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HomeMy WebLinkAbout0172 SCUDDER BAY CIRCLE - Health 172 SCUDDER BAY CIR. CENTERVILLE A = 187 018 JaREcYC(FD�yl UPC 12534 ' 1QpR '�, J� HASTIN©S,UN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 172 SCUDDER BAY CIRCLE Property Address POHL Owner Owner's Name information is required for CENTERVILLE MA 02632 12-5-13 every 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 A. General Information forms on the �\ computer,use 1. Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. DOUGLAS A BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE MA 02632 �dOD City/Town State Zip Code 508-420-4534 S14297 Telephone Number License Number ,8,.Certification 1 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. 1 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 12/5/13 Inspector ignature 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. q I t5ins•3/13 Title 5 Officit1nspe,,, onn:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 172 SCUDDER BAY CIRCLE Property Address POHL Owner Owner's Name information is required for CENTERVILLE MA 02632 12-5-13 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM WAS OPERATING PROPERLY AT TIME OF INSPECTION B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exMtration 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•3/13 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 172 SCUDDER BAY CIRCLE Property Address POHL Owner Owner's Name information is required for CENTERVILLE MA 02632 12-5-13 every page. Cityrrown 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 172 SCUDDER BAY CIRCLE Property Address POHL Owner Owner's Name information is required for CENTERVILLE MA 02632 12-5-13 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) 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 1/day flow t5ins•3/13 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 172 SCUDDER BAY CIRCLE Property Address POHL Owner Owner's Name information is required for CENTERVILLE MA 02632 12-5-13 every page. Citylrown 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- 1 0,000g pd. ❑ ® 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•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 172 SCUDDER BAY CIRCLE Property Address POHL Owner Owners Name information is required for CENTERVILLE MA 02632 12-5-13 every 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): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 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 M 172 SCUDDER BAY CIRCLE Property Address POHL Owner Owner's Name information is required for CENTERVILLE MA 02632 12-5-13 every page. Citylrown State Zip Code Date of Inspection D. System Information Description: ACCORDING TO PERMIT SYSTEM CONSISTS OF A 1500 GALLON TANK D-BOX AND A S.A.S CONSISTING OF 6 HI CAP INFILTRATORS WITH STONE Number of current residents: - izl(g f,3 Does residence have a garbage grinder? fcccoMM J'_Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No information in this report.) Wc-O-i,.7s i % cocci-e� Laundry system inspected? A o scp t(c O e r i F,e3 (0-I ElYes ❑ No /�uml,N)S WC C.V er 't1n(0 ( W&C cycle: Seasonal use? cv�d �J c-}c�`NS it 11 Yes ❑ No w t" (Gu�l IN�p fiGNIz— Water meter readings, if available(last 2 years usage(gpd)): Detail: 2012-------484.9 2013-----413 GPD Sump pump? ❑ Yes ❑ No Last date of occupancy: 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: s 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 s 172 SCUDDER BAY CIRCLE Property Address POHL Owner Owner's Name information is required for CENTERVILLE MA 02632 12-5-13 every page. Citylrown 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: 5 00 /2)rr3 l J'S �2cQt-r rcr'1( 51ept-ic 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 previou's inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank, Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 Y rY ' 172 SCUDDER BAY CIRCLE Property Address POHL Owner Owner's Name information is required for CENTERVILLE MA 02632 12-5-13 every page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2000 ACCORDING TO PERMIT Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 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.): Septic Tank(locate on site plan): 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 Sludge depth: 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 172 SCUDDER BAY CIRCLE Property Address POHL Owner Owner's Name information is required for CENTERVILLE MA 02632 12-5-13 every page. Citylrown 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 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 How were dimensions determined? 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 COULD USE PUMPING FOR MAINTENANCE �Urn�FCJ 12 Tt�, C'� ScG+-ir trCA,-> d—t.C. 1(21' � Imo,' 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 172 SCUDDER BAY CIRCLE Property Address POHL Owner Owner's Name information is required for CENTERVILLE MA 02632 12-5-13 every page. Cityrrown 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 M , 172 SCUDDER BAY CIRCLE Property Address POHL Owner Owner's Name information is CENTERVILLE MA 02632 12-5-13 required for every 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.): BOX WAS LEVEL NO SIGNS OF LEAKAGE OR FAILURE AT TIME OF INSPECTION 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: NO OBSERVATION PORTS FOUND t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 172 SCUDDER BAY CIRCLE Property Address POHL Owner Owner's Name information is required for CENTERVILLE MA 02632 12-5-13 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: 6 ® 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.): 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments •°` 172 SCUDDER BAY CIRCLE Property Address POHL Owner Owner's Name information is required for CENTERVILLE MA 02632 12-5-13 every page. Cityrrown 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-3/13 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 M , ' 172 SCUDDER BAY CIRCLE Property Address POHL Owner Owner's Name information is required for req CENTERVILLE MA 02632 12-5-13 every page. Citylrown 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 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 172 SCUDDER BAY CIRCLE Property Address POHL Owner Owner's Name information is required for CENTERVILLE MA 02632 12-5-13 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 8FT 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: OFF CONSTRUCTION PERMIT WITHOUT DESIGN PLANS,DATED JUNE 16TH 2O00 AT BARNSTABLE BOARD OF HEALTH Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth,of Massachusetts Title 5 Official Inspection Form, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M '< 172 SCUDDER BAY CIRCLE Property Address POHL Owner Owner's Name information is CENTERVILLE MA 02632 12-5-13 required for every page. CitylTown 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF BARNSTABLE LOCATION 7°z 5�'yod�.e XAL 68elf SEWAGE �'1000 1n- VILLAGE ASSESSOR'S MAP & LOT ''(./ INSTALLER'S NAME&PHONE NO. --7-,7 e-V-2-(/r r SEPTIC TANK CAPACITY /'S0U LEACHING FACILITY: (type) 7 NO. OF BEDROOMS V BUILDER OR OWNER 06 �iiF PERMITDATE: 6 t o —d J COMPLIANCE DATE: Ln Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet i 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 I r �U ABC- v c i 00 No. O� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Application for Miopozal *pg;tem Con.5truction Permit Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components bA Location Address or Lot No. I / Owner's Na me,Address and Tel.No. Assessor's Map/Parcel ZF70 I ? y Installer's Name,Address,and Tel.No. 7 — ad-t/5 Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder(Alo Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures s Design Flow wo gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of R&mirs or Alterations ) i en Answer w a lcable Uo ( P r �- 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 b his Board of Health.ol l Signed Date -/L v 0 Application Approved by Date Application Disapproved for the following reasons Permit No. '~ Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Comptiartce THIS IS TO CE TYY, that.the On- i Sewage Di osal System Constructed( )Repaired (Upgraded( ... ) Abandoned( )by 1 ` at I'?2 Y e n cAnstructed in accordance with the provi ons of T'd 5 and the fo Disposal System Construction Permit N dated Installer Designer The issuance of this pe t shall, .o be co ued as a guarantee that the sys ein,. k�lunctio as de3igned Date / ` Inspector % �%l G � ._ ;'i I 1 (X/ FeeIV- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS, Di!gpooaf *potem Conotruction Permit Permission is hereby granted to ConsUpct( )Repair(!/jUpgrade( )A andon� ) System located at 1 -7 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: Constru Pion natfst be completed within three years of the date of t rr�. Date: 1 I J Approved by 1 I � � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °y< 172 Scudder Bay Circle Property Address Robert&Julia Rice Owner Owner's Name information is required for Centerville, Ma. 02632 9/8/2008 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:When filling out A. General Information SII Q� forms on the U computer,use 1. Inspector: 1 8-7 r (::)18 only the tab key to move your Raymond F. Dumas, Jr. cursor-do not Name of Inspector use the return key. Dumas Landscape Const. Inc. Company Name 564 Old Stage Rd. Company Address Centerville, Ma. 02632 City/Town State Zip Code 508-778-0249 S1437 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this addressIand that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on m training and experience in the proper function and mai tenan `'P Y 9 P P p cpj,T orr•site sewage disposal systems. I am a DEP approved system inspector pursuant to ction 45.34Q6f Title 5(310 CMR 15.000).The system: t� s ® Passes ❑ Conditionally Passes ❑ Fps ""f ❑ Needs Further Evaluation by the Local Approving Authority t� e co -1 9/8/2008 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. [I 10/1 Rob Rice Septic Inspection.doc•03= Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page t of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M ' 172 Scudder Bay Circle Property Address Robert&Julia Rice Owner Owner's Flame information is required for Centerville, Ma. 02632 9/8/2008 every 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. Answer yes, no or not determined (Y, N, ND)in the ❑for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is 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. ND Explain: ❑ 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 ❑ obstruction is removed Rob Rice Septic Inspection.doc•OWN Title 5 Official In spection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form v Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M ' 172 Scudder Bay Circle Property Address Robert&Julia Rice Owner Owner's Name information is required for Centerville, Ma. 02632 9/8/2008 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cunt.): distribution box is leveled or replaced ND Explain: ❑ 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 ❑ obstruction is removed ND Explain: 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 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. Rob Rice Septic Inspection.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 172 Scudder Bay Circle Property Address Robert&Julia Rice Owner Owner's Name information is required for Centerville Ma. 02632 9/8/2008 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health(cunt.): ❑ 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 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 %day flow ❑ ® 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. Rob Rice Septic Inspection.doc•lXjM Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of IS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 172 Scudder Bay Circle Property Address Robert&Julia Rice Owner owner's Name information is required for Centerville, Ma. 02632 9/8/2008 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cunt.): Yes No ❑ ® 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. Rob Rice Septic Inspeetion.doc•03= Tide 5 Official Inspection Form:Subsurtace Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ti 172 Scudder Bay Circle Property Address Robert&Julia Rice Owner Owner's Name information is required for Centerville, Ma. 02632 9/8/2008 every page. Citylrown 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)] Rob Rice Septic Inspection.doc•03108 Title 5 Official 1 n Forth:Subsurface nspeclio Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 172 Scudder Bay Circle Property Address Robert&Julia Rice Owner Owner's Name information is required for Centerville, Ma. 02632 9/8/2008 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 Number of current residents: 5 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 ears usage 220000 gal 2007 g ( y g (gpd))' 178000 gal 2006 Sump pump? ❑ Yes ® No Last date of occupancy: 9/8/2008 Date Commerciallindustrial 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: Last date of occupancy/use: Date Other(describe): Rob Rice Septic Inspecdon.doc•03I08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 172 Scudder Bay Circle Property Address Robert&Julia Rice Owner Owner's Name information is required for Centerville, Ma. 02632 9/8/2008 every page. Cityrrown state Zip Code Date of Inspection D. System Information (cunt.) General Information Pumping Records: Source of information: Barnstable sewage treatment facility 6/30/04 4/23/06 7/3/07 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): Approximate age of all components, date installed(if known)and source of information: 6/19/2000 Were sewage odors detected when arriving at the site? ❑ Yes ® No Rob Rice Septic Inspeetion.doc•03108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 172 Scudder Bay Circle Property Address Robert&Julia Rice Owner Owner's Name information is required for Centerville, Ma. 02632 9/8/2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 31"feet Material of construction: ® cast iron ❑40 PVC ❑other(explain): Distance from private water supply well or suction line:. town water feet Comments(on condition of joints, venting, evidence of leakage, etc.): ok Septic Tank(locate on site plan): Depth below grade: 20" inchesfeet 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: 6x6x10 Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 34"inches Scum thickness 3" inches Distance from top of scum to top of outlet tee or baffle 4" inches Distance from bottom of scum to bottom of outlet tee or baffle 14"inches How were dimensions determined? measure stick Rob Rice Septic Inspection.doc-0=8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 172 Scudder Bay Circle Property Address Robert&Julia Rice Owner Owner's Name information is required for Centerville, Ma. 02632 9/8/2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tee conditions good Liquid level at outlet tee at level 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 j Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping:. Date 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 [Q other(explain): Rob Rice Septic Inspection.doe•03M Tice 5 Official Inspection form:Subswface Sewage Disposal System•Pape 10 of 1b Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments, 172 Scudder Bay Circle Property Address Robert&Julia Rice Owner Owner's Name information is required for Centerville Ma. 02632 9/8/2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping:. Dace Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ® No Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert at level 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 level and no signs of leakage Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Rob Rice Septic Inspection.doc•OWS Me 5 offidaf Inspection Fomr.Subswtace Sewage Disposal System•Page 71 of 15 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 172 Scudder Bay Circle Property Address Robert&Julia Rice Owner Owner's Name information is required for Centerville, Ma. 02632 9/8/2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 6 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology. infilltrators Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): soil conditions good, all sand Rob Rice Septic Inspectiw.doc•03M Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 172 Scudder Bay Circle Property Address Robert&Julia Rice Owner Owners Name information is required for Centerville, Ma. 02632 9/8/2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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 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.): Rob Rice Septic Inspection.doc-OWN Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Fora, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments < 172 Scudder Bay Circle Property Address Robert&Julia Rice Owner Owner's(dame information is required for Centerville, Ma. 02632 9/8/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (coat.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. �X �Q,oH l 30` Rp,4a of 14()�4 9IVY Rob Rice Septic Inspection.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 172 Scudder Bay Circle Property Address Robert&Julia Rice Owner Owner's Name information is required for Centerville, Ma. 02632 9/8/2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 8.5 ft 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: hand auger Bottom of leach field 5.5 ft above ground water Rob Rice Septic Inspectlan.doc•03/08 Title 5 Official Inspection Form:Subsurface Sews ge Disposal System•Page 15 of 15 0� COmM0\WEAI,TH OF MASSACHUSETTS _= �o EXECUTIVE OFFICE OF ENVIRONAIENTAI.. AFFAIR. b 00 DEPARTMENT OF ENVIRONMENTAL PROTECTION ocT f ��f0 4 0NE R'I\TER STREET. BOSTO\ 1LA 0210E (61 i) 292•;i:i(ul � 10 1999 y oEEpprr TRUDY CO?: i Secretary ��\ , ARGEO PAUL CELLUCCI ]�A� B�P.fHS CommisS;oae:- Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM `73� PART A CERTIFICATION SCJ��' "`�C\n' Name of Owner 30'\N �1 Property Address: �. •� C�/ ,`��i ddres/s of Owner:k`77 nc ]C�lG3 iLvt , Date of Inspection: d� �-Srinit •Ch L� l EC K cszp '<`�lName of Inspector: (Pleas a r' ��= 1 am a DEPP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: i CA Y-r'r Fk v° .• r,. llsn Itb.'Fu f . MaiGng Address:-? &,n • 2--g�FG L-ed:!5:/Yj2dE-t=_ I74-t oZC4'(� Tdephone Number: TSG �_( 3 s—c /Lt • ZG CERTIFICATION STATEMENT certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes _ Needs Further Evaluati n By the Local Approving Authority _ F ils �j �( + 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 thirty (30) days of completing this inspection. It the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS (� rE? c> S ��' I s t yo-S 0 (`u ct r � G,v,', ' -c"", 'A revised 9/2/98 page Iorll h Vr Im d on Rtcy<led Pjpa SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (contirwed) 'r op'erty Address: ',1Z�L ,}C4vL S Jwnef: Date of Inspection: INSPECTION SUMMARY:- Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15'.303 exist. Any failure criteria no$ evaluated are indicated below. _ COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If 'not determined", explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four times a year due to broken or obstructed pipets). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed revised 9/2/98 P2ge2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: / Owner: Date of Inspection: 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 the public health, safety and 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of surface water /J _ Cesspool or privy is within 50 feet of a bordering vegetated wetland orraa salt marsh. 21 SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC.WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system(SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water an for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 31 OTHER revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM D PART A CERTIFICATION (continued) property Address: Owner: Date of Inspection: D. SYSTEM FAILS: You must indicate either "Y s" or "No" to each of the following: have determined t\iedbe e of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is ideThe Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No _ Backup oacility or system component due to an overloaded or clogged SAS or cesspool. _ Discharg effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS cr cesspool. Static liquid leventedistribution box above outlet invert due to an overloaded or clogged SAS or cesspool. _ Liquid depth in cesspool is�\essan 6" below invert or available volume is less than 1l2 day flov.. _ Required pumping more thames in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ Any portion of the Soil Absorption,\System, cesspool or privy is below the high groundwater elevation. e within 100 feet of a surface water supply or tributary to a surface water supply Any portion of a cesspool or privy i . _ Any portion of a cesspool or privy is within a Zone I of a public well. _ Any portion of a cesspool or privy is within 50 feet of a private water supply well. i less•than 100 feet but greater than 50 feet from a private water supply well with no n onion of a cesspool or privy s for Any p attach co of well water analysis analysis. If the well has been analyzed to be acceptable, att PY acceptable water quality coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either "Yes" or—No- to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10.000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply _ the system is within 200 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 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/96 Page 4ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST 1 Property Address: M-4"J Owner: Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: k' Yes No V _ Pumping information was provided by the owner, occupant, or Board of Health. -+� — None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N;A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. 46 The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: Existing information. For example, Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)1 The facility owner (and occupants, if different from owner) were provided with information on the proper maintenaacs cf SubSurface Disposal Systems. • r revised 9/2/98 PAge5ortt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 'roperty Address: Owner: — Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: 614V g•p•d./bedroom. Number of bedrooms (design): Number of bedrooms (actual): Total DESIGN flow_ Number of current residents: • Garbage grinder(yes or no): 0. Laundry (separate system) (yes or no): If yes, separate inspection required Laundry system inspected (0or no) Seasonal use (yes or no):tJ Water meter readings, if available (last two year's usage (gpd): (.� Sump Pump (yes or no): F---) Last date of occupancy:]Ri&&<20j1— COMMERCIALIINDUSTRIAL: Type of establishment: Design flow: qpd 1 Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: + Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: � t !"v���c ,�\c a- b <<x�Lksi� c System pumped as part of inspection: (yes or no) �4 If yes, volume pumped: gallons 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known) and source of information: s I r Sewage odors detected when arriving at the site: (yes or no)-LN•t:+ revised 9/2/96 Page 6(if II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: Owner: Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade:_ Material of construction:_cast iron_40 PVC_other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:_ (locate on site plan) Depth below grade:_ Material of construction: _concrete_metal _Fiberglass _Polyethylene —other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: :omments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert. structural integrity, evidence of leakage, etc.) GREASE TRAP: (locate on site plan) Depth below grade:_ 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: / Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) revised 9/2/98 Page 7or11 v, 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART C SYSTEM INFORMATION (continued) 'roperty Address: Owner: Date of Inspection: TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ etal _Fiberglass_Polyethylene_other(explain) Material of construction:_concrete_m Dimensions: Capacity:___gallons Design flow: gallons/day ` Alarm present Alarm level: Alarm in working order: Yes _ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evid ce of leakage into or out of box, etc.) PUMP CHAMBER:_ (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) i revised 9/2/98 pAgesorII III SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) `roperty Address: � 5�,u(�,�:6, Owner: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan, if possible; excava ion not required, location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:lvt' leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: ( ote condition of s il, signs of hydraulic failure, level of pon 'ng"da soil, condition of vegetation, etc.) i �� `� I1:�0 C .r CESSPOOLS:_ (locate on site plan) Number and configuration: : Depth-top of liquid to inlet invert: 7epth of solids layer: )epth of scum layer: I I Dimensions of cesspool: C t X f r Materials of construction: V ) .sc-:u�t Indication of groundwater: tJ17 inflow (cesspool must be pumped as part of inspection)� �20�VN el 1, C Comments: (note condition of soil, signs of hydraulic failure, lev I of ponding, conditio of%7tation, etc.) v SI c ;i a 51 3l1 4.4Q V 1 St'.S�r Cl,t�\.�.Ct;v` W1,�..CcPrl.. C.OJt�. tv�r�. L�:'1C.'�.4t•L CC:'�+•��L`'j 1 �J\V� 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.) revised 9/2/98 Page 9of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) property Address: )wner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 61 revised 9/2/98 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) roperty Address: Owner: Date of Inspection: NRCS Report name jN)1) - — - Soil Type_ -- - Typical depth to groundwater_ _ _ USGS Date website visited VV3 Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope :vi"7 f Surface water i'M Check Cellar 0" Shallow wells 14 Estimated Depth to Groundwater —V�S eet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators. installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) revised 9/2/98 Page 11 of 11 TOWN OF BARNSTABLE " c. LOCATION % 7°� S�'�/D,r�rz.P_ !'Jsl/ /i%/Cf;o SEWAGE #62000 ,2— VII.LAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 777 6P-0 ¢/ � 1 i SEPTIC TANK CAPACITY f.5S00. LEACHING FACILITY: (type) ,(,— NO.OF BEDROOMS tf i BUILDER OR OWNER 6 A ii,, PERMITDATE: — // —oJ COMPLIANCE DATE: J i Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by, j f ` 10 ?� � � I TOWN OF BARNSTABLE a C'"\ LOCATION �°2 5������-° .�Y l/%1�fP SEWAGE #621000 216-2- VII,LAGE ASSESSOR'S ®MAP & LOT INSTALLER'S NAME&PHONE NO. i�4 SEPTIC TANK CAPACITY /Svv LEACHING FACILITY: (type) NO.OF BEDROOMS V BUILDER OR OWNER ieoh A ' - PERMITDATE: Al COMPLIANCE DATE: 6119106 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist . on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by /4,/, it, 33�s TOWITI OF B:V-NSTABI E LO&Vi7i ! _ Q� SEWAGE # _ VJ"1!LAGS P®!,���\ ASSESSOR'S lvLkP LLT�— LNSTALLER'S NAN E&PHONE NO. p SEIFUC TANK CASACITY QQ55 LE.kCG FACILTI"f: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER DATE: COrvTLLANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table'@''-&n.qe ff a i _ Fc Private Water Supply Well and Leaching Facilirr (Lf any wells exist on site or within'00 feet of leaching facility) L4 A Edge of Wetland and Leaching Facility (If any wetlands exist withia 3100 feet of leaching facility) Furnished by -- _-_- � � � � . 1 �L�Z - �e� .. ®� � �2 � � �- ►b,6Y (�Z a�Q�,w oil 4- 16� No. oa�7 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Rpplication for rji2;poza1 *pgmem Construction Permit Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. 1� U;elk� b Owne�r`n's_Naame,Address andcTeel.No. Assessor's Map/Parcel `'T y� Installer's Name,Address,and Tel.No. 7 4--q9 Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(Wo Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow wo gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Rinairs or Alterations(Answer w en applicable) do 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 b his Board of Health. t Signed Date le o Application Approved by Date Application Disapproved for the following reasons Permit No. "" Date Issued r� - - No. i( 0j/6 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes ` PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYication for Migozar 6pgtem Construction 3dermit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components PP F Location Address or Lot No. V h Owner�ress,qnd Tel.No. ` Assessor's Map/ParceI /a?7o 18 Installame,Address,and Tel.No. 7 7 �' ell Designer's Name,Address and Tel.No. J�4 Y !.7•-Qc� � Type of Building: Dwelling No.of Bedrooms L/ Lot Size sq.ft. Garbage Grinder ' .Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures ' .t Design'Flow 4�y0 gallons per day. Calculated daily flow gallons. !'Plan Date Number of sheets Revision Date Title Size of SeAc-Tank Type of S.A.S. Description of Soil - p Nature of R irs or Alt J rations(Answer en cable) M;M� /S o0 1-" D 44.11t 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 this Board o Hea th. y Signed /�V/ (— Date G -4, -e'o Application Approved by �`" ® r Date Application Disapproved for the following reasons Permit No. Date Issued - THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CE , that the On- ' Sewage Disposal System Constructed( ) Repaired (Upgraded(� ) Abandoned at 1`7;L l n nstructed in accordance with the provi ' ns of T' 5 and the fo Disposal System Construction Permit N J5 dated 6 16" o O Installer 7fi�''7 �o� Designer , „� _ 1 The issuance of this pe t shall be o ued as a guarantee that the sys �fu'n`ctio as de igned � Date `% Inspector r ZY97 Zo.� ————————————————————————Fee'-_ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE,. MASSACHUSETTS Miopool 6potem Construction permit Permission is hereby granted to Cons ct( )Repair(!/Upgrade( )A andon( ) System located at 1 -7 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:Constru /on m st be completed within three years of the date oft s i . ' Date: ! ®0 Approved by s �Y 1i6i99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH .kN, -D APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) L -tom t�.,bouyo hereby ce:=y that the application for disposal works construction permit signed by me dated L 11e -- o 0 concerrunQ the property located at L--1 2 meets all of the S following criteria: Fr • T'ne failed system is conne^ed to a residential dwelling only. There are no commercial or business uses associated with the dwellins. • The soil is classified as CLASS 1 and the percolation rate is less than or equal to j minutes per inch. • There are no wetlands within 100 fee:of the proposed septic system • There are no private wells within 130 feet of the proposed septic srstern • There is no increase in flow and/or change in use proposed • T-here are ao variances requested or needed. • The bottom of the proposed leaching facility•vill not be located less than five feet above the d' ma-dmum adjusted groundwater table elevation. (Adjust the goundwater table using the Frimotor me;hcd when apolicablel • If the S.A.S. will be located with'_i0 feat of any ve?etated we lands. the bottom of the proposed leaching facility will not be located less than fourteen 0 1) feet above the ma.,c rrium adjusted zoundwater table elevation, Plea.se complete the following: A) Tao of Ground Sur ace 3iriation(using GiS informacion) 3) G.W. Elevation _the A--2(. -igh G.W. Adjustment D=,RENCE 3E FWEEN a,and 3 SIGNED : D a.i E: (Sketch oroposed plan of s;se^i on backl. q::�cailh roldcr:c-t No. �9..-...-5.72- _ Fmcl; .00............ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ................TQWa...............OF...............&xt. $tAU9................................................ Appliration for Bispniial Works Tonstrurtinn ramit Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at: 2 Scudder Bay-Circler..Centerville..._02632 --•-----•---------------------•-•-•-••-------...........------------------------------•---•-...... Location-Address or Lot No. Thomas Boucher 72 Scudder Bay.Circle, Centerville 02632 ......-•-----•---------------------------------------------------------------------------- ------.... Owner Add ess Wa A & B Cess_pool_ Service 128 Bishops Terrace, 9� annis 02601 Installer Address 4 Type of Building Size Lot----------------------------Sq. feet V Dwelling—No. of Bedrooms.........._ .................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ---------------------------- No. of persons_...__2_...____.._..._.._.. Showers ( ) — Cafeteria ( ) p' Other fixtures _______________________________ _ _ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. r G4 Sgptic Tank—Liquid capacity------------gallons Length---------------- Width................ Diameter---------------- Depth.............. Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-----------------_- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_.-__---_-___---___----- Li, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -----------------------------------------------------------------------------------------------------------------------------------------------------------•- ODescription of Soil--------------54nd--•----•--•....•--------------------------------------------------------------------------•----------•-•---•------.......=.................... x U -----•---•-----------•-------------------------------•-------••-----------•------•------------------•----•----------------------------•------•••---................................................... ----------------------------------- ----------------------------------------- ------------------------------------------------------------------------------------ ......................... U Nature of Repairs or Alterations—Answer when applicable._._--_Installation- of a-_1,.000---gallon.stone__- ced, ire--c t ...(overf1gKl!.............................................................................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of i i:'�. ,. p 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 e. _3X- 8/30�79 Application Approved By...... ------------- ��c-d/� ......................---- •--- 8f... -'-a -------------- Date Application Disapproved for the following reasons:................... --------•--.. .............. ----------------------------------------------------------------•---------•--------------------------------- •------------------------------------------------------------------------------ ------------- Date Permit No.l ----------------------------------------------- Issued.......------8/30�79------•-----•----.....---- Date No._-7.9=....15.7.2, FEB...$.5,A.Q........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWn..............OF................B 33?Ti8table---------------.---.------..-..---•----------- Applira#ion for Bigpu,ial Workii Tomitrurtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at: .7.2.J'5audd_er._lay...C. .r*ala,.--Qeate=il.le•---�632 ----------------•---_----------------------------------------------------------------------------- Location-Address or Lot No. 1'hQ�n� _.Pauc x -----------.............................................. 7-2--.�cudde�.Ra:>t G�.a�l1�-��te�ui�le----026-32•- Owner Address ............................................. 128..Bishops--Te acsr--Hyatm1s-----02641•----------•---. Installer ar. Address d Type of Building , Size Lot............................Sq. feet U g— -Expansion Attic ( ) Garbage Grinder ( ) Dwelling No. of Bedrooms.- ---•----3...___•---•------------------ a yp g p ......... Showers ( ) — Cafeteria ( ) d Other—Type fixBuresi,n- No. of ersons______,2____._'b ---------....................................................... Design Flow.....................................7....gallons per person per day. Total daily flow............................................gallons. W x 9 Septic Tank—Liquid capacity?..,_,.....gallons Length................ Width---------------- Diameter................ Depth................ Disposal Trench—No. ............. Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) � Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-____-_____-____-____.-. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a --•-•...............•-------••--•••-•-•-•-•---•--•-•---•-•-••--•--•.....................------..............•---•----•--...•-•-•----....................----- ODescription of Soil---------------�d............................................................................................................................................... :- Ut 14 ----------------------------------- ` U Nature of Repairs or Alterations—Answer"when applicable-------Xhatallation...of-.a.-1,000--gallon-_.stp-ne__. paQkjad,...Prerm t_-leaah Pit--(-axedioxz ...................... ........................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TI i_ y g g p y 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. Signed-'f_ 1,= .......... r� ;. �' / 4 i C Date Application Approved By....... A ......... /30/79--------------- Date Application Disapproved for the following reasons:................------.......................................................................................... . ----------•------------------•---....------------------------.....------.....-------------------------------•-•--•-••--•••--••-•••-•-----•-------•---------•-----------••-•----•---•••••--•••--.......-- Date Permit No.79- ......._.... .. -- Issued............$/30179----------•----------•---. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........................T..own.......O F.........Barnstable................................................. Tnrtifiratr of Tomplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (X ) byA-&._B Cesspool_5erVlee,_._12_--Biahops_.Teraces,ae_.--HAnn_J ._MA.....02601.............................................. Installer at 2-.....cudder B y.Cice+ QZ� eS5�ll7e,_.MA----02632__--..Thomaa.lnucher-............................................. has been installed in accordance with the provisions of TITI! j of The State Sanitary Code as described in the application for Disposal Works Construction Permit e`__7_ . dated_....5/_30/79........................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE ..... Inspector3D--7 �-------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .....T OF....................Barns#,a.ble......................_.._............ ` - FEE$.r�..00............ �iu�ruu�il ur�� �un��rn�ion rani# Permission is hereby grantedA•&_ B.Ceesp ool__Ser y;Lca.,-..128.lishapa_Te=aea,...Hyar iS.,...Q2601 to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at No22..Scudder-Bay--Circle, Centerville,_- I!�i__02b32-----__Thoma-s..Bouaher......................................... { Street as shown on the application for Disposal Works Construction Pe it NR _-________________ Dated-------------8/30/71............ ----------------•-•-----...-•------ oarrd.Fo Ieat • 8/30/79 DATE ------:-- FORM. 1255 HOBBS & WARREN. INC.. PUBLISHERS „- LOCATION 1 SEWAGE PERMIT NO. 1--7 2 5; e VILLAGE c J-ti , INSTA LLER'S NAME R ADDRESS okV 8 U I L D E R OR OWNER 3 ' DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED r � Q G ��Rd