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Home My WebLink About0014 GROUSE LANE - Health 14 Grouse Lane (Hyannis) A=268-263a 1 i i e i -ro , Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Grouse Ln Property Address Patricia Smith Owner Owner's Name information is required for every Hyannis MA 02601 10-21-11 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. A. General Information 1. 1 nspector: Shawn Mcelroy r Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification C I certify that I have personally inspected the sewage disposal system at this address and tk at 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 maintenan a of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Sectionj5.340lof Title 5(310 CM 15:000).The system: ti' 0 ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 10-21-11 Inspector's Signature Date I 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. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage I Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Grouse Ln Property Address Patricia Smith Owner Owner's Name - information y ation is Hyannis MA 02601 10-21-11 required for every page. Cityrrown 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: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no" or""not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•11/10 - Tdle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Grouse Ln Property Address Patricia Smith Owner Owner's Name information is required for every Hyannis MA 02601 10-21-11 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 inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless.Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Grouse Ln Property Address Patricia Smith Owrer Owner's Name information is regt.ired for every Hyannis MA 02601 10-21-11 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: ' I� D System Failure Criteria Applicable to All Systems: Y pp Y You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters 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 t5ins•11/10 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 14 Grouse Ln Property Address Patricia Smith Owner Owner's Name information is required for every Hyannis MA 02601 10-21-11 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: ❑ ® 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 facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either`yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection- Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Lt,=-,1/10 y, j +, 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 c G M 14 Grouse Ln Property Address Patricia Smith Owner Owner's Name information is required for every Hyannis MA 02601 10-21-11 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes"or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑, Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs'of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 r t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Grouse Ln Property Address Patricia Smith Owner Owner's Name information is required for every Hyannis MA 02601 10-21-11 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 5 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: 10-2011Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) v 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 0 No Water meter readings, if available: t5ins•11/10 ,_ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 14 Grouse Ln Property Address Patricia Smith Owner Owner's Name information is required for every Hyannis MA 02601 10-21-11 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (f yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 14 Grouse Ln Property Address Patricia Smith Owner Owner's Name information is required for every Hyannis MA 02601 10-21-11 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2001 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 14" feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints,venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: 8"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: 12" t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Com monwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 14 Grouse Ln Property Address Patricia Smith Owner Owner's Name information is required for every Hyannis MA 02601 10-21-11 page. Cityrrown 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 20 Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and,no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 14 Grouse Ln Property Address Patricia Smith Owner Owner's Name information is required for every Hyannis MA 02601 10-21-11 page. Citylrown 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 ❑ 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 t5ins•11/10, _ Tdle 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 �M 14 Grouse Ln Property Address Patricia Smith Owner Owner's Name information is required for every Hyannis MA 02601 10-21-11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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 evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from chambers. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 6 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 14 Grouse Ln Property Address Patricia Smith Owner Owner's Name information is required for every Hyannis MA 02601 10-21-11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2-500's ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields -number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of pondingi damp soil, condition of vegetation, etc.): Leach chambers in good condition with stain line at 8"from bottom of chamber. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M �~ 14 Grouse Ln Property Address Patricia Smith Owner Owner's Name information is required for every Hyannis MA 02601 10-21-11 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.): 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.): t5ins 11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 14 Grouse Ln Property Address Patricia Smith Owner Owner's Name information is required for every Hyannis MA 02601 10-21-11 page. Cityfrown 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 G 6D-- 13' C`- G 4/0`6 t t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage`Disposal System Form -Not for Voluntary Assessments wM 14 Grouse Ln Property Address Patricia Smith Owner Owner's Name information is required for every Hyannis MA 02601 10-21-11 page. Cityrrown 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: 10, 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: Original design plans show no groundwater at 10'. s i II 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 °M 14 Grouse Ln Property Address Patricia Smith Owner Owner's Name information is required for every Hyannis MA 02601 10-21-11 page. Citylrown 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 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF BARNST'ABL.E LOCATION �� ry u �G_ t/ � � SEWAGE # VIILLAGE �� izn iS ASSESSOR'S MAP& L,OT .___ _ ( IN§tAL LER'S NAME&PHONE NO. ` I SEP'I1C 'TANK. CAPAGrrY /5TZM i L ACHNG FACIIg.I'M (tM) !ii a" r g (size) NO.OF'BEDROOMS _ . ,BUJLDlaR OR OWNER, i; :( PERMMI TDATE: COWLIANCE DATE: . .�. _.. --- ' Separation Distance Betweep the, Maximum Adjusted Groundwater Table to the;Bottom of Leaching Facility Fee" Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leashing facility) Feel Edge of Wedand and Leaching Facility(if any wetlands exist within 300 feet of cachi is fiacilary) Fureaished by � � a � ) G I TOWN OF BARNSTABLE LOCA 0.N 49, 6 X 0 u s L-4 SEWAGE VILLAGE_ )1.4 "-15 ea eET ASSESSOR'S MAP & LOT�C�S INSTALLER'S NAME&PHONE NO. T P A4A C,q,—A /g e&. i;oA, SEPTIC TANK CAPACITY n LEACHING FACILITY: (type) e`L'/��D W C114-Af of4ests (size) NO. OF BEDROOMS BUILDER OR OWNER `�� PERMTI'DATE: � COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist Within 300 feet of leaching facility) Feet Furnished by .�� T, / �' .. , � _� -� . : � � v i �` �`� �� .. �� ,/ -�'" f }�, �. No. . Fee $ 5 0 0 0 � THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01pprication for Migpogaf Opgtem Construction Permit Application for a Permit to Construct( , )Repair( )Upgrade V Abandon( ) O Complete System 20 Individual Components Location Address or Lot No.1 4 Grouse Lane Owner's Name,Address and Tel.No. 5 0 8-8 6 4-0 0 9 2 West Hyannisport,Mass. Bob Puchalski Assessor'sMap/Parcel : ic ; A G 3 14 Grouse Lane West Hyannisport,MA Installer's Name,Address,and Tel.No. 5 0 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8—7 7 5—3 3 3 8 J.P.Macomber & Son Inc. J.P.Macomber & Son Inc. Box 66 Centerville,Mass.02632 Box 66 Centerville Mass .02632 Type of Building: DwellingXXXNo.of Bedrooms 2 Lot Size sq.ft. 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 Size of Septic Tank I � CI Type of S.A.S. Description of Soil L()amY hnnPvgand to €in® Sind Nature of Repairs or Alterations(Answer when applicable) Install 1 -1 5 0 0 gallon septic tank and one !71 �ek S S � 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 is ued by th' 11 d of liealth. Signeda Aw. e Date6 2 7 01 Application Approved by Date Application Disapproved or the following reasons Permit No. �� Date Issued ...-�.• ,.--rq, fI„ ..may..._ - ,. Fee $ 50.00 THE COMMONWEALTH OF MASSACHUSETTS�„ Entered in computer: - Yes PUBLIC=HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETT& Application for 33i!5pogal 6potem Con!6truction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System 29 Individual Components Location Address or Lot No.1 4 G r ou s e Lane Owner's Name,Address and Tel.No. 5 0 8—8 6 4—0 0 9 2 West Hyannisport,Mass. f Bob Puchalski Assessor'sMap/Parcel q 4/,� 0 A 6 3 14 Grouse Lane West Hyannisport,MA Installer's Name,Address,and Tel.No. 5 0 8-7 7 5-3 3 3 8 Designer's Name,Address and Tel.No. 5 0 8—7 7 5—3 3 3 8 J.P.Macomber & Son Inc.. J.P.Macomber & Son Inc. Box 66 Centerville`,Mass.02632 1Box 66 Centerville Mass.02632 Type of Building: DwellingXXXNo.of Bedrooms 2 Lot Size% sq.ft. Garbage Grinder( ) Other Type of Building A`&- No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Loamy, honey cancl +0 f i n- R=nA Nature of Repairs or Alterations(Answer when applicable) Install 1 -1 5 0 0 gallon septic tank andone distribution box_ 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 is�jued by t Bodrd of ealth. Signed 4 Date6/�2 7/01 ,y Application Approved by Date ®'. ' � f Application Disapproved 1ror the following reasons Permit No. r :� Date Issued THE COMMONWEALTH OF MASSACHUSETTS r BARNSTABLE, MASSACHUSETTS 6ertif irate of (ComprianceG,-/' . el THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repairedg- )Upgraded( ) Abandoned( )by J.P.Macomber $ Son rInc. at 14 Grouse Lane West H annis ort Mass. ' has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permi dated VO-- Installer J.P.Macomber r A Son T n c, Designer --J.P.Macomber & Son Inc. The issuance of this permit shall not be construed as a guarantee that the syste n will function a desig ed. Date � 'U Inspector �Qe No.42raff�'" e_F ;- Fee $ 50.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS lwiopotal *pgtem Conotruction Permit Permission is hereby granted to Construct( )Repair Upgrade(X)Abandon( ) System located at 14 Grouse Lane Was Hy' anniSp6rf,MgsQ_ Y iR J 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. r Provided:Construction must be completed within three years of the date of a t. Date: 1 `5 Approved L �~ l/6199 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) ); Joseph P.Macomber Jr. hereby certify that the application for disposal works construction permit sighted by me dated 6/2 7/01 concerning the property located at 14 Grouse Lane West Hyannisport MA meets all of the Mowing criteria: • The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There are no wetlands within 100 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table clevadon. (Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S. will be located with 250 feet of any vegetated wedands, the bottom of the proposed leaching facility will not be located less than fourteen (14) feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevadon(using GIS information) B) G.W. Elevadon j +the MAX. FUgh G.W. Adjustment. DIFFERENCE BETWEEN A and B SIGNED ; DAI-E;6/27/01 (Sket pr sed plan of system on back). q:health folder.cent Existing cesspool New Box New 1500 gallon Septic tank. 0 , i -2- A ............. 5-- 'P M-1 TOWN OF BARNSTABLE LOCATION Z.4 SEWAGE # VILLAGE ASSESSOR'S MAP. T INSTALL.ER &.LOT 7— 'S NAME&PHONE NO, SEPTIC TANK:CAPACITY j - 16 LEACHING FA" ----------- CILrry: (type) (size), BUILDER OR OWNER PERM lTbAlt: DATE: SeparationDistance `7----- n Betwee the:, "Max1muirl Adjusted Groundwater Table to the Bott o ; W� vate ater Supply, Well Pri Gm f Leaching.Facility Facility Fee . and Leaching Faci ty ( „any t W611S exist T,...,si e or withn.200 feet of leaching:facili Ed: f �TP of and LeAchin F g Facility(if any we Feet. wetlands exist Within 300.feet.of leaching facility) Furm'shed by Feet ----------- ------------ --------- Q; I$ RECEIVED L.UMNfUN WtAL i ri vi vif'►33A%-si iS%I i.3 'PVrrl TTT-%IP OPP1rl= O:FNVIRnNMFNTAL AFFA s MAY - 1 ht rl; llEPARTMENT O r.N ViR, ), iiV3riN i AIL r itiv z- F BARNSTAgLE 1§ �9 W�1=Y" nVF U•rX*TFR CTRFFT ROSTn\. AlA 02108 617-292-5500 ALTH DEPT. WILLIAM F.WELD /Z/� ✓ �� y r,.... 1 Secret an, Govemor �/6� � � UN�G 3�� ---- - ARGEO PALL CELLUCCI ` G UATlU b.5 brCl'f Yu Lt.Gotemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPtCIIUN Mutt -----_- -- rAK I A rroperty Aafiress: . ' � r , *a►} ..ta...rr _r n....,o.. 11�� ' Gova: .,, ...,t..�...•.. - V t �.., a nro 2nnrnwpA cvctpm mjcnprta�r �pursuant to Section 15.340 of it 5 (310 CMR 15.000) rmmnanvNa me: +ni.I�_hviC�['O �i(f�► f-�. ��— , Mailine Address: .. n x�rn.E9 t2.a Wl t l ll�:i�l/y/ ��, � Telephone Number: " <--25 _ ,.t/ U CERTIFILAIIUN SIAMM NI r+ .A he1nur is tma arr,tratP .,io. 1 certlly that I have personally inspected lrle Sewage ut,. aticrc» a:-- .,•1..»„�,,,,��•v» ..,r-..-� -_--- -- - - • and ovnpripnrp in the nroner function and and comp)ete as L) the ii-e uY'1nS}SCU:Un. ,-.,c.ii,iYc�...G r-- ....-•^ ..^..- - , - .. „� :1CCPC Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails ] Inspector's Signature: the enr,rn..ine d,,,thnrity within thirty (30) days of completing this he Sysierfl - ,:.L_ - .L.. a .+Peon iinw of to onn and-nr greater. the inspector and the system owner shall submit ._Ln.. -_ +L.. .r. .. .,,.he � nrnnriote^raoinnnI nffirp nf�thp r)pnariment of Environmental Protection. The original should be sent to the system.owner nnrl rnnipc cent to the Liuver. if applicable. and the approving authority. INSPECTION SUMMARY: Check A, 8, C, or D: A) SYSTEM PASSES: ICI have not found any information wnicn inaicates mar me byiiem viv,'airra eiTr Any tailure criteria not evaivateti are-t-n sriru-1— COivcMEN T 9: til SYSTEM CONDITIONALLY-PAJ3t5: One or more system components as described in the "Conditional- Pass",section need to be repiaceu or repaired. ine Syiicm, tk. s+ completion of the replacement or repair, as approved by the Boats al-r ieaiin, will pass. .,.,.......:.,-..:.... •,.It ;nctanraC If"nnt rlptPrminpd PtrMain why not. Indicate yes, no,-or not determined t>, N, Or rrV/• Llex„vr vaav v+ vc-ac,,,....a..v.. ....... ...,.•.....a-- .. .._. _-_.-.-.._. -- , -.r'- t, :_ _._,• ..,r•__, +r.r. ., r..,Pr�tl+r h.2c.nrn.,iripd the cvopm inspector with a cony of a Certificate of i tic Dcijiit La",% :..� „YJ^�. r...__�. _�. .. --- _-- -,-.- "� `-...nL:anCe faMoched) indirnting that the tank was installed within twenty(20)years prior to the date of the inspection; or the cpntir tank_whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltratiort, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 3 of 40 5"vu5vni=��e 3MTir,ii"LTi Si VSAL 3r grii itvSr GLitt3N ti::i DA DT D CHECKLIST 0 t Property Address: f L V-0 U 3_A/ Owner: Date of Inspect►on: r'i. 1. `Y•. ' ..` i each Gt t,-Pa ii0 ipie C�. .V.C. VVu lu3tin.;�ie tite4.� �♦ + r0. i i loii ii c, �No ..... Yes Nn Pumping information was provided by the owner, occupant, or Board of Health. f� None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of thisinspection. - As UUili pal lj it UEEf+ {1tL,lial IC_U and eriHi�+i led, it VtC i' tiiCy we not available ..itli w,ee The fariiity nr dwPiling was. incppopti for signs of sewage back-un. I The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. v _ Ali system components, excluding the Soil Absorption System, have been located on the site. ---A/L �_ c ccFrtiG tr.::r. :::ar: .v.c5 vc:c u:rzisvz: - c",-p:znzev., —A rMe of rho —re, rnLwin. rf fnr rn. — we• t _mt - nrilinr of hnflac. nr toot matorial of rnnctrirrtinn dimon6nnc tiE+nth of lintrid; denth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: U _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information, Ex. Plan at B.O.H. L_ [�_1J 1:1 [ L [_:t..-� ' .i �,. D.w !' m rinn f distance n i� ® V_ vetrrtnuteu in tnC tirlu tit any ut the ranurc Crii2iip reiatcu w Part z is at ►nn.. , apprC,....a..,+. C . unacceptable) i1 C 9n7l31,,b)] v..a..zz Y.u...z! i.....w�..,nv,l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address; Owner. Date of increctinn. B) SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settles or uneven distribution box. The system wiii'pass inspection if(with approve Of the Board of Health). Describe observations: broken pipem pre replaced obi ructio^ is 6�,o_,ed i dirtrihiotion hnl is levelled or replaced The system required pumping mole than four 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) ire replaced obstruction is mmoved C) FURTHER ENIALaUTATION IS REQUIRED RV T41jRnAR-n OF HEALTH: Conditions exist which require further eval ation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF EALTH DETERMINES THAT THE SYSTEM 1S NOT FUNl HOVINI NG iN A ir'wNNER WHICH WILL PROTECT THE PUBLIC H-EA a r1 AND SAFETY AND THE 'cN V IRONmcN T mess ool-or rir is within SL f€e; �a surface water G p Y l' Cesspool or privy is within Sn fpeI h1 a hnrrlerino vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD O HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MAN ER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 1'vu luck to a surface water supply or tributary to a surface water supply. The system has a septic tank and sail bsotption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and sail hcnrntinn system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil bsorpt ion system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a we I water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from th t facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to det mine distance (approximation not valid). 3) OTHER 1 (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: O-ei ner: Date of Inspection: D) SYSTEM FAILS: You must indicate ei,•.er "Yes" or"No" as to each of the following: I have determined that the cyst, violates one or more of the following failure criteria as defined in 310�011 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes, No Backup of sewage intil facility or system component due to an 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. Static liquid level in t ie distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cessp of is less than 6" below invert or available volume is less than V2 day flow- Required Required pumping m re than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pu ped Any portion of the S it Absorption System, cesspool or privy is.below the high groundwater elevation. Any portion of a ces ool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a ces ool or privy is within a Zone I of.a public well. Any portion of a ces pool or privy is within 50 feet of a private water supply well. _ Any portion of a ces pool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water qu iity analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, v atile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: You must indicate either "Yes" or "No' as to each of the following: The following criteria apply t large systems in addition to the criteria above: The system serves a facility ith a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and he environment because one or more of the following conditions exist: Yes No the system is wit n 400 feet of a surface drinking water supply the system is wit in 200 feet of a tributary to a surface drinking water supply the system is ro I ted in a nitrogen sensitive area (Interim Wellhead Protection Area- IWPA) or a mapped Zone 11 of a public water su ply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 i SC�RSjJR_sACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: G VV'/s e � Owner: 6'J. T`6�ctt;n� Date of Inspection: f Ft.^.:':r CONDITIONS nrR111 r,JTl..�7. ALSILENTIAL- D`sign flow: I.1d -.*-A nnrn fnr S A,S, Number of bedrooms:_J!2— Number of current residents: Garbage grinder (yes or no):_Ilt* Laundry connected to system (yes or noTyf.� Seasonal use (yes or no):_b& plater meter readings, if available (last two (2)year usage(gpd): Sump Pump (yes or no):,,jn& Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gallons/da� Grease trap present: (yes or no) Industrial Waste Holding Tank p sent: (yes or no)_ (`ton-sartitary waste discharged the Title 5 system: (yes or no)_ Water meter readings, if availa le: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of nspection: (yes or no), If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tank/disuibution box/soil absorption system ingle cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) OtherI/A Technology etc. Copy of up to date contract? APPROXIMATE AGE of all components, date installed (if known) and source of information: 7 Sewage odors detected when arriving at the site: (yes or no)Ae b (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSI+E i7DN FDkM -PAkf C SYS-Mvi iNFORMAliON (coniinued) U v i Date of Inspection:— ou 'JI/ }� I,`• ;> 6AD ��i�,� Inspection:— -:y i - BUII.DiND SIMIR: (Locate on site plan) Depth below grade: 1�r Material of construction: jC cast iron _40 PVC—mheT (explain) Divan— from nr=vaWe water supply wall ns curt'.3n LLine..e Diameter / Comments: (condition of joints, venting. evidence of leakage. etc.) r'S SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction. _concrete _metal Fiberglass _Polyethylene _other(exptain) If tank is metal, list age_ Is age confirme by Certificate of Compliance _(Yes/No) Dimensions: Sludge depth: Distance from top of sludge to bottom of tlet tee or baffle: Scum thickness: Distance from top of scum to top of outl tee or baffle: Distance from bottom of scum to bono, of outlet tee or baffle: .How dimensions were determined: Comments: (recommendation for pumping, conditi n of inlet and outlet tees or baffles, depth of liquid,level in relation to outlet invert, structural integrity, evidence of leakage, etc.) GREASE TRAP: (locate on site plan) Depth below grade: ' Material of construction: _concr to _metal _Fiberglass _Polyethylene —other(explain) Dimensions: Scum thickness: Distance from top of scum to of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumpi g, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leaka , etc.) (revised 04/25/97) / ?age 6 of 10 r t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) I Property Address: Lj i/S1J5 J t4 r l Owner: Pu(c-L, �� S k - h ram- �p 0 rU Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determ/ ed to be present, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) CESSPOOLS: _ (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: �C + Materials of construction: (?�Vt C3y� _ Indication of groundwater: Y1.rA_z inflow(cesspool must be pumped as pan of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of pond ing, con,di//tion of vegetation, etc.) PRIVY:_ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATiON (coniinued) Property Address: Owner: Date of inspection: TIGHT OR HOLDING TANK: (Tank must be pumped prior to, orrat time, of inspection) 0ocate on site plan) f (ylaleridl o. construction: --lo...ar' —meal _F:b^rglass �Dolyc hmlle.-c Dimensions: Capacity: gallons Design flow: galions/day Aiarm level: Alarm in working order Yes; _ No t flat- ....._ �. Date of pf'Cl"5VU5 �.l't915iV151�: Comments: f (condition of inlet teP condition of a)-arm wnc!flaat switrhes, etc.) f DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert:_._ . Comments: (note if level and distribution is equal, evidence of solids car ver, evidence of leakage into 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 coridii on of pump diarnber, condition of pumps ar appurtenances, etc.) fravisad 04/2S/47) ?age 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (confinued) em -! r PropertyvpePropertyi�uusi raavess;. Date of Inmectinn; t- SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at ieast two permanent references landmarks or benchunarws i GG E" -.Fi {t �. L.. Lt.� {... ...�.. locaie all we+is wfthln iv0, \LV4^:C:+uric p!l�Hiib wafeG suppGy comes ^., ouse)- Cv 1 V Lea v I x5 e...s 9 of 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) � Property Address: P `t t�SX i� - Owner: ')0"' -tuc-L,R Date of Inspectio n: . , Depth to Groundwater /V Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abueing property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Chect; ;.u.,...p;np...� records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) . , 2 I L� ��T f-�'L<" O D 1 V v ti (s9v3aaad 04125/97) Peke 10 of 10 PART VIII: ONSITE SEWAGE DISPOSAL REGULATION SECTION 5.00: UPGRADING OF SUBSTANDARD ONSITE SEWAGE DISPOSAL SYSTEMS ADOPTED 11/10/9$EFFECTIVE 1/1/99 FTFIE Tq�,_ Town of Barnstable MMSMLF.i639. Board of Health `0� AIFG A1A'�A P.O.Box 534,Hyannis MA 02601 Office: 508-790-6265 Susan G.Rask,R.S. FAX: 508-790-6304 Ralph A.Murphy,M.D. Sumner Kaufman,M.S.P.H. UPGRADING OF SUBSTANDARD ONSITE SEWAGE DISPOSAL SYSTEMS PURPOSE: The possible contamination of the sole source aquifer by substandard onsite sewage disposal systems presents a serious threat to drinking water affecting public health. This possible contamination also poses a threat to areas designated as wetlands affecting the environment and public health. This regulation is adopted pursuant to the power of the Board of Health conferred by Chapter III, Section 31,of the General Laws: Septic systems consisting of one cesspool shall be upgraded to conform to 310 CMR 15.00,the State Environmental Code,Title V,Minimum Requirements for the Subsurface Disposal of Sanitary Sewage and the Town of Barnstable Board Health Regulations. This regulation shall apply to any septic system inspection conducted in accordance with 310 CMR 15.301 of the State Environmental Code,Title V. This regulation shall also be strictly enforced during the building permit application process. Susan G.R sk R.S., Chairman Sumner Kaufman, M.S.P.H. Board of Health Town of Barnstable onsitess i�arceId y LOT 121- t � ain: PUCHALSKI, ROBERT PAQUIN, DAVID P Arid 1 �; 8 00001176 O BOX 518 0 WEBSTER / MA 01570 \ &e 00-0000-000 ; ✓ /'y r y i 060283 ` f /n'� 758 258 .,r �o do G pd�l 11t. J�n�ary st PUCHALSKI ROBERTy 0683 Ref' 3758/258 �� alUesnd.x. 000043000 ,, an , 000069300 xe 0000000000 ,.. ,,. l.ocatio' 14 GROUSE.LANE x: 0637 rntg: 0095 ` ire ist HY y _�% Sec 1 de: 0000 ��tgk 0000� � S i i