The URL can be used to link to this page

Home My WebLink About0029 MUSKEGET LANE - Health . 29 Muskeget Lane, Centerville A=170-034 p No. 42101/3 ORA ESSELTE 10� O O O O i D �. n 10 2016 23:56 Jim The Inspector Man 5085349919 page 1 Commonwealth of Massachusetts t Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Z f �y " 29 Muskeget Lane Property Address David Sinclair a Owner Owner's Name F+ information is ✓ N required for every Centerville . MA 02632 1-8-16 �.. page. City/Town State Zip Code Date of Inspection OD 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 I�3� `pN1u°1!Irua�i on the computer, / OF MA q��4i use only the tab ``�� '.• S`s9�+'� key to move your 1. Inspector: cursor-do not �$: JAMES use the return James D.Sears =�: _ key. Name of Inspector ;ro Capewide Enterprises, LLC •, o�_ o;_� Company Name 153.Commercial Street ,iq�UsiI N 5 9 Company Address Mashpee MA 02649 Cityfrown State Zip Code 608-477-8877 S1623 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 16.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority spectol 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. isin's•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 17 k0 V - _ V i Jan 10 2016 23:56 Jim The Inspector Man 5085349919 page 2 c Commonwealth of.Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 29 Muskeget Lane Property Address David Sinclair Owner Owner's Name information is required for every Centerville MA 02632 1-8-16 page. Citylrown 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: The system is a 1500 Gal. Tank D Box and four infiltrators. 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-m 3 . Title 5 Official Inspection Form:Subsur ace Sewage Disposal System-Page 2 of 17 Jan 10 2016 23:56 Jim The Inspector Man 5085349919 page 3 Commonwealth of.Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 29 Muskeget Lane Property Address David Sinclair Owner Owners Name information is required for every Centerville MA 02632 1-8-16 page. city/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumpslalarms 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 t5ina•3113 - Title 5 Official Inspection Form:Subsjrfacs Sewage Disposal System•Page 3 of 17 r Jan 10 2016 23:56 Jim The Inspector Man 5085349919 page 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments. 29 Muskeget Lane Property Address David Sinclair Owner Owner's Name information is required for every Centerville MA 02632 1-8-16 page. CitylTown 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 ❑ z 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 El or clogged SAS or cesspool El ® Liquid depth in a ws p®1 is less than 6" below invert or available volume is less than Y2 day flow AF.4601AF t5ins-3113 Title 5 Official Inspection Form:Subsurface Sawage Disposal System-Page 4 of 17 Jan 10 2016 23:56 Jim The Inspector Man 5085349919 page 5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s 29 Muskeget Lane Property Address David Sinclair Owner Owner's Name informationis required for every. Centerville MA 02632 1-8-16 for page. City/Town Siate 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: ❑ 0 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 watersupply ❑ ❑ 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 an operator of large P Y 9 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. ISina•3113 Title 5 Official hspection Form:Subsurface Sewage Disposal System•Page 5 of 17 - Jan 10 2016 23:57 Jim The Inspector Man 5085349919 page 6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Muskeget Lane Property Address David Sinclair Owner Owner's Name information is required for every Centerville MA 02632 1-8-16 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done_ You must indicate "yes"or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? 13 ® 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 NIA) ® ❑ 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 Sail 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): NA Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Wins•3113 Title 5 ofridal Inspection Form:Subsu face Sewage Disposal System-Page 6 of 17 Jan 10 2016 23:57 Jim The Inspector Man 5085349919 page 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Muskeget Lane Property Address David Sinclair Owner Owner's Name information is required for every Centerville MA 02632 1-8-16 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1500 Gal_ Tank D Box and four infiltrators. Number of current residents: 2 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2014-47,000G is g ( y g (gP �)' 2015-60,000Ga!'s Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date Commercialli idustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(9Pd) Basis of design flow(seatslpersonslsq.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: l5ins-313 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 0117 Jan 10 2016 23:58 Jim The Inspector Man 5085349919. page 8 Commonwealth of Massachusetts W Title 5 .official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 29 Muskeget Lane Property Address David Sinclair Owner Owner's Name Information is required for every Centerville MA 02632 1-8-16 page. Cityrrown 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: NA 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. 0 Other(describe): 151ns•3!13 TrUe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Jan 10 2016 23:58 Jim The Inspector Man 5085349919 page 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Muskeget Lane Property Address David Sinclair Owner owner's Name information is required for every Centerville MA 02632 1-8-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1996- Permit#96-473. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 22" Depth below grade: 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.): 4" PVC SCH 40. Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate)' ❑ Yes ❑ No Dimensions: 1500 Gal. Precast H-10 Sludge depth: 2" t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Jan 10 2016 23:58 Jim The Inspector Man 5085349919 page 10 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 29 Muskeget Lane Property Address David Sinclair Owner Owner's Name information is required for every Centerville MA 02632 1-8-16. 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 28 Scum thickness 1 a.. Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 17e How were dimensions determined? Asbuilt-TapeSludge Judge 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 at woking level. Tank and cover's at 1' below grade. In and outlet tee's. No sign of leakage or overloading. 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•3/'3 Title 5 official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 117 Jan 10 2016 23:58 Jim The Inspector Man 5085349919 page 11 Commonwealth of Massachusetts Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Muskeget Lane Property Address David Sinclair Owner Owner's Name information is Centerville MA 02632 1$-16 required for every page. City/Town State Zip Code Date of Inspection Da 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•3P3 - Title 5 Official Ina pection Form:Subsurface Sewage Disposal System•Page f 1 of 17 Jan 10 2016 23:58 Jim The Inspector Man 5085349919 page 12 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Muskeget Lane Property Address David Sinclair Owner Owner's Name information is required for every Centerville MA 02632 1-8-16 page. CityfTown State Zip Code Date of Inspecllon 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.): D Box is 16"x16"-20"below grade w/two lines out. Box is clean and solid. No sign of over loading or solid carry over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No` Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *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: t5ina•3l13 .Title 5 Official Inspection Form,Subsurface Sewage Disposal System•Page 12 of 17 Jan 10 2016 23:59 Jim The Inspector Man 5085349919 page 13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 29 Muskeget Lane Properly Address David Sinclair Owner Owner's Name information is required for every Centerville MA 02632 1-8-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4 ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternadve system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is four infiltrators/4'stone. Chambers are 3' below grade. Ck D Box and camera out to chambers. Chambers are wet No sign of over loading or solid carry over. 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-3113 - Title 5 Official Inspection Forth:Subsurface Sewage Disposal System Page 13 or 17 Jan 10 2016 23:59 Jim The Inspector Man 5085349919 page 14 Commonwealth of Massachusetts Title 5 Official Inspection .Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 29 Muskeget Lane Property Address David Sinclair Owner Owners Name information Is required for every Centerville MA 02632 1-8-16 . 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.): 15ins•3/13 Title 6 Official Inspection roan:Subsurface Sewage Disposal System•Page 14 of 17 Jan 11 2016 00:00 Jim The Inspector Man 5085349919 page 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Muskeget Lane Property Address David Sinclair Owner Owner's Name information is required for every Centerville MA 02632 1-8-16 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 R-l- -so K I z ° ° 37, 3 EJ t5ins•W3 _ _ Title 5 Official Inspection Forin:Subsurface Sewage Disposal System•Page 15 of 17 ` r Jan 11 2016 00:00 Jim The Inspector Man 5085349919 page 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments •' 29 Muskeget Lane Property Address David Sinclair Owner -Owner's Name information is required for every Centerville MA 02632 1-8-16 . page, Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells N Estimated depth tq`h'igh ground water: 14'+ 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: Per paper work on file at B.O.H. no ground water at 14'+ Bottom of chambers at 5' below grade Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsuface Sewage Disposal System•Page 16 of 17 Jan 11 2016 00:00 Jim The Inspector Man 5085349919 page 17 to Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 29 Muskeget Lane. Property Address David Sinclair Owner Owner's Name information is required for every Centerville MA 02632 1-8-16 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 tsins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 17 of 17 TOWN OF BARNSTABLE N LOCATION SEWAGE #�� VILLAGE CA1\ ASSESSOR'S MAP & LOT/70 INSTALLER'S NAME&PHONE NO. M V 7 y C1 SEPTIC TANK CAPACITY l Kn t �A`�,- f) gQ-X LEACHING FACILITY: (type) t'` �C �T^�T �s (size] NO. OF BEDROOMS 14 BUILDER OR OWNER fXNA-V�C- C S,C\k(— PERMIT DATE: l I cI& COMPLIANCE DATE:- !� Separation Distance Between the: N 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 ands exist within 300 feet leaching f cili �� Feet Furnished by A A o s, A-ko 3 s Ze6x 53 �Z . f Ao 5i Q Fi ASSESSORS MAP NO:�__ No. PRRCEL NO: _ Fee ) THE COMMONWEALTH O MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for Bigw5ar *p5tem Cott.5truction Permit Application is hereby made for a Permit to Construct( )or Repair(--�an On-site Sewage Disposal System at: Location Address or Lot No. Qq ra)u Owner's Name,Address and Tel.No. 54Z.Q,r �G,U2 Assessor's Map/Parcel r M U S y am _ e Installer's Name,Address,an�Tel.No. �,S QC1 Designer'''slName,Address and el.No. d .� `- �� v �o- �s 5 Type of Building: Dwelling No.of Bedrooms Garbage Grinder 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 TC .applicable) �� ` 1 «� sC"G �� J �-f r� i �a/ 1-�r- bCcs � cs�� 14 j 1XC(.0.S V&Vcr 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 C not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Signed a Date Application Approved b Date Application Disapproved for the following reasons Permit No. /101-71S Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS l Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced( P�on by n r k r InstallerC at C has been constructed in accordance with the provisions of Title 5 anA the for Disposal System Construction Permit No. dated Date Inspector •-- e / THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE S- TEM WILL FUNCTION SATISFACTORY. ---^--�--------------------- No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 30i5pozal *pgtem Construction Permit Permission is hereby granted to l< A_t l_nL 5 J cG+op'_ to construct( )repair( 4an On-site Sewage System located at No.# '9 5 M(,5 ycgk2k ! C, >`2 — C Rs�C r r i ) t 11 n U " Street / and as described in the above Application for Disposal System Construction Permit. No. a Date 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 three years of the date below. 01 Date: �T Approved by 7�e Board or Health No. '^ Fee THE COMMONWEALTH OKMASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Ztp Aicatton for 33i5pogar bpgtem Congtruction Permit � Application is hereby made for a Permit to Construct( )or Repair(✓4an On-site Sewage Disposal System at: Location Address or Lot No. ° �r U S �� Owner's Name,Address and Tel.No. 4 S f� 0 \ f Assessor's Map/Parcel Installer's Name,Address,and Tel.No. cJ-la C.j Designer's Name,Address and el.No. (,cm k c1_6 v �l-t Type of Building: Dwelling . No.of Bedrooms _ Garbage Grinder 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 Nj Nature of Repairs or Alterations(Answer when applicable)� � t_d b `AcY_4 c cr-C: 5{r1 r-R- yOn 1 c,+ j AC 1-0s IVAdtJ- 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 Board of H Signed Date /�1 7 Application Approved by , Date _4 �-/ l Application Disapproved for the following reasons . Permit No. 4T`�iy Date Issued ell!? ------------ —.------------------------- f CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) I, ^� , hereby certify that the application for disposal works construction permit signed by me dated / ' N L , concerning the property located at an N►USt4CJ W_. ( i� --meets all of the following criteria: ti 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 /here is no increase in flow and/or change in use proposed There are are no variances requested or needed. SIGNED : DATE: i r N ita LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. ;� �', (��O � �� `tL`�� I _----