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HomeMy WebLinkAbout0119 ARROWHEAD DRIVE - Health 1,r19Arrowli�ead�Drive >�:��.�{�`� : A 271, _05 1 f I 1 n a i 0 a 1 a 1 SEWAGE INSPECTIONS LOCATI.O.N 119 Arrowhead Drive DATE 11 /1 /02 j _.__:VILLAGE Hyannis,Mass. 02601 ASSESSOR'S MAP & LOT271 -0 5 6 •INSP CTOR Joseph P.Macomber Jr. SEPTIC TANK CAPACITY 1 000 gal 1 nnG + Rnx LEACHING FACILITY: (type) 4-Infiltrators (Size) 1 1 ' X25 ' ' NO. OF BEDROOMS 3 BUILDER OR OWNERNat i nna 1 Cnnctnct i nn rnm=an4z Tnr iE OWNER MAILING ADDRESS Mike Rosembaum 27 Adams Street Braintree,Mass. 02184 7 0 3 LO ` . \/ �10 0 TOWN OF BARNSTABLE G L°.�CA I.ON 1/`1 ��/Iil aHalt.v� at ivy SEWAGE # VII.LAGE �ji t�,_v�►i� ASSESSOR'S MAP & LOT :a-7 INSTALL-ER'S NAME&PHONE NO.12,io r 77 SEPTIC %4,NK CAPACITY ;/G0 0 LEACHING FACILITY: (type) 1-,fl 7.eI91 T01P S' (size) NO. OF BEDROOMS BUILDER OR OWNERua PERMITDATE: " Y '4 q COMPLIANCE DATE: 9 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 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 litv� 3 . A 13rJk,e,., 13 COMMON, WEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS - a DEPARTMENT OF ENVIRONMENTAL PROTECTION a i TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property;Address: ( (,l NNa Ca-1 tOwner'sme: -t Owner's Address: c Date of Inspection: C _ -�, W Name of Inspector: (p ase,pr^in�t Q� �kDte�- o Company,Name: Clo- c Mailing Address: w ,��, c a r�- Telephone Number: - - cT m 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 D)EP approved system inspector pursuant to Section 15.340 of Title 5(310 CIVIIt I5.000). The system:' Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails .f'.•IY J ��O Inspect®r'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 I ****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 6of use. .I I i Page 2 of i i OFFICIAL INSPECTION-FORM-NOT FOR VOLUNTARY ASSESSMENTS, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORD PART A i CERTIFICATION(continued) Property Address: i Owner: Date of Inspectio . Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section I A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMRI 3 3 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: 1 ne or more system components as described in the"Conditional Pass"section need to be replaced or re iced.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"aw determiwr explain. pkzl se 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 inspectio I 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. i ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or bstructed pipe(s)or due to a broken,settled or uneven distnba ion box.System wffl pass if(with a roval of Board of Health): I broken pipe(s)are replaced obstruction is removed distribution lm is Iaveled or replaced ND ex lain: i e system required pumping more than 4 times a year due to broken or obstructed pipe(s).The sy3b=will pass in ection if(with approval of the Board.otf Heaitb) broken pipe(s)are replaced 1 obstruction is removed ND a)[lain: I . 2 Page 3 of 1 i OFFICIAL. INSPECTION FORM-NOT FOIL VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM.INSPECTION FORM PART A' ' CERTIFICATION(continued) Property Address: kea 1S Owner: C Date of Inspectio ; i C. Further Evaluation is Required by the Board of Health',."-:- Co rti sexist which require further evaluation by the Board of Health in order to determine if:the system is failin to protect public health,safety or the environment. i 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 i 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: i 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. i I The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. I The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. i The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more front a priva water supply well**. Method used to determine distance **This stem passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria d volatile organic compounds indicates that the well is free from pollution from that facility and the presen a of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure crit ria are triggered.A copy of the analysis must be-attached to this form. I .. j 3. Other: i i 1 •i i 4 f i Page 4 of 1 I . OFFICIAL,INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT'S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR PANT A CERTIFICATION(continued) I Property Address: i Owner: n1 ` ! Date of Inspection: 1 i D. System Failure Criteria applicable to all systems.. i You must indicate`yes"or"no"to each of the following.for all inspections: I � Yes No ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool! -�`- - harge 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 sspool iquid depth in cesspool is less than 6"below invert or available volume is less than '�2 day flow equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number tunes pumped i-iy portion of the SAS,cesspool or privy is below high ground water elevation. j 7 Any portion of cesspool or.privy is within 100.feet of a surface water supply or tributary to a surface ater supply. _ y 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 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.] i d�©(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as j described in 310 CNM 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. i E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,OWgpd to 15,000 gpd. , Yo ust indicate either"yes"or"no"to each of the following: ( e following criteria apply to large systems at addition to the criteria above) s, no i _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tribulary.to a sm drinkingweer supply the system is located in a nitrogen sensitive area(bittmin We1) wad Protection)btae —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 significant threat under Section E or failed under Section:D shall upgrade the system in accordance with 310 CNR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL.Ee1SPECTION FORAY—NUT FOR VOLUNTARY-ASSESSMENTS i- SZJBSIJRFACE.SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART B 'CHECIMIST Property Address: C de Owner: l �iLIQ Date of inspection: 02 Check if the following have been done.You must indicate"yes"or"no"no"as to each of the following: Yes 110 ping information was provided.by the owner,occupant,or Board of-Health Were any of the system components pumped out in the previous two weeks? _ �H the system received normal flows in the previous two week period? !' Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available.note as N/A) Was the facility or dwelling inspected for signs of sewage backup i 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? i The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Y s 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 CNIR 15.302(3)(b)] I 6 Page 6 of 1'1 OFFICIAL.INSPECTION FORM. NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSALSYSTENt INSPECTION FORM PART C SYSTEM INFORMATION Property Address: I Owner: fidw Date of trispecti6ni, FLOW CONDITIONS RESIDENTIAL Number of bedrooms.(design): .Number of bedrooms.(actual):. j i DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 3, 7 Number of current residents: 0 kkl Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):29 of yes separate inspection required] ' Laundry system inspected es or no): Seasonal use: (yes orno)&_> Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no): �S i Last date of occupancyie= � COMMERCIAIJI IDUSTRIAL Type-of establishment: Design flow(based on 310 CMR 15.203): d e Basis of design flow(seats/persons/sgtetc.): y 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: Was system pumped as part o th pection(yes or no): If yes, volume pumped:_gallons—How was quantity pumped determined? Reason for pumping: TE OF SYSTEM eptic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool —ivy i Shared system(yes or no)(if yes,attach previous inspection records,ifany) Innovative/Alternative technology.Attach a copy.of the curient.operation aad aainteaance contract(io obtained from system owner) Tight tank _Attach a copy of the DEP dal —Other(describe): Approximate age of all components,date in (if known)and ,�f in lion: i Were sewage odors detected when arriving at the site(yes or no): � Page 7 of 11. OFFICIAL.INSPECTION,FORM—NOT FOR YOLUNTARY..ASSESSMENTS SUBSURFACE,:SEWAGE DISPOSAL SYSTEX INSPECTION FORM FART:C SYSTEM INFORMATION(continued) Property Address: l Owner: IrA I n 1U,Q Date of nspectio r/ I • BUILDING SEWER(locate on-site plan) Depth below grade: Materials of construction:_cast iron -Y 40 PVC_other(explain): Distance!from private water supply well or suction line: Comments(on condition of joints,yenting,evidence.of�ge,etc.): at Ql!�d2 SEPTI6TANK: V(locate p site plan) Depth below grade: Material of construction: , concrete_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: y�il' Sludge depth: J/ Distance from top of sludge to bottom of outlet tee or baffle:_L Scum.thickness:Z> ZV 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: �c�fi-9t- e� Comments(on pumping recommendations,inlet and outlet tee or baffle condition,'structural integrity, liquid levels as related �to outlet invert, evidence of.leakage,etc.): j GREASE TRAP:_(locate on site plan) i 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.): I Page 8 of'11 OFFICLAL.INSPECTION FORM. ' NOTT FOR VOLUNTARY t�SSESSMENTS SUBSURFACE SEWAGE DISPOSAL L SYSTEM INSPECT,TON:FOI M P ;T C SYSTEM INFORM—ATION(continued) Property Address: C AM(IM61711 AW Owner: Date of Inspection: i 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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: j Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: present present must be opened)(locate on site plan) 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.): PUMP CIIA1VIBER: '(locate on site plan) Pumps hi working order(yes or no): Alarms in working order(yes or no): Coi-nments(note condition of pump chamber,condition of-pumps and appurtena^ces,etc.): i • i j i 8 Page-9 of 1.1 OFFI.CIAI,.INSPECI'ION FORNL—..NO.-FOIL".L—,t TNT -X- ASSESSMENTS- SUBSURFACE SEWAGE.DISPOSAL SYS'I'E1VI.INSPECTIQ FORM SYSTEM,INFOE!Mi n 1�1;(continued) Property Address .1MA . Owner: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): Cate on site plan,excavation not rouireO If SAS not located explain why: Type leaching pits,number. leaching chambers,number.V/ leaching galleries,number: leaching trenches,.number,length: leaching fields,.number,dimensions: overflow cesspool,number. inno ative/alternative system Type/name of technology:. Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): i CESSPOOLS:A (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): Coi-nmen i(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:Y: (locate on site plan) Materials of construction: Di-melons: Depth of solids: Conunen i(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): I ' I 9 Page 10 of .�rrvr�vea gwc��o�virnv d3aa .�.cY..o, 3i7ud,a vasas a 3AU � �a� � ^ 7 a s. a$ ` -:� AIRYSSSE_��v� I- �p:e�g i SI)33SUR,* FACt. SiE'ifiJAG �°','SPOSAL.SYSTEM INSFEECTION Fes : V A'0T i' a lY1Y a..V i • i �AMEid 1 F V_Ar—".(continued) I rope aM__. ,� ;�l J—P I rsup'aea n�rafa�s z-ao. i Owner: Date of insae_tio { I SKETCH OF SEWAGE DISPOSAL SYSTEM i rovide a sketch of the sewage disposal system including ties to ai least two permanent reference 1�,d�u�..s or! benchmarks. Locate all wells within 100 feet. Locate where public water supply esters the building. j i )e-)/7 i ! i i Y i i I I i k I i i I i' 7 10 i Page 11 of11 I • OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT'S SUBSURFACE SEWAGE IDISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: tJ�< j Owner: Date of his0ection'D Zf SITE EXAM Slope Surface water Check cellar! Shallow wells Estimated depth to ground watereet I 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) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must desc;;be low you e,tablished the high ground water elevation: L L� ' _ i i i i i i f ' of DATE11 /1 /02 PROPERTY AD.DRESS :119 -Arrowhead Drive --- ------------------- Hyannis,Mass. ------------------------ 02601 ------------------------ S On the above date, I inspected the septic system at the ab This system consists of the following: . 1 . 1 -1000 gallon septic tank. 2. 1 -Distribution box. 3. 4-Infiltrators. 11 'X25 ' Based on my inspection, I certify the following conditions: czt-1 �p 4.._ This is _a title five septic system. ( ,Installed 11 /9/99 ) 1 5. The septic system is in proper working order at the present time.; 6 Pumped septic tank at time of inspection.Heavy Scum & solids layers were present. SIGNAT / UR Name : J . P . Macomber Jr . Conipany :�josp_ph _p�_ M_@comter 8 Son , Inc . i . Address : BQx _�,fz............. QgnS.e_vLL_tsL -QZ_632-0066 Phone : 5 0 8- 7 7 5- 3 3 3 8 THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tan ks•Cesspools-Leachflelds Pumped & Installed Town Sewer Connectlons P.O. Box 66 Centerville, MA 02632-0066 775.3338 775.6412 • 1 .\ COMMONWEALTH OF "SACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION • f y .TITLE 5 OFFICIAL. INSPECTION-FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBS URFACE.SEWAGE DISPOSAL SYSTEM FORM PART A `• _ CERTIFICATION Property Address: 1 1 9 Arrowhead Drive, Hyannis,Mass, Owner's Nametqati oval Const-ruct•i nn Company Inc. Owner's Address: 27 Adams Street- Braint-raa -Mace 02_: Rd Date of Inspection: 1 1 /1 /02 Name of Inspector: (please print) Joseph P. Macomber Jr. Company Name: J.P. Macomber, & Sons Inc Mailing address: Box 66 ` 1 C ntPrvi 1 1 P 'Ma f12632 Telephone Number: 508-775-3338 . . , CERTIFICATION STATEMENT - I certif) 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 .ratntne 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. o(Title 5 (310 CMR 15.000), The system: • v��2 SeS .. Conditionally Passes. _ Needs Funher Evaluation by the Local Approving Authority Fails lnspec'tor's Signature: L401Date:I W'OV The system inspector shal mit 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 now of 10,000 , gpd or greater, the inspector and the system owner shall submit the'repon 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 authorir). Notes and Comments j '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.differeot-; s conditions of use. • ti Title 5 Inspection Form 6/15/2000 page I ' � A .�ti f Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:119 Arrowhead Drive HYannic�MaGS_ Owner: National Constuction Company Inc. Date of Inspection: 11 1 /0 2 Inspection Summary: Check A,B,C,D or E/ALWAYS-complete all of Section D jA. Syste Passes: �. I have not found an information hich indicates that any of the failure criteria described in 310 CMR 15.303 or to 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: , ShLn- sP ic system is in proper working ordet-at the present time_ C B. System Conditionally Passes: -Z& One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health, will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined" please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. 'A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1 1 9 Arrowhead Drive Hyannis,Mass. Owoer: National Construction Company Inc. Date of Iaspection:1 1 /1 /0 2 C. Further Evaluation is Required by the Board of Health: Conditions exist which require fwther evaluation by the Board of Health in order to determine if the system is failing to protect public health,.safety or the envirorunent. I. S*N•stem 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 wbich will protect public bealtb,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is witbin 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 rributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I of a public water supple. N The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. /V0 The system has a septic tank and SAS and the SAS is less than 100 feet bye 50 feet or more from a private water supple 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 anached to this form. 3. Other: 3 Page 4 of 1 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) I I Property Address:1 1 9 Arrowhead Drive Hyannis,Mass. Owner: National Constructional Company Inc. Date of Inspection: 1 1 /1 /0 2 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No � _ D at of sewage into facility or system component due to overloaded or clogged SAS or cesspool 1/ ischarge or ponding of effluent to the 'surface of the ground or surface waters due to an overloaded or /Alogged SAS or cesspool _✓ Static liquid level-in-the distribution box above outlet invert due to an overloaded or clogged SAS or /cesspool y�a>sdTA��S / t-r _ // Liquid depth incasspeel is less than 6"below invert or available volume is less than 'h 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 portion of the SAS, cesspool or privy is below high ground,water elevation. �y 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 I of a public well. v 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 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.l -�-b�-(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 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. 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 e system is within 400 feet of a surface drinking water supply 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. 4 =aic 5 of F OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Properr} Address:1 19 arrowhead Dri ve I-jXs�n n i G�1s1a.c a Owner: r3tinnal Can--traction Company Inc. Date of lospectioo: 1 r1 rn2 Check if the following have been dons You trust indicate 'yrs" or"no" as to each of the following: Yes So mptng information was provided by the owner, occupant, or Board of Health �2ierc anN of the system components pumped out in the previous two weeks — Has the system received normal flows in the previous two week period ? d Havc large volumes of water been introduced to the system recently or as pan of this inspection were as built plans of the system obtained and examined? (I(they were not available note as N/.A) Was the facility or dwelling inspected for signs,of sewage back up? Was the site usspected for-signs of break out ? Wcrc all system component;eluding the SAS-located on site ? / ram,----�-"- I/ _ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condr;:on T inc baffles or ices. 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 prover .maintenance of subsurface scA age disposal systems ? The size and location of the Soil Absorption System (SAS) on the site has been determined basso or Yes 0 Existing information. For example, a plan at the Board of Health. �7. Determined in the field (if any of the failure criteria related to Pan C is at issue approximation of dis=^:c ;s ;nacccptabIc) O 10 CMR 15J02(3)(b)) S • Page 6 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1 1 9 Arrowhead Drive Hyannis,Mass. OwnenNational Cons rti ion Qompany Inc. Date of Inspection: 11 /1 /0 2 FLOW CONDITIONS RESIDENTIAL �, Number of bedrooms(design):L Number of bedrooms(actual): DESIGN flow based on 310 CMR 1,5.203 (for example: 110 gpd x H of bedrooms): '1d Number of current residents: ZkXAAWA7 Does residence have a garbage grinder(yes or no): AD Is laundry on a separate sewage system yes or no):W (if yes separate inspection required) Laundry system inspected (yes or no): P.S Seasonal use: (yes or no): NB Water meter readings, if available (last 2 years usage(gpd)):2001 —72, 000 gallons=1 97. 26 GPD Sump pump(yes or no): A26 2002-87., 750 gallons=240. 41 GPD Last date of occupancy: COMM ERCiAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): d Industrial waste holding tank present (yes or no):IV Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: A Last date of occupancy/use: AM OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: 11 1 02 Maint. Was system pumped as part of the inspection (yes or no): S If yes, volume pumped:ADM gallons - How was quan iry pumped determined? Reason for pumping: Heavy Scum & solids layers were present. TYPE OF SYSTEM Septic tank, distribution box, soil absorption system ',EV Single cesspool &Overflow cesspool 44 Privy IQShared 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 /I Attach a copy of the DEP approval to Other(describe): Ap roximate age of all co onents,d t m called(if )and so a of information: Were sewage odors detected when arriving at the site(yes or no): 6 Page 7 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:1 1 9 Arrowhead Drive Hyannis— ,Mass-Owner: National Construction Company Inc. Date of Inspection: 11 .1 169 BUILDING SEWER(locate on site plan) Depth below grade: Materials of consrruction: .rIVcast iron 40 PVC jother(explain): t)4 Distance from private water supply well or suction line: id"/- Comments(on condition ofjoints, venting, evidence of leakage, etc.): Taints apTPar tight-No evidence of leakage.The system is vented througg the house vents. TiNK SEPTIC : t/ (locate on site plan) 1A10 /ik"le-5 J) �`�Depth below grade: �— Material of construction: ncrete, meal fiberglass,e.,Lpolyethylene .,�other(explain) AM If tank is metal list age: is age confirmed by a Certificate of Compliance (yes or no):t/� (attach a copy of certificate) Dimensions: �%� �4 ��� ��� Sludge depth: _r Distance from top of slud@e to bosom 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 bosom of outlet tee or baffle: How;'were dimensions determined:Pumped at time of inspection. Corronents(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): _ Pump The septic tank every 2-3 yearsInlet & outlet tees are in nl ar•a ThP tank i c ctriir-tiirally sound and shtlwS no Signs ofJ— lea1kaaSge.Pumped tank at time of inspection. Heavy scum & GKIASE TEAFyAloate onesite plan) Depth below grade:,uL Material of construction:.PJ�9concrete��4 metal.�fiberglass 4ejolyeLhylene4'/4other (explain): A—M Dimensions: Scum thickness: IVA Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: fie. Date of last pumping: iYA' Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of.leakage, etc.): GrPasP trap is not prPsent 7 Page 8 of 1 I f OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM TART C SYSTEM INFORMATION(continued) Property Address: 1 1 9 Arrowhead Drive Hyannis,_Mass. Owner:National Constrtiction Company INC. Date of Inspection: 1 1 /1 /0 2 TIGHT or HOLDING TANI x&,64, (tank must be pumped at time of inspect ion)(locate on site plan) Depth below grade:A— Material of construction: AP concrete metal fiberglass eg polyethylene tZ4 other(explain): Dimensions: All) Capacity: A14 allons Design Flow:-Q gallons/day Alarm present(yes or no): Alarm level: __AhL Alarm in working order(yes or no):A Date of last pumping: Comments(condition of alarm and float switches,etc.): Tight or holding tanks are not present. DISTRIBUTION,BOX: Zif present must be opened)(locate on site plan) ' I 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.): Distribution box has one lateral.No evidence of solids carry nvPr_No evidence of leakage' 'into or out ot tfte box. PUMP CHAMBERt/,X,1f_(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Piimn rhamher is not present. 8 Page 9 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C .SYSTEM INFORMATION (continued) Property Address:1.1 9 Arrowhead Drive Hyannis,Mass. Owner: National Cons uc ion Company Inc. . Date of Inspectional 1 1 02 SOIL ABSORPTION SYSTEM (SAS): k (locate on site plan,excavation not required) _4-infiltrators 11 ' X25 ' :�-2' If SAS not located explain why: Located; See page , 10 Type V leaching pits, number: 0 leaching chambers, number: 4 inf iltrators 11 'X25 'X1 3" 4)6 leaching galleries,number:_0 At) leaching trenches,number, length: C> AQ L leaching fields, number, dimensions: p j)b overflow cesspool, number: Q innovative/alternative system Type/name of technology:.2!;� 0. fl_9-'R Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): Loamy sand to boney medium sand to fine sand.No signs of hydraulic failure or port ing, of s are dry. normal. CESSPOOLSxt"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 laver: 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.): Cesspool - ara nat present PRIVY/4�tL(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.): y . Privy is not present 9 Orjr IOo/It OFFICIIN! INSPECTION FORA - NOT FOR VOLUNTARY ASSESS.. EN SU8$URS. CE SCWACE DISPOSAL SYSTEM INSPECTION FORS PART C SYSTEM INPOR lLATION (conilnvco) a-cotrn .00.<,119 Arrowhead Drive Hyannis, . ass Nut- -E��. struction Company Inc. �i i pl snip ci oo: , , ire n� ^ SKI TCH OP SEWACC PISPO AL SYSTCM Ao� of i ittith o/,nt it..tlt'oiipolil tylltm InclV4(n; IIt1,t0 II Itill f1,roDtrmtntnl ftftrcncc I1n�r,,,c ..,ln-.n 10011,11 lot tit wntrt public VP I Pp Y tnicrl int bvilo,nl 19 ItT 10 �.OiTUN 1EAL =51ATE 509 420 8945 P.02/J4 • i 3 '•► �7 __ 5 TOWN OF 13ARNSTABLE C, LOCJIOI r �y �R�a a�Ne�� ,Dayr SEWAGE 40 73 7 VII LAG)r N,44 &a r ASSESSOR'S MAP& LOT 3 L-OF S6 INSTALLER'S NA-leM&PHONE NO. irl Rio r.t g S"��L,C r_ 77z 0 Ci f SEPTIC TANK CAPACITY —Z ao o LEACHING FACILITY: (type) 1A1- zeL7.P,,.o S _ (size) NO.OF BEDROOMS BUILDLR OR OWNERtc�a PERMITDATE: _ - Y -9 q COMPLLA.NCE DATE: I!_ Separation Distance Between the: Maximum Adjusted Oroundwater Table and Bottom of Leaching Facility . Feet Private Water Supply Well'and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(if any wetlands exist within 300 feet of leaching facility) eet Furnished by I Page 1 I of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1 1 9 Arrowhead Drive Tay Owner: NationalonssMat � Company Inc. Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells / Estimated depth to ground water 'r`� feet Please indicate (check)all methods used to determine the high ground water elevation: YES Obtained from system design plans on record - If checked, date of design plan reviewed: 1 1 /1 /0 2 YFS Observed site(abutting properry/observation hole within�1 SO feet of SAS) yp q Checked with local Board of Health-explain: Obtained as built plan YRS Checked with local excavators, installers-(anach documentation) yp Accessed USGS database-explain: http;f`/town,barnstable.ma,us. You must describe how you established the high ground water elevation: Used: Gahrety & Miller Model. 12/16/94 Ground water elevations aboveµ sea 1eve1 UsPri' nhcarvatinn well data, June 1992 Use-d TTOF ' cl Ru l 1 eti n 92-000-1 Plate #2 Annual ranges of ground vi vrounoa water elevations. 4 Infiltrators 11 'X25 ' 1 7 :eet Groundwater:" Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frim ter p p Method Therefore, the vertical separation distance between the boa m� Of the leaching pit and the adjusted groundwater table is - feet. 1I " `"R1T.—n•fTT TT 1Ti.�.T•'n f[ J1'Zt.��::T1Tr:.i'l"s�.�Ar.Y:"'L."TLT.r�. .. '1•OwN Or Barnstable BOARD OF HEALTH 0 S1111S(1RFACF• SEWAGE 1)I SPOSAL SYSTEM I N31 F TTION FORM - PART D .- CERTI FI CATION •••T'••1•T••.••.:.—T.1 T.^.T.TT.r..Tl•�:TI TZ T'.TTf TT.r•.t—•.•1^.T1 TAT/'^Tr-TtT.•a�/�y�� ,^^^1mmTT�. -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRES$119 Arrowhead Drive Hyannis,Mass/ . ASSESSORS MAP , DLOCK AND PARCEL # 271 -056 OWNER' s NAME National Cbnstruction Company PART D -. CERTIFICATION NAME OF INSPECTOR Joseph P . Macomber Jr COMPANY NAME Joseph P. Macomber &'"ion Inc COMPANY ADDRESS Box 66 Centerville Mass 02632 Street Town or Clty Stat9 ZIP COMPANY TELEPHONE ( 508 ) 775-3338 FAX ( 508 ) 790-1578 CERTIFICATION STATEMCNT I certify that I have personally inspected the sewage disposa`1 system nt ®rlecoinmendaL* ioris his address and that the information reported is true , accurate , and omplete as of the time of . inspection , The inspection was performed and any 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 ne : Systeri PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public Ilealt)l or Che environment as defined in 310 CMR 15 . 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* �\ The inspection ullich I ),five con�'trcted has found that 'the system fails to Protect the 'public he.alt)l and the environment in accordance with Title 5 , 3.10 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection for Inspector Signatur i Date O( n(ej* copy of this ert.ification must be provided to the OWNER, the DUYER where a}opl icabl e ) and thu DOARU OF HEAL'1'1l . * If the inspection FAILED , thl• ol,no r or operator shall upgrade • the eystem within one xear of the dnte of Che inspection , unless allowed or required otherwise as provided in 310 CPlR 2. 5 • 305 . partd , doc TOWN OF BARNSTABLE -W 2896 Ordinance or Regulation W/ARNING NOTICE Name of Offender/Manager � 1 6o t Y Wdob Address of Offender ArV a„ A6Y 411 , MV/MB Reg.# Village/State/Zip f7 DI Y �r )�fC I a !al 1A OZ !� /V�t1 T Business Name r n _ /,pin►�fon 1h 20 Business Address S'ignature .of En orcing Officer Village/State/Zip Fj� , r/ �sf Location of Offense (� 445 A/AXCA L.R [)om/ 456WRVHM0 / (.�f Enforcing Dept/Division Offense �lV V 1� .� l��{►- �-'4' V�I Y111� � _ Facts f I�t �¢"? I IY V! �Y -/ � r m o-��01'61tj 09 PW l/i44/0c*2" 0 This will serve only as a warning. At this" time no legal action has been taken. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. ""L'r+�•'4�Y��`�.sr:;rt''y�,''ia'�►i%yi�:�u'r:1�ivK•"^''7�r�4,1ry- '' R. �y�ia�i +'�''�"i�,6t»�.y:�:i�..__ _ _ TOWN OF BARNSTABLE BARW9�.. . Ordinance or Regulation WARNING NOTICE , l w Name of Offender/Manager C r h Address of Offender ' Prv(-), Any L f .1 , MV/MB Reg.# Village/State/.Zip hVAIAN-1 Arw�.t , MIA A - Business Name f` 1 �/pm; on _ 7 20f+1 Business Address "�/ ;f,.� Signature .of Enforcing Officer/_ .� Village/State%Zip' � • / Location of ,Offense Enforcing Dept/Division "NOf f ensa �//•.::A dc C c..- !f Cw 'y'✓I .I(� f r Facts" J f� / �::1'� �f.t.� : C •_"�1t./� � �.; Pj' V This will serve only as a warning. At ,this ..time no legal action has been taken. ;"It is -� the goal- of Town agencies to achieve . voluntary compliance of Town ,� Ordinances, Rules and.. Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. n*•f ��', x No. ! 7 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: O�j PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Yes ZIppYtcatton for Mf 6pont *pgtem Con5tructton Vermtt Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) (komplete System 0 Individual Components "nnnn ��n� on iN i l Location Address or Lot No. `� � Owner's Name,Address and Tel.No. 1 Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 370 gallons per day. Calculated daily flow 3 Lf gallons. Plan Date ® er of s eets Revision Date Title Size of Septic Tan _ Type of S.A.S., Description of Soil Nature of Rep ai or Alterations(Ans er when applicable) lyre 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 lhe_prs�� of the Environ tal Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Boar ` -7 Signed 1A Date Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued No. ' / 'Fee 1-7 p' �1n THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSE- S Yes ZIPPYication for �Diopozal *pttem Conaruction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon C5Complete System ❑Individual Components Location Address or Lot No.1 Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. 4� Designer's Name,Address and Tel.No.Zo ; P Type of Building: Dwelling No.of Bedrooms Lot Size s' .ft: Garbage Grinder( ) Other Type of Building No.of Persons F Showers( ) Cafeteria( ) Other Fixtures �'s Design Flow gallons per day. Calculated daily flow �� '' r gallons. Plan Date m -*Number of sheets Revision Date Title 0(2 / Size of Septic Tank Type of S.A.S. ` r «-tA '`Description of Soil (Ajg Nature of Repairs or Alterations(Ans er when applicable)'' e'I r' Date last inspected: ; Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the 5 of the Environmental Code and not to place the system in operation until a Certifi- '�• sate of Compliance as been issuedby this Boar Signed Date 4 Application Approved by Date d Application Disapproved for the following reasons Permit No. Date Issued r. ' �' THE COMMONWEALTH OF MASSACHUSETTS `BARNSTABLE,,,MA-SSACHUSETTS P, � � ertifirate of'Ompriance . THIS IS TO CLRTYFY, the On-site Sewage Disposal St 'Constructed( )Repaired( )Upgraded(� Abandoned( )by - a at 0 een constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. f dated Installer Designer The issuance of this ermit shall not be construed as a guarantee that the syste will function as designed. Date / 9^�� Inspector _ __1t1 ————————————— ————————————————————— -- ..�aj No. ', Fee ---7 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS M!5po.5ar *pztem Conotruction Permit Permission is hereby granted to ConsAruct )Repair( )Upgrade( )Abandon( ) System located at 'r 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 ee7completed within three years of the date of this t. Date:TlZ_��1 " �1 ApprovedG✓i i .y 116i99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AIND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated 3`S C concerning the property located at /19 A-62d"e--C,2 meets all of the following criteria: "- e 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 �ZThere are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed /TIere are no variances requested or needed. /The bottom of the proposed leaching facility will not be located less than five feet above the ma.�dmum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimntor 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(1.1) feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface elevation(using GIS information) �6. B) G.W. Elevation _the Mra2C. FUgh G.W. Adjustments? = O 7 D9FERENCE BETWEEN A and B SIGNED : DATE: (Sketch proposed plan of system on back]. q:health Colder.c--rt 1 c (1 O Q �1 v TOWN OF BARNSTABLE LOCATION SEWAGE # 9Z - 7 3 7 VILLAGE ASSESSOR'S MAP & LOT Q.7 l-0 S 6 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /i v LEACHING FACII.ITY- (type) lam/le/LeIZ-AeKI (size) NO. OF BEDROOMS i BUILDER OR OWNER �j2.col, 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 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 E77�� - � (/ D LOCATION SEW A.CE PERMIT N0. VILLAGE /� A4QXj + 5 �psS STA LLER'S NAME i ADDRESS l 2 � & .L 0UILDEIII OR OWNER AT / pzJ Al— ,J5 / 0 oZ 7 A© A-A4 S v� T. ��r'LA�rclT�'L.oif' 6?/fi4 SS DATE PERMIT ISS E D 414czc DATE COMPLIANCE ISSUED 9 O �IY No.� _....--- THE COMMONWEALTH OF MASSACHUSETTS BOAR®. OF HEALTH ........... oF............." L ..4.R.-11r !.&.......................... App iration for Biipnaal Workii Tonatrnrtinn Permit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal S stem at• ....-- ------.. '.. ... .... Locat' Add s r No. jE ;fc ... ® .. sue. � ,, r • - .....................•--- • ..........•. Owner Addres c .... ���! l '1 ... tea._ @vp a,S Installer Address dType of Building/ Size Lot............................Sq. feet Dwelling No. of Bedrooms..:.... ...................Expansion Attic ( ) Garbage Grinder �v Other—T e of Building ------------------ No. of persons............................ Showers — Cafeteria Q, Other fixtures .. •.•... - ------- W Design Flow}. ............ .1-.=........ ...,.gallons per person per day. Total daily flow___ �?�3....._........._.___gallons. 1:4 Septic Tank L Liquid'capacity./t ('gallons Length................ Width................. Diameter...-............ Depth................ W Disposal Trench—No..................... Width.................... Total Length........... __..._. Total leaching area....................sq. ft. x - Seepage Pit No......I............. Diameter....__Z`�._._.._.. Depth below inle ..._.. ........... Total lgacl�n�area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 0 G�/� Percolation Test Results Performed b a— y— �� f Y �..... �kl�� = Date rr ,al Test Pit No. 1____.G .. Depth to ground water____T .3'..minutes per mch Depth of Test Pit.................. p gr ,/J._._._.......... GT,, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to round water.................... Q'+ ......•• ...../.. 1. O ....................... C..- .........*....... ......... Description . Q-- ... ...... - ---------------------------------------------- -----------------------------------------------------------------------------------------------------------------------------------------•----------------------------------------------------------••-- 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'IT .s p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. ign .. .. ... ... .... ••-•••--•-•--•-...... ....................... --- •-••--......--•-••------- � � -ate Application Approved BY--------- .-•. .. . . ••.�� ------- - ------------------- -•-- .l� - Date Applicatior'•Disapproved for the following reasons-------------------------------------•-----------....---------------------------------------------------.....•--- --------•-•---------------------------------•---------------------------------------.........------------...----------------------------------------------------------------------...••••--••---...••••-- Date PermitNo......................................................... Issued_.......)'.......................................... Date r A. -ta No...................... Fxs,,, .- . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �, �. " Q.Ltf.Yl.................OF........:....., v4.��'��,`s ?± f. _............. Appliration for Biopooal Workii Tonotrurtion Permit Application is hereby made for a Permit to Construct �or Repair ( ) an Individual Sewage Disposal System at: ; + .... �" ® , �� ,u ,y. .J-•..........................•----------------------............. gl Celtg A o N .. --•--•..................... o .. ................. ... ��-- _- Ownej /�,. — Address w� 01 ' .J �leCt�[ Lo et°(r ILUe jI� 0 .......................................... ......•-••••-•---•............•. ........---- -•"-- Installer Address UType of Building,, Size Lot............................Sq. f t Dwelling No. of Bedrooms..........,._.......................Expansion Attic ( ) Garbage Grinder Fv� p-I Other—Type of Building ........... ....... No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ------------------------------------------------- w Design Flow............. ..1.._.. .....-__igallons per person per day. Total daily flow-___��'TZ. l.................gallons. WSeptic Tank Liquid capacity._ ....gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length........ Total leaching area....................sq. ft. Seepage Pit No------I............ Diameter....._fl-___--_- Depth below inlet...... yotal e�ac��pg area..............._sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Q ��G /!'i�_ y» Percolation Test Results Performed by..-..___�5 ..� t&j ....'. ....!.................. Date_..._._...__...._............_...�.... a Test Pit No. I.._.2x'_.minutes per inch Depth of Test Pit.................... Depth to ground water...../ -y..._-.-_. (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -- C Ix ........ GP O Description of Soil....._'..0.....3 r jt (✓�fGG�q G ' ------••-'----••------... x c, w VNature 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 i iT LEE y g � g p y 5 of the State Sanitary Code—The undersigned further agrees not to 1-ice the system in operation until a Certificate of Compliance has been issued by the board of health. igne ... ..........................••-•-••-••••-•--•--...........-----........-••••'---• ............•--,-' Date i Application Approved By......... {���< �- ................. -•-•` l Dated----•^- Application Disapproved for the following reasons:................................••--••.....•-•.............•-----•-••-•--•--•--•-••--•----••--'•---•......------ ---••••••-••'••-••-•---•••...........-•---•'•-•--'•'----.•-•••-•--•••-•'•--'•-'-•--•'•---•----•'-_...•"-.................•'---'-'•••------------•-'•---•----•-•---•-•-•-'----•'-------•------••"•'•'•-- Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...............1,.,,.I'7%s�1 .....OF............ .4114............. Trrtifiratr of TontpliFanrle TLT S I TO E IFY, That he Individual Sewage Disposal System constructed ( ) or Repaired ( ) by..... .. ' t ........................ `lo at.... .......uiuv � G_ll!+t ,�,=�tl.----' ••�•--- } ����`�� `� has been installed in accordance with the provisions of TITLE j of The State Sanitary Co e as described in the J1application for Disposal Works Construction Permit No......................................... da.ted... .'.� r" �` O THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.............................................•--•--•-•-•----._.._._....._...--.. Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD ,O HEALTH d -r ..... �1..........OF...... ........ 7......................... .....-................. No......................... FEE........................ Rio uott� o ko o trwtil�at rrmit Permission i reby granted••-- '- 1w% Q� -•----. a --- --•-..... to Const ct e�air ( an In 'vid 1 Se e Dis osal stem ► I at No.. l t. , A. �-s ��...4 k--.. ��--------- •_.--- 1�_. Street as shown on the application for Disposal Works Construction, Pit .:.. .... Dated_____ .."., .�.' .�...' f* ................................ DATE.....-•-•-•----.....--•-•-•••••..................................."-.........• Board of Heal h FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS :, 11 P_"` IZ A .t- �. •i O '11TS➢ Iti a jF � ,_ 1. I ��� IUOrre + +.. l.'!' t.l,} "�;f Sq.. 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