Loading...
HomeMy WebLinkAbout0069 STERLING ROAD - Health 69 Sterling�Road Hyannis A-268-160 J i I Commonwealth of Massachusetts W Title 5 Official Inspection FormOQ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments C' 69 Sterling Road, Hyannis / Property Address Harris Owner Owner's Name information is Hyannis MA 02601 June 16, 2016, required for every Y y page. City/Town State Zip Code Date of Inspection N {f0 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not David B. Mason use the return key. Name of Inspector David B. Mason r� Company Name 4 Glacier Path Company Address � East Sandwich MA 02537 Cityrrown State Zip Code 508-367-1617 S1287 Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority June 20, 2016 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP: The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 hop I Commonwealth of Massachusetts W Title 5 Official Inspection Form, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 69 Sterling Road, Hyannis Property Address Harris Owner Owner's Name information is Hyannis MA 02601 June 16, 2016 required for every y page. Cityrrown State Zip Code Date of Inspection B. Certification (coat.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 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: The results of the inspection represent the conditions of the system oberserved on June 16, 2016 at 12:45 PM and is not representative of the condition or operating ability of the system beyond that point. There is no guarantee that the system will continue to operate in the future. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts v Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 69 Sterling Road, Hyannis Property Address Harris Owner Owner's Name information is required for every Hyannis MA 02601 June 16, 2016 page. City/Town State Zip Code Date of Inspection 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 manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh ' t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth o monwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 69 Sterling Road, Hyannis Property Address Harris Owner Owner's Name information is required for every Hyannis MA 02601 June 16, 2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or 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 Y2 day flow t5ins-3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 69 Sterling Road, Hyannis Property Address Harris Owner Owner's Name information is required for every Hyannis MA 02601 June 16, 2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following,'in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 69 Sterling Road, Hyannis Property Address Harris Owner Owner's Name information is required for every Hyannis MA 02601 June 16, 2016 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were nct available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 i t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 69 4M Sterling Y Road, Hyannis Property Address Harris Owner Owner's Name information is required for every Hyannis MA 02601 June 16, 2016 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 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 ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d Yes 9 ( Y 9 (gp ))� Detail: 2014, 43,500 gallons and 2015; 54,000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: currentDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ® No Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No Water meter readings, if available: (Sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pace 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 69 Sterling Road, Hyannis Property Address Harris Owner Owner's Name information is required for every Hyannis MA 02601 June 16, 2016 page. CityTTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/user Date Other(describe below): General Information Pumping Records: Source of information: Board of Health Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type,of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (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(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts w� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 69 Sterling Road, Hyannis Property Address Harris Owner Owner's Name information is required for every Hyannis MA 02601 June 16, 2016 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Leaching trench installed in September of 1995 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.5 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 10 inchesfeet 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: 1000 Typical Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 69 Sterling Road, Hyannis Property Address Harris Owner Owner's Name information is required for every Hyannis MA 02601 June 16, 2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 36" Scum thickness 5 Distance from top of scum to top of outlet tee or baffle 3 Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Scour Stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Effluent level with outlet invert. Tank is 10 inches below grade. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness — Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 69 Sterling Road, Hyannis Property Address Harris Owner Owner's Name information is required for every Hyannis MA 02601 June 16, 2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: — Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts • w Title 5 official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 69 Sterling Road, Hyannis Property Address Harris Owner Owner's Name information is required for every Hyannis MA 02601 June 16, 2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Effluent level with 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.): Viewed distribution box with camera. No evidence of solid carry-over 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: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 69 Sterling Road, Hyannis Property Address Harris Owner Owner's Name information is required for every Hyannis MA 02601 June 16, 2016 _ page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 1; 60' long ❑ 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.): 4'wide x 2' deep x 60' long. probed stone with no indication of hydraulic failure. No inspection port. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool r Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 69 Sterling Road, Hyannis Property Address Harris Owner Owner's Name information is required for every Hyannis MA 02601 June 16, 2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids - Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.).-. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 69 Sterling Road, Hyannis Property Address Harris Owner Owner's Name information is required for every y H annis MA 02601 June 16, 2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 69 Sterling Road, Hyannis Property Address Harris Owner Owner's Name information is required for every Hyannis MA 02601 June 16, 2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 18'feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: Groundwater Contour Map ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater Contour Map Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts • w Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 69 Sterling Road, Hyannis Property Address Harris Owner Owner's Name information is required for every Hyannis MA 02601 June 16, 2016 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked E Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 f Assessing As-Built Cards Page 1 of 2 r TOWN OF BARNSTABLE LOCATION 14Vi4NN+S SEWAGE# f$-1732. VILLAGE_(,Q SfEaQlin c [�)A✓ ASSESSOR'S MAP&LOT J L-I(20 INSTALLER'S NAME&PHONE NO._UJ E RobinJ5ci l $rpEl'G 77$-'?7%-, SEPTIC TANK CAPACITY 1.n6n C .l � r LEACHING FACILITY:(type)_ IfPct� 1-110' k (size) a K 4. ,(001 No.OF BEDROOMS 3 BUILDER OR OWNER I­EfE2 PERMPTDATE: �S COMPLIANCE DATE: 96i gs Separation Distance Between the: Maxinuan Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any,wetlands exist within 300 feet of leaching facility) Feet Furnished by w `Q �urh http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=268160&seq=1 6/16/2016 -` COMMONWEALTH of MA,SSACHUSETTt s ExECu rrvE OFFICE OF ENVIRONAmrTAL AFFAIIts " DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A' CERTIFICATION ,� J Property Address: G S4 t R 1 t Owner's Name:cf k-i�C +^'�C��'2S KIP Owner's Address: Date of Inspection: T;mac>g Name of Inspector.(please print) SP,0_VA--,!—C>nP_S Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1 089 Centerville, MA Telephone Number: t 5081 775-8776 + CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported ` below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuan71oS ion 15.340 of Title S(310 CNIR 15.000)- The system:CS Conditionally Passes Needs F Evaluation by.the Local Approving,Authority s Inspector's Signature: Date: �l d�c The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Headi'or , DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000" gpd_or.greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****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 P system will perform in,the future under the same or different conditions of use. Title S Inspection Form 5/I52000 page I MI 6111-7 Page 2 of i 1 j OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM FART A CERTIFICATION(continued) Property Address: ( Owner: Cris - C S Date or inspection; Inspection Summary: Check A,B,C,D or E I ALWAYS complete stl ofSeetioa D A. Sys inPasses: l have not found any information which ind"tcates 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: <VI 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 .explain_ following statements_If"not determined"please - . The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial inf ltration or exfettration or tank failure is itttmincat g existing taj*is replaced with a complying septic tank as approved by the Board ofHeattlh will pass inspection if the •A metal septic tank will pass inspection if it is structurally sound,not leaking and if Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in,the_distribution-box ilue twbroken or -Obstructed4pipe(s)or due-to a approval f Board of Health);broken,settled or uneven distribution box_System will pass inspection if(with broken pipe(s)are replaced Qbstruction:is,removed disi<tbution box is leveled or replaced ND explain: The system required pumping snore than 4 times a year due to bnktn or obstrtxte pass inspection if(with approval of the Board of Health): d P (s).The system will broken pipe(s)are replaced r obsWctina isstmosrod ND explain: Page 3 of l l OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: r , Owner:DNCt Sit vv� t,1�Ce CQ S Date of Inspection: 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 15303(1)(b)that the r' system is not functioning in a manner which will protect public health,safety and'the environment: _ Cesspool or privy is within 50 feet of a surface water ' _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 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 I of a public water supply. ' The system has a septic tank and SAS and the SAS is'withiit SO 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 frofi a t private water supply well" Method used to determine distance ' f 'This system passes if the well water analysis,performed at a DEP certified laboratory,for colifornl 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. bther: f f 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) , Property Address: Owner: on cLi-e-S „ r Date of inspection: " D. System Failure Criteria applicable to all systems: You must indicate`yes'.or"no"to each ofthe following for all inspections:, = Yes No f , 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 y Liquid depth in cesspool is less than V below invert or.available volume is less than%day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number /of times pumped c//Any portion of the SAS,cesspool or privy is below high ground%rater elevation. Any portion of cesspool or privy is within I00-feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy,is within a Zone I of a public well. _ Oy 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,f et from a private u-attr• supply well with no acceptable water quality analysis.(This system passes if the well water analysis,. performed at a DEf 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 ofthe analysis must be attached to this form.] - (Yes/No)The system fails.1 have determined that one or more ofthe 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 faciaty with a design flow of 10,000 d to 1�5,000 .. t; gP . , gpd- You must indicate either'-Yes"or"no"to each of the following: (17te 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 I1 of a public water supply well If you have answered"yes"to any question in Scainn E the system is considered a significant threat,or answered "yes"in Section D above the large system has fru'led_The owner or operator of a"large system considered a significant threat under Section E or failed under Section D shalt upgrade the system in accordance with 310 CMR 15.304.The system wwner should contact the appropriate regional office of the Department. 4 Pages of II OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY-ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B f - CHECKLIST Property Address:(0 Owner.Chi i$�,tY.� �N•c A_S Date of Inspection: Check if the following have been done.You must indicate`yes"or"no"as to each of the following: • ii Yes No slPumping information was provided by the owner,occupant,or Board of Health ✓/Were any of the system components pumped out in the previous two weeks 7 ✓ Has the system received normal flows in-the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection ✓ _ Were as built plans of the system obtained and examined?(If they were not-available note as N/A) _✓ — Was the facility or dwelling inspected for signs of sewage back up Was the site inspected for signs of break out? .. Were all system components,excluding the SAS,located on site? :,• _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _ -"/Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? - t The size and location of the Soil Absorption System(SAS)on the site has been determined based on: t Yes .no F _ 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)13 10 CMR 15.302(3)(b)) t H Page 6 of I I . OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS ' ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property-Address• Owner: Date of Inspection: o F FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):. Number of bedrooms(actual): 3 DESIGN.flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): . ' Number of current residents: 0 4 - Does residence have a garbage grinder(yes or no): VLO Is laundry on a separate sewage system(yes or no):AP [if yes separate inspection required] Laundry system inspected(yes or no):'v A— Seasonal use:(yes or no): Nu , Water meter readings,if available(last 2 years usage(gpd)): L Sump pump(yes or no):,NJ a�a� Last date of occupancy: COMMERCIAL/INDUSTRIAL �y 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 readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION- Pumping Records Source of information: Was system pumped as part of the inspection(yes or no)>'%A:1 If yes,volume pumped: gallons—flow was quantity pumped determined? Reason for pumping: ,..— TT SYSTEM septic tank,distribution box,soil absorption.system _Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no):AID 6 fate 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACL?SEWAGE DISPOSAL SYSTEM INSPECTION FORM FART C.: �t(,�, SYSTEM INFORMATION(continued) ` • t Properly Address*. S�Ve'-,1 owner: LV11r, ryl�t'e� Date of Inspection: - BUILI)MG SEWER(locate oil site plan) - Depth below grade. : •t Materials of construction:_cast iron ✓40 PVC_other'(explaui}: Distance from private water supply well or.suction lure: Comments(on condition of juuUs,tventing,evidence oficakage,ctc.): SEPTIC TANK:Z(locatc on site plan) - Depth below grade: Material of construction:_✓cuncrete_metal Fiberglass__polyctliylene F ' _odlcr(cxplain) If tank is metal list age:_ is age confirmed-by a Cutifica(e of Compliance(yes or no):_(attach a copy of ' certificate) / _ Y Dimensions: lrx0e Sludge depth: !0 Distance from top of sludge to bottom of outlet tee or bagle: _ g scum thickness: _ Distance from top of scum to top of outlet tec or battle: ,? Distance Gorn bottom of scum to botio►n of outtct tee or battle: I were dimensions dctcnnined:�P.tr ��- _ a'x �/bt[cntrd►+t✓rf3 :+ : Comments(on pumping recommendations,inlet and outlet tec or baffle condition,structural integrity, liquid IcvcI' E , as related to outlet invcA,evidence of leakage,etc_.): 4�Le GREASE TRA1':-#V`locate on site plan) f Depth below grade: Material of construction: concrete_metal_fiberglass____}solyeth)tene mother (explain): Dimensions: Scum thickness: - distancc iron)top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottorn of outict(cc or baffle: Date of last pumping: Continents(on pumping recommendations,Wet and outlet tcc or baffle eonditio.i.structural integrity,liquid Icvcls as related to outlet im'cri,evidence of leakage,etc.): 7 8OI it OFFICIAL INSPECTION FORA-1—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOItNI PART C f SYSTEM INl:OItA-IATION(con(inucd) ierly Address ki RG V- 11 ter• V� ��sS `�Q, U�S of Inspection: , 71T or HOLDING TANK:/vAtmik must be pumped at time of inspection)(locate on site plan) th below grade: erial of constriction:_concrete metal fiberglass_polyethylene other(explairt): , tensions: acity: gallons ign Flow: gallons/day rn present(yes or no): rm level: Alarm in working order(yes or no):— c of last pumping: + nrnents(condition of alann and float switches,etc.): 3 STRIBUTION BOX: (if present must be opcned)(locate on site plan) _. pth of liquid level above oullct invert: to s; , muncnts(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of kagc into or out f'box,etc.): T r[ L X-s.S �.�! E.�c/�.. 4�� 1 4:: c y�ir..+c A.4 'ScJtC/J /Kai JCcL�i�v. 1. . pr )AIP CIIAMBER!—(locate on site plan) mps in working order(yes or no):_ arms in working order(yes or no): _ munents(note condition of pump chamber,condition of pumps and appurtenances,etc.): 6 Page 9 of l l OFFICIAL INSPECTION-FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ` \�C �`,� Owner: Date of Inspection: mac SOIL ABSORPTION SYSTEM(SAS): ✓ (Ioeate on site plan',excavation'not required) If SAS not located explain why: . • Typ leaching pits,number. i leaching chambers,number leaching galleries,number: leaching trenches,number,length: I _ 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 podding,damp soil,condition of vegetation, etc.): D tfe-r vc, (-sk ytio +mac CESSPOOLS: lA kesspoW must be pumped as part of inspectionxlocate 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.): PRI VY?�4(locate on site plan) Materials of construction: Dimensions: Depth of solids: Continents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of i I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: q �UGG Owner: Date of Inspectiou: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. a' &Aami� 13 y 3 ko cd tff s A.3 -3f 3.9 10 ,Paige I L of 17 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM DART C SYSTEM INFORMATION(continued) Property Address:(oc Owner. Date.of Inspection: ejr SITE EXAM Slope Surface water Check cellar Shallow wells . Estimated depth to ground water S4-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 propertylobservation hole within 150 feet of SAS_) Checked with local Board-of-Health-explain: Checked with local excavators.installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: - --�ryR>•mod�•-��Cr' /La-j Z"316-41--Ahecl P.nriJSYt/b TD»AJ yY �G�/1SJ��'L --`vim:r -tra��' •fG/�%T_il/ ,/�/�-�� t 11 . 1 No. o Fee • '� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE. MASSACHUSETTS ricatfori for M-4pogat *pgtemc Con.5truction 3permit Application for a Permit to Construct( )Repair(v )Upgrade( )Abandon( ) ❑Complete System Frndividual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 6f 9f��'�'� /4 1ew/A?A�5 Assessor's Map/Parcelaoil/PS Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 13 Lot Size sq. ft. Garbage Grinder( � Other Type of Building e_$y PwceNo.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow �� gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 1'`le? / OQA Type of S.A.S. Description of Soil X 3 Z XZ Nature of Repairs or Alterations(Answer when applicable) J+-/'���� �"�i �� l��Ce /yIF Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b this Board of alth. Z Signed Date Application Approved by Date Application Disapproved for a following Mreasons Permit No. Date Issued No. 7 Fee / -, ,_„ THE COMMONWEALTH OF MASSACHUSETTS - •Entered in computer: Y Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIpplication for �Digponl 6pgtem Congtruction Permit Application for a Perrtut to Construct( )Repair(V)Upgrade( )Abandon( ) ❑Complete System I YI'T vidual Components Location Address or Lot No. � -/ Owner's Name,Address and Tel.No. Assessor's Map/Parcel a��� 14 t ex rlrlls Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. r Por foCo�`%G�rs�: 4 Type of Building: f "� Dwelling No.of Bedrooms 13 :: Lot Size sq.ft. Garbage Grinder( � Other Type of Building e- No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow //d gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title eo Size of Septic Tank %�7 /DDD Type,,of,S.A.S. V �h 7174-1,0'7WS Deicription of Soil q 3 Z 2- Nature of Repairs or Alterations(Answer when applicable) .fi 7�l e �i�GG J�io e a 1' Zeov&a /0--� 7-0 �/�bone Ai Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental*Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by his Board of alth. / / °^'y Signed Date 2-` ;P 9 9 Application Approved byffefollo�wing ! Date Application Disapproved fo reasons N Permit No. r-" Date Issued r ------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTI , that the On-site Sewage_Disposal System Constructed( )Repaired( V11upgraded( ) Abandoned( )by Z 114 r D ' G-f ilcra"70-. at ,1- Ib7aY i9 S h s b constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit N o. dated Designer The issuance of thisVYtWIof a construed as a guarantee that the sy wild un�cyt(io�n as de I$�ne/d. /t Date Inspector No. © Fee 1 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE,, MASSACHUSETTS Migpogai bpgtem Congtruction hermit Permission is hereby granted to Construct(� )Repair( Upgrade( )Abandon( ) System located at ✓cXerl/ y /06 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 mus b e completed within three years of the date of t e 't. Date: �4:�Iq q Approved byis�p d" - �J2ifTa L'U ` ti, r G t. 1/6M 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) , I, 6��1�7` J. Ol � hereby certify that the application for disposal works jy construction permit signed by me dated Z����9 , concerning the property located at5 meets all of the following criteria: J 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 V/There are no private wells within 150 feet of the proposed septic system V/There is no increase in flow and/or change in use proposed /There are no variances requested or needed. ✓ The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] l ( ✓ 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) a 5 B) Groundwater Table Elevation Z® max.adjusted g.w. DIFFERENCE SIGNED : DATE: �yti [Sketch proposed plan of system on back]. _ w ,, �a � 9 health folds•art� ��- t - �� : .x.F � �.,£-� � u _� ,a t*^-.�'rf.a�"µ�fiH ."�,.w.l•E,,.r���� .a..� ,�. � s. _ S -.''". �7+-�'.'e. -•3 � TOWN OF BARNSTABLE LOCATION 14$LdNEV,S SEWAGE# 25-/732 ':itLLAGE. l�9 S'16AP—Icn4 G)AV ASSESSOR'S MAP&LOT 6 INSTALLER'S NAME&PHONE NO. _ _L,-)C— 1o6;n9St #J 564k- 775—?7_7(- SEPTIC TANK CAPACITY /.oon 9 al S--, LEACHING FACIIITY: (type) 16AC�, i-IU: k (size) .1 ? 4 to® NO.OF BEDROOMS 3 BUILDER OR OWNER fEE2 ���dC5 PERMTTDATE: / COMPLIANCE DATE: 9h I9 S Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by s tir � At o l AN 3�r R� Fee 3 0 .0 0 No. THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 0(ppIttation for Mtgpogal 6pgtem Congtructton permtt z Application is hereby made for a Permit to Construct( )or Repair( x)an On-site Sewage Disposal Syste m at: Location Address or Lot No. Owner's Name,Address and Tel.No. 69 Stearling Way Peter Halks nn/ Installer's ame,Address,and Tel.No. Designer's Name,Address and Tel.No. W.E. Robinso Septic P.O. Box 1089 Centerville Type of Building: Dwelling No.of Bedrooms 3 Garbage Grinder( ng Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil sand Nature of Repairs or Alterations(Answer when applicable) Title V 6 0 ' leach—trench 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 Environme tal Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by th' Bo d of Healt . tomc Signed !N k Date Application Approved by Application Disapproved for the following reasons Permit No. Date Issued 440 No. Fee 3 0.0 0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS s: application for Migpogal *pg;tem Construction Permit Application is hereby made for a Permit to Construct( )or Repair( X)an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. E9 St/elbrling Way Peter Halks Installer YNarne,Address,and Tel.No. Designer's Name,Address and Tel.No. W.E. Robinso Septic 'YEA .P.O. Box 1089 Centerville t- Type of Building: Dwelling No.of Bedrooms 3 Garbage Grinder( ng Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flovia'I gallons: Plan Date Number of sheets _ >:' lRevision Date Title '� Description of Soil sand ' leach-trench # Nature of Repairs or Alterations(Answer when applicable) Title V 60 Date last inspected: t 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 Environme tal Code and not to place the system in operation until`a Certifi- cate of Compliance has been issued.by th' Bo d of Heal Q l c Q Signed l/y d Date !`/ Application Approved by Application Disapproved for the following reasons t' Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of Compliance - THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/re—placed OC )on by W.E. RobinsonSeptic for Peter Halks at 69 Stearlin Way ba-F,.bew constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No- d vl Use of this system is conditioned on compliance with the provisions set forth bel w: ----- No. �� Fee 30.00 —_--- THE COMMONWEALTH OF MASSACHUSETTS N PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 1Wigpo!6a1.*patent Construction Permit Permission is hereby granted to W.E. Rob3�nso Septic Service to construct( )repair(x )an On-site Sewage System located at 69 Stearling Way and as described in the above Application for Disposal System Construction Permit.The applicant ecogniz s his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction /stt�b comyleted within two years of the date below. �y I C.) P Date: % Approved by /f i 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 S , concerning the property locate&at L 1�'°� l �'— �`'r meets all of the following criteria,: • There are no wetlands within 300 feet of the proposed septic system • There are norprivate wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There.is no increase in flow and/or change in use proposed • There are no variances requested or needed. , SIGNED DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan'should'be submitted]':. -- c � : � o �� fl: �. 1 � � r '� � . � .� � �. � �t . f �. ,� : .- , _ r .. t �...