
.. �•'.. er d J s �, ,�z i-- �� !......� .i� 1 1 P...1._ ..... 1-f!`.�.' Pr:v.
.... ..-
Owner Address
W
Installer Address
Type of Building Size Lot_!-—:..E...` _..Sq. feet
.—I Dwelling—No. of Bedrooms............... ___.___.__.__.__..__......Expansion Attic,(.,..---j-° Garbage Grinder.._"
aOther—Type of Building Lc_ . !. ._...._.. No. of persons--------Vic................ Showers ( ) — Cafeteria-('')
dOther fixtures .--.:. •--•----------•-•-----•-••---- . .....-------------•-•-•-••--•--._............_..
W Design Flow____________________________'='.:�-_._gallons per person per day. Total daily flow__-_-__-� ....................gallons.
W Septic Tank—Liquid capacity/92'?_.gallons Length..S...�_`:._ Width.��__`.'..(_-.'_'Diameter.......... -_`�1__...... Depth. _.........
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No........I----------- Diameter-----.4-------- Depth below inlet.... Total leaching area.. ;.05...sq. ft.
z Other Distribution box (vj Dosing tank
...s .�:Z.7 �/ ------ Date...... •� L �............
a Percolation Test Results Performed by. .............................:.........................
Test Pit No. 1____`�.: F"'..minutes per inch Depth of Test Pit...l.�.'.:_____ Depth to ground water__ .t. ..`�1 D U_s e
f14 Test Pit No. 2... ..�___..minutes per inch Depth of Test Pit... _._.. Depth to ground water..1.2:_�............
P4 -•-••------•-----•----------•--•-•••-•--•-•-•-•-----••••••-•------•-•---••------••••----------•....•..............................................
Description of Soil.......... �... . m � - ..V`� L W �� 1=z.s
..... . .
- _V .............................................................. s
,j___......
VNature of Repairs or Alterations—Answer when applicable...............................................................................................
-------------------------•-•-•-------•--------•----•-•-------------•-••----------•..........------------....---.---------------.............---••---•---•-- ...........................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Sig ed,^._.. •----••-•------•--•-•---
Date
Application Approved By.................-.........
--....... .....: •�------ _ ✓���'/�'"'/-
ate
Application Disapproved for the following;redsons:--------••---•-----•----......•-••-----------------•-------•--------•--------•--••---•-------•--•------•-•-••---
J
--------------------••-•--•--•.-•--------------••...---------•--...•--•--...._....-----•--•------......._...--•---------•--•--•----•-------------•----------•--•-------•-•------------------•-•-••••--•---
` -y� Date
PermitNo......................................................... Issued--•---------------....................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........ !?.VV!> '......0F... ............................
..........
(LIErrtifirate of Toutpliana
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ('-�or Repaired ( )
by--------------------•------••------•------.----.-------•------------•--------_--------------------- ----------•--•-----•-••------------•-----------.-.-----------------------------•-----•------•--
Installer
---
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Codas.described in the
application for Disposal Works Construction Permit No.-_____--__-g(.Fr..`:_�® _ dated--------- . .......................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANI E THAT THE
SYSTEM WILL FUNC11ON SATISFACTORY.
DATE................... JR . Inspector..... ------------•----------------------------------•-------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
7.`.c.� W.A OF.. t ✓i? =J.s:i_��_� ..-.:'�................:........�......-5 �.a
No......................... FEE.. `•
Disposal yWorks W111ntrnrtinn rrntit
Permission is hereby granted...�._ _ � I:_� `. ........_ _ __ _ ____
to Construct (v'ror Repair ( ) an Individual Sewage Disposal System
at No...!L!2.�... _....�— •i 1_/_ ..►�r+! --, �� J`"f` `"J .................................
Street
as shown on the application for Disposal Works Construction Permit ... Dated........!j_ __l-q<--------------
14—
+� a th ---------- --------------
DATE........... ••-----•...........-...................................... eafd
FORM 1255 A. M. SULKIN, INC., BOSTON
f
r
76
`�v ASSESSOR'S MAP N0. °— cD--\ PARCEL
LOCATION SEWAGE PERMIT NQ.
L [2 ore �c, �. V\ \® &
VILLAGE
� — �.�.r -ems�•. \\ �
INSTALLER'SNAME i ADDRESS
VP
.R U I L D E R. OR OWNER
L t)o —
I
1
DA T E : P E R M I T ISSU E 'D ,�, r
f
DAT E COMPLIANCE ISSUED