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Home My WebLink About0010 GOOSE POINT ROAD - Health - Hyanrii's A 252 , 0 l o i o ((i 1� o i TOWN OF BARNSTABLE LOCATION IQ G OOSc. PO i n-) Rd__ SEWAGE#c +L6 / VILLAGE Yuan n;S ASSESSOR'S MAP.&PARCEL INSTALLER'S NAME&PHONE NO. i o-o o&_10 SEPTIC TANK CAPACITY .D X c o�cc' �' 'i -O/vL LEACHING FACILITY-(type) (size) NO.OF BEDROOMS OWNER PERMIT DATE:SIT—J 3 COMPLIANCE DATE: I Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist ori' 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 FUWSHED BY - AZ_ yy . REAR.; ,93 G - O No. CPO 3 �"�' 7 Fee O U THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ye PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ftPlication for Misposal 6pstem Construction Permit --�gDy Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. /0 aoosse-Pb n r paer's N e,Address,and Tel.No. Own ic-MIC �Rrunw (51)8) 7 1�2g2 Assessor's Map/Parcel � o�J'a-v 0 5 O � I staller s e,Address,and el.No. Designer's Name,Address,and Tel.No. fi( Name, SD8-4-77-0(a5� 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(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) lQ 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 Certificate of Compliance has been issued by this Board o ealth. geed Date ( ((3 I Application Approved by Date It 1 1 3 I ) Application Disapproved by Date for the following reasons Permit No. / 3 4 Date Issued l No. /� Fee /0 U THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: „ Ye PUBLIC HEALTH DIVISION -.TOWN OF BARNSTABLE, MASSACHUSETTS application for Misposal 6pstetn Construction 3permit -- GD Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. /0 6,905P-Po I n T Owner's Name,Address,and Tel.No. Assessor'sMap/Pazcel �\ �'j a- �OSQ POD Owner's �r�un�o (502) Z•9,Z — (vZgZ 7 Installe 's Name,Address,and el.No. Designer's Name,Address,and Tel.No. 74 xCGVa4(on 509-1�-77-0&53 Type of Building: s ! f r, i Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures *--' Design Flow(min.required) gpd ' Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) T 1 IO 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 Certificate of Compliance has been issued by this Board ofAjealth. f gned Date .1 113 13 Application Approved by Date Application Disapproved by Date for the following reasons ry y Permit No. y y Date Issued l 3 THE COMMONWEALTH OF MASSACHUSETTS D BARNSTABLE,MASSACHUSETTS L Certificate of Compliance y THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(✓) Upgraded( ) Abandoned( )by �� I.(0 at io rj n0c t>: 1 nT P_DA 6 has been constructed in accordance `< with the p�ov'sions of Title 5 and the for Disposal System Construction Permit No:��'5 Wgdated / 3 I Installer (� Designer )U I #bedrooms Approved design flow gpd The issuance,of this permit shall not Pe construed as a guarantee that the systemrwill�funioj* Ted. DateInspector\` No. Fee Jid m THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction 3permit -'DX Q�j Permission is hereby granted to Construct( Repair(✓) Upgrade( ) Abandon( ) System located°at to 5 ' t^ ' and as described in the above Application for Disposal System Construction Permit. The applicant recognized 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 date of this p rmit. Date 1 �� Approved Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �.. 10 Goose Point Rd. Property Address Christopher& Michele Brunco Owner Owner's Name information is required for every Hyannis Ma 02601 Nov-12-13 _ page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information � on the computer, use only the tab 1. Inspector: key to move your cursor-do not use the return Matthew Gilfoy VVV key. Name of Inspector B & B Excavation,Inc. reb Company Name 14 Teaberry Lane Company Address R Forestdale MA 02644 City/Town State Zip Code 508-477-0653 S113640 Telephone Number, License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am,a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Nov-12Nov-1 -133 Inspector'stignature Date The system inspector shall submit.a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and.under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. d 15ins•11/10 Title 5 Official Inspectir.rSubsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Goose Point Rd. Property Address Christopher& Michele Brunco Owner Owners Name information is required for every Hyannis Ma 02601 Nov-12-13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System-Passes: ® [ have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.' - Comments: B) System Conditionally Passes: :. ❑"One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by -the Board of.Health, will pass. Check the box for"yes", "no" or"not determined"(Y, N, ND)for the following statements:"lf"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. EJ Y ❑ N ❑_ ND (Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Goose Point Rd. Property Address Christopher& Michele Brunco Owner Owner's Name information is required for every Hyannis Ma 02601 Nov-12-13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) - 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 in pection,if(with approval of Board of Health): ❑ broken pipe(s)are replaced : ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N. ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system.will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed. ❑ Y ❑ N ❑ ND (Explain below): C) Further.Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary.Assessments '�.,. 10 Goose Point Rd. Property Address Christopher & Michele Brunco Owner Owners Name information is required for every Hyannis Ma 02601 Nov-12-13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: _.❑ The system has a septic tank,and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system,has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a,private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to'determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3: Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes .No Backup of sewage into facility or system component due.to overloaded or El ® clogged SAS or cesspool 0 ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow l5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts w u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Goose Point Rd. Property Address Christopher& Michele Brunco Owner Owners Name information is required for every Hyannis Ma 02601 Nov-12-13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ 0 Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is.within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of.a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any:portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® 'Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet .from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] The system is a cesspool serving a facilit with a design flow of 2000 d Y P 9 Y � 9 9P - _. ❑ ® 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in.310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be.considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes'.' or"no"to each of the following, in addition to the questions in Section D. Yes No 0 E 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. l5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 10 Goose Point Rd. . Property Address Christopher& Michele Brunco Owner Owners Name information is required for every Hyannis Ma 02601 ` Nov-12-13 page. City/Town State Zip Code Date of Inspection C. Checklist - Check if the following have been done. You must in "yes" or"no" as to each of the following: Yes- No ❑ N' Pumping information was provided by the.owner, occupant, or Board of Health ❑ M Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two.week period? Have large volumes of water been introduced to the system recently or as part of ❑ ® this inspection? Were as built plans of the system obtained and examined?(If they'were not ® ❑ available note as N/A) ® ❑Y Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? .® ❑. Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank .. .. inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the'facility owner(and occupants if different from owner) provided with ❑ ® information on the.proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue ❑ ® ... .approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System.Information Residential Flow Conditions: Numberof bedrooms(design): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments 10 Goose Point Rd. Property Address Christopher& Michele Brunco Owner Owner's Name information is required for every Hyannis Ma 02601 Nov-12-13 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 4 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use?; ❑ Yes ® No Water meter readings, if available.(last 2 years usage(gpd)): Detail Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) 'Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Goose Point Rd. Property Address Christopher& Michele Brunco Owner Owners Name information is required for every Hyannis Ma 02601 Nov-12-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: . Date Other(describe below): i General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ® Yes ❑ No If yes; volume pumped: 1500 gallons How was quantity ? tank size q y pumped determined. Reason for pumping: maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. i ❑ Other(describe): 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Goose Point Rd. Property Address - Christopher& Michele Brunco Owner Owners Name information is required for every Hyannis Ma 02601. Nov-12-13 _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age.:of'all components, date installed (if known)and source of information: April 1996 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 21 Depth below grader feet Material of construction: ®cast iron JZ 40 PVC ❑ other(explain): Distance from p >10rivate water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in working order no sign of leakage or blockage Septic Tank(locate on site plan): Depth below grade: 15" feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) .If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ® No Dimensions: 1500 gal Sludge depth: no sludge 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Goose Point Rd. Property Address Christopher& Michele Brunco Owner Owner's Name information is required for every Hyannis Ma 02601 Nov-12-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle no sludge Scum thickness no scum Distance from top of scum to top of outlet tee or baffle To scum Distance from bottom of scum to bottom of outlet tee or baffle no scum How were dimensions determined? scour stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank is structurally sound with tees in place and showing no signs of leakage. Tank pumped upon completion of inspection for maintenance 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 15ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Goose Point Rd. Property Address Christopher & Michele Brunco Owner Owners Name information is required for every Hyannis Ma 02601 Nov-12-13 _ page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: , Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments " . 10 Goose Point Rd. .. . Property Address Christopher& Michele Brunco Owner Owner's Name --- information is required for every Hyannis Ma 02601 Nov-12-13 page. City/Town State Zip Code Date of Inspection D. System Information (cant.) Distribution Box(if present,must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments.(note if box is level and distribution to outlets equal, any evidence of solids carryover, any j evidence of leakage into or out of box, etc.): D-box replaced with new D133 2013. Pump Chamber(locate on site plan): . Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No i Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): . Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why:., l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Goose Point Rd. Property Address Christopher& Michele Brunco Owner Owners Name information is required for every Hyannis Ma 02601 Nov-12-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) - Type ❑ leaching pits number: El leaching chambers': number: ❑ .leaching galleries number: .. . leaching trenches number, length: 1(60'X4'X2') El 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.): At time of inspection leaching appears to be in working condition. No sign of hydraulic failure 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 i Materials of construction i Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Goose Point Rd. Property Address Christopher& Michele Brunco Owner Owners Name information is required for every Hyannis Ma 02601 Nov-12-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure,.level of ponding, condition of vegetation, etc.): i 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.): I l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth,&Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 'y 10 Goose Point Rd. Property Address Christopher& Michele Brunco Owner Owner's Name information is Hy annis Ma 02601 Nov-12-13 required for every page. Cityffown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached'separately - /� 1 � r n AT:536 ' z A2=144 ' — f . t - t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Goose Point Rd. Property Address Christopher& Michele Brunco Owner Owner's Name information is required for every Hyannis Ma 02601 Nov-12-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ®: Surface water ® Check-cellar ® Shallow wells.. . Estimated depth to high ground water: >12 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record 'If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked:with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS TOPO maps show no high ground water in area. GW at 47'while bottom of leaching at 6.7' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments . 10 Goose Point Rd. Property Address Christopher& Michele Brunco Owner Owners Name information is required for every Hyannis Ma 02601 Nov-12-13 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® .System information—.Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I l5ins•11/10. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 r to k 25160 P:9257 211F815 a_a1-06-2�-311 a 10 = 40ct NOTICE: The Town of Barnstable ..recommends_that the T lir�nt seek legal advice to prepare a properly worded deed restriction document. DEED RESTRICTION 0. WHEREAS, S her aao Vic ele ►^t�h o of I ��-- (owners name)l`Tni Bjp Pn i,j T i?-,A U i I A U,�(0 3 Z MA (address) r1 oz 6 jz- is the owner of I V 6 o0se Q�, I a ,(/�A. located (address) at MA (hereinafter referred to as anftdr4aC4 ing shown on a plan entitled "Subdivision of Land in f(o, MA, Property of et al, duly recorded in Barnstable County Registry of Deeds in Plan Book 1� , Page Or on Land Court Plan Number WHEREAS, as the owner of said lot has (owners name) agreed with the Town of Barnstable Board of Health to a restriction as to the number of bedrooms which can be included in any home built on said lot as a pre-condition to obtaining a disposal works construction permit in compliance with 310 CMR 15.000 State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage; WHEREAS, the Town of Barnstable Board of Health, as a pre-condition to granting a disposal works construction permit for a septic system in compliance with 310 CMR 15.200, State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage, and authorizing the issuance of a building permit for the construction of a single family home on this property, is requiring that the agreement for the restriction on the number of bedrooms in any house constructed on the lot be put on record with the Barnstable County Registry of Deeds by recording this document, deedr /I N 1 C rdoes hereby place the NOW, THEREFORE, t�lfl ,fir ^ , U � (owner's name) following restriction on his above-referenced land in accordance with his agremeatwAh he_.T_wn..of d-of- a , wM+cf�-estrietion sba* run with the land and be binding upon all.successors in title: 1• fu�lr 60'/M 3 may have constructed (address) upon the lot a house containing no more than 2- ( ) bedrooms. c{tri'sfv�OA A�it(�'�I.eLP ,6ruh agrees that this shall be.permanentdeed '(owners name) restriction affecting located on L�40P n� �/, C- MA,V!and being shown on the plan recorded in Plan Book , Paged Or on Land Court Plan Fo title of see the following deed: Book , Page . Or Land Court Certificate of Title Number Executed as a sealed instrument day of pees' signature Owner's signature Owner's signature COMMONWEALTH OF MASSACHUSETTS . ss 120 Then personally appeared the above-named known to me to be the person who executed the foregoing instrument and acknowledged . the same to be free act and deed, before me, Notary Public My commission expires: (date) dee& BARNSTABLE REGISTRY OF DEEDS n ' CERTIFICATE OF ANALYSIS page: 1 m Barnstable County Health Laborator Report Prepared For: Report Dated: 02/14/2003 Order N mb ik-8 2qOW 4 Michelle Michaels TO W 10 Goose Point Rd. HEAL H DEpTABt E Centerville, MA 02637 Laboratory ID#: 0318864-01 Description: Water-Drinking Water Sample f#: 04342 Sampling Location: 10 Goose Point Rd Centerville MA Collected: 02/07/2003 Collected by: S Rask Received: 02/07/2003 EPA 524.2- Volatile Organics by GUMS ITEM RESULT UNITS MDL MCL Method N Tested LAB: GUMS 1,1,1,2-Tetrachloroethane BRL ug/L 0.5 EPA 524.2 02/11/2003 1,1,1-Trichloroethane BRL ug/L 0.5 200 -EPA 524.2 02/11/2003 1,1,2,2-Tetrachloroethane BRL ug/L 0.5 EPA 524.2 02/11i2003 L1,2-Trichloroethane BRL- ug/L 0.5 5.0 EPA 524.2 02/11/2003 L17Dichl6roethane BRL ug/L 0.5 EPA 52.4.2 02/11/2003 '1;1=Dich1oroethene- BRL qg/[ 0.5 7.0 EPA 524:2 02/11/2003 ...... O _ L..,11+..1 . 1;1-Dichloropropetie BRL ug/L 0.5 EPA 524.2 02/11/2003 1,2;3=Trichloro6enzene BRL- mg[L 0.5 EPA 524.2 02/11/2003 1,2,3-Trichloropropane BRL ug/L 0.5 EPA 524.2 02/11/2003 1,2,4-Trichlorobenzene BRL ug/L 0.5 70 EPA 524.2 02/11/2003 1,2,4-Trimethylbenzene BRL ug/L 0.5 EPA 524.2 02/11/2003 1,2-Dibromo-3-chloropropan BRL ug/L 0.5 EPA 524.2 02/11/2003 1,2-Dibromoethane (EDB) BRL ug/L 0.5 EPA 524.2 02/11/2003 1,2-Dichlorobenzene BRL ug/L 0.5 600 EPA 524.2 02/11/2003 1,2-Dichloroe4hane BRL ug/L 0.5 5.0 EPA 524.2 02/11/2003 1,2-Dichloropropane BRL ug/L 0.5 EPA 524.2 02/11/2003 1,3;5-Trimethylbenzene BRL ug/L 0.5 EPA 524.2 02/11/2003 1;3-Dichlorobenzene BRL ug/L 0.5 EPA 524.2 02/11/2003 1;3=Dichloropropane BRL pg/L 0.5 EPA 524.2 02/11/2003 1,4-Dichlorobenzene• =0.7 qg/L 0.5 5.0 EPA 524.2 02/11/2003 2,2-Dichloropropane BRL ug/L 0.5 EPA 524.2 02/11/2003 2-Chlorotoluene' - BRL ug/L 0.5 EPA 524.2 02/11/2003 4=Chlorotoluene•. - BRL- ug/L 0.5 EPA 524.2 02/11/2003 Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 Page: 2 CERTIFICATE OF ANALYSIS Barnstable County Health Laboratory Report Prepared For: Report Dated: 02/14/2003 Order Number: G0318864 Michelle Michaels 10 Goose Point Rd. Centerville, MA 02637 Laboratory ID#: 0318864-01 Description: Water-Drinking Water Sample#: 04342 Sampling Location: 10 Goose Point Rd Centerville MA Collected: 02/07/2003 Collected by: S Rask Received: 02/07/2003 Benzene BRL ug/L 0.5 5.0 EPA 524.2 02/11/2003 Bromobenzene BRL ug/L 0.5 EPA 524.2 02/11/2003 Bromochloromethane BRL ug/L 0.5 EPA 524.2 02/11/2003 Bromodichloromethane BRL ug/L 0.5 EPA 524.2 02/11/2003 Bromoform BRL ug/L 0.5 EPA 524.2 02/11/2003 Bromomethane BRL ug/L 0.5 EPA 524.2 02/11/2003 Carbon tetrachloride BRL ug/L 0.5 5.0 EPA 524.2 02/11/2003 Chlorobenzene BRL ug/L 0.5 100 EPA 524.2 02/11/2003 Chloroethane BRL ug/L 0.5 EPA 524.2 02/11/2003 Chloroform 0.8 ug/L 0.5 EPA 524.2 02/11/2003 Chloromethane BRL ug/L 0.5 EPA 524.2 02/11/2003 cis-1,2-Dichloroethene BRL ug/L 0.5 70 EPA 524.2 02/11/2003 cis-1,3-Dichloropropene BRL ug/L 0•5 EPA 524.2 02/11/2003 Dibromochloromethane BRL ug/L 0.5 EPA 524.2 02/11/2003 Dibromomethane BRL ug/L 0.5 EPA 524.2 02/11/2003 Dichlorodifluoromethane BRL ug/L 0.5 EPA 524.2 02/11/2003 Ethylbenzene BRL ug/L 0.5 700 EPA 524.2 02/11/2003 Hexachlorobutadiene BRL ug/L 0.5 EPA 524.2 02/11/2003 Isopropylbenzene BRL ug/L 0.5 EPA 524.2 02/11/2003 Methyl-tert-butyl ether BRL ug/L 2.0 EPA 524.2 02/11/2003 Methylene chloride BRL ug/L 0.5 5.0 EPA 524.2 02/11/2003 n-Butylbenzene BRL ug/L 0.5 EPA 524.2 02/11/2003 n-Propylbenzene BRL ug/L 0.5 EPA 524.2 02/11/2003 Naphthalene BRL ug/L 0.5 EPA 524.2 02/11/2003 p-Isopropyltoluene BRL ug/L 0.5 EPA 524.2 02/11/2003 sec-Butylbenzene BRL ug/L 0.5 'EPA 524.2 02/11/2003 Styrene BRL ug/L 0.5 100 EPA 524.2 02/11/20013 Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 r — _ Page: 3 CERTIFICATE OF ANALYSIS Barnstable County Health Laboratory Report Prepared For: Report Dated: 02/14/2003 Order Number: G0318864 Michelle Michaels 10 Goose Point Rd. Centerville, MA 02637 Laboratory ID#: 0318864-01 Description: Water-Drinking Water Sample t/: 04342 Sampling Location: 10 Goose Point Rd Centerville MA Collected: 02/07/2003 Collected by: S Rask Received: 02/07/2003 tert-Butylbenzene BRL ug/L 0.5 EPA 524.2 02/11/2003 Tetrachloroethene BRL ug/L 0.5 5.0 EPA 524.2 02/11/2003 Toluene BRL ug/L 0.5 1000 EPA 524.2 02/11/2003 Total xylenes BRL ug/L 0.5 10000 EPA 524.2 02/11/2003 trans-l,2-Dichloroethene BRL ug/L 0.5 100 EPA 524.2 02/11/2003 trans-1,3-Dichloropropene BRL ug/L 0.5 EPA 524.2 02/11/2003 Trichloroethene BRL ug/L 0.5 5.0 EPA 524.2 02/11/2003 Trichlorofluoromethane BRL ug/L 0.5 EPA 524.2 02/11/2003 Vinyl chloride BRL ug/L 0.5 2.0 EPA 524.2 02/11/2003 Approved By:•'l/ (Lab Director) Z/i y/Zc�3 Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 COMMONWEALTH OF MASSACHUSETTS • EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED G� S� (9 5o SEP 18 2002 TITLE S TOWHEOALTBH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION 1 �— Property Address G Goo a 01✓tRd eti e.rv, Ifle, Owner's Name: t Owner's Address: ce-,l ie<1,1 Ile, z,01",4 Date of Inspection: ` / // MAP Name of Inspector..�ease print) Gi4-- O%S `1 i MAP Company Name: /d/'li/ -- C- ; Mailing Address: LOT Telephone Number: a 9J CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true.accurate and complete as.of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: l/ Passes Conditionally Passes Needs Further Evaluation by the Local Appro%ing Authority Fail Inspector's Signature: ! :- Date: X,21,1.loj The system inspector shall submi 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 10.00o gpd or greater.the inspector and the system owner shall submit the report to the appropriate regional ofice of the DEP. The original should be sent to the system owner and copies sent to the buyer. if applicable.and the approving authority. Notes and Comments This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. I Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: �Q G005 0,0 1 f✓ oa 6 Owner, ci ✓1 f,s 4e✓^ Date of Inspection: o Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A�71 Passes: have not found any info rmation which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist Anv failure criteria not evaluated are indicated below. Comments: B. SSvstem Conditionally Passes: /1 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 structumuv 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 wrill pass inspection if it is structural)y 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. Svstem 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 Healthy broken pipe(s)are replaced obstruction is removed ND explain: r , Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: /0 600 /lp,�, C� .-✓, e /� a63� Owner. G vices, e V— Date of Inspection: ki,o O 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 i 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 enviroumefir _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within.50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis, performed at a DEP certified laboratory. for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy'of the analysis must be attached to this form. 3. Other. f 'Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: I i Date of Inspection: d c D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes N _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or /clogged SAS or cesspool V Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or /cesspool _ V Liquid depth in cesspool is less than 6"below invert or available volume is less than'h day flow �Wequired pumping more than 4 times in the last year NOT due to clogged or obstructed i �of times pumped p pe(s).Number : �r►y portion of the SAS,cesspool or privy is below high ground water elevation. ✓A ny portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface /water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. V�j y 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 N U (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 — _ 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 3'10 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B IICHECKLIST Property Address4r06 0 Olei , a6�, Owner. `�i✓�<q I Date of Inspection: o Check if the following have been done.You must indicate`ves"or"no"as to each of the following: Yes o Pumping information was provided by the owner.occupant or Board of Health Were any of the system components pumped out in the previous two weeks Has the system received normal flows in the previous two week period 4:L-�ve large volumes of water been introduced to the system recentiv 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 manhol es 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 siz e and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes/no Existing information. For example.a,plan at the Board of Health: V" Determined in the field(if any of the failure criteria related to Part C i is unacceptable) [310 CUR 15.302(3)(b)J sat issue approximation of distance i -------------- Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 0 t<cj ;-, &,✓/' P�aG3„� Owner. ZC4 7 Ce*S -f I.,- Date of Inspection: gel OZ p FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):gZ_ Number of bedrooms(actual): DESIGN flow based on 310 CUR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no):I*VO Is laundry on a separate sewage system(yes or no):Q [if yes separate inspection required] Laundry system inspected v or no): Seasonal use: (yes or no): Water meter readings,if available(last 2 vears usage(gpd)): o?000�- pZ�j poo aoo 1 Sump pump(yes or no): �`V 0 00 Last date of occupancy: ,z n COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gnd Basis of design flow(seats/persons/sg8.etc.): ' Grease trap present(yes or no): Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):— Water meter readings.if available:. Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: vy ed v a _ 0 L, WW-I —, Was system pumped as part of the inspection(yes or no):_ v If yes.volume pumped:_gallons—How was quantity pumped determined? Reason for pumping: TYP F SYSTEM JZ"§epuc tank,distribution box. soil absorption system _Single cesspool _Overflow cesspool _Privy Shared system(yes or no)(if ves.attach previous inspection records.if any) _lnnovative/Alternatiye technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all component&date installed(if q,<m)and source of information: - — O Were sewage odors detected when arriving at the site(yes or no): Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) ' Property Address: C C�'�se IV)7 - 19j 1.44 Owner. Date of Inspection: aLo BUILDING SEWER(locate on site plan) Depth below grade:. C�/ Materials of construction:_cast iron —"-O PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints.venting,evidence of leakage,etc.): SEPTIC TANK: (locato on site plan) i Depth below grade: /s � Material of construction: l concrete—metal fiberglass—polvethylene _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: GA I V Sludge depth: Distance from top of sludge to bottom of outlet tee or baffler 4� Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottorn of outlet tee or�� How were dimensions determined: U/� /eo, C97&71 C P Comments(on pumping recommendations. inlet and outlet tee or baffle condition. structural integrity. liquid levels aled to outlet i vert. Bence of leakage,etc.): _ _ � Avt o �O sec p!„i GREASE TRAP:/1/pocate on site plan) Depth below grade: — Material of construction:.—concrete metal fiberglass_poh•ethvlene 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 oil e: Date of last pumping: Comments(on pumping recommendations. inlet and outlet tee or battle condition, structural integrity. liquid levels as related to outlet invert.evidence of leakage. etc.): Page 8 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Aq in� Owner. Date of Inspection: 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: eaLons Design Flow: eallons/day Alarm present(yes or no): Alarm level: Alarm in worldng order(yes or no): Date of last pumping Comments(condition of alarm and float switches.etc.): DISTRIBUTION BOX: (if 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 to or out of box.etc.).- PUMP CHAMBER (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber.condition of pumps and appurtenances.etc.): • V Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Aq v� Owner. Gaut Lois �1/ Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan.excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries.number: -F,-" 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 -zL 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 laver: Depth of scum layer: Dimensions of cesspool: Materials of.construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil..signs of hydraulic failure.level of ponding•condition of vegetation etc.): PRIVY:Zoocate 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.): Page 10 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /o (9—O� e p f Owner.l�iNCu y+ Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM . Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building. fuseoo �or�ctl Ga�py� 14/-A - �� 9L/ /,.;7a0 ye411a17 eP'`�` r 1 ..................... Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM/INFORMATION (continued) Property Address: (�-t70 YO rr / yr Yr P 1�v2.(o Owner. �N C Date of Inspection: t52 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the hig h 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: To LA.h v 7 4,0,1S Checked with local excavators installers-(attach documentation) Accessed USGS database-explain: :Youmust es� 'be how you established the high ground water elevation: /�6 t��=/Tev o 7,-,1 ' I�1��, �rroNnct�q�r ICJ /•f/ . ti TOWN OF BARNSTABLE � SEWAGE # Zfd VILLAGE o yaASS� MAP&LOT Z �-��✓'b INSTALLER'S NAME&PHONE NO.L-f1e,&&e7 /he.—c u— e!b -7->1 SEPTIC TANK CAPACITY 4 �EVO LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER O OWNER S�PpL� PERMIT DATE: J14 COMPLIANCE DATE: V/i�g 6 Separation Distance Between the: Maximum Adjusted Groundwater Table and'Bottom of Leaching Facility 6 K' Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) l�K Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i � O a � t W C I • 1 J ?. `� `C4 OWN OV-B STABLE - I:UC;kTION d�/ 11 m�� SEWAGE # VILLAGE ASSESSOR'S MAP & LORX INSTALLER'S NAME&PHONE NO.. SEPTIC TANK CAPACITY LEACHING FACILITY: (ty ) U�Gh P v-�- (size) Ub o NO. OF BEDROOMS BUILDER OR 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 on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 fe t o leac ng facility) Feet Furnished by 1 . s .,,j 'n fTr In 1, t, SESSORS PARCQNO• � .No. QS� Fee i THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for ;h5pp t *pgtem Congtructiott permit Application is hereby made for a Permit to Construct( )or Repair( L<an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. a PPLe— 456 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 2 Garbage Grinder Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil '• Z S-a—,jtL Nature of Repairs or Alterations(Answer when applicable) t%Xi s- Its'" Sa rae.- 7AFV)4-, f 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. Signed Date 4 .P Application Approved by Application Disapproved for the following reasons Permit No. ��j �1�� Date'Issued Fee THE COMMONWEALTH OF MASSACHUSETTS * PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Application for Migpoof *pgtem Construction Permit Application is hereby made for a Permit to Construct( )or Repair( an On-site Sewage Disposal System at: E ; r Location Address or Lot No. Owner's Name;Address and Tel.No. to O�oOSC- �DI+J�- 2 1� '75 W�'�5-iYRV (ecJ c. asLe~' CLAN Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. f I � Type of Building: �. Dwelling No.of Bedrooms Garbage Grinder NO) Other Type of Building No. of Persons Showers( ) Cafeteria( ) ` Other Fixtures— Af Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil Cr-Z- Nature of Repairs or Alterations(Answer when applicable) tl`NX�4%0L ��y� ,t-' 6a-"'L-.o►a� x . � ' u ,Q E? x 2' }crc� 7�tx,vc N 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. Signed c� — -� Date u r 7 Application Approved by Application Disapproved for the following reasons { I Permit No. �'�� Date Issued `"''` THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Dis osal System'installed( )or repaired/replaced( on by t�-\C_Y_tf OLQN1 -St for S.'v-kb fLC C.C�bSLa�� ' (Z� C'u"'f' has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. S,a dated Use of this system is conditioned on compliance with the provisions set f below: - -. s — // 1 No. �"� �/ �/ Fee " THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS lwigogal *potem Construction Permit Permission is hereby granted to (Z Ox� to construct( )repair( an On-site Sewage System located at 1't> Gobs L-Po\VJN- e-lti,K,— and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to r comply with Title 5 and the following local provisions or special conditions. All construction must be completed within two years of the date below. ` Date:Vf e-0 Approved i i i CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) I, mt U-;tt hereby certify that the application for disposal works construction permit signed by me dated-t , concerning the property located at iG c--00s�RbI V QIVLA meets all of the following criteria: 'O'k- There are no wetlands within 300 feet of the proposed septic system tk: There are no private wells within 150 feet of the proposed septic system (5 , The observed groundwater table is 14 feet or greater below the bottom of the leaching facility ti There is no increase in flow and/or change in use proposed There are no variances requested or needed. y SIGNED: r�s—�� DATE: . LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. 1�P�Int�hGt} lfi 'A11, e4 CGi�c.1; tto�i: • i �,�� C�C{'et{�f plci4, e-rd W�tIIS� Dr�s� tl o. ( > 1 �.r NY9(Tj�1,5�_#{1I S►6\\ � - � 8x55.KA • tg.Pmb cut amh i --' 1(IICIYM Oxwj i D C ® ® ® n 14.0' y , L)-4 Rowe i ' BrAl— 16 0' 3e.0' AREA.CALCULATIONS. SUMMARY LIVING AREA .BREAKDOW,N Descriptlon.. •. NotSizs ow: Net Totals Breakdn: . Subtotals, First Floor 1464.0 1464.0 First Floor 12.0 x 68.0 816.0 12.0 .x 38.0 456.0 12.0 x 16.0 192.0 Net LIVABLE Area (Rounded) 1 1464 13 Items (Rounded) 1464