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HomeMy WebLinkAbout0082 MERIDETH WAY - Health 82;g ASNE . CENTERVILLE A = 147 105 �IIII /J J�QcC�C,FO� j il/ c UPC 12534 N0, 2,,,-11533LQR NASTINQS, MN Commonwealth of Massachusetts , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form`-Not for Voluntary Assessments M s 82 Merideth Way Property Address Jennifer Desruisseaux Owner Owner's Name information is required for every Centerville MA 02632 3-6-14 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. A. General Information I , 1. Inspector: , I Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 3-6-14 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. """"This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 3/� I �� t5ins•3/13 Title 5 Official I s Form:Subsurface Sewage sposal stem•Page 1 of 17 F Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 82 Merideth Way Property Address Jennifer Desruisseaux Owner Owner's Name information is required for every Centerville MA 02632 3-6-14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. 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. es Check the box for"y ", 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 e p g years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 T J VV g B ARNSTt�L'L s>awAc?rv_ LOCA'"ON -- V�LLA�� J I'll G _.. A;SSESSOWS MAX. &LOT __... INS TA Ll.EX3`S NAME�t NONE NO. SEPUC TANK(.PbY'AdV- . g; (,'jiZl�iClc t��� (sx�e) _ —•---- i'o Of.OMMI bC�1.A1 lgcE S��sxre�tioyt;�t',P,utarir�3ettv�een Sl�� � . .. NitiXilnuYal�djwstcrJGeat�taiw�ttec7'atsletn,tiaci3e7ttotYtalXachcnl�tciltty � Vices 1'riva8c:�yJnt�r unfitly le, Witt L6et 'Aitr��?aciizty !'any�vf l9s exist 7rT��9 � -On sstG l�i?cixiYig fs�rilit}�)_ ��---•-----�- �» E?ge of,Wetland skid 1Loac, .i09 it:acility(�£any wGtAa»d4 exist 1��19Ili tA.'_00,&ct 0@ clliing ftilirya / )i"lltRl3lJt it�y .. J�bt�nGr�v+ mil!! ., ►` ; _ """ PP �.-,-- np /� p�33�" TOWN OF BARNSTABLE (��J �. �i�Q+ t 7�(-(1 LOCATION {� SEWAGE # VILLAGE Letv'C'�'.3a`�� ASSESSOR'S MAP & LOT 11Y 7-/OS' INSTALLER'S NAME&PHONE NO. �"�• SEPTIC TANK CAPACITYnN LEACHING FACILITY: (type) T�°f 46 H l0 (size) I I - 7 X Z LT" NO. OF BEDROOMS BUILDER OR OWNER �a'✓(Y�7L�2 PERMIT DATE: COMPLIANCE DATE: Z -9- 001 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility.(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 61 3� Commonwealth of Massachusetts W Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 82 Merideth Way Property Address Jennifer Desruisseaux Owner Owner's Name information is required for every Centerville' MA 02632 3-6-14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts ° Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 82 Merideth Way Property Address Jennifer Desruisseaux Owner Owner's Name information is required for every Centerville MA 02632 3-6-14 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 0 ® 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 El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts AMMM, Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 82 Merideth Way Property Address Jennifer Desruisseaux Owner Owner's Name information is required for every Centerville MA 02632 3-6-14 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 16,000 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 82 Merideth Way Property Address Jennifer Desruisseaux Owner Owner's Name information is required for every Centerville MA 02632 3-6-14 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes.of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ®_ ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan'at the Board of Health. ® ❑ Determined in the.field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow,Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts - _ - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 82 Merideth Way Property Address Jennifer Desruisseaux Owner Owner's Name information is required for every Centerville MA 02632 3-6-14 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No { Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 3-2014 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 82 Merideth Way Property Address Jennifer Desruisseaux Owner Owner's Name information is required for every Centerville MA 02632 3-6-14 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: p 9 Source of information: Owner--pumped2-2013 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP'approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form lod o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 82 Merideth Way Property Address Jennifer Desruisseaux Owner Owner's Name information is required for every Centerville MA 02632 3-6-14 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: 2001 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 18" at tank inlet feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: 12"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: 8" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 82 Merideth Way Property Address Jennifer Desruisseaux Owner Owner's Name information is required for every Centerville MA 02632 3-6-14 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 24" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. 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•W 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M •' 82 Merideth Way Property Address Jennifer Desruisseaux Owner Owner's Name information is required for every Centerville MA 02632 3-6-14 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 82 Merideth Way Property Address Jennifer Desruisseaux Owner Owner's Name information is required for every Centerville MA 02632 3-6-14 page. City/Town 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.): Good condition with water at working level and no sign of back-up from infiltrators. 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.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 82 Merideth Way Property Address Jennifer Desruisseaux Owner Owner's Name information is required for every Centerville MA 02632 3-6-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: Infiltrators ❑ 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.): Infiltrator leach field in good condition and empty at inspection with no sign of back-up into d-box or surrounding stone. 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-3l13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° M 82 Merideth Way Property Address Jennifer Desruisseaux Owner Owner's Name information is required for every Centerville MA 02632 3-6-14 page. City/Town- State Zip Code Date of Inspection D. System Information (cont.) a 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.): i I t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 82 Merideth Way Property Address Jennifer Desruisseaux Owner Owner's Name information is required for every Centerville MA 02632 3-6-14 page. City/Town State Zip Code Date of Inspection D. System Information (cons) 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 I 4 0 J ' k 3402 s t5ins-3(13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official, Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 82 Merideth Way Property Address Jennifer Desruisseaux Owner Owner's Name information is required for every Centerville MA 02632 3-6-14 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: 12 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: ® Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database- explain: You must describe how you established the high ground water elevation: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 82 Merideth Way Property Address Jennifer Desruisseaux Owner Owner's Name information is required for every Centerville MA 02632 3-6-14 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•3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 17 of 17 No.?el t Fee 's—d�d THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 01, Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for �Dioponl *pztem Comaruction Vermit Application for a Permit to Construct( )Repair(V11U10,pgrade( )Abandon( ) ❑Complete System 'Individual Components Location Address or Lot No 4�+� Owner's Name,Address and Tel.No. Assessor's Map/Parcel 1"A--�- 1�S , ,kA Ooik-Q, s e,Address,and T 1.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow qc( gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Cc,loctc-) /v r L (�L U Description of Soil 4�0 Nature of Repairs or Alterations(Answer when applicable) '-f— ac L t O S` tk 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 be B Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No.7,00 l 0 '77 Date Issued �00ordr _ w t No. 01 1/ 0� Fee Ste! THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN'OF BARNSTABLE., MASSACHUSETTS ZIpphratton for Otgpogar *pgtem Cougtruction Fermat Application for a Permit to Construct( )Repair Vj<pgrade( )Abandon( ) ❑Complete System [�dividual Components Location Address or Lot No. yf t' ,. Owner's Name,Address and Tel.No. Assessor's Map/Parcel ``,�— 'b ,,� iA iAv_,b ,(—o.r,. , alas s N e,Address, d Te.No. ( Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 23'J gallons per day. Calculated daily flow qC( gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank gac-3--Yi njrz.-Va Ae% Type of S.A S. A-, CcttAaGi`1 tA //-/?LTekV0 it Description of Soil Nature of Repairs or Alterations(Answer when applicable) NST 4 T:70* 0— 4%!-,k 1 G; k. l&I-V-o V9 S (A Z�l�t S�U1k2 {�K _s Yl C �!r� t_[tk 0VL.CZ 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 bgpli-issued-by_�oard-o h. QQ Signed Date Application Approved by :�-% Date Z d/ Application Disapproved for the following reasons Permit No. 1-07) Date Issued Q ————————————————————————— ————————————— THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CE tha the On-site Sage, tsposal System Constructed( )Repaired( )Upgraded Abandoned( )b ,� i,®�-- at Az- N-ve a/1 WIAi+VL'- has been constructed 'n ac ordance with the provisions of Title 5 and the for Disposal System Construction Permit No.Zed dated Z 0/ Installer Designer The issuance of this pe t shall not be construed as a guarantee that the sys will fuuti s designed. Date ��`f7.�v Inspector C • KAA,1001 Fee THE COMMONWEALTH OF MASSACHUSETTS IV 7-1a5" PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mtgpogai *pgtem Cougtructtou Permit Permission is hereby granted to Construct( )Repair( r�Up rade( )Aban on ) System located at `�S r�- ✓1 ls�� ('�,t �c. �,.t ���j 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:Constructs n rnust be completed within three years of the date of this it. Date: ?' �/ "� Approved by G 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) h bole , hereby certify that the application for disposal works construction permit signed by me dated cl; -iq�-D l , concerning the property located at .11�- ftv--s" er- meets all of the following criteria: V. This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling.�- e soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. ` There are no wetlands within 100 feet of the proposed septic system n✓ There are no private wells within 150 feet of the proposed septic system 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 not be located less than five feet above the maximum adjusted groundwater table elevation._[Adjust the groundwater table using the Frimptor method when as.plicable] +' If the S.A.S.will be located with 250 feet a a. of any ve,etated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted . groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation (using GIS information) B) G.W. Elevation 0,500+the MAX. High G.W. Adjustment./r'9 = p�10� DIFFERENCE BETWEEN A and B S D : DATE: [Please Sketch p pos d plan of system acl:]. NOTICE Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert �ow V d Polo �i� I r TOWN OF BA.RNSTABLE �. ��� -ter-c� LOCATION, l �'�� SEWAGE # VILLAGE C i h 3' -__-ro `\ - ASSESSOR'S MAP & LOT l y 7—/05— INSTALLER'S NAME&PHONE N . �. SEPTIC.TANK CAPACITY LEACHING FACILITY: (type) (size) H X ZZ x Z LT— NO. OF BEDROOMS )J BUILDER OR OWNER �a'✓C�G.71�. PERMITDATE: —Z'fjv l COMPLIANCE DATE: Z —9-Za01 Separation Distance Between the: " Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by ii 01 ' 1` c?I• 1: r ; LOCATION , 4A- SEWAGE PERMIT NO. VILLAGE 4ii1J I N S T A LLER'S NAME i ADDRESS R UILDER OR "'OWNER /� A Z TX %✓�eJ_ ^ ' DATE PERMIT ISSUED Y . 4' DATE COMPLIANCE ISSUED di L) L d j r� o A,) j t Fps.. ..5`..�..................... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ...........................................OF.......................................................................................... Appfiration for Disposal Works Tonstrnrtion .erntit Application is hereby made for a Permit to Construct ( ), or Repair ( ) an Individual Sewage Disposal System at: ........ ..-• - .._.....--.........: -----•-----•-------------------------- ........�a.-f�-•---.. --�2 ......................................... Location-Add r s or Lot No. , .. . .... .....J�.l, ............................. Owner Address ................... C .Y . //. ....... Installer 1>ddress U Type of Building Size Lot1Gf_,� ...Sq. feet Dwelling L;< of Bedrooms........._�.........................Expansion Attic ( ) Garbage Grinder ( ) 04 Other—Type of Building ---------------------------- No. of persons......................,_._'_ Showers ( ) — Cafeteria ( ) aOther fixtures -•---•--•----------------------••-••--••---••---•. ._... -----------•.... a w g gallons per person per day. Total daily fl'w___ ...........................gallons. Design Flow.--..•----•-••lam-�•-----•-- --•-• � WSeptic Tank—Liquid*capacit .R?f..gallons Length�..a.._.. Width_�./`2.",ti iamete �________._•__ Depth................ x Disposal Trench—No,3:7 •_.. c.. Width.../Z. _..... Total Length....,©.__:;__ T'.�tal leaching area�.V.....sq. ft. Seepage Pit No------------ ........ D'ameter--_._............... Depth below inlet.................... Total leacl'i"'ng area..................sq. ft. z Other Distribution box Dosing tank aPercolation Test Results Performed by.._. '�¢ _.. .... Date.".t. . ..S�E'_ ... Test Pit No. 1...... per inch Depth of Test Pit___,f�..._._._... Depth to ground water...,ll______________ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth;to ground water........................ x ....-.---•-------•--••---•--•••...............••-•-••......•-•------•--..... ..--. ----- O Description of Soil== �-- ,.�- ff�' ... _ L� 1�_-- .�1. :_ ic/ _ .._. / x f 11 �. ru z f ......---.•-------------------------------------- w U Nature of Repairs or Alterations—Answer when applicable...._........................................................................................... --------------------------------•---------------------------------------•--....----•----.............---•-------- --------------...-•---------•------------------------------................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System 'n accordance with the provisions of TITI,% 5 of the State Sanitary Code—The undersigned further agrees not place the system in operation until a Certificate w Compliance has is ued bythe b rd of h. ____. . / Application Approved By---- . �B • .... .... Application Disapprove o the following reasons------------------------------------•----•--•-----------•---•---------------------------------•-••--------•------ ...........................................••-•......-•-•---•-•-.............---•--•........•-------••--......----•-------••-••-•-•------••••-----•...--••----•-•••-•---------..._._ ......-----...-- Date TPermit No......................................................... Issued_....................................................... Date N0. `ZV_ �/ l... +� Flcs.15. .................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............ ........ ------------.:..OF...................................... ApplirFation for Zia pos al Works Tonotrurtion #rrufit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: J Location-Address or Lot No. !........ ......•........... .... :���. 1��f?.'.� ....�✓t l .1 Own Address � / ...... 'ems all f=f- -----•---•-•-----• G... �==Z�,C - �. ,1�.�.w A—,l�!fJ.r.?_ -- ddress U Type of Building Size Lot�4®,-_*,-�?....Sq. feet Dwelling6, l�o, of Bedrooms------------3.........................Expansion Attic ( ) Garbage Grinder ( ) `k Other—T e of Building Pk YP g --------•------------•-••--- No. of persons............................. Showers ( ) — Cafeteria ( ) d Other fixtures . ............:--------- --------------------------------•••...... . Design Flow..........f 1. .....................gallons per person per day. Total daily flow_....� t?•--_-----_-----•••----gallons. 9 Septic Tank—Liquid'capacity oQ..gallons Length}r�-.�..... Width.V.�,0..- Diameter,............... Depth................ Disposal Trench—No - ., y?... Width... . .:....... Total Len th..._... _ .'.._ Total.leaching area.. s . ft. � g �� g �•�•----- q Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box /� Dosing tank ( ) aPercolation Test Results Performed by.... __ _.e.. __•...... Date.. ..r Test Pit No. 1------Z,-.--.minutes per inch Depth of Test Pif..;/............ Depth to ground water...r!-/__-_-__---•_--. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Ix -----------------------------------• ---•--------- .............................................--......------•-•---....... _ O Description of Soil........... =------•- r � � ,/ --- ,1 -��Xf.t?.....p lc - Z � �'�--.�...-•- •fir?- -- - "_ x •-••••-•••••-------••-•-•--••••-••-•---••-•••-•-•••-•--•••----•-•-••----•••••--••••-•••••-•••••••••----•--••-••••----•-----...-•--••---•----••--•---•••••••--••.................•...... ................ V 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 TITIS 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. gned......••--......••. . ---•----•---------------------------•••--•--•-••-•-• ..... ApplicationApproved B .... ..-----•---•••............. .....•-----.........--•-•----•----•••-......--•-••-•-•-- --- y ........... Application Disapprove or he following reasons:--•------------------•-----••-------------------------------•---------------------------•--••••••••••........._ ....----•...................•.......................•••......•.•...........•...-----.•••••......••.......-"Date••......------ PermitNo.......................................................-- Issue(L....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF f9rdifiratr of TompliFanrr T IS I TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( ) by..... .................................. ........................I. -- ---------.......--------------------------•-------............---------...----------.......---- f. nstaller at. has been installed in accordance with tZpions of TIZi 5 f h antar o d c ' ed in the a lication for Dis osal Works Constrermit No... .�TF _'- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® A GUAR TEE THAT THE SYSTEM 1AI�FU C;ION SATISFACTORY. DATE..... .. ................................................... Inspector--- - --- --------------•-••-------•--••------------•-------••---......---...--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH L� Q ........................................... ! `G OF......................................................................... .......... FEE No. '. .� ... ....... t ro ko %Tons#.r ion rruaat Permission is hereby granted...... -----------------------------•-•-------•----------•-----.....---•-•••••.................•--- to Construct ( r epair ( ) ro uald e Disposal System' Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... Board of Health DATE....................................................... FORM 1255 A. M. SULKIN, INC., BOSTON 'DG,516W .'DA-TA SW6,tg.. P-AMIL`{ 3 15t ZOOMS f • t.JO 6A¢.Y>�i4 GcLI UDER. �— /Gl I a /02 ' ` . . AFL 3 )( Ito 33v c.FM:> 1 5MPTIC ' -rA jLe • a50 ',c.fCPO y. d95 (.PD (000 Ge.L. 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