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HomeMy WebLinkAbout0024 PINE VALLEY ROAD - Health 0. 24 Pine Valley H annis 070 ;r a " o u 0 n Commonwealth of Massachusetts w= Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address /1 ri- oNner aNners Name 7't 0� 60/ 7:: � Jr 1� information is f _ required f or ev ery Zip Code Date of Inspec on page. City/Town Slate 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. Mporta f orrns A.n A General Information filling out forms on the computer, ("Jj use only the tab 1. Inspector: I key to move your � cursor-do not {� O l,,�Pj use the return Narre of Inspector —,�/�// ,ke/y, � L /V 1� 0 LQ Ir v Company Name �D,f g7 Company Address G'S �VI A✓`1 �o� //, s b 7 Ctty/Town Stat© Zip Code Telephone Nunter 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 �10R 15.000). The system; Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority J / Inspecto s Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 god or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only 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. Ons 3113 Title 5 Official Ins cn am SubsurfacoSawageDT/System•Pe®e 1.117 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments pa. a Lf i i l� a Ile 1 Property Address ' FOCA lr✓J( V" Ow ner Ow ner's Name information is /�,� /5 required f or every —'1 page. City/Town State Zip Code Date of I spe ion B. Certification (cont,) Inspection Summary: Check A,B,C,D or E / always corn plete all of Section D A) System sses: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15,304 exist, Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ one or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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): 15 ns-W 3 Title 5 Official Ins pection Form Subsurf ace Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments _ a Property Address Fo 'Vl✓0 I,e V^ Ow nerrm ON ner's Name information is arl✓1 l f ' /14 o;�0 0 required for every —— page. City/Town State Zip Code Date of Insp ction B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box, System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a mannerwhich 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 tlua a Official ins pacu«,F am subsui ace Sewage olsposd system-Page 3or 17 t9ns•3/13 Commonwealth of Massachusetts Title 5 Official p ial Inspection Form >: s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address L-1v'Vll�r Ow ner Ow ner's Name information is 61 Vi o l SLC) required for every page City lTown State Zip Code Date of Ins ctio 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 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 ❑ lg' Liquid depth in cesspool is less than 6" below invert or available volume is less than '/: day flow l5m 3/13 Title 5 official iris pection F orm:Subsurface Sewage Disposal system-Page 4 of 17 Commonwealth of Massachusetts Rm Title 5 Official Inspection Form IWO Subsurface Sewage Disposal SystemForm -Not for Voluntary Assessments Property Address ON ner Cw ner's Name W�/ information is f q/ & 5 required for every State Zip Code Date P lnsl5eclon page. C 7 ow n B. Certification (cont.) Yes No El Re pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ny 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. ❑ — ,r' y portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ny 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.] ❑ e system is a cesspool serving a facility with a design flow of 2000gpd- 10,000g pd. ❑ The system fILLs. 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. t5ire 3113 TWO 5olflc9impe bonFormSubsulaceSewageDisposalSAtem-Page50117 f Commonwealth of Massachusetts x Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments _ �f �►�e. V-1 Ile ✓ J Property Address pcl�vttBr Ow ner ON ner's Name Information is required for every page. City/Town State Zip Code Date of I spe tion C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes N l� LJ 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? ❑ as 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? L� Was the site inspected for signs of break out? ❑/ Were all system components, excluding the SAS, located on site? ❑ Ld 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 een 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)J D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): ,330 . DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): t5ins-3/13 TIUe 5 Official Inspection Form Su bsurf ace Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments l �I^ // Q Property Address ' oUrvi i-ey- Ow ner Oav ner's Name information is / AWN 0a 6 o I �r / required for every own State Zip Code Date of In pecton page. Cit D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes No information in this report.) _, �^ Laundry system inspected? ❑ Yes B No Seasonal use? ❑ Yes No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑n Yes No fr'$H Last date of occupancy: Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CM R 15.203): Gallons per day(gpd) Basis of design flow(seatslpersonslsq.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: t5 ris.3/13 Tits 5 Of ficial ire poc ban r arm subsurt ace sewag a Di sposai system-Pap e 7 of 17 Commonwealth of Massachusetts i Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments lle Property Address Ow ner Ow ner's Name NI 0 6 0 information is R A��t r ///T l v / required for every State Zip Code Date of Inspection page. City/Tow n D. System Information (cont.) Last date of occupancy/use: pate Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ 'ISingle cesspool /� L Overflow cesspool 11- ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy.of the DEP approval. ❑. Other (descri be): Title 5Offid8l ins pocbon F orm Subsurface Sewage Disposal System-Pape 8 of 17 t9ns-W13 I Commonwealth of Massachusetts w Title 5 Official Inspection Form ' 6 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Ile lei Property Address �o�r�rei. Ow ner Ouv ner's Name information is Q N f f - a,2 6,2 S required for every State Zip Code Date of Ins ctio page. City/town D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information. Were sewage odors detected when amving at the site? ❑ Yes C� o Building Sewer(locate on site plan): Depth below grade: feet Materia construction: cast iron 40 PVC other(explain): / l 0 y Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 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: Sludge depth: t-9ru-3113 T I U e 5 0f fici al inspection Form Su bsurf ace Sewage Disposal System-Page 9 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0- l✓�-2 1� G7 / ,2 Property Address /__0 lit►r V1 l-e✓ Cw ner Cw ner's Name A / information is G�� //� O _) 6 o s required for every / �` page. City/Town State Zip Code Date of In pecti n D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, exAdence of leakage, etc,): 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 t5ns 3113 Title 50fflclallnapecdonForm:Subsirface Sewage Disposal System•Page 10of 17 f C Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a Property Address FIOLA Y✓1 t P►_ Ow ner ON ner's Name information Is required for every State Zip Code Date of In ti n page. City/Town P ec 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 attach ed? ❑ Yes ❑ No Ons•3/13 Title 50lfidel Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Ile �-j Property Address ON ner O,v ner's NameAl information a i 4 r required f or ev ,A ery State Zip Code Date of Ins pTction page. City/Town D. System Information (cont.) 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 into or out of box, etc.): Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): " If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 15ins V13 Tiue5Offciai inspectionForm Subsurlace SewagGOisposel System-Page 12 d 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form A a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments d? V/ V4 Property Address Otrt#I'✓1 C� Ow ner Cw ner's Name / information is required for every State Zip Code Date of In pec on page. GtylTown D. System Information (cont.) �/ j� 1 Type: /` leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovativelaltemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc,): Oki if V1 Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): 3 —7 Number and configuration J En Depth—top of liquid to inlet invert ? •, �„ Depth of solids layer / �� �i U Depth of scum layer Dimensions of cesspool Ov c nl�u 9)(9G Materials of construction Indication of groundwater inflow ❑ Yes Tile501ficial Impec ton Form SubstXface Sewage Dispose!System•Pape 13d V t5ins•3113 f Commonwealth of Massachusetts w Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form -Not four/Voluntary Assessments Property Address ON ner ow ner's Name information is required for every � c►✓i✓ifs � -f _ page. CtytTown of State Zip Code Date of Ins ection 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.): thins•3113 Title50fficial Inspection Form Subsuface SewageDlsposal System Page U of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments fr'1 t l/of /e Property Address U(/1✓v1(•e v- Cw ner Cw naps Name information is G required for every i page. Cily/Town State Zip Code Date of spa lion D. System Information (cons) 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: G3 - � 3 rr of t�� (r5 r 3 ,��o,Q oA��s bcr FQOn pry I . \ I 14a- 3 fl t5ins•o9to8 G Title 5 Offloal Inspection Form:Subsurface Sewage Disposal Sysiem•Page 15 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form 6 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address 50 lit✓(iJ uP� O,ry ner CW ner's Name information is y�#1PI I - /✓¢ required for every i 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: 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 ❑ 'served site (abutting property/observation hole within 150 feet of SAS) 40 Checked with local B a d of Health -explain: °� �r✓ ` ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database- explain: You must describe how you established the high ground water elevation: 61V V li1 C) �Pl� V" ` 7L D Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ris-3113 Title 5 Official inspection Form Subsurface Sewage Disposal System Page 16of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,r Property Address Orr ner ON ner's Name information Is required for every — page. CiryrTown 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 ;;Syk�e�h temInformation— Estimated depth to high groundwater tc of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3113 Title 5Ofricial Inspoctlon Form Subsurface Sewage Disposal System Page 17 of 17 (w � D TOWN OF BARNSTABLE LOCATION ay"1 ,,k¢-4 /0Ak f,y SEWAGE# .;2 PV `393 VILLAGE �0,���5 ASSESSOR'S MAP&PARCEL aZyR 667 INSTALLER'S NAME&PHONE NO. o2wspl� �p`r�s2l� SUg"`17� 77 sepifte LEACHING FACILITY.(type) (size) NO.OF BEDROOMS 3 PERMIT DATE: I -3— I I 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 Y FURNISHED B F '.J LA , 11 W S � w No. Q/ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zipplicatiou for Bisposal 6pstem COustCuction i3ermit Application for a Permit to Construct( ) Repair a Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. ►h o._k�-Q Owners amine Addre s and Tel.No. 7 � ®/ a C-1 r l�� � ) 11.. Y-Yam$�d �� (�-�LO/f� Assessor'sMap/Parcel - S 07 ;1� 4"-& �ct11 �s Installer's Me,Address,and Tel.No.SL'&-417—Y9-7-7 Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 � } Lot Size ,g 35 Ncfce�'s sq.ft. Garbage Grinder( ) Other Type of Building ��5 "`��a I 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) a V�, 1",\,2n- 5 Q� t7 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 of Health. / y Sign Date Application Approved by Date 11 Application Disapproved by Date for the following reasons Permit No. a© 11 Date Issued c f9 -------------------------------Y�.� • .. : .-ten..• .•_. rf•yi..F✓-�:•.,�.,,,,,,,,s...,�, ^� x._ _rr ::.:x-•..... :.4-=.+-..• 4F.. �-. ...- �...,+.. w.,,xr,��.... .. No.,:�o// Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplitation for MistJOSal iopstrm Construction Permit Application for a Permit to Construct( ) 'Repair N4 Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.p'1 V l ti-Q V 0,\\R Y �' Ow er'sNa�e,Address,and Tel.No. ,�Jg-�P-3�(� Assessor's Map/Parcel a 1/8/07 D 6�, � 01,,-e �al i w QU � Installer's Name ddr ss,and Tel.No.S09-'( - Designer's Name'Address,and Tel.No. Q � Type of Building: Dwelling No.of Bedrooms 3 Lot Size r 35 °'`r S sq.ft. Garbage Grinder( ) Other Type of Building PQ-S ``�`c,I No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Datek 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) �-- v� � -�a— o v Q t 'S O� 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 Certificate of Compliance has been issued by this Board of Health. / Signe (� Date Application Approved by Date 3 1 Application Disapproved by Date for the following reasons Permit No. Do 11 Date Issued 13 THE COMMONWEALTH OF MASSACHUSETTS 11111_V_ V BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,tha the On-s'*�Sewage Disposa system Constructed( ) Repaired(V ) Upgraded( ) Abandoned( )by ca Ljl c)k e.. �'1 -,z �"�`r 1 S 2.5 L —C at a U `^� u ya`"`^ 5 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit Ns2 ��—3 _3 ' � 1 3/1 ) dated Installer C -W,` c Cv��'4(�O C�S�s Designer #bedrooms 3 Approved design flow gpd The issuance of this permit shall not be construed as a guarantee that the system-Will—function—as designed. Date Inspector- ------------------------ � --� =----No.----d -------------.--------------=--------------- _---__------Fee`�GC/ ---------- _ . . THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Disposal 6pstrm Construction 3permit Permission is hereby ranted to Construct(/ \) Re ai(Jr Upgrade( ) Abandon( ) System located at Y � - 1r 1�`�j✓ GT ' .�yC��''�`S 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 ust pa completed within three years of the date of this p rmit. Date ( I Approved b� _� Y i t ' Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1 s Property Address Owner Owners Name 1 !information is ,required for da 60/ ;every page. Cityrrown State Zip Code Date of Ynspeco6n i I 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. i Ilmpor filling ;When filling out A. General Information i ;forms to the \ 1 a computer,use 1. Inspector: !only the tab key 3 to move your lS>✓ l/� ! ;cursor-do not Name o Inspector'use the return Pector / key Z�Vkll 0 Company Nam Company Address i Z:-GS4 CitylTown State � Zip Code✓ V O / / /y� / � 7 T ����r.., y Telepho4-NumbeK License Number ` = ! B. Certification , I certify that I have personally inspected the sewage disposal system at this address and thatAhe information reported below is true, accurate and complete as of the time of the inspection. TLe 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 i Inspe s Signature Date I 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. i ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. i IS+ns•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page t of 17 i i ; Commonwealth of Massachusetts UTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1W Property Address �Uf✓JIQ✓ Owner Owner's Name I information is Oa 60/ 3 Ja required for ��a✓1✓1/S' 1"L— every page. City/Town C71. State Zip Code Date of 16spe6bon B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D i A) Syste Passes: i I have not found'any information which indicates that any of the failure criteria described in 310 CMR 15.303 or-in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: � I i i l j 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. j Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. j 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 r will pass inspection if,the existing tank is replaced with a complying septic tank as approved by the Board of Health. l •A metal septic tank:will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. i { ❑ Y ❑ N ❑ ND (Explain below): I ! I I I 1 � I1 I I i 1t5ins•09108 Tile 5 Official Ins , pecUon Form:Subsurface Sewage Disposal System•Page 2 of 17 i Commonwealth of Massachusetts Title 5 Official In Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments lug' gol Property Address - Owner Owner's Name 1 information is required for A✓1 d I! every page. City/Town State Zip Code Dat6 of I spection B. Certification (cont.) ! B) System Conditionally Passes(cont.): l i ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): � I ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): j ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): , I i I ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): I JI I ! I I 1 1 I i i i 1 I ❑ 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): I ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): III ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): i � I I � i l I I ! C) Further Evaluation is Required by the Board of Health: i 1 ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if 1 i the system is failing to protect public health, safety or the environment. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water i ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh f15ins•09(06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 I Commonwealth of Massachusetts j Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments R/ UV Property AddressOF— I , /- Oy/n ese- Owner Owner's Name i information is required for a✓1✓�U Dat b o Al / every page. City/Town State Zip Code Date ohnspikton B. Cei -ification (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. I ❑ The system has;alseptic tank and SAS and the SAS is less than 100 feet but 50 feet or i more from a private water supply well". Method used to determine distance: I i "This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: li i i i i D) System Failure Criteria Applicable to All Systems: You must indicate ".Yes" or"No" to each of the following for all inspections: i Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ d Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Q/ 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 5"below invert or available volume is less than '/z day flow &ns•Moll rifle 5 Official I nspeetion Form:Subwrfaa Sewage Disposal System•Page a of 17 fI I I .I Commonwealth of Massachusetts Title 5 Offidiial Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name �/J,( I information is /qC17G✓l4"'1 S /. '✓7 0�6 0� Al � required for I. every page. Cityrown State Zip Code Date Of Insp6ction 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. j ❑ LIQ 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. ❑ L�' 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 f 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, i 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- ❑ Ld' 0,000gpd. { The system fails. I have determined that one or more of the above failure ❑ criteria exist as described in 310 CM 15.303, therefore the system fails. The i system owner should contact the Board of Health to determine what will be necessary to correct the failure. j E) Large Systems: Ta be considered a large system the system must serve a facility with a design flow of 10,060 gpd to 15,000 gpd. i For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the jquestions in Section D. j Yes No I ❑ ❑ the system is within 400 feet of a surface drinking water supply i ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply I ❑ El Area system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well Id If you have answered,"yes"to any question in Section E the system is considered a significant threat, j 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 i system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t&-r-0908 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of 1 Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a �)j 7 // gj Property Address FOu✓d1��r� Owner Owner's Name information is 'required for c�v►✓lp 0,4601 every page. Cityfrown State Zip Code Dat of Ins 'on C. Checklist j Check if the following have been done. You must indicate"yes" or"no" as to each of the following: i Yes ❑ 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 ❑ C! this inspection? Were as built plans of the system obtained and examined? (If they were not / V ❑ ❑ available note as N/A) I i ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? i [�❑ Were all system components, excluding the SAS, located on site? , i �, ❑ ❑ 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 een 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): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): ; i I l�ns•o9ma Title 5 Official M i SpeCtlon Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address �O In r%✓1/e✓ bvimer Owner's Name Information is �_ 6y 6 0 I 3 �a//j required for '�`�rs - every page Gty/Town State Zip Code D of Aspection D. System Information Description: (_e::SS 0 0/ a Number of current residents: Does residence have a garbage grinder? ❑ Yes No i Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ET-"No i Laundry system inspected? ❑ Yes ff�No L� i Seasonal use? ❑ Yes No i Water meter readings, if available (last 2 years usage (gpd)): Detail: i i Sump pump? ❑ Yes Quo C U r/e� Last date of occupancy: Date ` Commercial/IndustHal Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (Iseats/persons/sq.ft., etc.): 1 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: i lupins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 i Commonwealth of Massachusetts Title 5 Offidial Inspection Form Subsurface Sewage bisposal System Form -Not for Voluntary Assessments Ile 9j Property Address octrote✓ jOwner Owner's Name informationaired is / Dd 6o /a / �required for G�v1�� every page. City/Town State Zip Code 0 of I ction j D. System Information (cunt.) i Last date of occupancy/use: Date Other(describe bel'ovy): i I General Information Pumping Records:' p' g Source of information: ��w S G 5 0 — D t-✓ 074 Was system pumped as part of the inspection? ❑ Yes No i ! If yes, volume pumped: gallons j How was quantity pumped determined? fReason for pumping;: Type of System: j ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool Overflow cesspool ❑ Privy ; I j ❑ 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 I ; + ❑ Tight tank. Attach a copy of the DEP approval. i I ❑ Other (describe): t5/ns 0908 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 UV I Property Address Owner 1�10L- /✓I!�!� Owner's Name Information is A�I vIl s G 60 J �d squired for every page. City/Town State Zip Code Date of Inspettion D. System Information (cont.) ell Approximate age of all components, date installed (if known) and source of information: I C2sS/� 0/1 ��� sl'4 "L /9�0— o ! j Were sewage odorsldetected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: feet Mate ' of construction: cast iron ❑ 40 PVC other(explain): Distance from private Water supply well or suction line: feet i Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) , i i 4 If tank a k is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•09/08 Title 5 Oficat Inspection Form:Subsurface Sewage Disposal System•Page 9 0!17 i Commonwealth of Massachusetts iV;W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments Property Address �ourvll2r (Owner Owner's Name ,information is !required for 1 �l 6 a .3 !every page. Cityrrown State Zip Code Date o inspe lion I D. System Information (cont.) Septic Tank (cont.) I Distance from top of sludge to bottom of outlet tee or baffle Scum thickness I I Distance from top of scum to top of outlet tee or baffle j Distance from bottorh of scum to bottom of outlet tee or baffle t How were dimensions determined? Comments (on pumpimg recommendations, inlet and outlet tee or baffle condition, structural integrity, f liquid levels as related to outlet invert, evidence of leakage, etc.): I I I I 1 I I i Grease Trap(locateldn site plan): ! Depth below grade: feet I Material of construction: i ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): I i Dimensions: I Scum thickness i Distance from top of scum to top of outlet tee or baffle Distance from bottomi of scum to bottom of outlet tee or baffle I Date of last pumping: Date i t&ru•avoe Title 5 Official Inspeclion Form:Subsurface Sewage Disposal System•Page 10 of 17 i Commonwealth of!Massachusetts Title 5 Offi.6ial Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments UV Property Address — Owner owner's Name information is G,4 f Qa 6 0� jZ/ required for /4 every page. Cityfrown State Zip Code Date of Ins ction D. System Information (cunt.) I Comments (on pumoing recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): i I I i Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: I i ❑ concrete� ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): i I �f Dimensions: Capacity: gallons I Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No i Date of last pumping: Date I Comments (condition' mf alarm and float switches, etc.): k i i ' Attach copy of curr(§,nt pumping contract (required). Is copy attached? ❑ Yes ❑ No i 'Sins•09rob - Title 5 Official Inspection Form:Subsurface Sewage Disposal Syste m•Page 11 0!17 I I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface( Sewage Disposal System System Form -Not for Voluntary Assessments i C V • �� �� Ile Property Address Owner Owner's Name information is required for `7 G(!1✓1/I �� l every page. City1rown State Zip Code Date ins bon D. System Information (cont.) 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 into or out of box, etc.): I i Pump Chamber (locate on site plan): I Pumps in working order: ❑ Yes ❑ No i Alarms in working order: ❑ Yes ❑ No Comments (note con,chtion of pump chamber, condition of pumps and appurtenances, etc.): I Soll Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: I i I -- tLs•,)4roB Title s Official Inspection Form:subsurface sewage Disposal system•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disiposal System Form •Not for Voluntary Assessments l Property Address Vl/lA t er QVmer Owner's Name information is Dodd 0� 11A f required for c`o�i every page City/Town State Zip Code Date 6f Ins ction j D. System Information (cont.) 11e— Type: s� leaching pits number: D leaching chambers number: i ❑ 9 ❑ leaching galleries number: I ❑ leaching trenches number, length: I i j ❑ leaching fields number, dimensions: i i ❑ overflow cesspool number: innovative/alternative system Type/name of technolo gy: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): I /i 1 0�► t q }14-1/7 7— J/-'� /Ic I 1 I Cesspools (cesspool must be pumped as part of inspection) (locate on site Ian): 3 Lt Number and configuration n Depth —top of liquid to inlet invert °� Depth of solids layer Depth of scum layer . I Dimensions of cesspool I �oc /�/o� �loc I✓ Materials of construction 1II Indication of groundwater inflow ❑ Yes No !tins•osto8 Title 5 Official Inspection Form:subsurface Sewage Disposal System•Page 13 of 17 I { I Commonwealth of'Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Rd Property Address 2 Owner's Name nfprma tion is vl a ki✓t(( A�" o•2 6 0 required for ev6ry page. City/Town State Zlp Code Date o nspe D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 4cito n G -1 re 3s o o Privy(locate on site!plan): Materials of constructimn: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): tsins•oeroe Title 5 Offiriai Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 i f Commonwealth of Massachusetts Title 5 Official Inspection Form IVSubsurface Sewage bisposal System Form -Not for Voluntary Assessments ILVJ. - ;- q V.:' Ile 9,J Property Address i Owner Owner's Name infuriation is required for t,2a 60/ A."k�l a y►✓1 it every page. City/Town State Zip Code Dat of Irdpection 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 c water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately G3 — � —a3 o P�P W,5 Soo, - a9 C. oa&� Faon t APB'-T6el pry - i 14a- 3 y t7 d a — .3S tsns•osvoe Time 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 ( > VC, // Property Address F7O'LA/✓1 OWner Owner's Name infmrmation is M required for "1 G✓t 4/S every page. Otyrrown state Zip Code Date ofinspe6on D. System InformAtion (cont.) Site Exam: ❑ Check Slope ❑ Surface water O�O ❑ Check cellar CO Ll n 4V w ❑ Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked; date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with ocal Board of Health -explain: 1 rs ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: �i,f�Y�✓ a> �-- �o,s �Cam. �ior� ( f � -Ole 0-1 f l0 4 n d�✓ri Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins-09ro6 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 �a Ile, ad Property Address FQ L1✓0lev Ov ner Owner's Name Ay information is 0�6 0 reeuired for ��(f evjry page. Cityrrown State Zip Code Date o Inspe lion E. Report Completeness Checklist inspection Summary: A, B, C, D, or E checked ErInspection Summary D (System Failure Criteria Applicable to All Systems)completed. L� stem Information—Estimated depth to high groundwater Sketch of Sewage.Disposal System either drawn on page 15 or attached in separate file i I ; I t5ins•09I08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 i F THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Apptiration for Disposal Works Tonstrnrtion Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ( -- an Individual Sewage Disposal System at: 02 y >•vE vst ac�Y ✓ __ _..._................. - .------------------•----------•--- .. - - .................. Location-Address or Lot No. ��E1� ,tea✓2�+(F/c _d6WM rII-1_�t=.._.... ..... ............. .. Owner Address a .............................�d�vsT�. :.,.=`-''�C--------------------------------------- ---�v_--.-'�......��6-----...4..•✓%" !`Lt"_.......---•----------- Installer Address Q Type of Building Size Lot----------------------------Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) a p., Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ------------------------- Q --------------------------------•--------------•--------..............---------- w Design Flow-----------------------------------------•-_gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length-------_------- Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter-__-____-___-___.-_- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water_________________----_.- G%, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ------------------------------------------------- -------•-----------------.-----------------------------------------------------------------.----- O Description of Soil..G.................................................� 2 - z - 4447; --.. x ------------------- .--- -----------s. s ................................ w -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- UNature of R pairs or Alterations—Answer when applicable____??_'n_-------O^!t=__-------/rod-0.......__�?`t��_�..._ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been isgued by t e board of health. Signed�,..� P� ..............a.,,--- . .......--....----------------------- b ` '-�-�-------- Date� q ApplicationApproved By ------------- � U . ------ ---------------------------------------------------- . Q to Application Disapproved for the following reasons- ----------------------------- -- ---------------------------------------------------------------..................---------------- ..................................................- ---------------------------------------.------------ ---- -- -----------------------..---------------- ------ -------------------------- ........................................ Date PermitNo. ............. -------- .y.. Id ....................... --.-........................................ ssue ----.. Date � '1 J Fss....�. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appfiratilan for Disposal Works Tomitrnrtirin ramit Application is hereby made for a Permit to Construct ( ) or Repair ( )-�an Individual Sewage Disposal System at: ,2� pi vE VA"L GFU r1d -.-. Location-Address or Lot No. -F ,�t�• Gov 2 Nlcr`................................................ ----...E`-..T icv�«. ..-•--------------------•-----...•............................. ... Owner Address ....-----•--•--- 6 ,cvr. a = _. ----------------------•---------- Installer Address Type of Building Size Lot----------------------------Sq. feet V Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) `k Other—T e of Building No. of persons............................ Showers — Cafeteria 04 Other fixtures ------•------------------------------•-------•-•------ 94 W Design Flow.............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No.......... Ke idth.................... Total Length___........._.__.... Total leaching area_..........._..._...sq. ft. Seepage Pit No.-_---------------• Diam .._ ............... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) � Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -----•-•----------------------•--........-•--•-----------------......._..------....-•••-••-•••••--•......................................................... O Description of Soil 9-2- ------&ULS 2 - r2•--••••• Z ---•••-- S.r+c x V ..............••-•-•••......-----•..._...-----•••---•-••------•••----------••.......•. W x -•-•-•-•--•-----------------••-•-•••-----••••-••-•-••--•-•-•--------••-••••••--••••-•--...-•--•-•---••--------•------•--------•----•-------•---•-- ..................................................... U Nature of Repairs or Alterations—Answer when applicable....! -------- ^!C.':......e--o Ob.........�?f�A41....LSs*C ffw't Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed .._�� ...Cn,? ..... ...: ---------------------------------- ------ u Dace ApplicationApproved By .................� J..... - t ------------------ri..j...------------------------------...------------....------------. Gl...-.te e Application Disapproved for the following reasons- --------------------------------------------------------------------------------- .......-.................................. -------------------- ------------------------------------------------------------------------------- ----------------------------------------------------- .............................. .... ---...------'---------------------- Q, Dare Permit No. ............./ ... ... Issued -- .............................................................. Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C�er#tfirate of 011uxnylianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired y Insraller at ...-9y ...VAG`t QQ � ....... .�-�.r�..`15- tv1�LL . ....... .............. - ..................- has been installed,in accordance with the provisions of TITLE 5 ff The State Environmental Code as described in the application for Disposal Works Construction Permit No. ......7_ :7...114.1.I4......... dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE. / ���---------------------�---------------------------- Inspectors- � / ��.......... r................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Disposal Works Tunstrnrtuan f rrmit Permission is hereby granted.......kk.�t�C`t_..__._�.'pwgv. 00O T:"J -..............................................•-•....... ......................... to Construct ( ) or Repair ( an Individual Sewage Disposal System atNo.....=z .............1w 0l\�L...t.f. ........ .--------•---...................----------•--------•---•--••--••-- Street �j L� as shown on the application for Disposal Works Construction Permit No._�..)..=_....��., .. Dated......................................... �.�d. ..............................................................................•-•....•-- Boar Health DATE....................• F .••..•....•.•.....•........... FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS 4 s TOWN OF BARNSTABLE LOCATION i SEWAGE # — 4V— VILLAGE r fi6ts&S MAP LOT INSTALLER' NAME & PHONE NO. 1 SEPTIC TANK CAPACITY P2 LEACHING FACILITY:(type) L-. gar Size) � NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER R OR OWNER J"'�.Q cP T 1/41'Al --P"7` DATE PERMIT ISSUED: (T-I I f � 1 DATE COUPLIANCE ISSUED: C S, VARIANCE GRANTED: Yes No �- I