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HomeMy WebLinkAbout0025 WOLLEY ROAD - Health 25. Wolley Road H,annis P A = 270 159 3� �a " m e C 0 I�� o TOWN OF BARNSTABLE V U;CATION � o� � SEWAGE # VILLAGE e'(0115 ASS §SOR'S MAP & LOT y INST*b1t&R'S NAME&PHONE SEPTIC TANK CAPACITY LEACHING FACILITY: (type) ✓► (size) 41 .x a?5 NO. OF BEDROOMS BUILDER OR�� �.r\ t�`�ejn►��� PERMITDATE: C0I01MNgff DATE: G a+6 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by a S U� Page 10 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 WOLLEY RD HYANNIS, MA 02601 Owner: DEBORAH THOMAS Date of Inspection: 6/10/02 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. ,I A j ' o g :;; D AA aS k YL fA '� L F , 14 1LOT qS 04 �to� To THE nJA�I��-�� ll �r� - C��_ MORTGAGE INSPECTION PLAN AND TYS`11 ILE �N6LIRE]ts. LWATFIy IN I cBztr c TMAr THE �BII�INcs sHaWN Do ( -2 cxfNtT)RM M SETBACK IREQUIREMEN 3 �.y/�-�N 1� I.E (iRON .r SIDE R'REAR SETBACK ONLY) WHEN CoNSTRUOI>p. OR ARE EXEMPT FROM.VIOLATION ENFORCEMENT Ac ON UNDER MASS. CU. •nnE VII; CIIAPT'E�t 40A, sEOpoN 7,.UNLESS OTNERVASE NOTED. MASSACHIJSM I rURWER.CERTIFY IHAT 1Hi PROPERTY IS NOT- LOCATED INt THE ESTABU%0 FLOOD DEED HAZARD Akk OOMMUNITY PANEL NO.0 000 I-0005C DATF- Z—` 72 BOOK 318�- THIS COMPANI IS NOT RESPONSIBLE FOR ANY INDENIURES UADE SUSSFAUFNT.TO THE RECORDED DATE Of THE LATEST DEED OF RECQRD. PAGE 9 WHENEVER T3 WN(S ARE SHOW LESS THAN ONE FOOT FROM THE vm CERT. No. /- . TFiNOTFPA MORE PR.EC95C SURVEY BE MADE TO VERIFY THM M s Z2(o THIS CERTLFIGA710N IS BASED ON 1W IIoCA110H CF SURVEY M o 1 PLAN BK PAGE q REP T A PROPERTY r,,U Y. VERIFICATION OF SURVEY M vm' PLAN f MA 7BC AeGIr�AONM"PUSFiED ONLY BY A14 ACCURATE. INSTRUMENT DRIVEWAW.ARE N TED I§ c�RTIFlOA-SON TO BE USED FOR MORYGA I® as � �� I• �2 ,©s OFFSETS AS SHOWN ARE NOT No.9629 UST_'D FOR THE ESTABUSHMENT OF PRO < 5 �~ w AD c^ V n ENGINEERING I- V CO. l P.O. BOX 1244 ,LAMES W. BOUGIOUKAS R.L.S. 0955 Al�,s 373°2396 i All r OVAJim f ra P.T O T S � t sono T,�-5 of'� beep 50 no i U6C5 q�" 1. t'}Vt�Jnvret� � ro Exzavq aox i 1 f 4 ' ' COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS i- &AW k4;;;A- Bi E d DEPARTMENT OF ENVIRONMENTAL PROTECTION 2H6 JAN I Q P M 1 43 7 SVS fSJd TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 25 Wolley Road (J Hyannis MA 02601 Owner's Name: Melissa&Daniel O'Connell Owner's Address: Same T 341,35" Date of Inspection: December 28,2005 Job# 05-378 Name of Inspector: PATRICK M.O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: .r _X_ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature- Date: 12/28/05 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should.be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments: Infiltrators have no standing water, recommend pumping tank. ""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. M Title 5 Inspection Form 6/15/2000 P page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 25 Wolley Road,Hyannis Owner: Melissa&Daniel O'Connell Date of Inspection: December 28,2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _XX_ 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: Titles i Tnenartinn Rnrm Arl Vnnnn 2 Page 3 of I 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 25 Wolley Road,Hyannis Owner: Melissa&Daniel O'Connell Date of Inspection: December 28,2005 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 a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Title Iq Tnmartinn 17nrm 611 VIAnn 3 Page 4 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 25 Wolley Road,Hyannis Owner: Melissa&Daniel O'Connell Date of Inspection: December 28,2005 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: 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 ''/z 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 _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 form.] _No_(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 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. Titla i Tnenartinn Fnrm gli r%i,)nnn 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 25 Wolley Road,Hyannis Owner: Melissa&Daniel O'Connell Date of Inspection: December 28,2005 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 part 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)] Titla C Inenantinn Fnrm Frl s/)nnn 5 Page 6 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 25 Wolley Road,Hyannis Owner: Melissa&Daniel O'Connell Date of Inspection: December 28,2005 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:3 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): Seasonal use:(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Two years total: 168,000 gal.=230 gpd. 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): gp,d 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: None Source of information: Owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped:igallons--How was quantity pumped determined? Reason for pumping: 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): Approximate age of all components,date installed(if known)and source of information: Leaching system installed: 8/11/99 Were sewage odors detected when arriving at the site(yes or no): No TIt1a G lnanantinn Rnrm 411;ionnn 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: 25 Wolley Road,Hyannis Owner: Melissa&Daniel O'Connell Date of Inspection: December 28,2005 BUILDING SEWER: XX (locate on site plan) Depth below grade: V Materials of construction:_X_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: XX (locate on site plan) Depth below grade: 6" Material of construction:_X_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: 10.5' long x 5.8'wide—1500 gal. Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle: 28" Scum thickness: 6" 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: 8" How were dimensions determined: STICK WITH HINGE FLAP. 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 are intact and clear,liquid level at bottom of outlet invert Recommend numains tank GREASE TRAP: No (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.): Titles G Incn tinn vn m fll;mnnn 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: 25 Wolley Road,Hyannis Owner: Melissa&Daniel O'Connell Date of Inspection: December 28,2005 TIGHT or HOLDING TANK: No (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: XX (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: No (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.): Titla G tnvr%APt;^n Rnrm 411«,)nnn 8 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: 25 Wolley Road,Hyannis Owner: Melissa&Daniel O'Connell Date of Inspection: December 28,2005 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: _X_leaching chambers, number: Four infiltrators. 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.): Checked interior of infiltrators with pipe camera and found no standing water or evidence of surcharge.Probed stone around SAS and found stone to be clean and dry. CESSPOOLS: No (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: No (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.): Titles 4 Tnanartinn Fnrm An v)nnn 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: 25 Wolley Road,Hyannis Owner: Melissa&Daniel O'Connell Date of Inspection: December 28,2005 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. Wolley Road Water service Driveway 4 infiltrators 11 x 25 42 48 34 34 28 25 # 25 T;*1P S TncnPn}Inn Rnrm All IMAM 10 • Page I 1 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 Wolley Road,Hyannis Owner: Melissa& Daniel O'Connell Date of Inspection: December 28,2005 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 25 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) _X_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 below el.25 and topo map shows property above el.55. Titles C Inonai.tinn Rnr 4/1 ci,)nnn 1 I COMMONWEALTH OFMASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION a � tl s OW TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL SYSTEM FORM PART A RECEIVED CERTIFICATION Property Address: 25 WOLLEY RD HYANNIS, MA 02601 JUL 0 8 2002 Owner's Name: DEBORAH THOMAS Owner's Address: 25 WOLLEV RD'HYANNIS,MA 02601 TOWN OF BARNSTABLE HEALTH DEPT. Date of Inspection: 6/10/02 - t. Name of Inspector: (please print) '- JOHN.GRACI NIAP Company Name: t'" SEPTIC INSPECTIONS PARCEI. • Mailing Address: P.d.BOX 2119 TEATICKET, MA.02536 LOT L II Telephone Number: 508-564-6846" X 508'=564-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and,maintenance of on site sewage disposal-systems. I am a DEP approved system inspector pursuant to Section 15.346?'Title'5(310 CMR 15.000); The system: X Passes _ Conditionally 'asses _ Needs Fur -Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 6/10/02 The system inspector shall submir a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspe ion. 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 approvi:,a authority. Notes and Comments SYSTEM PASSED TITLE V INSPECTION.,RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ""This report only dcscribes;co'it'ditions at the time of inspection and under the conditions of use al that lime.'Phis inspection does not address hpw;`ke-,system will perform in the future under the same or different conditions of use. Titfr 5 fncnrrtinn Fnrm (./15/�Mfl Page 2 of OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A .CERTIFICATION (continued) � Sf. .t Property Address: 25 WOLLEY RD HYANNIS,MA 02601 Owner: DEBORAH THOMAS Date of Inspection: 6/10/62 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ; X 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 PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. B. System Conditionally Passes:` _ One or more system components.' 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 overn20 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-hvailable. ND explain: n/a n/a Observation of sewage balckup'or'b'reak odt 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 _ obstructi`on is'removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping'iA6r�',thai 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the 13b'ard'of Health): _broken,pi,pe(s)are replaced _obstruction is removed ND explain: n/a kill. 3' Page 3 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 25 WOLLEY RD HYANNIS,MA 02601 Owner: DEBORAH THOMAS Date of Inspection: 6/10/02 " C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require Tfurther 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 o`'Health (and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic'tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. _ The system has a septic!Nrik 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`tc'deterii'ine distance n/a i "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: a n/a � F A Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM F t, PART A CERTIFICATION`(continued) Property Address: 25 WOLLEY RD HYANNIS, MA 02601 Owner: DEBORAH THOMAS Date of Inspection: 6/10/02 D. System Failure Criteria applicable to'all systems: You must indicate"yes"or"no"to each of the following for all-inspections: 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 ''/z 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&. X Any portion of the SAS,cesspool or privy is below high ground water elevation. _ X Any portion of cesspo611, ,privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cessp�o�,,or,privy a within a Zone 1 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 cbliform bacteria and volatile organic compounds indicates that the well is free from pollution from tilihi 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.I >> (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 systen(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 sysiem 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 X the system is within 400 feet of a surface drinking water supply X the system is within 206'feet of a'tribu`•tary to a surface drinking water supply X the system is located in a nit'r'ogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water'su'pply well If you have answered,','yes",t'o.'any question in Section E the system is considered a significant threat,or answered "ves" in Section D ahmve the large syste has failed, The owner of operator of any lame system considered a significant threat under Section E or failed under Section 1)shall upgrade the system in accordance with 310 CMIZ 15.304. The system owner should contact the appropriate regional office of the Department. q d Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM t PART B CHECKLIST i Property Address: 25 WOLLEY RD'HYANNIS,MA 02601 Owner: DEBORAH THOMAS Date of Inspection: 6/10/02 Check if the following have been on You must indicate "yes"or"no" as to each of the following: Yes No X _ Pumping information'w6s provided by the owner,occupant,or Board of Health X Were any of the system coiilponents 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 waterbeen introduced to the system recently or as part 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 manholesl 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'Absor`ption System (SAS)on the site has been determined based on: Yes no , X _ Existing information. For exaiz.mple,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)] {i,, t S!i Page 6 of I I L OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 25 WOLLEY'R'DI*HYANNIS,MA 02601 Owner: DEBORAH THOMAS Date of Inspection: 6/10/02 +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: 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)):4Ww w 21 DU(] Sump pump(yes or no): NO v i- S 4I060 Last date of occupancy: n/a 9 COMMERCIAL/INDUSTRIAL, Type of establishment: n/a , Design flow(based on 310 CMR 15.203): n/a'gpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or!io): 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 H, i 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 bok;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: NEW SEPTIC 1999 PERMIT 1199-19.5 Were sewage odors detected when arriving at the site(yes or no): NO +Fiit , 5t Page 7 of 1 I OFFICIAL INSPECTION{FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 WOLLEY RD HYANNIS,MA 02601 Owner: DEBORAH THOMAS Date of Inspection: 6/10/02 f BUILDING SEWER(locate oq.site plan). L. Depth below grade: 14" 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: 8" ' Material of construction: Xconcrete:=metal_fiberglass_polyethylene other(explain)./a If tank is metal list age: n/a Is age Co ed.by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 150OG L 10' 6" H 5' 6" W 5' 8"" Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 33" Scum thickness: 1" v. 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: 17" How were dimensions dete'rinined: 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 EVERY'TWO�YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP:_(locate on site plan)- .. Depth below grade: n/a r _ Material of construction: concrete dnetal_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 recommendalfsons, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a :i 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: 25 WOLLEY`RD,HYANNIS, MA 02601 Owner: DEBORAH THOMAS Date of Inspection: 6/10/02 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',SO 1 6 D. PUMP CHAMBER:-(locate on site"plan) Pumps in working order(yes or no)''IVO Alarms in working order(yes or no):NO' Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a t v R Page 9 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM IN` PECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 WOLLEY RD HYANNIS, MA 02601 Owner: DEBORAH THOMAS Date of Inspection: 6/10/02 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: n/a 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 INFULATRATORS;APPEAR TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. SYSTEM SHOWS NO SIGNS OF FAILURE.BOTTOM IS AT 4'. 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 ti r �� Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 'SYSTEM INFORMATION(continued) Property Address: 25 WOLLEY:RD HYANNIS,MA 02601 Owner: DEBORAH THOMAS Date of Inspection: 6/10/02 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. 1A � A � R 5 D C AA 35�� 31 qj YL fA L S ( I i w , in Page I I of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM t PART C SYSTEM INFORMATION(continued) Property Address: 25 WOLLEY RD HYANNIS, MA 02601 Owner: DEBORAH THOMAS Date of Inspection: 6/10/02 SITE EXAM _Slope _Surface water ` _Check cellar Shallow wells Estimated depth to ground water 12+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 exca`vatdr',installers-(attach documentation) NO Accessed USGS database=explain;n/a Y S i a You must describe how you established the high ground water elevation: HAND AUGER- 12+ FT. i i't •e s, .•_ 5? ^:Y"'"""' - .a.--,..-�:. �,..x.. '°'" 'Lx '�"y�Y•m'tT—^ ..,'ra @*`+;.'� c.ro- .,.�+....x:.�y",�y,,� r""svoz`T""r"�` `}4'71f�""'�—}--. .,c.-- .,�- ev -- TOWN OF BARNSTABLE BAR—W 0 I Ordinance or Regulation WARNING NOTICE _ -- -- Name of Offender/Manager � � Address of Offender_ ,_ e 1 MV/MB Reg.# - Village/State/Ziph VA AJIN 17/ } , �_ . f {a� , Business Name Business Address ;; ifr "Il!' '�' Signature ofE 'forcing Officer Village/State/Zip 1 ®r Location of Offense a i/iz) /' : C»;�) ` -) - PV`.,fV11 �\^[ �'"�oarMioal"C— - { Enforcing Dept"/1?ivision Offe rise. i '1l - c-L�� Facts `" .N V {f' rM� t �. �f jf` � 1Rtlf1 � UP, AV !�-//AM' This will serve only as a warning. At this Mime no legal action has! beiin taken. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in ' appropriate legal action by the Town. W , ' WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT. ,;._.�_..�.,...pe.�TFi.�ra-..��:.,tis;_�+'m•--.,..'—s in-"!.i' -S�:2c .. � ('r_.a' -'�F R'•;- „_` . y�.'N"�'rF 4h T"�:h,l+=' � }7.'�A.� �Yf S k .M1; �-:.:� .. .- TOWN OF BARNSTABLE BAR Ordinance or Regulation WARNING NOTICE Name of Offender/Manager#' (,� � Address of Offender � t n, ' MV/MB Reg.# Village/State/Zip # / ? t r ' `> at + '}i ...„ 2<Y -7/ Business Name wam/pmls` no . f 4 Business Address Signature of Enforcing Officer Village/State/Zip ( L# ¢f r.rT Lo tion of Offense, a , Enforcing Dept}/DiSision Offense. Facts • ` �. d ,. �k . !` ri . fF This will serve only as a warning. At this time no legal action has/ bedh taken. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. "Mjt WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT. TOWN OF BARNSTABLE %O�.ATION SEWAGE # Vli.LAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY i-f-m nc=ti LEACHING FACILITY: (type) A V M ffif w (size) NO.OF BEDROOMS c BUILDER OR OWNER �� �� IYIQ l PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) " Feet Fumished by �u z5q -115 S r LIE0 TOWN OF BARNSTABLE LOCr ZrION -AX 641014 L y A SEWAGE # VILLAGE /-kUez4�i c ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. ,C A a e_- �l SEPTIC TANK CAPACITY /tea eJ LEACHING FACILITY: (ty (size) NO.OF BEDROOMS BUILDER OR O R PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by a �. ,� �; N . �� � � w �;, �i, � -�..- - ..�,�-, ;�:. �f .; ,� . �,� ,,. � ;; ;, � >� � ,Y I • `M ' ,� � ;� ' i .1 *` '�. TOWN OF BARNSTABLE LOCATION o w 1 r.� SEWAGE # VILLAGE ASSESSOR'S MAP & LOT12 INSTALLER'S NAME&PHONE NO. 471 c.4142 Sg,�! SEPTIC TANK CAPACITY /,o Q LEACHING FACILITY: (ty ) 1 ti 7/•7AM t S (size) t/ NO. OF BEDROOMS BUILDER.OR O R d1i Y"I PERMITDATE: COMPLIANCE DATE: r r Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by rrV 57 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 0[ppYicatiou for Diopogal 6pgtem Congtructiou Permit Application for a Permit to Construct( )Repair( )Upgrade(V"Abandon( ) )6Qomplete System El Individual Components Location Address or Lot No. wner's Name,Address and Tel.No. Assessor's Map/Parcel --:�?r-70 r Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 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 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank l <,_D3'D dZ- Type of S.A.S. Description of Soil�S Nature of Repairs or Alterations(Answer when applicable) b`�1�1 S� �`�� ex) �e Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has issue y Signed \� Date Application Approved by o Date00, Application Disapproved for the following reasons Permit No. Date Issued .......... s �: Fee THE COMMONWE'iOF MASSACHUSETTS Entered in computer: Yes E - PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 0(ppricatton for ;Di.5poi41­*pgtem Construction Vermtt Application for a Permit to Construct( )Repair( )Upgrade(V/ Abandon( ) ` omplete System ❑Individual Components Location Address or Lot No.,73S(K--XD c Owner's Name,Address and Tel.No. ( + E Assessor's Map/Parcel G 0 (1-. Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. S <c�•� S 4 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 gallons per day. Calculated daily flow � gallons. Plan Date Number of sheets Revision Date ` Title Size of Septic Tank l �c27 `_j VA Type of S.A.S. a Description of Soil T, � SV0 a " Nature of Repairs or Alterations(Answer when applicable) !: VA S nD cJ.� v- eG Date last inspected: r ' Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has een issue y 7� Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded Abandoned( )by it -, D—e_e,A 0 C 5-(-e!-1 c at t C hias)b n constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Designer _ / The issuance of this permit hall of"be construed as a guarantee that the ystem will function a4 designeAT�r �� Date Inspector ' / ,/ i' "( fi'i� No. �-7/� --------- Fee st) �—' THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Owt000al *pgtem Construction Verna Permission is hereby granted to Construct( )Repai ( )U rade Abandon( ) System located at : t l� -i 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: �d // Approved by,,W, ./J Al' 1/6/99 NOTICE: This Form Is To Be.Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, b� hereby certify that the application for disposal works construction permit signed by me dated "/o"ci� concerning the property located at vZ� Quo ( meets all of the following criteria: v The failed system is connected to a residential dwelling only. There are no commercial or business �us�es associated with the dwelling. L-- The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within 100 feet of the proposed septic system There are no private wells within 150 feet of the proposed septic system Cs,- There is no increase in flow and/or change in use proposed here are no variances requested or needed. l ne bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] �/• If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W. Elevation C �+the MAX.High G.W. Adjustment�, _ DIFFERENCE BETWEEN A and B SIGNED DATE: �v�S [Sketch proposed plan of system on back]. q:health folder.cert �a 1 Ma �I i i