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HomeMy WebLinkAbout0097 STRAIGHTWAY - Health 97 Straightway Hyannis P A = 268 212 r i TOWN OFBARNSTABLE :*C:ATION - `� ST��� �` t/A SEWAGE # VILLQ AGE 1 S ASSESSOR'S MAP & LOT a�,--L- I' MW INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY C LEACHING FACILITY: (type) Pl-r (size) OL S dnZ NO. OF BEDROOMS 3 BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum AdjustedGroundwatert B ttom Le chin Facilit Feet s Table o the o of Leaching g Y 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�n snc,c, M � W I c. f rc'c' 0 � W OD 1C L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 97 Straightway — Property Address Curtis Pierson Owner Owner's Name information is Hyannis MA 02601 Jul 29, 2010 required for y y every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer,use 1. Inspector: (� only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name _I — 189 Cammett Road Company Address Marstons Mllls MA 02648 _ reran City/Town State Zip Code 508.428.1779 SI 12855 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority i r T" July 29, 2010 Job# 10-192 _ C,) I ector's Signature Date i !-- $ E 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 m rn has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the f report to the appropriate regional office of the DEP. The original should be sent to the system owner o c-o and copies sent to the buyer, if applicable, and the approving authority. oc.:.:3***This report only describes conditions at the time of inspection and under the conditions of use I ~ 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Dis sal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments yt 97 Straightway Property Address Curtis Pierson _ Owner Owner's Name information is required for y H annis MA 02601 July ,29 2010 - every page. City/rown State Zip Code Date of Inspection B.'Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Tank is not in need of pumping at this time. Leaching pit had 8-9"of effective leaching. 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-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '( 97 Straightway Property Address Curtis Pierson Owner Owner's Name information is Hyannis MA 02601 Jul 29 2010 required for Y Y every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of,Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 97 Straightway Property Address Curtis Pierson Owner Owner's Name information is Hyannis MA 02601 Jul required for Y Y 29, 2010 every page. Cityrrown 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 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_day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 97 Straightway Property Address Curtis Pierson Owner Owner's Name information is Hyannis MA 02601 Jul 29, 2010 required for y Y every page. Cityrrown 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 11 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5, Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 97 Straightway Property Address Curtis Pierson Owner Owner's Name information is Hyannis MA 02601 Jul required for y y 29 2010 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)) D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 — DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 97 Straightway Property Address Curtis Pierson Owner Owner's Name information is required for Hyannis MA 02601 July 29, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 — Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): — Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Currently Occupied. 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: — t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 97 Straightway Property Address Curtis Pierson Owner Owner's Name information is Jul Hyannis MA 02601 29 2010 required for y y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Unknown 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): l5ins-OgMS Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 97 Straightway Property Address Curtis Pierson Owner Owner's Name information is Jul Hyannis MA 02601 required for y _ y 29, 2010 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Unknown Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 1' Depth below grade: feet Material of construction: ®cast iron ❑40 PVC ❑ other(explain): — Distance from private water supply well or suction line: feet — Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 6"feet Material of construction: ®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.5'long x 5.2'wide- 1000 gal. _ 2" Sludge depth: — t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 97 Straightway Property Address Curtis Pierson Owner Owner's Name information is required for Hyannis MA 02601 July 29, 2010 every 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 28" Scum thickness Trace Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is not in need of pumping at this time, liquid level was found at bottom of outlet invert and baffles were intact and clear. 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 — l5ins•09/08 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 97 Straightway Property Address Curtis Pierson Owner Owner's Name information is H annis MA 02601 required for Jul 2010 Y y 29, every page. Cityfrown 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 l5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 97 Straightway Property Address Curtis Pierson Owner Owner's Name information is Hyannis MA 02601 Jul required for y y 29, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No solids or high stains present. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: l5ins•09108 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 kj i 97 Straightway Property Address Curtis Pierson Owner Owner's Name information is required for Hyannis MA 02601 July 29, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: One 6x6 pit. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: — Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching pit had stain lines indicating 8-9"of effective leaching. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration — Depth—top of liquid to inlet invert — Depth of solids layer — Depth of scum layer — Dimensions of cesspool — Materials of construction — Indication of groundwater inflow ❑ Yes ❑ No l5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 97 Straightway Property Address Curtis Pierson Owner Owner's Name information is Jul Hyannis MA 02601 required for y y 29, 2010 every page. Cityfrown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments "( 97 Straightway Property Address Curtis Pierson Owner Owner's Name informationiredfor is Hyannis MA 02601 Jul 29,2010 required for Y Y every 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 ............ . . ._.. Straightway Water Service r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r ry r r r r r r r r r r r r r r rrrr r r r r r rrr r r r r r rrrr r r r r r rrrrrr r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r rrrr r r 25 24 25 f Commonwealth of Massachusetts d Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 97 Straightway Property Address Curtis Pierson Owner Owner's Name information is required for Hyannis MA 02601 July 29, 2010 every page. Citylrown 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: 20+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water at el. 15 and topo map shows property at el.40. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09= Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �( 97 Straightway Property Address Curtis Pierson Owner Owner's Name information is required for Hyannis MA 02601 July 29, 2010 every page. City/rown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1✓of 17 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLU T RY FORM ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL PART A DEED CERTIFICATION Property Address: 97 Straight Way annis MA 02601 Owner's Name: R St. Germain Owner's Address: Q / Date of Inspection: October 29 2002 V V� Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Map: 268 Mailing Address: P.O. Box 49 Parcel: 212 Osterville MA 02655-0049 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage f the inspection.disposal system aThe inspection was performed basted on my reported below is true,accurate and complete as of the time o training and experience in the proper function and mainten 340 of Title 5(310 CMR 15.000). The system:ance of on site sewage disposal I am a DEP approved system inspector pursuant to Section 15 Passes Conditionally Passes Authority Needs her Evaluation by the Local Approving " Fails Date: October 30 2002 Inspector's Signature: The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or em or has a DEP)within 30 days of completing this inspection.owner shall submit the report to thetapp appropriate region floffice oow of f the gpd or greater,the inspector and the system own approving DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the app g authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 97 Straight Way Hyannis, MA Owner: Ray St. Germain Date of Inspection: October 29, 2002 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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 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. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. 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 ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 I Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 97 Straight Way Hyannis, MA Owner: Ray St. Germain Date of Inspection: October 29, 2002 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 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 aseptic 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: . 3 Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 97 Straight Way Hyannis, MA Owner: Ray St. Germain Date of Inspection: October 29, 2002 D. System Failure Criteria applicable to all systems: You must indicate either`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 '/z 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. ✓ 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 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.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CN1R 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 System: 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 97 Straight Way Hyannis, MA Owner: Ray St. Germain Date of Inspection: October 29, 2002 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ _ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection ? Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ _ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS,located on site? ✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ _ 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(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 97 Straight Way Hyannis, MA Owner: Ray St. Germain Date of Inspection: October 29, 2002 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 2 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): and 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: None on file-per treatment plant Was system pumped as part of the inspection(yes or no): No If yes, volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: The owner was going to have the system pumped after the inspection 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Unknown Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 97 Straight Way Hyannis, MA Owner: Ray St. Germain Date of Inspection: October 29, 2002 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: Approx. 16" 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) Dimensions: 1000 gal. Sludge depth: 5" Distance from top of sludge to bottom of outlet tee or baffle: 27" Scum thickness: 12" Distance from top of scum to top of outlet tee or baffle: 9" Distance from bottom of scum to bottom of outlet tee or baffle: 3" How were dimensions determined: Measuring 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.): Tees were present The liquid level was even with the outlet invert. There were no signs of leakage. Recommend pumping every three years. GREASE TRAP: None (locate on 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.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 97 Straight Way Hyannis, MA Owner: Ray St. Germain Date of Inspection: October 29, 2002 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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.): The D-box was level and clean. There were no signs of leakage. PUMP CHAMBER: None (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.): 8 • Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 97 Straight Way Hyannis, MA Owner: Ray St. Germain Date of Inspection: October 29, 2002 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 6'x 6'W 2'stone-per as built leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): The pit had approximately Y of water on the bottom. The scum line was approximately 3'6"up from the bottom. There were no signs offailure. The bottom to grade was approximately 86". CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 • Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 97 Straikht Way Hyannis, M4 _ Owner: Ray St. Germain Date of Inspection: October 29, 2002 Map:268 Parcel:212 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. I O � 3 Y 1 A/ a 3 10 Page 11 of 11 ♦r OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 97 Straight Way Hyannis, MA Owner: Ray St. Germain Date of Inspection: October 29, 2002 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water - 20',+f- 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: Topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: The bottom of the leach pit to grade was approximately 8'6" Using the Barnstable topographic map and the Cape Cod Commission water contours map the maps were showing approximately 20'+/-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,written or implied, relating to the system, the inspection and/or this report. 11 q y� TOWN OF BARNSTABLE f� LOCATION l 7 57N,/&- 77; SEWAGE # vl VILLAGE � /�f7 _ ASSESSOR'S MAP & LOT r INSTALLER'S NAME & PHONE NO. ILIA � � -7 SEPTIC TANK CAPACITY 6 ► � LEACHING FACILITY:(type) PCL (sue) (9 NO. OF BEDROOMS PRIVATE WELL-O'R UBLIC ATER BUILDER OR OWNER DATE PERMIT ISSUED:, *w DATE C01IPLIANCE ISS°JED: - r VARIANCE GRANTED: Yes uJ �e / V 0 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ear c TOWN OF BARNSTABLE Department Appliration for UWposal Works Tonstrfir in Date- - Application is hereby made for a Permit to Construct ( ) or Repair ()() an Individual Sewage Disposal System at: ���(��� '-7-------------------•--------....................� .1�..................---- --... � 9 ' ...................... Location/�A dressss or Lot No. .... —.._.. .._......_.+G[..;*dress ............................. ................................ ----•-----------------.. ...... ... /Qwne �� J Address Installer Address dType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) '_4PL4 Other—T e of Building No. of persons................----------- Showers — Cafeteria Q'' Other fixtures -•----------------•----•......-- . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area...-----------------sq. ft. Seepage Pit No-_-------------_-- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit-_______••-_-______ Depth to ground water........................ (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-----------------...... . a ........................................-.................................................................................................................... 0 Description of Soil..............................-.................................................--------------------------------------------------------------------------------------•- x V ----------------------- --------------------- ------------------- ---•----------------------------------------------------------------------------- --------•----------------------------------------------- W --••-------------------------------------------- -----•-•-•--------------------•-•-•-...--•-----•••---•-----------•-••--•-•----------------------------- -f -- -------------• ---- x _ -�i U Nature of Re arse r Alterations—Answer when applicable �!__�_�-_______________________________�._...._____._..___.__. ••-• •--------t1�2.---...---� `�� ------------------------•--------------------•--•------------------------•••------•-•-•••••... Agreement. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in.accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued V the board of Health. igned ---------- � -�-------------------- -Q----------------L- G...................... ......1- - Dte ---- ------------------_ ----------_----- APPllcation Approved By ---------- . 7...... . D to Application Disapproved for the following reasons- ----------------- ----- --------------- ---- .------.......---------......... --- --....----- --------_---------------------------- Permit No. Y 2�_ /-�1... �r . Issued ----- � - �'`� Date Q � THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratilan for Disposal Works Tonstrnrtiun� Trani# Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at: � r ��� Location Add or Lot No. ..... '....................... ............................... Owner W ti1G �� Address a �. �t/ --........... ........ ...... Installer Address UType of Building- — Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) a Other—Type of Building a gyp g ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures --------------------------------------•--------------.....----------------------------------------•---•---------------------•-•-•-.......... W Design Flow............................................gallons per person per day. Total daily flow....................................____....gallons. WSeptic Tank—Liquid capacity.............gallons Length................ Width................ Diameter................ Depth....- ........ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area.....................sq. ft. Seepage Pit No..................... Diameter...-----............ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) , Percolation Test Results Performed bY.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f3;., Test Pit No. 2........:......;minutes per inch Depth of Test Pit.................... Depth to ground water...---.................. 04 ••••••••--•---•--...•-•••••--------•-----••-•-•--•••••••••-•--•--••-•••-••---•--•-----•-•••--•----•.......................................................... 0 Description of Soil...............................................................................----------------------------•-------•---•---'-----------------------------••---•-•--•--- x W ---•--••-------------------------------------:..•-•--•-•--•-•-••-•••-•------------••......---•---•----•-•-••-•-----•---•....--••••• --------------- ' U ,Nature of Repairs or Alterations—Answer when applicable--.......,� _. _ -........................................................ t --------------------------------------------••-•------•---•---•---.--------------------------------•--••------•-------------------------------•----------..•... Agreement:` The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. _ igned .... ........................... 9 ---------------------*--- ..------------------------------------ Da[e Application Approved BY -­~�.... ------------------- ---------------------------------------- Date Application Disapproved for the following reasons- -------------------s---..........----------.....---...-------'-��.. ------......------------------............................. ----------.................................. - --------------- -------- -------------------------------- -------------------------------- ----- ----------.......................................-- --- --------- ----------- Permit No. .. T �� .. `'--- .--..��... ........... Issued ........... " Dace r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .TOWN OF BARNSTABLE -� CEertifirate of'Graylianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( x ) by - K. ...:................. M1.r2. ..0 a.!;`�.................-------- . ...........------...........----------------------------------------------------- . cl Installer has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in ' the application for Disposal Works Construction Permit No. .4-c"----1�7. ... dated ...� �-..THE ISSUANCE OF THIS CERTIFICATE SHALL NOT IfE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE. -.-- .A 99-----------------.-.._--------------...... Inspector ...... � \ ? C yI -, THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �7 TOWN OF BARNSTABLE f� 2 V Disposal Works Tonstrudion Prrutit Permission is hereby granted............l .............. •G?7d?`J..........- .................... to Construct ( ) or Repair ( ,k)_an Individual Sewage Disposal System at No. ./...............e,_)7 4 // -j�G7- /'N .....--•• ..... ;•••- Street � r+ / as shown on the application for Disposal Works Construction Permit Nooq =.�. Dated..... �� ..1..'"__; ... .. DATE................................................................................ --•--...---••-•-----•.......................... Board of Health FORM 36508 HOBBS IN WARREN.INC..PUBLISHERS L O C A T ION Y C/l SEWAGE PERMIT NO. VILLAGE 4 ) Z4 7--- \3 C4 DJ A q IN TA LLER'S NAME i DDFIESS , BUILDER OR OWNER DATE PERMIT ISSUED 7 .7? :2 DATE COMPLIANCE ISSUED %_ �_ 7� ti � � �' _� _ c ., _ . : J TOWN OF BARNSTABLE LOCATION S`�r ��h�Wcw/ SEWA-6F# VILLAGE av1N 1SASSESSOR'S MAP&PARCEL 'S NAME&PHONE NO. iLlc32on t,eI/ L �-Irll�q SEPTIC TANK CAPACITY /a®O LEACHING FACILITY.(type) (size) I000 NO.OF BEDROOMS OWNER PERMIT DATE: ATE T,5e -7 110 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 ist within 300 feet of leaching facility) Feet FURNISHED BY 4.4 t 4 4 4 t 4 4 t t 4 4 4 4 \ t t 4 ♦ 4 t \ Y t t 4 Y \ t ♦ Y 4 Y \ 4 t 4 Y Y Y t Y Y 4 ♦ t ♦ t ♦ 4 ♦ t \ 1 ♦ t t t k Y 4 t t 4 t 4 k Y t t 4 \ 4 t 4 t 4 4 4 t t 4 4 \ Y Y t t t ♦ t t ♦ \ t \ t 4 Y t Y Y 4 4 t k 4 t \ 4 Y 4 t t ♦ 4 ♦ 4 4 4 t t 4 t \ 4 t 4 t t 4 t t Y Y Y 4 4 t Y Y Y Y t t t t 4 \ Y Y 4 Y t ♦ 1 4 Y \ 4 4 \ 4 t t 4 Y 1 \ t 4 \ \ ♦ t 1 1 \ J f J f J F J f f f f J f J f f f F J J f F f t t \ t 4 t t t t Y Y Y 4 k 4 4 4 Y Y 4 4 4 t 4 t ♦ 4 t 4 ♦ Y t t ♦ Y Y Y Y Y Y ♦ t k Y Y Y dw 25 25 24 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH 4J............OF...... 4A.R N s 2.. B.LLr Appliratiou for Disposal Works Tomundiuit tternfit Application is hereby made for a Permit to Construct (L-1 or Repair ( ) an Individual Sewage Disposal System at: ..S7-K L.rr..H-..7X A-Y... -.tyYA.Al A,,./I........ --•---•.Cd r.......d..3............................................................. Locati Address � .......................... t Nor/ '-------------------- --- -------..... �5/0 -- .... ._.c®....t e/ ...................... Owpner p ,e_�ddress a .......... ! + 1�=�-�s�Cs................................. .................... ..� Installer Address UType of Building Size Lot.142.66_i� ......Sq. feet ,. Dwelling—No. of Bedrooms....................................:.......Expansion Attic ( ) Garbage Grinder (N(1 aOther—Type of Building ..........................!t. No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ................................... W Design Flow.......... ......................gallons per I n per day. Total daily flow.........- .3 42....................gallons WSeptic Tank—Liquid capacityl®aO $-_.gallons Length .4:`''.. Diameter................ Depth..I..W..tJ x Disposal Trench—No..................... Width.....;;............... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........./_ -Diameter....(_.......... Depth below inlet...6.....______. Total leaching areaj.�_---sq. ft. Z Other Distribution box (�' ) Dosing tank ( ) 0 A- �'O"7^ ' Percolation Test Results Performed byRt_N (_b...A=.0.-l.,5051JE&D....&.5,.-- Date_.��`B_.....;>y.�.���.. Test Pit-No. L.Z.L- _minutes per inch Depth of Test Pit...!' .__.__... Depth to ground water._N A ,67.... 0s4 Test Pit No. 2................minutes per inch Depth of Test Pit.............•...... Depth to ground water......._................ ----------------------------------------------•---------•------------------•---------•--.--•--------- --------.--. ----------....... ---•-............ O Description of Soil.......�._p.1.A..`�.1.G?.�'o'd./�./uD-------541 L�Sp�h�------'•--'....................................................... W 5 U Nature of Repairs or Alterations—Answer when applicable............................................................................................... --------------•------•--------------------•----------------------•-------------'--------••---------------------------------------------•--•---------•--------•--------------------------•--•-••--.-•--- Y Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITH.;,;. 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. - , Signed -,. - - �. _.._... ..._ Date Application Approved By........ r.- " �< ------- Date Application Disapproved for the following reasons:....................................----•'•--------•--...-•--••'--'•-'----•--•............. ..............- ,_ .............:...........:.......•-•----..._.._..-•--•-------••-•---------•-----•-------` --•`-----------------------------•-------------•----•--•------------------ Date Permit No.......................................... ( Issued_..... Date No._-•-•--•-�'�-........... Fes$.... ................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......'....6 ,a3 -....-......OF...... Appliration for Uiipouaal urkg Tonutrnr#ion rruat . Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: !-!�Q A)A�'----•--_- ........"..t'�_-_ :.......AI ............................................................ Locatio ddress � ...... !! ..6:.� ! .....�lV.' ........................ l..` �.p✓... .�`..a/.�or ��L!N•:L!� i� -.....----- W Owner Address "��:�. .................................................... Installer Address UType of Building Size Lot.Z©.A_! ,e.....Sq. feet Dwelling—No. of Bedrooms..........................................:.Expansion Attic ( ) Garbage Grinder (PVO a`4 Other—Type- of Building No. of ersons____________________________ Showers YP g ---------------------------• P ( ) — Cafeteria ( ) Other fixtures -----•--------------------------•-•- --•----------- Design Flow___.. .....................gallons per pe9p day. Total daily flow____.__ _ ._.._ ___.._._.__ llonsW WSeptic Tank—Liquid capacity.04W.gallons Length6 .� 1�.. Width.' _."ty_'". Diameter________________ Depth___ __y '._70 x Disposal Trench—No. ................... Width.............`::_.... Total Length.._. Total leaching area....................Sq. ft. Seepage Pit No.______..../_...... Diameter .. ...__..... Depth below inlet____ .......... Total leaching area s.0.0...sq. ft. Z Other Distribution box (; ) Dosing tank ( ) a A. joeow' aPercolation Test Results Performed byRoAaAsA>...4.__6-16e"0A.—D.....&J... Date__ ..... Test Pit No. L.e.4—. ._minutes per inch Depth of Test Pit___Z2.......... Depth to ground water.:&4i_!L;!e,__. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ .........................................................--- ......................................-•. O Description of Soil....... "_l' _..'.'.t' e!''1 +�3�.(U. .._... 'G!_ ?-'-&:''...............................•---•----•-•--.....-------- ------------ -•-----•-----------------------•--••••••--•••---------.._...--••--•---------•--•••-•--...----••......••...:----------------•-------•---•-----•-------••---••------•--------------••------------- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... 4 1 ........................................' '_____._._________.____________.__.....__..............................__ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with T 11 �. the provisions of TITLE:LE 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. _ Signed Date A lication Approved B �•• ' •_•----____- PP PP Ylr' � *..: .... ' 4 Date Apphcation.Disapproved for the following reasons:-------•-----------------•----•----......-------------------••----••-•-......--•---•----•• ---------•---- ................•-•------•-••--------•-----------•------------.............------------...----------•--••----•---•••........--••---• ••---••-•--------•......--••••--••••••••.....---•••-----........ Date Permit No. = Issued ......-- -----------•-----•-•---••-----. Date I THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH :'" . .."............OF....... ?/ .! .: a. "........................... Trdifira tt of Tompliaaurr" THIS IS TO C TIFY, Tha the Individual Sewage Disposal System constructed ( �or Repaired ( ) by !!1-1.. _..._ �. 1 = Installer at....... ''' ......Z ................. -----'� '''f •'' ,d ' ................................................. has been installed in accordance with the provisions of TF., j of 7(he State Sanitary C e as described in the application for Disposal Works Construction Permit N �� .........: ......... dated..... -- - _�.................... o• THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. J DATE................................................................................ Inspector..,.---------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1. ?..f 7...4)..........OF..........��,,0.90 ..A) . r.Z? lr................ v'J No.........��..�..._....._ �. .. FEE........................ a Dispouaal orku Tons a xtion rrmit Permission is hereby granted......... = x to.Construct ( 0')or Repair ( ) an Individual Sewage Disposal System at No• '�e? .......?r` ............ ..............*—.?/ N AV/, ............................................ Street as shown on the application for Disposal Works Construction P- it No t.. _. Dated.._'�^�_� .......... A. Via. ------------- DATE......................... ----•.............•----............................... Q Board of Health FORM 1255 HOBBS & WARREN, INC., PUBLISHERS LOT 1t� I m i N DrSt L. /� H . F`E L3. 7, /C 70 �a 3c�X r UeT F? 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