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HomeMy WebLinkAbout0006 NORTH WEST LANE - Health EWest Lane P 051 0)xf i foo,r d. NO. 152 1/3 ORA 10% l m-% t Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °? D /f/o �� j✓./e S try e, Property Address J 0s el) Ow ner Ow ner's tJame information is required for every page. City Now n State Zip Code Date of I spection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Importa f orrre A.n A General Information filling out forma I fj On the CorTpUter, use only the tab 1. Inspector: key to move you l cursor-do not rA o use the return Na me of Inspector —A key. l� Company Name Company Address , i►S C1 VV? City/Town ID& C ) _ n0 State Y g Zip Code Telephone N er j j License Nurnber 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 R 16.000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs F rther Evaluation by the Local Approving Authority Inspector's f gnature bate 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 god 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 aescribes 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. tsm•3113 Title 501acial inspection F am Subsurface Sewage Disposal System•Pape 1 of 17 L&e q/so I U-P y Commonwealth of Massachusetts VTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 6 /[/O/-� Property Address 0 12rleV7 ON ner Cw ner's Name information is C� ✓Vl llC- required for every �'G 'L page. City fTown State Zip Code Date of Kspec4ion B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) Sy�Ihave m se 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. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old` or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent, System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): 151r1s.Y13 TO 5018ciel Inspection Form Subsurface Sewage Disposel System-Page tot 17 .<n\ Commonwealth of Massachusetts ANNE& Title 5 Official Inspection Form 6 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 0 U �D/7 (,✓e 5 4 L-a vt L Property Address Ow ner Ow ner's Name I- information is +�✓�7 � �6 required for every Cellla page. Citylrown State Zip Code Date of'Inspliction B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5�,Y1 3 Title 5 Official Ins poctia)5 orm Subsulace Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form V Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 6 X/o fGt l/Ps J- Property Address 6) Q/t-e ✓J Cw ner Ow ner's Name information is �vI �� / �j4 pd c 3� ��� requlredforevery �Qw page. City rrown Stale Zip Code Date oonspedtion B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: D The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well"". Method used to determine distance: "*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. III 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 D a-,"- Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool D � 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 15ru•3113 Title 5 Official Inspection F orm:Su baurf ace Sewage Oisposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Itlo,r�t t les 4 Property Address Ow ner Ow ner's Name information is required for every page. City/Town State Zip Code Date of litspection B. Certification (cont.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or / obstructed pipe(s). Number of times pumped: ❑ Er 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. ❑ lJ Any portion of a cesspool or privy is within a Zone 1 of a public well, ❑ t_5 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ C�" 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.] ❑ EK The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000g pd. ❑ The system f ' §. 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. !Sire-Y13 Tlse 50ffldst Ins pectfon F am substrfwA Sewage Disposal system•Page 5of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address D Cry ner Owner's Name information is � cee, � Il � o�a 3arequiredforev h !/r � page. City/Town State Zip Code bate of spe tan C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ Ifs Pumping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system com components p pumped out in the previous two weeks? ❑ Has the system received normal flows in the previous two week eek period? ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was❑ the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CM 15.302(5)) D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms actual DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): l5ins•3113 Title 5 Official lnspechptForm Subsulace sewage Disposal System Page 6of17 Commonwealth of Massachusetts Title 5 Official Inspection Form V Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Ow nrr Ory ner's Nm ae /�H ✓Yi / 0'0 -6 5%)_ 9 // information is l(� required for every page. City/Town State Zip Code Dale df Inspection D. System Information Description: / / OD G !/ _—. Number of current residents: Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system? (include laundry system inspection El Yes No information in this report.) Laundry system inspected? ❑ Yes No Seasonal use? ❑ Yes No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM R 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 I Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Ons-Y13 Title 5 01ficiel Ins pec bon Form Subsurface Sewage olspow System-Page 7 of 17 Commonwealth of Massachusetts IVTitle 5 Official Inspection Form Subgurface Sewage Disposal System Form - Not for Voluntary Assessments 6 4110�f r;✓�J f Property Address Ow ner Owner's Name information Is required for every "o'- d T page. 5 flown State Zip Code Date o nsp ction D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of Sy m: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): I t5ns•3113 Title 5 Official Inspection F orm SUbsvf ao9 Sewage Disposal System•Pepe 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form V Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 6 /(/r,�� C✓es Property Address Ow ner Cw ner's Name ,�A information is pN /v/ /)l.� required for every '�I (/o" J page. Cityfrown State Zip Code Date of Ins coon D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: feet Material of constructi;40 El cast iron PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, ev+dence of leakage, etc.): Septic Tank(locate on site plan): Dept h bel ow g ra de: feet Materia construction: concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate ❑ Yes ❑ No Dimensions: Sludge depth: Ons•3113 Tide 501ficiel Ire pectlm F arm Subsurface Sewage 01sposal Syslem•Pepe 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 C✓Ps� ZG vLe-- P Property Address ON ner Owner's Name information is )_ v!'`4 �� 6LT� required for every ✓�' 21 page. City/Town State Zip Code Date of 16spection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): tt✓`� N /IJ � Y�'�i�.Q� it /V a vq 1-7 OoG Con �l�lon i 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 tSns-Yl3 Title 5 Official Ins pactlonForm Subsurtace Sewage Disposal System-Page'10d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments IV 6 Property Address ' Ow ner Owner's Name / information is �N41/y!! .4required forevery page. Oty[Town State Zip Code Date of�spection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade.- Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per dad Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: pate Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Mrs•Y13 TI0501fidj Ins pec ton Form Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments d7 6 �0-'4 G , s c Property Address Cw ner Ow ner's Name information is Qt,. ry Od L required for every page. Cityfrown State Zip Code Date of i6spection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plate !n Depth of liquid level above outlet invert � v/ 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 So(i / A/P ��a ltis Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No' Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): ` If pumps or alarms are not in wonting order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: tyre•3l13 Title 50"cial inspection Form Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal system Form - Not for Voluntary Assessments i' o✓ � (,./ems�- 2 411 Property Address ellf Ow ner ON ner's Name information is required for every page. Gty/Town state Zip Code Date of I14pec bn D. System Information (cost.) /3y��� Type: L� ���� rsu �lo✓I C� NG�^^ ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): � '/ 7000417n Y7�,,9-7 Lie , 0 Sl f/I f 0 /u w G �r 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 t5ns.y13 Tide50flicial InspectionFcrm Subsirface Sewage Disposal System-Page 13of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System ' Form - Not for Voluntary Assessment's / 6 Property Address Ow ner ory ner's Name information is / l required for every V 0� C Sd page. Cityfrown State Zip Code gate of Inspect' n D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Ons 3113 Title 5Oftiel Irsper,6onForm Substewe Sewage 0lsposd System•Page 14d 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form 5 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 4i10,����s� Property Address O+vner AN ner's Name etl is required P LA�✓v! required for every �p page. Otyfrown State Zip Code Date of Ingpectibn D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where Ic water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately -- - �O 19r*•3(13 TiUe 5Offcial iris pectionFam Subeutace Sewage Disposal Syelem Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary T Voluntary/ Assessments Property Address A �J /l�O✓7(� (., /_I / t Cw ner Ow nerIs Name information is V� �d 1 G�//informrequired foreveryr-'eA / // p� page. Uy/Town State Zip Code Date Inspe tbn D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high 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 loc oard of Health-explain: Gas J_ l es� ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: -5-)e W7 io�A,- Before filing this Inspection Report, please see Report Completeness Checklist on next page. Wns-3/13 Tine 5 oraciar ire pec eon F orrrt suosirface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address CwN ner Ow ner's Name information is '�/JA Oa��� required for every '�' ✓y� � / /fr page. City(Town State Zip Code Date f Inspection E. Report Completeness Checklist Inspection Summary:'A, B, C, D, or E checked Q' Inspection Summary D (System Failure Criteria Applicable to All Systems) completed U- System Information —Estimated depth to high groundwater 0--'Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 15ns•N13 TiUe50fficial ins pec don Form Subsurface SewapeDlsposal Syatam•Pape 17d 17 I TOWN OF BARNSTABLE LOCATION � AAA/(,Zsa SEWAGE # AV 3-a361 V ..LAGE Cer/1".1`/,c ASSESSOR'S MAP& LOT-Ili ®S INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /f GEC LEACHING FACELR Y: (type)SW C L Agq size) it Ye?S ( NO.OF BEDROOMS BUILDER AWNE V,14S PERMITDATE: Z2 - COMPLIANCE DATE: " — G 3 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 fie - r. TOWN OFGB�A�RNSTABLE LOCATION oL SEWAGE # VILLAGE ASSESSOR' AP &LOT NAME&PHONE NO—Z�,/— PI&CIr SEPTIC TANK CAPACITY LEACHING FACILITY: (type (size)C D CtJX S� NO.OF BEDRO BUILDER R II, OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist dd�� on site or within 200 feet of leaching facility) r'T' Feet Edge of Wetland and Leaching Facilit If any wetlands exist within 300 et of ac in facil' ) Feet Furnished No. �'c.�� J is' � Fee .c v THE COMMONWEALTH OF MASSACHUSETTS entered in computer: I/ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppricatfon for �Diopoe;al 6pgtem Construction 3permit Application for a Permit to Construct( . )Repair(c/)Upgrade( )Abandon( ) m omplete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Asses 's a P cel Q� �>� Installer's Name,Address,and Tel.No. C�! v Designer's Name,Address and Tel.No. Cotes j 7/`�3 (�OGr�i? �d Z�ls y/ Type of Building: Dwelling No.of Bedrooms Lot Size 1.J y sq.ft. Garbage Grinder( G Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 33z69 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tani�/,�`OD Type of S.A.S. 2 — 441 4kW1 ,S Description of Soil �,S`X Z• $ .Z' Z- Nature of Repairs or Alterations(Answer when applicable). Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Si ned Date ��y Application Approved Date 6 Application Disapproved for the following reasons Permit No. Q00 3 "" Date Issued �/ G . rf THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: �. PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes F 1?c C 1 2pplication for Migootal *paem eongtruction permit Application for a Permit to Construct( )Repair(�)Upgrade( )Abandon( ) er omplete System ❑Individual Components Location Address or Lot No. / Owner's Name,Address and Tel.No. Ass essg;'s 1 FS cel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.'r y y5 / Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder Other Type of Building i No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow .33© gallons. Plan Date '7T/,7 n 3 Number of sheets Revision Date Title S Si Yti° /b y v/Ile Size of Septic Tank ;`O.� Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 7---/t/e 1� Date last inspected;, Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. S`gned Date Application Approved H _ Date I4 JG Application Disapproved for the following reasons Permit No. 3 —" Date Issued �/ G THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( ) Repaired (L1 )Upgraded ( ) Abandoned( ))by k1 1_1 at ai/ .r u��l�t-°/���' has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. Z 40 3 3(r dated 19`w ` O 3 Installer Designer The issuance of this permit shall not be construed as a guarantee that the system Wctlo de g d!Date j Q Inspector . No.0 3 t" ' Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS lwigool *pgtem Construction Vermtt Permission is hereby granted to Const ct( )Repair(V Upgrade( )Abandon( ) System located at L�j �D/ /t/S�.S>` Zip r'�0,Aefffy/•�P i 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 must be completed within three years of the da of this e• t. Date:_ �Ly 3 Approved b , TOWN OF BARNSTABLE LOCATION 4 %%o� � ���� L SEWAGE # VII,LAGE C��`���, ASSESSOR'S MAP &c LOT O, INSTALLER'S NAME&PHONE NO. �a^�iar�, •�,^� -- SEPTIC TANK CAPACITY If C£L LEACHING FACILITY: (type)Si3� C L / dam, .d�(size) f7 x.?S NO.OF BEDROOMS BUILDER WNE G6l�c 4�' PERMIT DATE: COMPLIANCE DATE: '((- Separation Distance Between the: , Feet Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by r 6� /bbb oil i i ti./ BORTOLOTTI CONSTRUCTION, INC. A' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Adams Prop e,:p 'MCM i aotiuU5. � N Date of Inspec} Map arceL, Own S E.7_ S CHECK IF.THE FOLLOWING HAVE BEEN DONE: PART A - CHECKLIST v PUMPI,N G INFORMATION WAS REQUESTED OF THE OWNER,OCCUPANT,AND BOARD OF HEALTH. v NONE OF THE SYSTEM COMPONENTS HAVE BEEN PUMPED FOR AT LEAST TWO WEEKS AND THE SYSTEM HAS BEEN RECEIVING NORMAL FLOW RATES DURING THAT PERIOD. LARGE COLUMES OF WATER HAVE NOT BEEN INTRODUCED INTO ` THE SYSTEM RECENTLY OR AS PART OF THIS INSPECTION. AS-BUILT PLANS HAVE BEEN OBTAINED AND EXAMINED. NOTE IF THEY ARE NOT AVAILABLE WITH N/A. v THE FACILTrYOR DWELLING WAS INSPECTED FOR SIGNS OF SEWAGE BACK-UP. THE SITE WAS'INSPECTED FOR SIGNS OF BREAKOUT. v ALL SYSTEM COMPONENTS,EXCLUDING THE SAS,HAVE BEEN LOCATED ON THE SITE. v THE SEPTIC TANK MANHOLES WERE UNCOVERED,OPENED,AND THE INTERIOR OF THE SEPTIC TANK WAS INSPECTED FOR CONDITION OF BAFFLES OR TEES,MATERIAL OF CONSTRUCTION,DIMENSIONS,DEPTH OF LIQUID,DEPTH OF SLUDGE, DEPTH OF SCUM. /THE SIZE AND LOCATION OF THE SAS ON THE SITE HAS BEEN DETERMINED BASED ON EXISTING INFORMATION OR APPROXIMATED BY NON-INTRUSIVE METHODS. THE FACILITY OWNER(AND OCCUPANTS,IF DIFFERENT FROM OWNER)WERE PROVIDED WITH INFORMATION ON THE PROPER MAINTENANCE OF SSDS. PART B - SYSTEM INFORMATION FLOWCONDITIONS RESIDENTIAL No of Bedrooms G .C1�1'1/--No of Cu rent Residents 4 y Garbage Grinder Laundry Connected to System Seasonal Use NON RESIDENTIAL: Calculated flow WATER METER READINGS,IF AVAILABLE: GALLONS Pumping Records and Source of Information: 1,ece-1,WLA11 I SYSTEM PUMPED AS PART OF INSPECTION?/V IF YES,VOLUME PUMPED= GALS Reason for Pumping: TYPE OF SYSTEM: Septic tank/distribution box/soil absorption system Single Cesspool Overflow Cesspool Privy Shared system (if yes attach previous inspection records, if any Other(explain) C�"f ��0 ' — /CAS' G( 4t1e_Alo Ap mate age of all components. Date Installed,if known. Source of information. » . ' ) k SEWAGE ODORS DETECTED WHEN ARRIVING ATTHE 3TTE7 " slr" eM,k r Y- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM u, `0. PART B. SYSTEM INFORMATION (Continued) EP Depth below grade'_d r ;a Dimensions: .. „ Material of construction Concrete Metal FRP Other} Sludge Depth Distance from top of sludge to bottom of outlet tee or baffle Scum.Thickness - Distance from Top of Scum to top of outlet tee or baffle Distance from bottom of Scum to bottom of outlet tee or baffle Comments: DISTRIBUTION B X: DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT Commenfs: .. PUMP HAMBER: Pumps in working.order? Comments: SOIL ABS RPTION SYSTEM SAS : IF NOT PRESENT,EXPLAIN: TYPE: �p '.(� `j i/ l .' Comments: ' _ � Q CESSPOOLS: Number and configuration Depth—top of liquid to Inlet invert Depth of solids layer Depth of scum layer Dimension of cesspool Materials of construction �,: s/.lo Ind k anon of groundwater nflow(cesspool must be pumped) Comments: tom" ' PRIVY: Q Materials of construction Dimensions Depth of solids Comments: q A�} �^j1' "�''�`" �� x,�r.J°��,�.� iR°"A,�yW W. J> :. YS ,iY 4 J ���. Vf� �h:& L , i : 4 t 4 � i ri, � F � ' t `•i4. r w� ,4��>s�'a`'°" ,c.� �:;krS' - y �Cn�f-„ 1..� •< r'`s, �5 LS "+ ye"'1' of a i;F� .¢, r _ 2, k ,y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B — SYSTEM INFORMATION (Contlnuedl SKETCH OF SEWAGE DISPOSAL SYSTEM. INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCES.LANDMARKS OR BENCHMARKS. LOCATE ALL WELLS WITHIN 100' �1 w� v DEPTH TO GROUNDWATER: DEPTH TO GROUNDWATER METHOD OF DETERMINATION OR APPROXIMATION: 074 WS . 4 �r s �'•y18 xiaS> ,,�4+��� ',p4.�r t �;h.�`"r f ,sue. �" '�ryaF a � _ 2 � `�..,4..! 4� t".�.,. 6J?t �• .���r C���r+l4l'r�at F � �,�,z!,...a. f �4i. R -.a �. '�' '( }�- fY. i,y1"' y �.t .rr. 1^j+ �':'_ 'k {'. .. ... 5ta„','' ¢.' ..;,�� 9 M1!4,.• i. ...Y �.... " ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM A PART C — FAILURE CRITERIA (Indicate Y—.yes N—no ND—not iletsrmined.Describe basis of determination.If'not determined",explain why not) Backup of Sewage into Facility Discharge or'pondirig of effluent to the surface of the ground or surface waters? Static liquid level in the districution box above outlet invert? Liquid depth in cesspool, 6°below invert or available volume, 1/2 day flow? Required pumping 4 times or more in the last year? Number of times pumped Septic tank is metal. cracked?structurally unsound?substantial infiftration?substantial exfiftmtion? tank failure imminent? Is any portion of the SAS,cesspool or privy,below the high groundwater elevation? Within 50 feet of a surface water? Within 100 feet of a surface water supply or tributary to a surface water supply? Within a Zone I of a public well? / Within 50 feet of a private water supply well? / Within 50 feet of a bordering vegetated wetland or salt marsh (cesspools&privies only, not the SAS)? Less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis? If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds,amonia nitrogen and nitrate nitrogen. PART D — CERTIFICATION INSPECTOR: ROBERT J. BORTOLOTTI ADDRESS: 765 WAKEBY ROAD, MARSTONS MILLS. COMPANY: BORTOLOTTI CONSTRUCTION INC. MA 02648 (508) 771-9399 CERTIFICATION STATEMENT I CERTIFY THAT I HAVE PERSONALLY INSPECTED THE SEWAGE DISPOSAL SYSTEM AT THIS ADDRESS AND THAT THE INFORMATION REPORTED IS TRUE,ACCURATE AND COMPLETE AS OF THE TIME OF INSPECTION. THE INSPECTION WAS PERFORMED AND ANY RECOMMENDATION REGARDING UPGRADE,MAINTENANCE AND REPAIR ARE CONSISTENT WITH MY TRAINING AND EXPERIENCE IN THE PROPER FUNCTION AND MAINTENANCE OF ON—SITE SEWAGE DISPOSAL SYSTEMS. CHECK ONE: I HAVE NOT FOUND ANY INFORMATION WHICH INDICATES THAT THE SYSTEM FAILS TO ADEQUATELY PROTECT PUBLIC HEALTH OR THE ENVIRONMENT AS DEFINED IN 310 CMF 15.303. ANY FAILURE CRITERIA NOT EVALUATED ARE AS STATED IN THE'FAILURE CRITERIA'SECTION OF THIS FORM. I HAVE DETERMINED THAT THE SYSTEM FAILS TO PROTECT PUBLIC HEALTH AND THE ENVIRONMENT AS DEFINED IN 310 CMR t5.303. THE BASIS FOR THIS DETERMINATION IS PROVIDED IN THE"FAILURE CRITERIA'SECTION OF THIS FORM. INSPECTOR'S SIGNATURE: DATE: , ORIGINAL TO SYSTEM OWNER,COPIES:BUYER(if applicable),APPROVING AUTHORITY , r t ,(' n.�SrL- ciw�'Sk�`.4�FC', y. 'Tz�✓» x �k �PS1 Yro;�' '' .,n�4n;G ,� r :: r" � �b � y f. " $" F °L.P yY tir - r. X L t ry, 3w.FJ � S �.s F�3'X ! '.�• `�' tJrt SJ `A "$$ 4h 'i f ��5 y .}� I� � ... i y+:.+� �.:.,, ^S .. �4 t Y .,��, i Sy'..' apr S`-Y+♦ TOP FNDN. AT EL. 51 .,3' SYSTEM PROFILE TEST HOLE LOGS mom a ACCESS COVER TO WITHIN 6" OF FIN, GRADE (NOT TO SCALE) Pr 3VIDE INSP`c`CTION PORT WITHIN ACCESS COVER (WATERTIGHT) TO s" OF FIN. GRADE ENGINEER: LISA LYONS, RS 50.2' MINIMUM .75' OF COVER OVER PRECAST WITHIN 6" OP FIN. GRADE 2% SLOPE REOUIRED OVER SYSTEM �o 50.0 WITNESS: SAM WHITE kh RUN PIPE LEVEL 2" DOUBLE WASHED PEASTONE DATE: 7/3/03 / 48•� Ll FOR FIRST 2` 3` MAX. < 2 MIN INCHLOCUSPROPOSED 1500 PERC. RATE /48.25` TANKGALLOH SE1T0iC 48 0' 47.7' CLASS i SOILS P# .8 ��{ ) GAS 47 1' m C7 0 0 (� CO C� BAFFLE 47.18' MIN 46.90 ED CO C] 0 E3 IO m m 0 4' AROUND ( 2 7. SLOPE) 6" CRUSHED STONE OR MECHANICAL E7 d 0 0 �-- 44,90' ELEV. COMPACTION. (15.221 [2]) 1 2' EEI CO COO 0 0000 p" Q 50.0' RTE 28 oc _ c DEPTH OF FLOW = 4 ( 2 9, SLOPE) ( 1 9 SLOPE) 3/4" TO 1 1/2" DOUBLE WASHED STONE A TEE SIZES: INLET DEPTH r 10" LS OUTLET DEPTH - 14" g" 1OYR 3/3 LOCATION MAP NTS FOUNDATION---- 11' SEPTIC TANK 41' D' BOX 13 LEACHI{JG ASSESSORS MAP 1$9 PARCEL 59 FACILIT'I' 6.3' SL *THE INSTALLER SHALL VERIFY THE " 1OYR 4/4 LOCATIONS OF ALL UTILITIES AND ALL 30 47.50' BUILDING SEWER OUTLETS AND ELEVATIONS PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM C PERC �� 38.6' -k 49.3 L \ . M/COS 2.5Y 5/6 I + 49.9 \\ •�� TRIPL 12" OAK \\ 49.3 136" 38.6' BENCH MARK -- HYDRANT: ON �'• \ NO GROUNDWATER ENCOUNTERED NOTES: + 49.7 + so: TAG BOLT# 733 EL. = 52.2 - - " W.BIRCH + a9• Nn� QWFD 50.0 \\ SEPTIC DESIGN: (GARBAGE DISPOSER IS 1. DATUM IS ASSUMED I ) (SAVE) \ DESIGN FLOW: _3 BEDROOMS ( 110 GPD) 330y,GPD 2. MUNICIPAL WATER IS EXISTING q USE A 330 GPD DESIGN FLOW ,a .. r', .,•- ,- -,� ,..• r: + 5o.i + 49.8 50.4 (� 0 SE=TIC TANK: 330 GPD ( 2 ) = 660 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO H- 10 o l_ /0.6 .r�, �` +os2 \ USE A -JaM GALLON SEPTIC TANK 5. PIPE JOINTS TO BE MADE WATERTIGHT. " + so•i 50.2 tic \ LE,+CHI 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. 12 ,P•PI E 0.3 + 49.2 SIDES: 2(25 + 12.$3) 2 (.74) 112. ENVIRONMENTAL CODE TITLE V. + 7. THIS PLAN IS FOR PROPOSED SEPTIC SYSTEM ONLY AND IS NOT TH e� so• SUnIRM. 51.0 \ BGTTGM: 25 x 12.83 (.74) TO BE USED FOR ANY OTHER PURPOSE. \5 (NO + `� 49.2 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4 C. FNON)' TOTAL: 472 S.F. 342 GPD .. + a9.9 " HObY" c ! 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT D 50.9 USE 9.7 LEACHING CHAMBERS (ACME OR INSPE�;TION BY BOARD OF 'HEALTH AND PERMISSION OBTAINED ! USf:�2� �500 GAL. 5" EVERGREEN + 50.3 j 493 EQUAL WITH 4 STONE ALL AROUND FROM BOARD OF HEALTH. 49.7 50'g / 10. PUMP & REMOVE (OR FILL W/CLEAN SAND) EXISTING CESSPOOLS + 49. / / EXIST. DWELLING + 50.9 \ /49.5 50.2 TF = 51.3' IN,\ / 50.9 \ PAVED \ / - TI TL E 5 SI TE PL AN \ PROPOSED SPOT ELEVATION OF � 6 NORTH WEST LAN E L ' 10\ 0x0 EXISTING SPOT ELEVATION 1 51.3 � 49.7 � IN THE TOWN OF: T ' /•' 100 PROPOSED CONTOUR 50, 15,a25 SF o / � (CENTERVILLE) BARNSTABLE `ti / 100 EXISTING CONTOUR 49.9 PREPARED FOR: CY WELLS + 50.5 20 _ 0 20 40 60 -----0 / BOARD OF HEALTH / �APPROVED DATE MA SCALE: 1" = 20' DATE: JULY 12, 2003 / � / off 508-362-4541 / lox M 362-98a0 50.0 �`T H Of (A*n cape engineering, inc, CIVIL ENGINEERS IA ._ VIL LAND SURVEYORS NosA•�48 ` " JJ 03-- 163 939 vain st. yarmouth, Ina 02675 �� A QJAL ° .L.S. DATE