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Home My WebLink About0158 SEABROOK ROAD - Health 158 SEABROOK RD., HYANNIS q I 4 i No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftphfation for Mispo9af 6pstem Construction 3permIt Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon X AComplete System ❑Individual Components Location Address or Lot No. 159 Owner's Name,Address,and Tel.No. S�AB�oo l C4PQLCS -F FLoa3 6+vnez-e4LZ-Z Assessor'sMap/Parcel SCn 03k. A59 5GAWAnoV_ R� 61e4KV1S Installer's Name,Address,and Tel.No. Jf'L1)9 CF7 arj 7 Designer's Name,Address,and Tel.No. Type of Building: t Dwelling No.of Bedrooms A Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) AN �()YJ ��L��LU far. &EVTlC_ Sk5l-ewx 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. Signed Date Application Approved by Date 16 _11/_/ Application Disapproved by Date for the following reasons Permit No. Q Date Issued 6 yr't i ---------------------------------------------------------------------------------------------------------------------------------------- V� No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION . TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftplitation for NsposaY 6pstrut Construction pert mit Application for a Permit to Construct( ) Repair(;,) Upgrade( ) Abandon X AComplete System ❑Individual Components Location Address or Lot No. 158 Owner's Name,Adddress,and el.No t MHOS + F;LOGk c�NZAL6Z. Assessor'sMap/Parcel 30'11Oag ��$se q . RX�. 6Y4&As- Installer's Name,Address,and Tel.No. 5O$ t f ri—Bari 7 Designer's Name,Address,and Tel.No. N/A Type of Building: Dwelling No.of Bedrooms A Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision'Date Title r Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) �d�1 DU+✓ �k(STt u fc 5�Tt c.. SfS� P 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 i Compliance has been issued by this Board of Health. / Signed Date r b Application Approved by Date G " Application Disapproved by Date for the following reasons. Permit No. '901 Date Issued 6 l c. ---------- ------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliante THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned(�)by <: 4PEc4v i dJC I{(St C-( c at 152 S tAE�ACDL 0 9YI` A)k)1S has been constructed in aaccc'o-dance ` with the provisions of Title 5 and the �for �Disposal System Construction Permit No.��^ ' 1 r dated Installer �& ae t i� � �c� �.L. Designer W A #bedrooms Approved design-flow gpd The issuance of this permit shall not be construed as a guarantee that the system ill function asdesigned Date V a Inspector ` s -----------------------------�----------------------------------------------------------------------------------------- ` Fee THE COMMONWEALTH OF MASSACHUSETTS VPUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction permit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon(X) System located at 5 8 S 6_A&1Z 0()t_ P_b M) 14 yrE NeV(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. \ 2SProvided:Construct' must i e c mpleted within three years of the date of this permit. Q Date 6 Approved by `) Postal CERTIFIED MAIL.-INECEIPT o (Domestic For delivery information visit our website at www.usps.como rqr- OFFICIAL. USE Ul CO Postage $ `�!— ru7% CertitiedFee N � Return Receipt Fee d ls1' rs O ((Endorsement Required) ,..Here Restricted Delivery Fee '��' O (Endon>emerd Required) O � �.. � Total Postage&Fees $ �• 1 Carlos & Flor De Maria Gonzalez 158 Seabrook Road Hvannic nan n')cnl Certified Mail Provides: ■ A mailing receipt ■ A unique Identifier for your mailpiece ■ A record of delivery kept by the Postal Service for two years Important Reminders: ■ Certified Mail may ONLY be combined with First-Class Maile or Priority Mail®. ■ Certified Mail is not available for any class of intemational mall. ■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. ■ For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailplece'Return Receipt Requested'.To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. ■ For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement'Restricted Delivery'. ■ If a postmark on the Certified Mall receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail recelpt is not needed,detach and affix label with postage and mail. IMPORTANT.Save this receipt and present it when making an Inquiry. - UNITED,STATES POSTAL,SERVICE- First Clas3FeesPaid Postage LISPSPermit No • Sender: Please print your name,address, and ZIP+4 in this box• Town of Barnstable r o Public Health Divisita 200 Main Street Hyannis, MA 02601-5 I - a 133 -- en SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Signature item 4 if Restricted Delivery is desired. ❑Agent ■ Print your name and address on the reverse X ❑Addre so that we can return the card to you. B. Received by(Printed Name) C. D e of Pel ■ Attach this card to the back of the mailpiece, / or on the front if space permits. D. Is delivery address different from item 19 1❑Ves 1 Article Addressed to: If YES,enter delivery address below: ❑ No Carlos & Flor De Maria Gonzalez 158 Seabrook Road Hyannis, MA 02601 3. Service Type ❑Certified Mail ❑Express Mail ❑Registered ❑Return Receipt for Merchar ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number (Transfer from service labeq 7 012 1010 0000 2851 17 0 8 PS Form 3811. February 2004 Domestic Return Receipt 102595-02-M f J Town ®f Barnstable Barnstable Regulatory Services Department ;'dcac + BA'RNSTABLE. `nAS& i639• Public Health Division �� m 200 Main Street,Hyannis MA 02601 2007 Office: 508-862-4644 Richard Scali,Interim Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7012 1010 0000 2851 1708 January 13, 2014 " Carlos & Flor De Maria Gonzalez 158 Seabrook Road Hyannis, MA 02601 IMPORTANT NOTIC l Map & Parcel 307-028 The Department of Public Works informed us that public sewer lines are now available in your neighborhood. According to our records, your property has a septic system. This letter directs you to connect your dwelling, at 158 Seabrook Road, Hyannis, MA, to public sewer on or before 12/30/2019. The old septic system must be either removed or filled in due to future safety concerns. This may be done by the same contractor who connects you to the sewer. Septic Abandonment Permits ($ 25) are issued at the Public Health Division, 200 Main Street, Hyannis. Failure to comply with this Board of Health Order may result in a complaint against you, in a court of law. For additional information pertaining to the sewer connection, please see enclosure. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health Enc Q:\SEWER connect\Sample order letters for sewer connection\158 Seabrook Rd Hy Jan 20I4.doc Parcel Detail http://issgl2/intranet/propdata/ParceIDetai1.aspx?ID=24574 ey ,.,.P,r- . B A27.MSTAC1LE3")`I � Logged In As: Pa rCel Detail Monday, January 13 LJ 2014 Parcel Lookup Parcel Info Parcel 307-028 ) Developer�LOTD_ ._. ._.__ _.._.. .. ID' Lot Pri Location 158 SEABROOK ROAD �� (71 Frontage Sec Road Frontage Fire Village{HYA N S I District LHYANNIS Town sewer exists at this Road _453 .__._�.�_._�.,_.__—.. .��f addressNo Index�1 Asbuilt Septic Scan: - � p Interactive 307028 1 Mapgh k Owner Info Owner FGONZALEZ, CARLOS& FLOR DE MARIA f Owner Streetl r 58 SEABROOI<RD City(HYANNIS � State Zip 2601 Country Land Info Acres!0.20 Use iSingle Fam MDL-01 Zoning FR _ Nghbd 10105 _� Topography I— Road Paved Utilities f Public Water,Gas,Septic � Location Construction Info Building 1 of 1 Year .._ . - -4-- Roof - Ext, Built19691 Struct Gable/Hip Wall Wood Shingle j Living -- _. — Roof _____ _ AC 11540 {Asph/F GIs/Cmp jNone Area Cover' Type — - Int' ;- F Bed i . F Style{Ranch ' Drywall 13 Bedrooms Wall Rooms ux � ' Model Residential Floor ICarpet Rooms i 1 Full+ 1 H �) �; A�,:;_. Bath �T Grade FAver- Heat r- Air � Total 5 Rooms Type I Rooms' Heat _., _.._. .___ Found- __ _...__ _----- Stories 11 Story Fuel[Gas -) ation'Poured Conc. Gross http://issgl2/intranet/propdata/ParcelDetaii.aspx?ID=24574 1/13/2014 TOWN OF Z ARNSTA.BLE q Lii%:ATION �S all�'')/1Lt SEWAGE # `MLAGE ��4kia if L4 ASSESSOR'S & LOT '_�:�� INSTALLER'S NAME&PHONE NO. & Rs SEP11C TANK CAPACITY IO a) LEACHING FACILITY: (type) F1 (size) NO.OF BEDROOMS BUILDER OR OWNER 2 PERMITDATE: /-1 -51 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 04;- � � .� .- TOWN OF-0,►.RNSTABLE U�Cf�'�1C•�e 6Y s� — SEWAGE # '� •.!'� i vE I—E 46-il#is ASSESSOR'S & LOT INSTALLER'S NAME&PHONE NO. SEP r. TANK CAPACITY 1,0 00 LEACHING FACILITY: (type) l h � 5, (size) NO.OFBEDROOMS BUILDER OR OWNER PERMIT DATE: //—9 —51 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) =~3 '°.-�Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by J O F 104� {t 7 No. �1 e2 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BAFtNSTABLE,, MASSACHUSETTS YYes 0(ppYfcation for Moozat *potent Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) Complete System V4ndividual Components Location Address or Lot No. I 1,5 � - Owner's Name,Address and Tel.No. ra-`�I'S Assessor's Map/Parcel d —O \Ift 010 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Ik i O-CA(ke-S.&P-?C Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow :173.O gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank ,A, nn ti Clr`O c�> Type of S.A.S. c S Cc g.5 -E`T 1r_- �-- Description of Soil Ak Q a. S mA.0 Nature of Repairs or Alterations(Answer when applicable) ALA- k2ew D-acl OL4= G t.S`t- c:)uL S1 -f Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has b e d e Q cal Signed Date Application Approved by 4d Date - Application Disapproved for the'AllowiW reasons Permit No._�9 d '��_ Date Issued . '6.n 1 �' .'.�..,�. t ,!r , .^'"'+ ✓^ �'� t7.w, "n.^Rta`n.rh-M h^_ yy,.,.f-♦r•Y-• � .. , . .rti . _ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PU3BLIC"HEALTH DIVISION -TOWN OF•BARNSTABLE, MASSACHUSETTS Application for Zizpogar *pgtern Construction Vermit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ^)t' ❑Complete System lrdndividual Components Location Address or Lot No. 8 rc��. Owner's Name,Address and Tel.No. Assessor's Map/Parcel d Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Vet 0--(->A(11F, � Type of Building: Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow Z`.n gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank cc< ti > Type of S.A.S. �� CR 7`tn r- Description of Soil 4 C lnt f) �. Nature of Repairs or Alterations(Answer when applicable) an A, C 0 JIL. j L t i lA.- CS r �� u( c AA Alm✓lA Vic'-. 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 b d ° Signed A Date f9- 0/ 6rApplication Approved by Date Application Disapproved for the llowi reasons Permit No. �/ci _ � _ Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded(( '. Abandoned( )by ;, at e",Ajo us4c,,"". S has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. —' dated Installer Designer The issuance of this pe t shall not be construed as a guarantee that the sys will fuAp, o as_desi ned. Date Inspector ---------------------------------------- No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS �ig�ogaY �pgtetn��ori�truction �erntit �, .,,,4 ,, Permission is hereby granted to Construct( ) epair( )Upgrade(L_)a andon( ) System located at S"I_c trr-r)� �Q \ •...� c., cw t/L t and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date: I 1 Approved by 1/6199 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) hereby certify that the application for disposal works 'construction permit signed by me dated 9-9 concerning the ,f property located at meets all of the following criteria: • The failed stem is connected to a residential sy 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. V- I✓ The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] Le If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W. Elevation +the NLAX High G.W. Adjustment. _ (� DIFFERENCE BETWEEN A and B SIGNED DATE: (Sketch proposed plan of system on back]. q:health folder.cent (� rc cQ � 1 i �-. r-. �1 i COMMONWEALTH OF MASSACHUSETTS FILECOPY EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS —_ DEPARTMIENT OF ENVIRONMENTAL PROTECTION � o 4.. MAP PARCEL • ®2 8 LOT TITLE 5 OFFICIAL INSPECTION FORINI—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION ' Property Address:L�j�j S �Rona ��•e i Owner's Nanle: [<Aq ,; '6TAt-IIVLa O,vner's Address: 42 7 tf-E lVi r;7 f=c°r,�_(�.V✓✓-1 c^,2 1 SS Date of Inspection:i Name of Inspector: (please print) Brad J White Company Name: `Vindriver Eaviromental . Mailina Address: 107 N.Main Street Carver,MA 02330� Telephone Number: (503)-E66-2503 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the.time of the inspection.The inspection was performed based on my training and experience in the proper Rinction 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 F Needs Further Evaluation by the Local pproving Au�� Fails Tv B 0,6 Inspector's Signature: Da • 1 ' Q .1.v`j 2004 The system inspector shall submit a copy Sis inspection report to the Approving Authori �He lth or DEP)-,,,i.thin 30 days of completing this inspection. If the system is a shared system or has a design w o 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional of i e of the DEP.The original should be sent to the system owner and ccpies sent to the buyer, if applicable,and the approving authority. Notes and Comments 5'vstam Pss�cs. .ALL Liujio LtUGLS LCES NC/T- ��L j¢Uv�l 5YS7Z-M Wt�L pc2FL'2✓YI. ��NDE2 Q /FFEga-4e-tj 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. Title 5 Inspection Form, 6/15/2000 page 1 Pace 2 of 11 , OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1 P �5TWA Owner:STnc-i(acA Date of Inspection: l-:2 e) -cry Inspection Summary: Cirecic A,B,C,ID 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 CHIP 15.30 t 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. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is inetal 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.metai septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: _ Observation of sewage backup or breakout or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): 'broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced N'D explain: _ The system required pumping more than 4 times a year due.to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 f Page3of11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: L5` Owner: �T�G�iC)l•, Date of Inspection: 1_20 Q I C. Further Evaluation is Required by the Board oil ealth: Conditions exist which require further evaluation by the Board of Health in order to deternine 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 Ci\1R 15.303(1)(b) that the system is not tuuictioning in a manner which �r-ill protect public health,safety and the environment: Cesspool or privy is withni 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply-or tributary to a surface water-supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well*".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: . Tiff. S Tnon f;-++V- 411;1l)nnn 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) •Property Address: 6p) Owner: 6•rr4&AoLA Date of Inspection: i-2 ,09 D. System Failure Criteria applicable to all systems: You must uidicate"yes"or."no"to each of the following for all inspections: Yes No Z Backup of sewage into facility or system cornponent 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 Y day flow 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. ,of Any portion of cesspool or privy is tivzthin 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.) tCD(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to deterrrune what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. -ratio c T. ... 4 f Page 5 of 11 • f OFFICIAL INSPECTION FORIM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:VrW5 Jc a e.>¢o%a�c eonp Owner: ra Date of Inspection: l-26 -c--i 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'? V 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: Yes no Existing information.For example, a plan at the Board of Health. V _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] -r;t„ q Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORAIATION Property Address: Ise-, �iER gLOoe �o 6�rati Ic�t_/��Owner: Date of Inspection: i —20'CH• FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): Number of bedrooms (actual): 5 _ DESIGN flow based on 310 CMR 15.203 (for exa,:ipie: 1 10 gpd x of bedrooms):��r: \lumber of current residents: C) Does residence have a garbage grinder(yes or no):NQ Is laundry on a separate sewage system(yes or no):,y [if ties separate inspection required] Laundry system inspected(yes or no)'(c s Seasonal use: (yes or no):yeti Water meter readings, if available(last 2 years usage(gpd)):to t",-,j 4, Vic;0 Sump pump(yes or no):Ra Last date of occupane COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary,waste discharged to the Title 5 system(yes or no):_ Water meter read nas, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of informationT(-z nc Lr—Ic2 6. CC, p Was system pumped as part of the inspection(yes or no):Kio 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 N 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) _Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known) and source of information: I g0j9 Fcn CA Were sewage odors detected when arriving at the site(yes or no):N0 6 Page 7 of 11 OFFICIAL INSPECTION FOR1\1—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1,15P?66A__;� i LJArs L N—k!!L- P — Owner:_'57P&1181 fi Date of Inspection:i� t - BUILDING SEWER(locate on site plan) Depth below grade: \Materials of construction: _cast iron / C?VC. other(ex:olain): Distance from private water supply well or si:ction line: ��Crr ontinents (on condition of joints,venting, evidence of leakage, etc.): SEPTIC TAINK: ,/ (locate on site plan) Depth below grade: at Material of construction:_concrete_metal_fiberglass__polyethylene other(explain) If tank is metal list age:— Is age confirmed by a Certificate of Compliance (yes or no):—(attach a copy of certificate) 1 �� Dimensions: P) Sludge depth: 2 Distance from top of sludge to bottom of outlet tee or baffle: ,-n Scum'thickness: F1.0c.r1,vE Distance from top of scum to top of outlet tee or baffle: Distance from bottom of'scum to bottom of outlet tee or baffle: f , How were dimensions determined: Mg—cs 2rLC) Comments(on pumping recomn;endations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage, etc.): T c ,D N c t; n cat t o i::, L.C-A 1--AG cs =---- GREASE TRAP:_(locate oil site plan) Depth below grade:_ Material of construction:_concrete—metal_fiberglass_polyethylene_other (explain): Dimensions: _ Scum thickness: Distance from top of scum to top of outlet tee or baffle: —_ Distance from bottom of scum to.bottom.of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage, etc.): T;r1A Inc.orr;nn 17-4l1;i1nnn 7 Page S of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORII'IATION(continued) Property Address: 156 !SEaII cn ecAn 11 1., VIS r-0 6 .. 0Nvner: 6rQr,r L.A Date of Inspection: 1-2_ -2-j 'TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberalass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarni in working order(yes or no): Date of last pumping: Cornments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: / (if present must be opered)(locate on site plan)(S,I.i 6rr.a.., &a-W") 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.): 10 CNY. ;�- D h S 0 L-1-0S 0-A Q 2-1 .)I SE2 N)d EAV—a Iru _17o— OUrr , PUi�'IP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): T;�10 Tnc�sarhinn T:n:..,u1 vinnn 8 _ ....._.._. ._.... - -- - - -- - --- Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTENI INFORM:ATION(continued) Property Address: 15Q� ��abL ILRo Owner: 4S'rr-Gl in" Date of Inspection: 1 U-C'-i _ SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan. excavation not required) If SAS not located explain why: Type leaching pits„number: _ leaching chambers,number: leaching galleries,number: H leaching trenches,number, length: leaching fields,number, dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): y 11 �•�'A-i 1 O��l •S ti�c�,2M�L CESSPOOLS: (cesspool.must be pumped as part of inspection)(!ocate on site plan) Number and configuration: _ Depth—top of liquid to inlet invert:_ Depth of solids layer: . _ Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): 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: f Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORAM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 15c Owner: Si bl Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEh1 Provide a sketch of the sewage disposal system!.ncji,.-i _g ties to at least two permanent reference landmarks or benchmarks. ,ocec,all wells within 100::e:t. Locate where public water supply enters the building. v` I c. r c 6 4 1 2- 4 o' �. T � 'T:rio G Tnc..A�fin,.Tlnrm(.I1 G/'J:1l1(1 10 . Page 11 of i l OFFICIAL INSPECTION FORNI—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 15D -7rcAPJ,�OIL _�D +tNAIUNIS , yyt4 Owner: 5TAGI iblA Date of Inspection: 1-20-o`i _ SITE EXAIM Slope ce water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: _✓ Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established.the high groundwater elevation: � C�Hcc.t« wrrH I ncA►-L 6-T nt)NOWA'f'15'2 I, '7 eZ)r (sA�r6Y5 �kLCae �i� � SOIL IS �2� �}L�D 1 TOWN OF BARNSTABLE + LOCATION �c�� el /1 SEWAGE # �-(�3CS VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. A & B CANCO 775-6264 6� SEPTIC TANK CAPACITY DD d LEACHING FACILITY:(type) size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER /ill DATE PERMIT ISSUED: 2— k7 a DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No t� --� � � L --�. • s `\ �� Q .' - .�: • ASSESSORS MAP NO: .._ z'S � PARCEL N0: No Fxs....%�G.-........... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH -Tow7l....................oF rn� . . App iration for Dhgpviia1 Morks Tomtrurtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at ........... -----------------------... ...•------------------------•-----•--•--�••-------------o-.- •-- oLcation- ddr Lo N I4r4rMrd_ .... . .1 /40- o -------- •-----•------- ROwner Ad ress a Q G'vmo #reed . �r._C¢t_*Q- •............... Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building ......... No. of persons............................ Showers — Cafeteria a Other fixtures -------------------------------- - W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width---------------- Diameter................ Depth......................... xDisposal 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 ( ) Percolation Test Results Performed by------------------------------------- ------------------- ----------• Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................--. Depth to ground water---...----.............. Li, Test Pit No.2................minutes per inch Depth of Test Pit.................... Depth to ground water...--.---............... •-----•-•----•---------•---.....---•-••---•---•-•----.....---•-••--•----------------------------•---......................................................... 0 Description of Soil..........................................•-.................................................................=.......................................................... x U ---------••---------•-•-----••--•------------------------------•---------------------------------•-------••-------. ----•-----•-----------------•-•-----••---•--•--------------•-----...--------•--•---- W ...........................................................------------•--------------•---------------------------- -------------------- ....--------------•••------- --------•---•--....•----.----- UNa ure of Repairs or AIter�tions—4nswer when applicable�Y.l� - J...�-I( C!&S ._� °ne- r-� ..................................................... Agreement: y The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITi 711• 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued bythe board of health. ��jJ . — Signed--.. .. - -•------------------------------ -� .8 --------- Date Application Approved By................ ... . . ` ="-- Date Application Disapproved for the following reasons:................................................................................................................ ....................•---------------•-------•---------------------------------------------------------•----------•-----•------------•...-----•-•-----------------••-•------------------•------------•--- pp Date PermitNo.------8..-7--'--- �r-----------------•--. Issued_....................................................... Date 4 FEs.... ..""............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH —TCiU�.YI_...................OF(rrt7 P Applira$ion for Bhspoiial Worko Towitrortion ranfit Application is hereby made for a Permit to Construct ( ) or Repair (-9 ) an Individual Sewage Disposal System atITS : ( y ....................---......... ...---•-- --•---........_----•--•----•--•---••--_------ --•--.._..-------------.._.._........-------•----. ---•---------------------•----..............•- s • Location.Address ! � �('tt j or Lot No.! ..t?i1 a�Cs 1G�C ,. ............................................r5 W f 9C� V Owner p Address r! �/ Ol,flora .�isCi �` �rl►1 •.,,...................Y•ee ftaa6t L1...........o-rROCt_ , � Installer Address t.. UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms........................_...................Expansion Attic ( ) Garbage Grinder ( ) a ' Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other fixtures _...._...---•--•••-------------- - W Design Flow...................._.......................gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid capacity............gallons Length................ Width--------_....... Diameter................ Depth................ W Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. x Seepage Pit No---------_--------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) `" Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water_______-___-__-__.__--.. Lz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ .............................................-............................................................................................................... 0 Description of Soil........................................................................................................................................................................ x U •---••--••-•••--•••-----••---•-••-•--------•----•------••-•••••••-•••-•--•--•-•-•-•••-•----------••.._...----••-•--•••-•---••-••-•--••---•-•----•••----•-•------••-------•-•--••--••-•--•--••---••---••- W --•-••••--•--•---------•-------•----------------•---•-••---•-•-•--------•------------••••--•••-•---•--••--••-•-••-. --._...-------••••-••---------••-••-••-•-••-_•---• •...----••-•••-••-••-•-•---••. UNature jof Repairs or Alterations—Answer-when applicable *�-_�re��__``-:�--�� ±�t��-•_r? >------'!t__._-__-_-_. .................................................1'�nrF' 14tilr � G?'t 4 =='�:_._..1 • £7u�C {s'1 6_ Gnu' 0 a t.Pr tRfrr+� , Agreement P ._...------••• ••. .•-•- The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T IT�..; p 5 of the State Sanitary Code— The undersigned further agrees.not to place the system_ in operation until a Certificate of Compliance has been issued by the board of health. l r � �� n�G � 6,- �I-�? Signed.......`^L.J............ ......................•-...----•-.._..•--•--•--•--...-- -^-•••-.. •Date .....•------• D y; Application Approved By................ --------------------- ........S--- (_.`1_cy - Date Application Disapproved for the following reasons:................................................................................................................ --...._.....••--•••--•-••----------••-•-•--••••••---•--•••--•--•-••-•-•••-•---•••-•.....--••••--------•-------•••--•-••••-•••••-•••••••----•-•-•--•••••••••---•••••-•••-••---•••-------•---••-•••-•-•--- Date PermitNo.----- --' J.ate -- Issued....................................................... Date (� THE COMMONWEALTH OF MASSACHUSETTS 1F" A BOARD OF HEALTH .A 1 t; ta3!�......................0F.....f 5t,rtI" rGi k� ...... .............................................................. Trdif iratr of Tomptiana THIS IS ,X CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (44) ' T .�.%., l�.C%--Yt.......J� .............................................................................................. by y_- .._.... ., ,j j Installer �..ri_f -••----- has been installed in accordance with the provisions of TIT , j of`-The State Sanitary Code as described in the application for Disposal Works Construction Permit No.......____-�_:___= .........'1_:___, dated_.-.... --- -------------•...................... THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.................!a........ ................................. Inspector--•-- ---- -----------------•-----•-----•----- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 7' ;.... . ........ .......................... No......_.... ••••-- _-- FEE....... ..:. Diupuua1 � urkn �uatu#rttr#iun [�ernti Permission is hereby granted.........------ ------------ •-•---------------------------------------- ........._._..... to Construct ( ) or Repair k) an Individual Sewage Disposal System atNo.................................................................................................................................................-.-_---------•--------------------•-••-•••-•- Street (f� ("� as shown on the application for Disposal Works Construction Permit No-5_,1_____:,_J_:�__.... Dated.......................................... _.. 'a�, .....................--- .....-•••••••. _ � Board of Health DATE_ _.t"! FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS