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HomeMy WebLinkAbout0075 WINDLASS LANE - Health 75 Windlass Lane Centerville P 192 076 �9Z8Ctmo 'PC 12543 !o.53LOR p�nC0�5�: '-ASTINGS,MN f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 WINDLASS LN Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is CENTERVILLE MA 02632 10/11/07 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. i Important: A. General Information When filling out (a forms on the computer,use 1. Inspector: only the tab key to move your MICHAEL DEDECKO cursor-do not Name of Inspector use the return key. COMPASS REALTY DEV CORP Company Name � P.O. BOX 2384 Colinpany Address MASHPEE MA 02649 ^ Cit'y/Town State Zip Code i 508-221-5003 ^s - Telephone Number License Number } B. Certification = ` I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection_The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section,-15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 10/11/07 In Jec 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. 28 GENERAL PATTON•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form 7. Subsu Mace Sewage Disposal System Form-Not for Voluntary Assessments w y 75 WINDLASS LN Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is CENTERVILLE MA 02632 10/11/07 required for State Zip Code Date of Inspection every page. Cityrrown 1 B. Certification (cont.) i i 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: i 13 S stem Conditional) Passes: Sy y El 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: i 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 28 GENERAL PATTON•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 + _ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 75 WINDLASS LN 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 10/11/07 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: i ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The f system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed i ND Explain: C)! Further Evaluation is Required by the Board of Health: 0 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. 28 GENERAL PATTON-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 75 WINDLASS LN Propertyl Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's�Name information is CENTE required for RVILLE MA 02632 10/11/07 every page. Cityrrow,n State Zip Code Date of Inspection i t B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑I 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". i Method used to determine distance: I **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. I 3. Other: j i 1 D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® Discharge or ponding of effluent to the surface of the ground or surface waters I 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 /Z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: Y ❑ ® 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. 28 GENERAL PATTON•08/06 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 75 WINDLASS LN Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is CENTERVILLE MA 02632 10/11/07 required for every page. City/Towli State Zip Code Date of Inspection I 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 falls. 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 f 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. I 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, on 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. 28 GENERAL PATTON•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 75 WINDLASS LN 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 10/11/07 every page. City/Towm State Zip Code Date of Inspection i 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? i ® Has the system received normal flows in the previous two week period? Q ® 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 ® 11 available note as N/A) f ® ❑ 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)] 28 GENERAL PATTON-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 i Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 75 WINDLASS LN Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is CENTERVILLE MA 02632 10/11/07 required for State Zip Code Date of Inspection every page. City/Town D. System Information Residential Flow Conditions: i 3 Number of bedrooms (design): 3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 i 0 Number of current residents: 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 . I Seaasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage(gpd)): N/A 9 ( Y 9 i Sump pump? ❑ Yes ® No Last date of occupancy: Date _ f 1 Commercial/Industrial Flow Conditions: 1 I -Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): i 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): 28 GENERAL PATTON•08/06 Title 5 Official Inspection Form: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 75 WINDLASS LN 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 10/11/07 every page. cityrrown State Zip Code Date of Inspection i D. System Information (cont.) General Information Pumping Records: Source of information: N/A I I Was system pumped as part of the inspection? ❑ Yes ® No i If yes, volume pumped: gallons How was quantity pumped determined? Re son for pumping: Type of System: ® Septic tank, distribution box, soil absorption system l ❑ 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) ❑ Tight tank. Attach a copy of the DEP approval. I❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 20,01 Were sewage odors detected when arriving at the site? ❑ Yes ® No 28 GENERAL PATTON•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i 75 WINDLASS LN 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 10/11/07 every page. Cityrrown State Zip Code Date of Inspection i D. System Information (cont.) Building Sewer(locate on site plan): 20 Depth below grade: feet Material of construction: I El cast iron ❑ 40 PVC ❑other(explain): Distance from private water supply well or suction line. Town water P pp y feet Comments (on condition of joints, venting, evidence of leakage, etc.): joints tight yes vented no sign of leakage. i I Septic Tank(locate on site plan): e Depth below grade: feet Material of construction: t ❑Iconcrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) i If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- 1000 GAL Dimensions: 4 Sludge depth: ; Distance from top of sludge to bottom of outlet tee or baffle 30" 1 Scum thickness 11" - Distance from top of scum to top of outlet tee or baffle -- Distance from bottom of scum to bottom of outlet tee or baffle 14" MEASURED How were dimensions determined? 28 GENERAL PATTON-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 °w 75 WINDLASS LN Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is CENTERVILLE MA 02632 10/11/07 required for State Zip Code Date of Inspection every page. City/Town 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 i Material of construction: i ❑;concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): I I I Dimensions: i Scum thickness i 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, lig6id levels as related to outlet invert, evidence of leakage, etc.): I I Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): I Depth below grade: Material of construction: concrete ❑ metal ❑fiberglass Elpolyethylene ❑ other(explain): 28 GENERAL PATTON•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 75 WINDLASS LN 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 10/11/07 every page. City/Town State Zip Code Date of Inspection D. Sy'istem Information (cont.) Tight or Holding Tank(cont.) Dimensions: i • Capacity: gallons Design Flow: gallons per day i Alalrm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No 1 I Date of last pumping: Date I Comments (condition of alarm and float switches, etc.): i i I *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): EQUAL WITH OUTLET INVERTS Depth of liquid level above 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 in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 28 GENERAL PATTON•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 M 75 WINDLASS LN 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 10/11/07 every page. City/Town State Zip Code Date of Inspection i D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): I I i Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: I i • f Type: I leaching pits number: i leaching chambers number: 4 LLJ 1 leaching galleries number: i 1 leaching trenches number, length: I leaching fields number, dimensions: i 0 overflow cesspool number: F 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, 28 GENERAL.PATTON•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 J • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 WINDLASS LN 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 10/11/07 every page. Citylrowh State Zip Code Date of Inspection i 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 l Depth of solids layer Depth of scum layer i Dimensions of cesspool i Materials of construction i Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): f f. Privy (locate on site plan): Materials of construction: i Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 28 GENERAL PATTON•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsu ;dace Sewage Disposal System Form -Not for Voluntary Assessments 75 WINDLASS LN Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is CENTERVILLE MA 02632 10/11/07 required for 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. " is rA i i i o i 28 GENERAL PATTON-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 Commonwealth,&Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments aM 75 WINDLASS LN Property Address C/O TODAY REAL ESTATE DAVID HOLT 1533 FALMOUTH RD CENTERVILLE MA 02632 Owner Owner's Name information is CENTERVILLE MA 02632 10/11/07 required for every page. Cityrrown State Zip Code Date of Inspection i D. System Information (cont.) Site Exam: i ®; Check Slope ® Surface water ®' Check cellar i ❑j Shallow wells Estimated depth to ground water: feet feet Please indicate all methods used to determine the high ground water elevation: f ❑ Obtained from system design plans on record i If checked, date of design plan reviewed: Date Observed site (abutting property/observation hole within 150 feet of SAS) I Checked with local Board of Health -explain: 1 Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: BARNSTABLE GIS You must describe how you established the high ground water elevation: BA, RNSTABLE GIS 28 GENERAL PATTON•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 Town of Barnstable �p THE Tp� Regulatory Services ,n�vsrnat E Thomas F. Geiler, Director �$ 9 A•�� Public Health .Division ATED MA'S 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 any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. TOWN OF BARNSTABLE / LOCATION. ` 75p ZI7 SEWAGE # 0?00/ c i�ILAGE L�✓i rry�/�� ASSESSOR'S MAP & LOT/q;Z 47 7! INSTALLER'S NAME&PHONE NO. S' SEPTIC TANK CAPACITY /r9 a ti LEACHING FACILITY: (type) ,7H lfv�r f3 of (size) /0•Y P'X a NO.OF BEDROOMS .3 BUILDER 0 OWNER PERMIT DATE: 3 O COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leachinig Facility (If any wells exist r on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 fe flFaching facility) Feet Furnished by 1 1p ` 0/��3�` 2, io La�av-s -7y ° 13 �� .370 39 ys- TOWN OF BARNSTABLE L©CATION C��# s �i �-�- .ram \a.Ss \� , SEWAGE # VILLAGE ASSESSOR'S MAP & LOT � INSTALLER'S NAME & PHONE NO. cN e'er SEPTIC TANK CAPACITY I o D c, LEACHING FACILITYAtype) J (size) Cn O0 �NO. OF BEDROOMS PRIVATE WELL OR UBLIC WA ' BUILDER OR`OWNER DATE PERMIT ISSUED: DATE . COMPLIANCE ISSUED: :Z2 VARIANCE GRANTED: Yes No r / /// ` �` y0 F .��� / '/ � �, S� 6 � o S- i� �,9. �� { �� t 1 I COMMONWEALTH OF MASSACHUSETTS r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION IWAP PARCEL LOT TITLE 5 = y OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESS ENTS� SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM,;,' --a PART A o � ' CERTIFICATION Property Address: 73 W,rd iC4 5 s uy< rn CQ h t✓:/i l A /1/1 �7 Owner's Name: 09n d"e /1" .e. Owner's Address: Date of Inspection: $—//—ON Name of Inspector: (please print J&4 , r� /I.; �fv Company Name: >�h �f i:c/r��e Srr✓� t� Mailing Address: IS2 tf/ HK f T /ga' v.7; /V/"/ls /Y/;l Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title_5(310 CMR 15.000). The system: t/Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of I I i OFFICIAL INSPECTION FORM—N0--TOR'VOLUNTARY ASSESSAVM,S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:- 7.f -41,i d lass / Owner: _�.nc(r Rouen e 1 J. Date of Inspection: _$—//— O Y Inspection Summary: Check A,B,C,D or E/ALWAYS complete`aH ulS tlo9 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 faihu+e 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;ou;.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 distribution box is leveled or replaced ND explain: The system required pumping more than 4 tines 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: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL:SYSTEM INSPECTION FORM PART I.. CERTIFICATION.(continued) Property Address: 733- -e _ con'er t/i .• � 114�7 Owner: _gh,4A-e /t'uye.11e//0 Date of Inspection: $— //—o y 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. _ 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 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,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of I 1 r OFFICIAL INSPECTION FORM—NOT,]FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL�SYSTEMINSPEC"TIONYORI,*, PART.A CERTIFICATION.(continued) Property Address: .-Wi.. IASS *e?,e n v," ,p Owner ti ye Rc-,-e-,e lea Date of Inspection: $ —/ —'O`l D. System Failure Criteria applicable to all systems:. ....,,, You must indicate"yes"or"no"to each of the following for all inspectioi s� Yes No V Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool V 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 v,'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. t/ 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. e/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 theAvell water analysis, performed at a DEP certified laboratory,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,provided that no other failiwe criteria are triggered.A copy of the analysis must be attached to this form.) (Yes/No)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 tocon=t the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 000 gpd to 15,000 gpd. 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) 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(Lnterim 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. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL:SYSTEM INSPECTION FORM PART B 'CHECKLIST Property Address: 7,S W,,Na la SS con er (// ; Owner: AAver /la Date of Inspection: $—//—o ll 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? i/ Were as built plans of the systerri obtained and examined?(If they were not available note as N/A) V/_ Was the facility or dwelling inspected for signs of sewage back up? _ Was the site inspected for signs of break out? ryGl �+r Were all system components,excl�mg tgie 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 jSAS)on the site has been determined based on: Yes no ✓_ 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(3)(b)) Page 6 of 11 OFFICIAL INSPECTION.FORM—NOT FOR"VOI UNTAkY ASSESSMENTS , SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM:INFORMATION Property Address: ZfUlln u s aH� 1 /v A49 Owner: n v ✓ yr Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): -3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x It of bedrooms): '330 Number of current residents: Does residence have a garbage grinder(yes or no): At* Is laundry on a separate sewage system(yes or no):_ o [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): Water meter readings,if available(last 2 years usage(gpd)): Nf o cca.,rI4 beca,%,,, ,F 51t,..k lt.s Sump Pump(yes or no): Al Last date of occupancy: scc a ,.t� COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): RDd Basis of design flow(seats/persons/sgft,etc.): 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/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: wr- W. 10G• Was system pumped as part of the inspection(yes or no):-Ale 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) Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components, date installed(if known)and source of informati9n: 3A_4 X-h iA'srlIi/ /o-2- $'9 ,51l5 'f Q'Bax /MST•►11d 3 -/6-0/ Were sewage odors detected when arriving at the site(yes or no): Nit 6 Page 7 of I 1 OFFICIAL INSPECTION FORM,NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 7S Gl/h o�lasS 1 AHe r yi/Ji /y1 Owner: A , ve.�, Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: ,;;el" Materials of construction:_cast iron 40 PVG_other(explain): Distance from private water supply well o ion line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_(locate on site plan) Depth below grade: IS' Material of construction: concret _metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: $ S Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: '51 Scum thickness: 31„ Distance from top of scum to top of outlet tee or baffle: .Distance from bottom of scum to bottom of outlet tee or baffle: i 2 How were dimensions determined: Mta s 4 r j-2 :R n of Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leaks�e,e�v: C.�l 7A••k /'S �,r✓c , 0$C- Jn �r q .S041 7 . COh� I11Dh /r.C{�r 4w+a� 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(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 75"W n J)aPs5 L A ti 2 Owner: r, let.� Q Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron 40 PVC_other(explain): Distance from private water supply well o ton line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_(locate on site plan) Depth below grade: I8 Material of construction: Cconcr]Q,_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: $ S Sludge depth: C) .2 Distance from top of sludge to bottom of outlet tee or baffle: '31 Scum thickness: _ Distance from top of scum to top of outlet tee or baffler , Distance from bottom of scum to bottom of outlet tee or'6afpe: How were dimensions determined: Mea s 4r,A2 .P vof Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leaksge, e C. / C l� 7a4oJ" j • Catic1� UD+1 lryCA� �'il�'//� 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(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 9 of 11 OFFICIAL INSPECTION FORM.—NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE,DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 7S— W.,+a(lass ,�A•+e Owner: ,47o v e.,a la Date of Inspection: X SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explainwhy:: Type leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: ✓ leaching fields,number,dimensions: /a'x 3 0 L x z' v<.. overflow cesspool,number: innovatMJalternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): �1 'JNf�III~N/,prs �1a •liQ.u�;J VN Sre� C�V•L'� ta�+%C� �� l��� pbOvt. /3allvn� 7��'O Ar 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 or 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.): 9 Page 10 of 11 OFFICIAWNSPECTION VORM:;-NOTFOR,V-bEUNTXAY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSA 'SY41tA INSPECTIONFORM PART C f.•:: • SYSTEM INFORMATION(continued) t Property Address: 7,f W" /o arQ. • Con Br v:/ � /NA ' Owner.�N�ko avQr, //G Date of Inspection: 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. . �..feY b"' lion °al 1 47 Z� Yr ca✓�rs , 3 bg 39 � .7. of Sl�S 10• Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS . : SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM C SYSTEM INFORMATION(continued) Property Address: 7S W.ra��att 1— Gh'7 Owner:�ro�v� l�av a.-r v lIq Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 17. Ifeet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) L.-Checked with local Board of Health-explain: al b.'11 IP14,ws ':on. ,B"H Checked with local excavators,installers-(attach docume tion) 7 Accessed USGS database-explain:j-o g, s ctsSPSsovs /o.f E�e�u7'v~s You must describe how youe est�a!blished the high/gro�+und water elevation: a u sfi.�dt 4214 to n--d a-a je 17, 3 tf5,45 y�.. // . Cs Jh�+ S S /d A �4t S„Q hCs T -/S 11 .r No. / ."' Fee J v THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: . • Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Application for Mi,5poga1 *pttem Cow6truction 3dermit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. ., Owner's Name,Address and Tel.No. Assessor's Map/Parcel 2� *-7ii Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �o. %.x �3 3 9 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 330 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 Repairs or Alterations(Answer when applicable) NSloll nrw Z_-4ok•�% /y 7 1 d KL 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 issue y is Board of Health. Signed Date ` Application Approved by Date b Application Disapproved for the following reasons Permit No. Date Issued 3 16 0 �,...;..a. .__...o_....... ... _ TOWN OF BARNSTABLE ( -- LOCATION SEWAGE # a?0°/ 'i5 T VILLAGE ,:�'&, 7 11'e ASSESSOR'S.MAP & LOT./`�oZ -�O-7�; INSTALLER'S NAME.&PHONE NO. SEPTIC TANK.CAPACITY LEACHING FACILrrY: (type) T �fy�rf�if (size) /° j NO.OF BEDROOMS 3 i ELP,I,'u'ER O OWNER _ PERMTT.DATE: COP IPLIANCE DATE: 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.fe f' aching facility)._ Feet. C Furnished b y ;i 1 CA �= .r .,. .! .. 77 1 ' 0 io / 3 D� yy s� y .7 y 13 �8 30 ys Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in compute% ' PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE,,, MASSACHUSETTS Ye 0(pprtcation for Mi.5pogar *p!5tem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. � Zh Owner's Name,Address and Tel.No. Assessor's Map/Parcel I,,- &7-0-5 Installer's Name,Address,and Tel.No. / Designer's:Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 330 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 Repairs or Alterations(Answer when applicable) ��S>­11 5 o ux LF Y 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 issue215Z Board of Health. Signed J C_ _ Date Application Approved by Date 3 D Application Disapproved for the following reasons - Permit No. '7,ee — 1 1—7 Date Issued 16 0 ----------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance - f THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( ) Abandoned( )by at L �^ has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated 3 '//5—U1 Installer Designer The issuance of th7i �eriniip shall not be construed as a guarantee that the syst n711 io as deli�{ed. Date 3 6 Inspector —� '�`�t��� r --------------------------------------- 4 No. — /S 7 Fee y THE COMMONWEALTH OF MASSACHUSETTS _ PUBLIC HEALTH,DIVISION - BARNSTABLE.;MASSACHUSETTS Migpool *p-�tem Con5tru -ion Permit Permission is hereby granted to Construct )Repair( ) pgrade( Ab ndon( ) System located at 7 ���'�/G fJ `` j cav and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction lust a completed within three years of the date of thi. ermit. 0/ Date:, 3 / Approved by� 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) L hereby certify that the application for disposal works construction ermit si ned b me dated ;3--/a/" 0 P g Y , concerning the property located at ell& meets all of the following criteria: • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There are no wetlands Within 100 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation..[Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation (.using GIS information) [� B) G.W. Elevation 3�— +the MAX. High G.W. Adjustment. = 3 DIFFERENCE BETWEEN A and B j SIGNED : DATE: [Please Sk proposed plan of system on back]. 'NOTICE Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert 1 a l�- a '�X3o � Xa G. i ,M W 7G No Fxs ...���... TiiE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ................... ..+NA..............of.BP, .ti4_5..75M&L__C __-____......................... ApphrFation for Dispas al Works Tonstratrtion Prrutit. Application is hereby made for a Permit to Construct ( or Repair an Individual Sewage Disposal sal System at: C --�1-------�-----------------••---....•-------------- L ,in-Ad ess or Lot l�S ---------------------------- ------..0-_-�O `-----��T� ��-----------........................................... Owner Addre .60Y Installer Address Type of Building Size Lot__162)_ _----Sq. feet U Dwelling—No. of Bedrooms.___.__................................Expansion Attic ( �j Garbage Grinder 4 b Other—Type of Building No. of persons____________________________ Showers — Cafeteria Q' Other fixtures ____________________________ W Design Flow...........67.� ........................gallons per person p:!er day. Total daily flow.......... _0___.._____________ lons.� WSeptic Tank—Liquid*capacity _gallons Lengthb_: __ Width*_G.__._ Diametet... ....... x Disposal Trench—No..................... Width.................... Total Length............__i_... Total leaching area....................sq. ft. Seepage �/ p .._. Total leaching area ._ q- ft. Other Distribution box See e Pit No..___.__-5.-._tl_.____. Diameter Depth below Inlet_3.:......._. .s z �% Dosin tank (j 4) '-' Percolation Test Results Performed by Date__.Qa`G"8 Test Pit No. 1---L:2....minutes per inch Depth of Test Pit.... ............ Depth to ground water..aQ ___�. A.eoo&ewf Q ( Test Pit No. 2.... __._minutes per inch Depth of Test Pit....L.l............ Depth to ground water______f.t_____________�-------------------------- --------------------------------------------------- ._....... .._._..... O Description of Soil_TA" 17 J0.=Z. -. ta.A 4_!.�__ �_3._. �_µ --_--i`� O_ tiL4_ .---•��i--- ..------ .1 _Z.Q-Z_�-�.5_.'Z`3.��►_1_5_ 40a7__ 0+�s J r_ane).:-S�l�_�_'_t_!__�fz54-_ E:tT��9> -QQ V Nature of Repairs or Alterations—Answer when applicable............................................................................................... ------------------------------------------------•-----------------------•-•.._..---......-------------•----....----•-----•---•----------._...-------------••........................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has n issued by the board of lth. Signed- ............. G` -' ?-----------• ..._ Dat ....... �...Application Approved B -----•__-__-•----•----• Lf Date' Application Disapproved for the following reasons:................................................................................................................ _........-•--••-----------•--•------------------------•----------•------......------------.._..---------..__.........•-•...----•-----••---------•------••------•--------•--------•--------•--•-------••-- Date ...�..i----------------- Issued_---------•---------------.._.._....._.... --------•--- Permit No.:........... Date Fimic THE COMMONWEALTH OF MASSACHUSETTS . 0 A BOARD OF HEALTH .._-. -Jv 1.�..............oF..��r�.1�:.t.3,`? ---._�_................................ Appliration for Disposal Works Tonutrurtiun rrutit Application is hereby made for a Permit to Construct ( kor Repair ( ) an Individual Sewage Disposal System at:, C •Location,-Addres or�YD,j No. ....- -•- --•-- -._....... n y v-______________________________ ! 0...eOP ..Q........6..._Addrp�s /T��I//� Installer Adeddrr•�eessss d Type of Building Size Lot... G.)-g ?_...Sq. feet U a Dwelling—No. of Bedrooms________5--------------------------------Expansion Attic (M�; Garbage Grinder (9)j aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures --------------•----------.................................................... W Design Flow............. ______________________gallons per person perr day. Total daily flow............ ._._ .............. 9 Septic Tank- Liquid capacity_ gallons Length. :_ ... Width. Diameter:---D-- Depth_.:�­ Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..........1---------- Diameter.......� � ...... Depth below inlet ` _ et-_—- ........ Total leaching area.. 2---sq. ft. Z Other Distribution box (�� Dosin ank (g)j '-' Percolation Test Results_ Performed ; Date...`2'.��?'8� a Test Pit No. L__. _ _.__minutes per inch Depth of Test Pit.....U........._._ Depth to ground water..�L�.__�_ �Oul-,&e rX4 Test.Pit No. 2..... _...minutes per inch Depth of Test Pit.....1. ............ Depth to ground water....................... O Description of Soi1-•--�- - :..Q. =9h11 - Z_ ,A 1.A----`�--u_C3so-r:.t_._32 3---V=-KAL �r ti;a S .t ti ;_..- ..: �. 4�-J , C_i114 sC;._`f i !!.................f \ ...----•-. ......... S . W _ __p %. h t Oa 1�- '? JS! t�t,7 ' ! ( ��_1_j - - x ---• ------------------------- --------- ----- --- - U, Nature of Repairs or Alterations—Answer when applicable.............................................................................................. . ..----:-•.•••------------•••••-------••••--•••--------•---•---•--•-••-------••--•-------....-•-------------------------•---••---•-•-------••••••--•--•-••••-------••-•••-•---•----•--••-•------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal. System in accordance with the provisions of TIIt LE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has-b,-7 issued by the board of health. Signed. ----•--- cr 3_:..---- --- Application Approved By.: D Da e Application Disapproved.for the following reasons:---•-----------------------••---------------•----------......-------------------•----------............---_•---- ....•••••-----------•......--••••-•---------------•---•----....••------•.....•------....----------------•------------•••-•---•------••••••---------•-•----•-•---••-------•......---•••--•-----...------ Date Permit No.------. ... - - .=�----•.../ ............... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BARD' OF HEALTH .. ? .'�F.........OF.........: ........................................... �r�rtifirttt.� ,af f�nut�rli�anr�e THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) � -.....---•----- --•-••--------------------•-------••••----•------••-----------•-•----........._•--•..._....••-- ..-•••••-•--...._ i.by Installer atS„_........�- C..---•--�. ,}+---•--------•---•-----------------------------•-•---------••---------•----•-------_------------------ has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No:--__•_•- ............. dated....____°: T, -- :_ ., - ..__,___• THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...................f �-- �--•--•--•-------•----...----. Inspector...-----.... .................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ^..'�: (r ;.y��. .....OF........... i:`s�.t 'y,......................................... FEE.... : _ I .. ... .. No.._: Disposal nrk,� �1anutrttrtion rrutit Permission is hereby granted = -. r:e = = ..A.-------•---•••••---•-----•----••-•••••••-••-•----••-•----•--•••-•---...----•••----••-•-•----••.....:... to Construct ( ) or Repair ( ) an Individual Swage Disposal System ,:,- .., Street as shown on the application for Disposal Works Construction Permit No..........._!`Y- Dated... -Z.. ............................... _ '-;�: , -k.as pro,. .�,.-. .... - DATE...........................-.................................................... Board of ealth FORM 1255 HOBBS & WARREN. INC.. 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