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HomeMy WebLinkAbout0239 STRAIGHTWAY - Health 239 Straightway Hyannis P A = 268 281 0 M Y. 1� a' d e d r s a t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 239 Straightway Hyannis, MA 02601 Property Address I .w John Durcan 14211 Helmsley Rd. Owner Owner's Nameirftrm required �y Midlothian VA 23113 5/9/2017 ;L per- Cityfro wn state zip code Date of Inspection ri Inspection rest, 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. Importaft Wien A. General Information filling out forms S'/ 3 e� on the computer, use only the tab 1. Inspector key to move your cursor-do not Paul Martin use the return Name of Inspector key. Cape Cod Septic Services Company Name 350 Main St Company Address W.Yarmouth MA 02673 Cfityfrown State Zip Code- 508-775-2825 S15016 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, :Pam ❑ Conditionally Passes ❑ Fads ❑ Needs Further Evaluation by the Local Approving Authority 511=017 Inspedors Signature Date The system inspector shalt 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 perlbm in the future under the same or different conditions of use. i5a►S 3M3 `r Title 5 Offiaat Fom:Suftiaraoe Sewage ,�Syshm 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 239 Straightway Hyannis, MA 02601 Property Address John Durcan 14211 Helmsley Rd (fir ownees Nam information is Midlothian VA 23113 5/9/2017 "eqwred fbr Y page. City/Town State Zip Code Date of Inspection B. Certification (corn.) 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: System in working condition 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 efitrration 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{eating and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•3113 Title 5 Official Inspection Fom Subsuftce Sewage Disposal system•Page 2 of 17 s Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 239 Straightway Hyannis, MA 02601 Property Address John Durcan 14211 Helmsley Rd. Owner Owner's Name inkffnation isreq Midlothian VA 23113 5/9/2017 page- for every CiAtyrrawn State Zip Code Date of Inspection 1�- B. Certification (cunt.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cunt): ❑ observation of sewage backup or break out or high static water level in the distribution box due or due to a broken settled or uneven distribution box.System will to broken or obstructed pipe(s) , 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: El 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 A 5.303(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•3M 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal SYsion-Pap 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 239 Straightway Hyannis, MA 02601 Property Address John Durcan 14211 Helmsley Rd Owner owner's Name information is Midlothian VA 23113 5/9/2017 required for every per- Cityrrown Stake zipCode 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 %day flow t5ins,3113 . Title 5 Official kispec bon Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 239 Straightway Hyannis, MA 02601 Property Address John Durcan 14211 Helmsley Rd. Owner Owners Name irdoffnation is for Midlothian VA 23113 5/9/2017 required or every Cityrrown State Zip Code Date of rrispeOon B. Certification (corn.) Yes No ❑ ® Required pumping more than 4 times in the last year HOT due to dogged 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 some a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes"or"nos 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 ❑ El the system is located in a nitrogen sensitive area(interim Wellhead Protection Area—PJVPA)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 t5ars.3f13 Title 6 Official Wispeclion 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 239 Straightway Hyannis, MA 02601 Property Address John Durcan 14211 Helmsley Rd. Owner Owner's Name ttor edorf r Midlothian VA 23113 519f2017 page- for every C�!Town State-State- Zip Cade Date of Inspection Pam- C. Checklist Check if the following have been done.You must indicate"yes"or"no7 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 ® El Was on the proper maintenance of subsurface sewage disposal systems? The sae 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 CHAR 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): 110x3- 330gpd t5ins•3/13 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 239 Straightway Hyannis, MA 02601 _ Property Address John Durcan 14211 Helmsley Rd Owner Owner's Name intmation is required for Midlothian VA 23113 5/9/2017 required for every Page- Cityrrown State Zip Code Date of Inspection D. System Information Description: 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(include laundry system inspection ❑ Yes ® No information in this report) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes 0 No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No 4/2017 Last date of occupancy: Date Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Garton per day Wd) 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: t5im-3113 Title 5 Official hWec ion Form:Sueaaface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 239 Straightway Hyannis, MA 02601 Property Address John Durcan 14211 Helmsley Rd Owner Ownees Name inf°rmat1On is Midlothian VA 23113 5/9/2017 ro4� every Page- Cityrrown state Tap Code Date of Inspection D. System Information (cost.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: No Records Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gams How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank,distribution box,soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ paw Shared system(yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Attemative 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): t5ss•3r13 Two 6 Mspecfion Fam:&bmsp a Sewage Disposal System•Page 8 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 239 Straightway Hyannis MA 02601 Property Address John Durcan 14211 Helmsley Rd. Owner Owners Name information is Midlothian VA 23113 5/9t2017 required for every PW. Citylrovm State Zip Code Date of Inspection D. System Information (corn.) Approximate age of all components,date installed(if known)and source of information: 1998 Per BOH records. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 28" Depth below grade: feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): +I V Distance from private water supply well or suction line: feet Comments(on condition of joints,venting,evidence of leakage,etc.): Line checked with sewer camera. Line found to be clean, properly pitched with no sign of root intrusion. Septic Tank(locate on site plan): 187 Depth below grade: fed Material of construction: ®concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain) If tank is metal, list age: y,M Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: i OOOCaI 4-6" Sludge depth: tays-3M3 Tfe 5 oftW 9mpeetion Fan[&buface Sewage D spy SyMn•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 239 Straightway Hyannis, MA 02601 Property Address John Durcan 14211 Helmsley Rd Owner Owner's Name information is Midlothian VA 23113 5WO17 required for emery page- �yrr� State ZipCode Date of Inspection D. System Information (cunt) Septic Tank(cont) Distance from top of sludge to bottom of outlet flee or baffle 1" Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Estimated Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 1000Gal tank in good condition. PVC tees in place and clean.Tank at normal operating level. Inlet cover T'below grade with outlet 19"below grade Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑metal ❑fiberglass ❑polyethylene ❑other(e)platn): 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 t5itis-sn3 rigs 5 Olfad kMeCW Fomc&bs,afaoe Sewage aspoW System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 239 Straightway Hyannis MA 02601 Property Address John Durcan 14211 Helmsley Rd. Owner Owner's Name 10fmation is Midlothian VA 23113 5/9/2017 required for every Cityrrown State Zip Code Date of inspection D. System Information (corn.) 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: gaum Design Flow. gakm 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 tsars.3113 Title 5 MOW ftpechw Form Subsurface Sewage DisposS9 System•Page 11 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 239 Straightway Hyannis, MA 02601 Property Address John Durcan 14211 Helmsleey Rd Owner Owner's Name fO1 reed for Midlothian VA 23113 5/92017 required or every page- City/Town State Zip Code Date of Inspedion D. System Information (corn.) 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.): H-10 DB-3 with 1 line in and 1 line out in good condition. Box is Clean and level with minimal solids carryover. No sign of overloading or hydraulic failure.Cover 29"below grade_ 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•3113 Title 5 Official frupection Forth: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 239 Straightway Hyannis, MA 02601 Property Address John Durcan 14211 Helmsley Rd Owner Owner's Name required 1 r is Midlothian VA 23113 5/9/2017 page- for every Cityrrown state T�Code Data of lwpedion Pam- D. System Information (coat.) Type: ❑ leaching pits number. ® leaching chambers number. 5-Infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number. ❑ innovativelaltemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): 5-Infiltrators with stone.Chambers found dry at time of inspection with no sign of overloading or hydraulic failure 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 Title t5irs•3113 e 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 239 Straightway Hyannis, MA 02601 Property Address John Durcan 14211 Helmsley Rd. Owner Owners Name Ifffimffion Midlothian VA 23113 5/9/2017 required for every State Zip Code Date of Ins j; page- D. System Information (corn.) 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•3113 Title 5 Official hspacbm FoffrL 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 239 Straightway Hyannis MA 02601 Property Address John Durcan 14211 Helmsley Rd Owner Owner's Name required iced fb Midlothian VA 23113 5WO17 � every State Zip Code Date of Urspectiort . Rage. Cdylrown D. System Information (corn.) Sketch Of Sewage Disposal System:Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locale 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 t5am,3113 Title 5 OFidal Inspection Forth: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 239 Straightway Hyannis, MA 02601 Property Address John Durcan 14211 Helmsley Rd Owner Owner's Name information Wfo isrequi Midlothian VA 23113 5/9/2017 PW- Cityrrovm state Zip Code Date of inspection D. System Information (corn.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells +IV Estimated depth to high ground water feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on recent If checked,date of design plan reviewed: �8 ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators,installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Test hole data per pllan on file at BOH No water at 10. Max bottom of leaching is 6 Before filing this Inspection Report,please see Report Completeness Checklist on next page. 3113 'roe 5 Official rnspection Form Subudwe Sawage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 239 Straightway Hyannis, MA 02601 Property Address John Durcan 14211 Helmsley Rd. Owner Owner's Name frdbrrnatiOt1 is Midlothian VA 23113 W912017 required for every page- Citylrown State Zip Code Data of inspection E. Report Completeness Checklist ® Inspection Summary:A, 6,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 hed in separate file G5ars-3N 3 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 17 of 17 V TOWN OF BARNSTABLE LOCATION a39 s'7'P G�.;AV SEWAGE# 9 -7!s' VUTAGE—#d - S ASSESSOR'S MAP&LOT 26 g- x 8 t INSTALLER'S NAME&PHONE NO. 1Y b c.4D a S-rO4i C 77�-0%fq SEPTIC TANK CAPACITY /tea LEACHING FACn11'Y:(type) /wi f/Lr94PO leS (size) NO.OFBEDROOMS---,L_ BUILDER OR OWNER PERMITDAT& I!-C-9B COMPLIANCE DATE:. Separation Distance Between the: Maximum Adjusted Quindwater Table and Bottom of Leaching Facility Fset Pavate water Supply wen and Leaching Fav0ity(If any wells exist on site or within 200 feet of leaching facility) Foot Edge of Wetland and Leaching Facility(If any wetly exist _ within 300 feet of leaching facility) Feet Fmished by Q a / 43�Q3� R i t COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS Z F DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED d A DEC 052002 h '�M SvgvaW TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION (n �i p Property Address: 239 STRAIGHT WAY HYANNIS, MA 02601 � 1 `� �I Owner's Name: ROHANNA Owner's Address: AL BISCEGLIA 358 COMPASS CIR HYANNIS,MA 02601 Date of Inspection: 11/19/02 COPY Name of Inspector: (please print) JOHN GRACI Company Name: SEPTIC INSPECTIONS ,nC Mailing Address: P.O. BOX 2119 TEATICKET, MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT I certify that 1 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: X Passes _ Conditionally sses _ Needs Furthe' valuation by the Local Approving Authority Fails Inspector's Signature: Date: 11/19/02 The system inspector shall su7bmityof this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this in 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 SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ****"I'his report only dcrcrihcw enndhlmis III Ille IIIIII' nt 111411lidhlll 111111 11111IF1 1111! I`11111IIII11114 III 110 Ill IIIIII (IIIII` I III4 inspection does not address how the,ryglcnl will 11cl-fol-Ill In Ill+ I1111111 I1111II°I' IIIP.N111111t III'IIIIII'I pill 1'IIIIIIIIIIIIIq III Imil: Page 2 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 239 STRAIGHT WAY HYANNIS,MA 02601 Owner: ROHANNA Date of Inspection: 11/19/02 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. 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. n/a 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: n/a n/a 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: n/a n/a 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: n/a Page 3 of I 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 239 STRAIGHT WAY HYANNIS,MA 02601 Owner: ROHANNA Date of Inspection: 11/19/02 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 systern 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 n/a "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: n/a Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 239 STRAIGHT WAY HYANNIS, MA 02601 Owner: ROHANNA Date of Inspection: 11/19/02 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for alLinspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ X Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped n/a. _ X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ X 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 forma (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to 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 now 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 X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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 "ycs" in Sec(ion D above llle Itir�e xylem hti� foiled: The m��ner or oher11lor of mnu Ire.�y.�len1 rnn�itlereri �i ,niF�ant lilreal under Section E or failed under Section D shall upgrade the syslenn in accordance wills :I III t'Ml( 15,01. Tlw n"ilrui owner should contact the appropriate regional office of the Department. Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 239 STRAIGHT WAY HYANNIS, MA 02601 Owner: ROHANNA Date of Inspection: 11/19/02 Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as pail of this inspection ? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up`? X _ Was the site inspected for signs of break out X _ Were all system components,excluding the SAS, located on site'? X _ 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 ? X _ 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 X _ Existing information. For example,a plan at the Board of Health. X _ 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)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 239 STRAIGHT WAY HYANNIS, MA 02601 Owner: ROHANNA Date of Inspection: 11/19/02 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: 4 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)):-nJa_ Sump pump(yes or no): NO Last date of occupancy: n/a ® 1 COMMERCIAL/INDUSTRIAL I Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X 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): n/a Approximate age of all components,date installed(if known)and source of information: 1985 BY rnvNElz Were sewabc odors deluded wlieti olI1vilig ill Ilit +aUt (y(,,4 ul wo. N11 Page 7 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 239 STRAIGHT WAY HYANNIS, MA 02601 Owner: ROHANNA Date of Inspection: 11/19/02 BUILDING SEWER(locate on site plan) Depth below grade: 22" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 16" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000 GALLONS" Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 32" Scum thickness: 2" 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: 16" 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.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING NOW AND THEN EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a Page 8 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 239 STRAIGHT WAY HYANNIS, MA 02601 Owner: ROHANNA Date of Inspection: 11/19/02 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE 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.): D-BOX IS STRUCTURALLY SOUND. PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 239 STRAIGHT WAY HYANNIS,MA 02601 Owner: ROHANNA Date of Inspection: 11/19/02 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type n/a leaching pits, number: 0 INFULTRATORS leaching chambers, number: 4 n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,etc.): DID NOT EXPOSE INFULTRATORS, NO INSPECTION COVER RAISED. INFULTRATORS APPEAR TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE. BOTTOM IS AT 6 FT. RECOMMEND RAISING INSPECTION PORT. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): n/a Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 239 STRAIGHT WAY HYANNIS,MA 02601 Owner: ROHANNA Date of Inspection: 11/19/02 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. Gcte IC fxv CIC A I � 4 V n AA 27 v T7 LlAA I Ab 3S ,�A 2S 2.1n0 t? IBC Z"j L Page 1 I of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 239 STRAIGHT WAY HYANNIS,MA 02601 Owner: ROHANNA Date of Inspection: 11/19/02 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 10+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER-10+FT. )�V._—r 4C � TOWN OF BARNSTABLE V LOCATION WX SEWAGE # /Y- r VILLAGE -//L/,tA/n/(57 ASSESSOR'S MAP& LOT IS l INSTALLER'S NAME&PHONE NO. �!?i1 C 7 7,P• O�o SEPTIC TANK CAPACITY =OA.&L zgpe z LEACHING FACILrff (type) tPUIORS (size) -� NO.OF BEDROOMS BUILDER OR OWNER ,... PERMIT DATE: ff^G- COMPLIANCE DATE: 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 '4o K` s. " it TOWN OF BARNSTABLE LOCATION,I F f4 SEWAGE # VILLAGE ASSESSOR'S MAP & LOT �lo b3 1 INSTALLER'S NAME&PHONE NO. XI I C je e Se?l r C 7 79- O(a SEPTIC TANK CAPACITY _.".AI= lee 0 LEACHING FACILITY: (type) ��7�/L� �dles (size) S NO.OF BEDROOMS BUILDER OR OWNER �. PERMITDATE: IJ-G -y COMPLIANCE DATE: I% l I 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 330 No. _� _K, Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0(ppYication for Oi!5pooal *p5tem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade(ZAbandon( ) ❑Complete System [Klndividual Components Location Address or Lot No. q,5_1 '(i ACd KT l,( A-3_y Owner's Name,Address and Tel.No. Assessor's Map/Parcel r�N��s V . 5 C_� Qle t-i G, /20 �_ 1 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Au 0-cA-P esc5N _x-a 15 4?4 F_-f2. +� Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow `�130 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 19R'e--', 9 T a L 6OC2 Type of S.A.S. ' f cct , L t`t4,, =vig L Description of Soil Nature of Repairs or Alterations(Answer when applicable) J , `-Z�v✓`�- � ��t Ld 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 Egyironmental Code and not to place the system in operation until a Certifi- cate of Compliance has been i��y this B f Health. Signed Date Application Approved by Date IZ- Application Disapproved for the glowingreasons Permit No. / — Date Issued No. 5 , wa Fee _ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Yes 01pplication for Migaal *p6tem CCongtruction Permit Application for a Permit to Construct( )Repair( )Upgrade(V Abandon( ) El Complete System ®.Individual Components Location Address or Lot No. ;t 1 +(`l��\T LuI44, Owner's Name,Address and Tel.No. Assessor's Map/Parcel Qce!w 2c t S G Gct ` % C�_ /2c) Installlerr'�'s Name,Address,and Tel.No. Designer's Name,Address and Tel.No. `1 �Yvt ��—(_ GSGP�\ -0 A! --T k 12 KGKa o Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow ­33 0 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank' !F— ST%n 160© Type of S.A.S. Y C.G 06<`f Description of Soil 5 m2D Nature4,11epairs or Alterations(Answer when applicable) 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 E iron mental Code and not to place the system in operation until a Certifi- cate of Compliance has been isss_ue y this Bo of..Health. Signed Date7,0 Application Approved by _Date ' Application Disapproved for the lowing reasons F � _ 1 Permit No. 7 f.5 Date Issued ; THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS tf'! Certificate of (Compliance ` THIS IS TO CERTIFY, that the On-site Sewage`Disposal System Constructed( )Repaired ( )Upgraded(,✓ ) -Abandoned( )by l ''L 15 5,-- ( ST i has been constructed inlaccordance with the;provisions of Title 5 and the for.Disposal5ystem Construction ermit No. Z- 7/ dated Installer Designer The issuance of this perm i l it shall not be construed as:a guarantee that the system w �function as designed. Date v l (n Inspector 11:�S, L �y - 7/6- Fee 15^0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migogal *pztem Con5truc 'on Permit Permission is hereby granted to Construct( )Repair( )U grade( Abandon( ) System located at 7 i A `' � 14-`4 �. � v�r✓l_i C f and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date: Approved by�_"�� t tu9197 A` 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 ENGINEERED PLANS) hereby certify that the application for disposal works I� construction permit signed by me dated /6 -' '7''1 , concerning the t property located at Gf S I 0 AARK wW A��:6 meets all of the following criteria: '' • There are no wetlands located within 100 feet of the proposed leaching facility There are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed There are no variances requested or needed. If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will=be located less than fourteen(14) feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) B)Observed Groundwater Table Elevation(according to Health Division well map) DATE: f SIGNED: i. LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER V , I k [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. i p... ' of health raider:art S �` Q t ./- L0`CATI0N SEWAGE PERMIT NO. VILLAGE INSjj�A LIER'S 94A1E A ADDRESS C914F 6 k�:-e K 0 U I l DE R OR tip ER DATE XIPERMIT ISSUED DATE COMPLIANCE ISSUED � - - - � �� �, S" �� �'.� `/� v`'l . N ��--- �n� !� �� p �1 p y • =? No Fps... U............... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH - C -- O F........f � L`L ApplirFa#iou for Diipniial Works Tonstraartinn ramit Application is hereby made for a Permit to Construct (V/) or Repair ( ) an Individual Sewage Disposal System at: ................�► .......... ...I..H y....: .s............... ..........................T--............................................................ Location-Address _ or Lot No. ....... ...•. ................................. . •.... .............. ------•--- W e /� Address �.... taller Address �r�Type of Building Size Lot..........................--Sq. feet V Dwelling—No. of Bedrooms...........-3................. _Expansion Attic ( ) 100 Garbage Grinder ( ) Other—Type T e of Building ............................ No. of ersons____.__..............._.____ Showers — yp g p ( ) Cafeteria ( ) Q' Other fixtures ............................ . el -----•---------------••---------------...-------- W Design Flow................. 5....._............__gallons per person pgr day. Total da�*1 flow--------- .® gall.-----••----------- ons. WSeptic Tank—Liquid capacity/ Qgallons Length_a_.6.".. Width.. _".. Diameter__- Depth..S_8" x Disposal Trench—No.......---.......... Width..-..---:-__-_____._ Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.........'---------- Diameter........C--______ Depth below inlet..2t ....... Total leaching area._Zff....sq. ft. Z Other Distribution box ( ✓) Dosing tank ( ) aPercolation Test Results Performed by--------�'';..�.__�11ten T!'}.<.................... Date.._/�./ .!_�........... Test Pit No. 1__________Z____minutes per inch Depth of Test Pit--------1--_----- Depth to ground water.....//............ fX Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ -------------------- ---- ------ ------------------••-------•••••.... -------------- .---- ----------------------------------- •------- -------------- O Description of Soil------------ . -------•-----••-••--------------•-------•-.... V -- : , i W ---••--------------------- ........................ `? U Nature of Repairs or Alterations—Answer when applicable-------------------------------_................................................................ ---------------------------•----------•--------•---------•-----------------------------------......--•-•--•---•....--------------•---.---------------•-------•-••••--••-••-•--•----•--•----•......---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of"T p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beel su.e-d---b--y-...h.-e board of th. Signed.....---•-�1G1 ------ •��' ---- yy�� ��JJ Date - -..Application Approved By- Z/Ya._._ //� -_1 .Z-1 11....----•---- Date Application Disapproved for the following reasons:----•--•-••-•-•--------••----•...:-•-------•--------------•--•-•-----------•---------•---• ••--••---••-----••- -------•--•-•--------------•----••-----•----.....---•---•---------•---•----------•-----------------.....---•••••---••--•-•-••---••-•-------•------•-•-•- ............................................... Date PermitNo.......................................................... Issued....................................................... Date J r c. N .�'�'.-. ........ � Fzes.. ......-' ..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....---....7 ...........OF........ ............................ : .................................w ,��t�ItT�t�ti�tt fur;�t��D��81� �rk� (�D[ti��lt.fi�tYtlt �Clertttt� Application is hereby, made for a Permit to Construct (V or Repair ( ) an Individual Sewage Disposal System at: Location_Address - or Lot No. 0.qPI _✓.�{f�'�.!�t T��: ..�'-- �57'.. y:°`��ot16!1 :.......................................... Address a -------------------- - ---- ., ............................... --•-•----•••----•---------...-----------•.....-- -•••....-----...........--------•--••..-•--•- Installer Address Type of Building Size Lot..... ..................Sq. feet Dwelling—No. of Bedrooms.............r�._..,,::.....................Expansion Attic ( ) jt/0 Garbage Grinder ( ) QI Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) A4 Other fixtures .._.. W Design Flow.................SS....................gallons per person perr day. Total da�jl fiow__._____3.-.3�(!1::) gal- WSeptic Tank—Liquid capacity/QO___gallons -.,Length_�__g...... Width._' Diameter---7 .4..._. Depth..�.�.... x Disposal Trench—No. ....•.... Width _..._--------- Total Length.....................Total leaching area....................sq. ft. Seepage Pit NO---------l---------- Diameter........ ......:.. Depth below inlet.__-3Af...._.. Total leaching area.../.4?9.... ft. Z Other Distribution box ( tl) Dosing tank ( ) '-' Percolation Test Results Performed b '` 0 _�li '? ................... Date_' Test Pit No. 1_____r_..__��­..minutes per inch Depth of Test,Pit..:. d Depth to ground water.....11___........... 44 Test Pit No. 2................minutes per inchh, Depth of Test Pit.................... Depth to ground water........................ -----------------------------........................................................ O Description of Soil............ _ ., 1a _ .................�2_'.' _t_ w P' F^ e>... "" :a'_ .Si+Aw.w. a Ifrr IP�C'rY'Cd�"`Y _....___.._...._.._..._.._...._.......-__._.___. T ......... .....•.._ ...._..•..--_ W ---•---- - ------ - -.� "�`.: --- ....'`� '� ----- UNature of Repairs or Alterations—Answer when applicable_____________________ _ __________ -------------------------•-------------------------........................................... Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'TT LE, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee suer)•-by he board oL4c 4th. 'Signed---•...... 1�------ ,,t! G�itC. --- Application Approved B yJ Date Date Application Disapproved for the following reasons------------------------------------------------------------•----------•-----------------------................. --•-••••----•---•-•••-•------•-------•--•-•-••------•••-•--...-----••-------•--•-------•------------••------•••--••••-•-••--•------•-----••••--•----------•-----•--------••-•-•-----------•••----••••--- Date PermitNo......................................................... Issued-....................................................... Date ' THE COMMONWEALTH OF MASSACHUSETTS 4�. p ,+ BOARD OF HEALTH .....................OF...... 6........................................................... T rtifiratr of Tlampt"'itt THIS IS TO CERTIFY That the Individual Sewage Disposal°S stem constructed ( ) or Repaired ( ) by.............. ".X.-------- ----------------------------------------------------------------- -------------------------------------------- p 1 i°4 Installer' at............Z7t- .....----- has been installed in accordance ith t e provis'on r. of The State Sanitary Code as described in the application for Disposal Works Construction Permit No. ..�/._ ___, ............... da.ted___.___.-_._._-___.....____-_____._._._........ "THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT TIME SYSTEM, WILL .FUNCTION SATISFACTORY. DATE....................: Y .... Inspector --------------------------------------•---•--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................. ........OF...... ....................................�. ............................. ..�' N - FEE---3 O Permission is hereby granted------...... .............. •------•---•-•••-••------••••-•••-•••-•-••......•-•••-••.............. to Construct (Lojolor Repair ( ) an Individual Sewage Disposal System atNo............1..�.._-----.I'll.-- . . ............ Street as shown on the application for Disposal Works Construction Permit,.No.................... ated.......................................... �!�a 02�0.e - 0AW DATE................................................................................ d of Health FORM 1255 HOBBS & WARREN. INC., PUBLISHERS g A f ,vst <� L,U T . 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