Loading...
HomeMy WebLinkAbout0749 SHOOTFLYING HILL RD - Health (3) 749 Shootflying Hill Road Centerville A= 192—017 iMiAD No. 2-153LOR UPC 12534 --------------- smead.com • Made in USA �OCYC(e . z S TOWN OF BARNSTABLEC LOCATION T �,�DO���1�//J�1 .� iNAGE # o2,04a2 VILLAGE C�jr°/?T tiPl/i��e° ASSESSOR'S MAP & LOT 07 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY lee© LEACHING FACILITY: (type) ��� • size) NO. OF BEDROOMS 3 BUILDER OR OWNER / PERMIT DATE: 0;L COMPLIANCE DATE: d/.2 Ld) 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 �ua P�-� . Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,w 749 SHOOTFLYING HILL RD Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is CENTERVILLE MA 02632 9/9/07 required for State Zip Code Date of Inspection every page. City/Town Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out �� forms on the computer,use 1, Inspector: only the tab key 1 s. to move your MICHAEL DEDECKO CC1 l cursor-do not 7Name of Inspector use the return key. COMPASS REALTY DEV CORP Company Name l P.O. BOX 2384 Company Address rf- _M_ASHP_EE MA �02649 T-- ; Brtan City/Town StateIp Code 508-221-5003 1 Telephone Number License Number C37 B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 9/9/07 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 749SHOOTFLYING HILL RD-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 f Commonwealth of Massachusetts .Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 749 SHOOTFLYING HILL RD Ji—rope Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is CENTERVILLE MA 02632 9/9/07 required for State Zip Code Date of Inspection every page. City/Town 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. [J 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 749SHOOTFLYING HILL RD•06/06 n Commonwealth of Massachusetts Title 5 official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 749 SHOOTFLYING HILL RD Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is CENTERVILLE MA 02632 9/9/07 required for — -—— State Zip Code Date of Inspection every`page. Cityrrown B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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 oard of Health (and Public Water Supplier, if any) 2. System will fail unless the B 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, and the SAS is within 50 feet of a private water ❑ The system has a septic tank and SAS supply well. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 15 749SHOOTFLYING HILL RD•08106 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 749 SHOOTFLY_ING HILL RD Property Address C/O TODAY_R_EAL_ESTATE_ DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is CENT ERVILLE MA 02632 9/9/07 required for - -- --- -- State Zip Code Date of Inspection every page. City/Town B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 El due to an overloaded or clogged SAS or cesspool El ® 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 '/2 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. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 749SHOOTFLYING HILL RD•OBI06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 749 SHOOTFLYIN_G HILL RD Property Address C/O TODAY_ REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is required for CENTERVILLE MA 02632 9/9/07 ---_--.-- ------_--..--_.-- every page. City[Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): 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. 749SHOOTFLYING HILL RD•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form 'Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 749 SHOOTFLYING HILL RD Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is required for CENTERVILLE MA 02632 9/9/07 —.._...—.__ 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? ® El available 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. ® El approximation 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)] 749SHOOTFLYING HILL RD•06/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w„ 749 SHOOTFLYING HILL RD Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is required for CENTERVILLE MA 02632 9/9/07 _.. every page. CityrFown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 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 d N/A 9 ( Y 9 (gpd)): Sump pump? ❑ Yes ® No N/A 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: Last date of occupancy/use: Date Other(describe): 749SHOOTFLYING HILL RD•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts 7. Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 749 SHOOTFLYIN_G HILL RD Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is CENTERVILLE MA 02632 9/9/07 required for --- ----- every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: N/A 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) El maintenance technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: N/A -- - Were sewage odors detected when arriving at the site? ❑ Yes ® No Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 749SHOOTFLYING HILL RD•08/06 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 749 SHOOTFLYING HILL RD Property Address C/O TODAY REAL ESTA_TE_DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is CENTERVILLE MA 02632 9/9/07 required for --_ ----- ----- every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron ❑ 40 PVC ❑ other(explain): Town water Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): joints tight, yes vented, no sign of leakage 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 ------------------------------------------------------------- 1500 GAL Dimensions: 2" Sludge depth: 32" Distance from top of sludge to bottom of outlet tee or baffle 1„ Scum thickness Distance from top Of scum to top of outlet tee or baffle 11" Distance from bottom of scum to bottom of outlet tee or baffle 14" MEASURED How were dimensions determined? 749SHOOTFLYING HILL RD•08/06 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 ,M 749 SHOOTF_LY_ING HILL R_ D Property Address C/O TODAY REAL ESTATE D_ AVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is CENTERVILLE .. ---.-._-- every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): NO NEED TO PUMP,TEES INTACT,STRUCTUALLY SOUND,LIQUID EQUAL WITH OUTLET INVERT,NO LEAKAGE Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions. Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 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): 749SHOOTFLYING HILL RD•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 749 SHOOTF_L_Y_I_NG HILL RD_ Property Address C/O TODAY REAL ESTATE_D_ AVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is required for CENTERVILLE MA 02632 9/9/07 - - ----- ----- - every page. City/Town 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: Date 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 EQUAL WITH OUTLET INVERT 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 LEVEL AND DISTRIBUTION EQUAL, YES SOLID CARRYOVER, NO LEAKAGE. Pump Chamber(locate on site plan): Pumps i:i working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 5 749SHOOTFLYING HILL RD•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 749 SHOOTFLYING HILL RD Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533'FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is required for CENTERVILLE MA 02632 9/9/07 --_--------- -- every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): S ' Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: a 0 leaching pits number: . . 2 I Z leaching chambers number: El leaching galleries number. p� ❑ 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.): SOIL SAND/GRAVEL, NO SIGNS HYDRAULIC FAILURE, PONDING DRY, NO DAMP SOIL, VEGETATION NORMAL Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 749SHOOTFLYING HILL RD•08/06 Commonwealth of Massachusetts • Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 749 SHOOTFL_YIN_ G HILL RD Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632, Owner Owner's Name information is CENTERVILLE MA 02632 9/9/07 required for ------- every page. City/Town 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.): s 749SHOOTFLYING HILL RD•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 749 SHOOTFL_Y_ING HILL RD Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is required for CENTERVILLE MA 02632 9/9/07 -. ----- every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. I LA- • • a i 1—i G Gz- y .4 t � t 749SHOOTFLYING HILL RD•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 y Commonwealth of Massachusetts 4 .. . Title 5 Official Inspec tion Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 749 SHOOTFLYING HILL RD Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is CENTERVILLE MA 02632 9/9/07 required for - - State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells 70.00' Estimated depth to ground water: 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: BARNSTABLE GIS You must describe how you established the high ground water elevation: BARNSTABLE GIS 749SHOOTFLYING HILL RD-08/06 Title 50Uicial Inspection Form;Subsurface Sewage Disposal System•Page 15 of 15 Town of Barnstable OF INE l0� p� ti Regulatory Services ti� a Thomas F. Geiler, Director BMWSfABLE, 9$A �9 •0� Public Health Division lED MA'S A Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report;this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the "Disposal Work Construction Permit". If you should have an questions regarding this re y y q g g s port,please contact the certified Septic System Inspector who conducted the inspection. I ` �Z- 1 -1 a LOCATION S GE PERMIT NO. -7y9 �q/, o v Vl'tL A G E INS�TA�LLER'S NAME A ADDRESS 1/V, Ion N �> tj s U 1 l D E R OR N`ER 1 �J"t DATE PERMIT ISSUED -2 G DATE COMPLIANCE ISSUED '.� A � � � // il � / � � � � � �� � r �� �� !�Q � �- � �. , � ,� . t . t:, U7 R o�....-S�....'Arm ........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........................ OF..... .... r... .................................... Apptira#ion for Disposal Works Tonstrnrtion thrmit Application is hereby made for a Permit to Construct {�) or Repair ( ) an Individual Sewage Disposal System at: Location-Address �P /{'p�' o t�e..� caner - Address •-•-•-•-•--- ------ . ...... - .................................. ----•-•--•----------•----••--•-----------------------•---•--_____'-- --•-•-•-•- Installer Address /l U Type of Building Size Lot... fps ®..Sq. feet �-, Dwelling-No. of Bedrooms...........•................................Expansion Attic/ Garbage Grinder Other—Type of Building ............................ No. of persons............................ Showers ( . ) — Cafeteria ( ) Q, Other fixtures = W Design Flow...................... ......_..__..gallons per person per day. Total daily flow............... .__...._...._...._..gallons. WSeptic Tank—Liquid'capacity. tW4allons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length..................... Total leaching area....................sq. ft. Seepage Pit No..._......I......... Diameter....... 'v? ..... Depth below inlet........ Total leaching area... .4_....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results,� Performed by.__... J�9.-�C. _ -....AI.? -0....... Date... ' __- ....... Test Pit No. L ... minutes per inch Depth of Test Pit..... ...... Depth to ground water._s,��✓e®".��. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -------`'-----------------------------------------•----••-•••--------._...--••-- i 1 O Description of Soil....----•�.....=-E2=------..__� �V������� ----- .... ...............�-----•- ''--a 4.. Wp� ............C... -f 7..... - b --------------------------------------------------------•----•-------------.. UNature of Repairs or Alterations—Answer when applicable............................................................................................... ------------------------------------------•-----•-•--------------------------------.........-•------------------------------------------------••------------------------•--•--------•--•Agreem ent: The undersigned agrees to install the aforedescribed Individual Sewage Disposal,System in accordance with the provisions of TITL 11 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iss ed by the board of health. Date LD Application Approved By•• . ------------------------------------------------- fate- _ — , Date Application Disapproved for the following.reasons:. . --------•-----------------------------------•-------------•----------------•------------------..._•••-.._.._ ..--•-••--•......................•----------•--------------....--------------------......--•---------•----•-•--••••--•---••-•-••-••-•••-•-•-•••••---------•-}-.•••-•-••••------•••-••--•---••-•-----•--- Date PermitNo..... l �..................................... Issued...................................................... Date l�� ,, THE,C,OMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF..... ..................................................................................... Appliration for Bispaii al Works Tonstrnrtion Famit Application is hereby made for a Permit to Construct ) or Repair ( ) an Individu Sewage Disposal System at: �� � ............... ........... ......... -....---- ............_._..L...S;?.. ... .....t:...._............__.........— ........_...__.................... Location-Address F s r f ner r Address ............ -^-- ! _� �'.................................. .................................................................................................. Installer Address �; U Type of Buildin Size Lot... t.�Z-✓-�-�":� ..Sq. feet Dwelling—No. of Bedrooms............ D...........................Expansion Attic Garbage Grinder (lam aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures ----- ------------------ ---------------- - - -- --------- ------ ,,r... WDesign Flow...................... .........____.gallons per person per day. Total daily flow--------- ' _`?....................gallons. WSeptic Tank—Liquid capacity.V_k!tallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area--------------.-----sq. ft. Seepage Pit No.____---.----------- Diameter........ ... Depth below inlet....... ......... Total leaching area.33- ---sq. ft. Z Other Distribution box ( ) Dosing pk a Percolation Test Resujts'i4_. Performed b ...._ _:' ._I. .?_. .�_:'� - -•---- /�a- �� �� Y w. �: Date-- ---P-•--•••. Test Pit No. %................minutes per inch Depth of Test Pit.vi. ...... Depth to ground water..01%'�t"... C;�1 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ D Description of Soil �"''.? r a 'J'J?!'j �a4 ` �a� ' ..... r t - v --..... ..........; ...........` ` ! f „r, '----------------------------------------------------------------------------- VW ---------------------------------------- --------------------------------------------------------=----------------------------------------------------------------------------------------------------- Nature of Repairs or Alterations—Answer when apply"cable...........................................................................................:... ....................................-..........-................................................................................................................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be n issued by the board of health. Signed........ - Application Approved BY----........ - •: ...---•.............................•-----•------.- _" __ Date Application Disapproved for the following reasons-............................-..............................................------ ............................. ..............................................-•--••--•-----------••---•-•-------•••----•----.....-•------•-••-•-----------•-•••-•------•-•--••-•-•-•---•--•-••-----•-•----••------••......--••-•----- Date PermitNo.---._...... i-.....--�----•-----•---.... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Tn#ifiratr of TiantpliFatta THISAIS T (CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by............P'"� ��`?................. ........_.....-------------------------- ----.. ............................................................................. ----- -------- -- ----- t. J �` I sta ler has been installed in accordance Ali the provisions of TITLE 5 of The State Sanitary Code as scribed in the application for Disposal Works Construction Permit No.._�a�= ���'£�----•••••• dated---1_2'����.................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTIJON VATISFACTORY. DATE.................................. ................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD, F�HEALTH - .. _.. ... ?" ..........OF...........:..:... ............lv � k 1=-..................... ca N a_'" �.... FEE.J. ............. 1i011rrs�)' r �nn #rnrimrn Prnti Permission as hereby granted -.... .............._.....--------------------------------------------------.....--------------.............---.... to Construct ( ) o>�Repa r (� an Individual Se 'age Disposal System ------------------------- Street as shown on the application for Disposal Works Construction Permit No _���-�?�_ Dated.....�.�' •-�r�-/! ........... ^• Board of Health DATE--------- --- =----r-'---- ------- 1-��-------------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS s'iz!'l 4it ZQ 7.4 1� ,1�c%�T���G.e�P�GE G,��,r/.�GYZoa•�f .: � /.�3 9�, � qg .3' ice_ SG.P.D _? �• gyp.. �� 1' T , 1Ef/c �.4iV/� 3�e� .tr�cs%"o =�+60. !n�?o 1 E n 8y 1 94 ToT%4 OL �7a 24 TL1V 141ram G, :4 LASS yG 8 g 1 x 8�P�tN OF `/7 Z/ j�k?, STANIL 7 PETER"i �� tN OF SULLIVAN, �,; �'.' RiCHAAD: ► o BAXTER Nov24048 -- �FSS/LtT't!l EN�`��., 9�c, ;�KQ� z't , A,2o E. SSA JB:c� G t::Z 4?; LSc�3So�C_ �. a5 ) PvG� s •� A/i/. r, ✓ %rao 64L / Box /.v✓. G.4L.! + Ta•vrc v G'.E.2T/F/EO PG OT pl-A ll } /Z d 4-3 GE.er/, Y 7 4T'T.�,�E' H!.t/ yE,� � 4 r a o -vim Eav;,GOM�Gys It/TXiTHE.Sid�;c;j,�E - ,2E6isr�.ec=�.L4rvv.S!/,2vEya,� T,oN!w oF.� �.✓s�.µr�c.�.aw� i.S �cio�- �c GFSr�,2li/L LaCQrE..o,GI//Tf//�/: T.�.�.E FL�taOPG.4/�/, • •shy l f/i�/,�E.e�aN.,Sfv�0O0��/pT l�,E USEp