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HomeMy WebLinkAbout0082 FURLONG WAY - Health 82 Furlong Way Cotuit -- A =022 — 087 — — — — a McKean, Thomas From: McKean, Thomas Sent: Friday, September 09, 2011 11:14 AM To: Dabkowski, Cindy Subject: RE: Amnesty Program Applicants Questionnaire's Hi Cindy, 1. 82 Furlong Way, Cotuit-APPROVED. 2. 712 Oak Street, West Barnstable- DENIED, too many bedrooms for the septic system and size of lot, on well water 3. 854 Phinney's Lane, Centerville- Under further review, housing inspector to schedule an interior inspection, first floor "office room to be viewed 4. 184 Thankful Lane, Cotuit-APPROVED for three bedrooms maximum. 5. 61 Tellegen Trail, Centerville-APPROVED for four bedrooms maximum. However, there is a special condition:, the first floor"study" room doorway entrance shall be five feet wide minimum without a door there in between the study and the bedroom, as shown on the submitted drawing. -----Original Message---- From: Dabkowski,Cindy Sent: Wednesday,September 07, 2011 1:55 PM To: McKean,Thomas Subject: Amnesty Program Applicants Questionnaire's Hello Mr. McKean Can you give me a status update for the following sites 1. 82 Furlong Way Cotuit 2.712 Oak St W. Barnstable 3. 854 Phinney's Lane Centerville 4. 184 Thankful Lane Cotuit 5. 61 Tellegen Trail Centerville Thank you Cindy Dabkowski l . 1 , Fax Send Report SEP-09-201109:35 FRI Fax Number 15087906304 Name BARNST.HEALTH Name/Number GMD / 915088624782 Page 1 Start Time SEP-09-2011 09:35 FRI Elapsed Time 00'16" Mode STD ECM Results [O.KJ i wll of Barnstable - Health Intipc:tnr Regulatory Services Tee Hours 8:30—9:30 �. Thomas F.Geller,Director 3:30—130 •� Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT-SEPTIC OUESTIONNATRE Date:June 20,2011 1, General Information: Size of Properly:0.46 - Address:82 Futiong Way Cotuit,MA 02635 Map 022 parcel 087 Name:Jean M.Neves Phone#:508-420.5100(w)508-326-0839 CJ 2a. How many bedrooms exist at your property now?3 2b. Are you planning to add any bedrooms?NO !f yes,how ni a y? U 2c. Flow many bedrooms total are proposed at this property(including the amuesty unit)?2 211.Please include a copy of the flour plans for the entire property. Neatly use a straight-edge. Show all existing rooms in the home and the proposed amuesty apartment. Provide width measurements of any open doorways. Please label each room clearly. 3. Is the dwelling connected to public sewer? NO If the dwelling is connected to public sewer,skip questions#4 titrough 119 below. � - 4. Location of dwelling is /NSIDE Or OU/:S/DE a Saltwater Estuary Pmtectioll Zone? 5. Location of dwelling is. 1NSME or OUTSIDE a Zone-ufContribulion to public supply wells?' - 6. Is dte dwelling connected to an ONSITF.WELL or to PUBLIC WATER?_ .y 7. Is a disposal works construction permit on file? ,YF.S nor? NO 8. If yes,how many bedrooms were approved according to this Permit? _. Bedrooms. c ra 9. Were any building permits obtained for cuustruction of additional bedrooms? YES or! NO —� W i0. Is there au t.•ngineercd septic system plan on file at the Health Division?. YES of NO w "rn 11. llas the septic system been inspected by a DEP certified inspector within the Last two years,? YES or` NO FOR OT'I:ICL'USR ONLY^�— ----�The Plthlic IIealth I)ivision has no objection to-�3—_bedrooms at this property. Special Conditions: Sign Datc: ' L �/yet 2:1GM0.FTuusing4lccussury Atrnrdable ApartMCul Yror,ram\ADMIN\F''URMS&l.HTI.1-FMHiank r ynnmtyyAAppI.D0c - wn of Barnstable Health Inspector *'THE r Regulatory Services Office Hours Doti g yery 8:30-9:30 Thomas F.Geiler,Director 3:30—4:30 BAMMSPABLE. * Public Health Division MASS. $ 1639. Aim Thomas McKean,Director �AtFD MA'I v , 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT — SEPTIC QUESTIONNAIRE Date:June 20,2011 1. General Information: Size of Property: 0.46 Address: 82 Furlong Way Cotuit,MA 02635 `' Map 022 Parcel 087 Name:Jean M.Neves Phone#: 508-420-5100(w)508-326-0839 2a. How many bedrooms exist at your property now?3 2b. Are you planning to add any bedrooms?NO If yes,how many? 0 2c. How many bedrooms total are proposed at this property(including the amnesty unit)?2 2d.Please include a copy of the floor plans for the entire property. Neatly use a straight-edge. Show all existing rooms in the home and the proposed amnesty apartment. Provide width measurements of any open doorways. Please label each room clearly. 3. Is the dwelling connected to public sewer? NO ; If the dwelling is connected to public sewer,skip questions#4 through#9 below. 4. Location of dwelling is INSIDE or OUTSIDE a Saltwater Estuary Protection Zone?" 5 . Location of dwelling is. INSIDE or OUTSIDE a Zone of Contribution to public supply wells? 6. Is the dwelling connected to an ONSITE WELL or to PUBLIC WATER? Ul $ > ZE 7. Is a disposal works construction permit on file? YES .1015 NO r 8. If yes,how many bedrooms were approved according to this permit? Bedrooms. co tV 9. Were any building permits obtained for construction of additional bedrooms? YES or NO 0 _ 10. Is there an engineered septic system plan on file at the Health Division? YES or NO _ 11. Has the septic system been inspected by a DEP certified inspector within the)ast two years? YES or NO ----------------------- -----------------------------=------------------------------ -------------- ------------ FOR OFFICE USE ONLY The Public Health Division has no objection to bedrooms at this property. Special Conditions:" Sign _ Date: lz& Z®t ' Q:\GMD-Housmg\Accessory Affordable Apartment Program\ADMIN\FORMS&LETTERS\Blank Form. amnestyapp 1.DOC FLV YRP� Flle No.: p05877A Case No:APP#NEVESAEAN-249 nrrawer NEV ES Zl t Q263 °pro pddness-82 R1Rt ONG WAY State:MA Bp�NSTABLE CO Lender:SOVEREIGN BANK i ' t Wwd Deck 92.0 i Kfthm © 3 Bedimm uow eed: 1 Lwaog � a io aantrr wood o m n N _ 5• 7' �g Room 11 RM Full t;a Sam Both porch Vo �° 1 t I,) )��)a��-� FIRST LEVEL 4 F !! BASE"MENT LEVE1 INot uusjded In qA) Skekh by APEX LNNG AI A ltid AREA.0 .. Ske.- Totals Code DescrWon. rsrse TIC= e32.00 - -" Get PL%st Via= 26_0 x 32.Q f TO�y�NN O BARNS''` LE . LOCATION 17 � ��SE WAGE # '- VILLAGE Cd ASSESSOR'S MAP a LOT INSTALLER'S NAME & PHONE•NO. AK SEPTIC TANK CAPACITY D �- (size} LEACHING FACILITY:(type} ATER 11 O. OF BEDROOMS PRIVATE WELL OR PUBLKW.. N BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: ►�' • No �= VARIANCE GRANTED: -Yes z7fh4� _ ,zZ ,. Accessory Affordable Apartment Program Page 1 of 1 McKean, Thomas From: McKean, Thomas Sent: Thursday, July 28, 2011 10:31 AM To: Dabkowski, Cindy Subject: Re: Accessory Affordable Apartment Program Hi Cindy, I reviewed the floor plan. I see where the applicant proposes to eliminate bedroom#2 and convert it into a kitchen and living room. The 1989 disposal works construction permit was approved for three bedrooms total. F After the conversion, will the property contain two bedrooms overall? Or three? From: Dabkowski, Cindy To: McKean,Thomas Sent: Wed Jul 27 14:23:24 2011 Subject: Accessory Affordable Apartment Program Hello Mr. McKean Attached please find an amnesty application along with floor plans for 82 Furlong Way CT. The Homeowner is requesting to create an accessory apartment in the lower level of the cape style home. Ms. Neves proposes to eliminate one bedroom in the lower level (turning it into a kitchen - living room). <<amnesty Ap 82 Furlong Wy CT .pdf>> Thank you Cindy 9 . 7/28/2011 1 COMMONWEALTH OF MASSACHUSETTS >- r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION d � . TITLE 5 • OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Pro,'erty Address �( Owner's Name: Owner's Address: -jii y 13a- t-A Date of Inspection: ` Name of Inspector- (please.print) �` �°�� f � Company.Name 1 , ti� Mailing Address: Telephone Number: 1c-'�4!:319 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 - apt ot�r i- -5'r -. f!i P—Mor pursuant to Section 15:340,of'Title 5(310�CMR45:000). �I-,e_s�ztexn w-Passes Conditionally Passes ` Needs Further Evaluation by the Local Approving Authority Fa' s Inspector's Signature:' Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000. gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments A... -.,U•c, - ,...r a .ww.. ..-v .r _..,. .n • ,..id^. w.Sidi;.tN#s.«..,.+-nP i..,.-may ,.. ..Y..uv...., F � •.-n ^.� ' ****This report only describes conditions at`the time of inspection and under the conditions of use at that t F time.This inspection does not address how the system will perform in the future under.the same or.different. conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: o2LLA, f> U` Owner: Date of Inspection: Inspection Summary: Check A,B,C,D or E./ALWAYS complete.all of Section D A. ystem Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310.CMR 15.304 exist.Any failure criteria.not evaluated are indicated below.. Comments: B. System Conditionally Passes: One or more.system components as described in the"Conditional Pass section need to be replaced or repaired.The system, upon completion of the replacement or repair; as approved by the Board of Health,Will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statementsAf"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 substaiival:,infiltration.or exfiltration or:tank..failure is imminent. System will pn�s mspP�t�nr if_tb.e_ 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 than4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health).: broken pipe(s)are replaced obstruction is removed ND explain: 2 i t . Page 3 of 11 F OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGEDISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: R` Owner. Date of Inspection: c306,57 C. Further Evaluation is Required by the Board.of Health: T 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 I System will fail unless t1fe 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 aseptic tank and soil absorption system (SAS)and the SAS is within.100 feet of surface water supply or tributary to a surface water supply. ti 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 tie SAS is'within 50 feet of a pnvale wafer supply well. _ The system has aseptic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance , "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds,indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5:ppm,provided that no other -failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: + F • 3 , S r Page 4 of I 1 OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A. CERTIFICATION(continued) Property Address: ��i� � , 2c), Owner:a11111A �{ Date of Inspectio D. System Failure Criteria applicable to all systems: You must indicate"yes".or"no"to each of the following for all inspections: Yes Nq� 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 '/2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number / of times pumped Any portion of the SAS, cesspool or priNyis below high ground water elevation: I/ 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 er privy is within a Zone 1 of a public well. Any portion of a cesspool cr privy is within 50 feet of a.private water supply well. Any portion of a cesspool cr 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 � � �1±rt nitrogen is equal to or]css-tha-n 5 pp.m, provided..that rto::o_th�r .:':u.re.^ k* ra:— are:triggered. A copy of the analysis.must be attached to this form.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in310 CMR 15.303,therefore the system fails. The system:owner should contact the Board of Health to determine what gill 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 questibn 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 or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Pase 5 of 1 l OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST . Property Address: C0 C 9 ' Owner Date of Inspection: / Check if the following have been done. You must indicate'"yes"or"no"as to each of the following: Yes No Pumping.information was provided by the owner, occupant,or Board of Health _ I 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 si--ns of sewage back up v Was the site inspected for signs of break out? Were all system components,.excluding the SAS;located on site Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition f.the baffles or tees,material.of.construction dimensions, depth of liquid depth ofsludge and depth of.scurn Was the facility owner(and occupants if different from owner)provided with information on the proper, mamtenance of subsurface sewage disposal systems The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes!� no Existing information. For example, a plan.at the Board of Health. Y _ Determined in the field(if any of the.failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 Page 6 of I I OFFICIAL INSPECTION FORM-NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION Property Address: Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL t/ Number of bedrooms(design): 3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 1.5.203 (for example: 110 gpd x#of bedrooms): j ' Number of current residents: Does residence.have a garbage grinder(yes or no)- Vo Is laundry on a separate sewage system U r no):/1/®.[if yes separate inspection required] Laundry system inspected(y s or no): 10 Seasonal use: (yes or no): 1 Water meter readings, if available(last 2 years usage(gpd)): Q — /�®0 Sump pump.(yes or no): y ¢ Last date of occupancy: COMMERCIAL/INDUSTRIAIWO Type of establishment: Design flow(based on 310 CMR 15.20): gpd Basis of design flow(seats/persons/sqF etc.): Grease trap present(yes or no):— Industrial waste holding tank present(ryes 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(dassr.h?�;_.._ _. GENERAL INFORMATION Pumping Records Source of information: 4 Wass stem pumped as art of i s rction or Y P P P no • ;(� P (Y ) _ If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,.distribution box,soilaksorption system _Single cesspool _Overflow cesspool _Privy _Shared system (yes or no)(if yes,attach previous inspection records; if any) _Innovative/Altemative 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): pproximate age of all co .ponen , date installed(if known) and source of information`. Were sewage odors detected when arriving at the site(yes or no) 6 Paae 7 of 1 1 OFFICIAL INSPECTION FORM—,NOT FORNOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART C SYSTEM INFORMATION(continued) Property Address: _ . Owner: `�i ---� Date of Inspection: c.V/'lr 0s BUILDING SEWER(locate on site plan Depth below grade: Materials of construction:_cast iron 40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting, evidence of•ieakage, etc.): - SEPTIC TANK: (locate on site plan) Depth below grade Material of construction:-JZConcrete'_metal_fiberglass____polyethylene _other(explain). If tank is.metal list aae:_ Is age confirmed by a Certificate of Compliance(yes or no):—7—(attach a copy of certificate) y Dimensions: ° Sludge depth: (� Distance from top of sludge to bottom of outlet tee or baffler Scum thickness: " Distance from top of scum to top of outlet tee or baffle: .3 Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Comments(on pumping recommen aligns, i let and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage etc. : r ) Inno r = 4' i GREASE TRAP• (locate on site plan) 6 Depth below grade: Material of construction: concrete_metal_fiberglass polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet_tee or baffle: - Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,.etc.): 7 Page 8 of I 1 OFFICIAL INSPECTION FORM.—NOT FOR YOLUNTARY ASSESSMENTS N SUBSURFACE_SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property A dress:' 4 Owner. Date of Inspection: 1-)0097 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on.site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain):. Dimensions:' Capacity: gallons Design Flow: gallons/day Alarm present.(yes or no): Alarm level: Alarm in working order(yes or no): Date of lastpumping: Comments(condition of alarm and float switches, etc.): t DISTRIBUTION BOX:-LI(if present must be opened)(locate on site plan) Depth of liquid'level above outlet invert: pp Comments.(note if box is level and.distribution to outlets equal, any evidence of solids carryover, any evidence of akaae into or.out of box c) PUMP CHAMBER(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: aCX .A Owner: / r Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):�z(locate on site plan, excavation not required) If SAS not located explain why:. Type leaching pits,number: -leehing chambers,number: eaching galleries,number: ` leaching trenches, number, length: leaching fields,number, dimensions: overflow cesspool,number: P 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. : CESSPOOLS: �a (cesspool must be pumped as art of ins ection locate on site plan) ( P P P P P )( P . ) Number and configuration: Depth'—top of liquid to inlet invert:- Depth of solids layer: t 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 vegetatibh-,.etc.).., PRIVY: 6 (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of..vegetation, etc.): 9 r Page 10 of 11 OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C, SYSTEM INFORMATION(continued) Property Address: ¢f� 9 Owner: LJ —, Date of Inspection: / i 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. 1 14 1 � •1 _ e ___. I 6 10 ro • Page 1 1 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1. Owner: Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater feet a Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with.local.excavators, installers-(attach'documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: q /� i Permit Number: Date: Completed by: S HIGH GROUND-WATER LEVEL COMPUTATION �ll `t y- Site Location: `� �'y era Lot No. Owner: �C� ��/ yL�// Address: Contractor: drh9, /�L��c� Address: ✓ � Lf`cS�yY �" / Notes: STEP 1 Measure depth to water table to nearest 1/10 ft. ......... ......... ............. Date month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: �'I OAppropriate index well..................................................... OB Water-level range zone ..................... ....... ....... STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well ........................... ! month/year STEP 4. Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 213) 7. 7 determine water-level adjustment'.................:..........................:............................................. STEP 5 Estimate depth to.hig'n water by subtracting the water level adjustment (STEP 4) from measured depth to water % 7 levelat site(STEP 1) ...:..............................:...............................:............................................ Figure 13.--Reproducible computation form. " 15 up, , . El, r Y y� V 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM t ga Fc�l ' RECEIVED Address of property 5 v`�`�'J Owner' s name Tracu� 6rru-r-e Date of Inspection 6 1 g IDS 9 1995 PART A DEFT'CHECKLIST Check if the following have been done: _4Z Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ✓ As built plans have been obtained and examined. Note if they are not available with N/A. ✓ The facility or dwelling was inspected for signs of sewage back-up. ✓ The site was inspected for signs of breakout. All system components, excluding the SAS , have been located on the site. ✓ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of. liquid, depth of sludge, depth of scum. The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. ✓ The facility .owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. r » 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If resident°ia:lt .3 nu r f �2VR: ohms _20 number of current residents NO garbage grinder, yes or no Y95 laundry connected to system, yes or no ft(O seasonal use, yes or no If nonresidential , calculated flow: Water meter readings, if available: Last date of occupancy GENERAL INFORMATION Pumping records and source of information: Y)ecle r �, L, cgiz oId System pumped as part of inspection, yes or no if yes, volume pumped 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) Other (explain) Approximate age of all components. Date installed, if known. Source of information: lo�1t3old, tjnn-I aAed 6/d6'/g9 Bc -nol bG rnL. -135 No Sewage Sewage odors detected when arriving at the site, yes or no 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK::_ (locate on site plan) depth below grade: 3 ' material of construction: concrete metal FRP other(explain) dimensions: 1,000 4g60. X b'/(G `' TbP a 02 sludge depth 30" distance from top of sludge, to bottom of outlet tee or baffle a' scum thickness o? at- - (e--r P�Pe , I ' *at- oW-c+ &4 distance from top of scum to top of outlet tee or baffle Id" distance from bottom of scum to bottom of outlet tee or baffle Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc. ) baI d oil ( n„P I e.�- o 1 1 �- OK nO . i o nr e a--P I-eaLa6C DISTRIBUTION BOX: X (locate on site plan) f�ren depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc. ) 11 ' hd-j®i,) G r77de n n Sol id C myar- Yl C) t n o i P.ref Q rood l�-BOX PUMP CHAMBER: (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc. ) Y ' 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -s PART B SYSTEM �I/NFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : /� (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: )OCa4cA o-n Q s k)j 14- r n..-A -ji R9 - 3_� "Totten 6-P ac_��(e Ln,5�jj LDd bu 6-e-rc l Labo tL, T-t1 ; 477-!&/5 Type leaching pits and number leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool , number Comments: (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) CESSPOOLS (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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,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, recommendations for maintenance or repairs,etc. ) i • 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' 8 �o ra OTU fl � S,']A'j , iq , DEPTH TO GROUNDWATER depth to groundwater G method of determination or approximation: ADS r;�S65 O►xP.- �o� tuj f 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe b.dsis of determination in all instances. If "not determined" , explain why not) \J0 Backup of sewage into facility? _Ala Discharge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the distribution box above outlet invert? VQ Liquid depth in cesspool <6" below invert or available volume< 1/2 day flow? Required pumping 4 times or more in theflast year. number of times pumped _ 1)0 Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: 9D below the high groundwater elevation? AYO within 50 feet of a surface water? A)Q within 100 feet of a surface water supply or tributary to a surface water supply? -00 within a Zone I of a public well? k) within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? 5� 00 within 50 feet of a private water supply well? rtll� less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis? If the well has been analyzed to be acceptable, attach copy of well water analysi for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector O u-s Company Name Company Address 1P O, 6" 4,69 (215-ff-u I'/I , 'Y"-)q , CO&55 Certification Statement 1 certify that I have personally inspected the sewage disposal system at this adress and that the information reported is true,. accurate and complete as of the time of inspection. The inspection was performed and any recommendations regrading upgrade, maintainance and repair are consistent with my training and experience in the proper function and maintainance of on-site sewage disposal systems. Check one: I have not found any information which indicates that the system fails to adequetly protect public health or the environment as defined in 310 CMR 15.303. Any failure criteria not evaluated are as stated'in the FAILURE CRITERIA section of this form. .. .1 have determined that the system fails to protect public health and the environment as defined in 310 CMR 15.303. The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector's Signature Date 9 Original to system owner Copies to: Buyer (if applicable) Approving authority y 3 }# 4 s r TO N 2F BARNST.�.B LE A N + / LOC TIC t 7 �04?io,z ;ZY SEWAGE y q Z 3 ' VILLAGE CQ i ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY fOD O 6A L. LEACHING FACILITY:(type) Z GALI Sys (size) NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLKWATER BUILDER OR OWNER TR,� � jf;? DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: / VARIANCE GRANTED: Yes No o. F , zzyer ,\ 6z b, zGqu.EYS Fri., t r ..,.} A _ a No-f..2..�~. Fns...../..............._i THE COMMONWEALTH OF MASSACHUSETTS (9 BOAR® OF HEALTH O.W.0. ..............OF.....��k! .XvpfirFatiun for Uhipavi al Vorkg Tumtrurtion rumit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ..... r_...tom.. .Q.t.. ............. ...... - or --- -- ------ ..................••... .. . Lot No. --- O ..................•-•---........Addrws. Installer Address Q Type of Building Size Lot:?9�t.IZO....._..Sq. feet aDwelling—No. of Bedrooms...........................................Expansion Attic Ald Garbage Grinder aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ----•------------------•-----•------------------------------ ----------••------------•------------- Desi n Flow......v?�.............................gallons per person per day. Total daily flow____-_-. 3a ......._gallons. W g g P P P Y• Y �-----------------•------ WSeptic Tank—Liquid capacity.l0-M..gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No................. ... Diameter.................... Depth below inlet.................... Total leaching area....._............sq. ft. z Other Distribution box Dosing,tank �,( Percolation Test Results Performed by.. A_� ...I .....b 4.L.................. Date_�.� v._`I 1__a_G.._....... aTest Pit No. 1...4 ......minutes per inch Depth of Test Pit....)-0.......... Depth to ground water__ _ (Y4 Test Pit No. 2---L2........minutes per inch Depth of Test Pit.....!............ Depth to ground water________________________ P4 -••••_•••-•-•-----------------•-••••••••••-•-•-•---••••---•••---•----••••-••--•----........---•------------•--•-•-•.... •-•----------- O Description of Soil...Q—.q.`.__OAA&j SU;SG01L_ '- - 1 O CL-, 04 _ A x -. , - �--- ---�..... Xxw_ 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'?Ti.;p of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee sued by the and o ieaoh. Signed•••. ------------- •-• ...... / ate Application Approved BY b�=• === V Date Application Disapproved for the following reasons:---....-•••••....•--•-•-•----•----•---•••-•-••••------••---•--•••-------•-••••---•--•-•••--•••-•--••-.....•----- ......•--•-•••••. -•--•-•••----•---••-•-•..............•----.........--••----••••------•--•-•••-------...-•••---------------••••-•----------------•••-•-------•--•---•••-•----•-•----•------•---•-•----- Date Permit No....0...--- ---------------- Issued........................................... at - r � NtKPZZ k_oT6? ........... 7 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ApplirFation for Dispati ai Works Tonitrnrtion 11rrmit Application is hereby made for a Permit to Construct ( ) or Repair ( )--an Individual Sewage Disposal System at: �o_Ikkc�. .... `I............. . /// Lo on d �// n or Lot No. . ............./.� ( ..... ��JY--�,---- ------------- ....................•..... -•-•---•----•--------_...........................••- w v k! w / Address ---------------------�----.....------1- IrLOE.......------------....------ ------....-------------- ...•.......------...•..•. Installer Address Type of Building Size Lot__.._..--1. d YP g 'ZS�t �-----_--Sq. feet Dwelling—No. of Bedrooms_._...:�?.................................Expansion Attic (�� Garbage Grinder (� Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures ------.••-•---•-----------•-•------•--•--•••-------------- ----•-••••••-- Design Flow.....S!...............................gallons per person per day. Total daily flow........213� gallons. WSeptic Tank—Liquid capacity_7�_gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.................... Diameter.................... Depth below inlet...._............... Total leaching area..................sq. ft. Z Other Distribution box (}�C-�. Dosing,tank (Kko ~" Percolation Test Results Performed by... ...... :_C................... Date.'I.w_a;..e ........ 1.4 Test Pit No. 1...Lz......minutes per inch Depth of Test Pit....1 v---------- Depth to ground water- rX4 Test Pit No. 2...�4Z:.......minutes per inch Depth of Test Pit......--_........ Depth to ground water........................ P+ ............................. --•-••••••--••••---••••-••-••-......•-••-••-•••-•....-•----•--•-•••---------...-••--••------••--•••. � t t /----- O 0 . G ODescription of Soil.. . Ac � .............VL x w ................-...........................................................................................................................-------.....................................-............... UNature of Repairs or Alterations—Answer when applicable._------_________________________________________•______-___-_-_--___--__--------_-------._.-__. ..•-•--------------••----•----•-••-•••-•-•-•-•••-•------••----.--.--•-------•-••••-•-•-...-_...•.•••------....-•----...•--••-•-•----•--••......-•--•-•----•--......................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with ('1T I•Ix•-� LE the provisions of 1 T t 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by t oard of h Signed. - -----------•------ -----�/ ate kAPPlication A Proved BY / 'i — :.jl .1�4�_ 6 _ ----P Application Disapproved for the following reasons:................................................................................................................ ..........................................................---------------•-----------------------------------------------•-------•-•-•••............-•--- Date Permit No.............. ... /= .. Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS OAR® FQQ H A .OF..... .. . ............. Trrtifiratr of Tomplianrr TH I TJ� IF , a h n' i ual Sewage Disposal System constructed ) or Repaired ( ) by..-•••L-•-� (/C ------------- I �.�� ........................................��) ...... ,.................. at.----------•� .I ........•`V/ liQ/ ..............�!�..A. .----W '-/-f.......................................................... been installed in accordance with the provisions of Ti - S of The ate Sanitary Cod as des ',be?' in the application for Disposal Works Construction.Permit No... _ ........ dated---�� (�f ............ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARA EE TT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..................... ....I t ---•---•••-----•----•------- Inspector..............W-10--•----•-•...............-----•--•-•----••-....... i THE COMMONWEALTH OF MASSACHUSETTS /l BOARD 6A H ALTv � No......................... FEE.- . .......... Maps � on rrntnt _ 1�� �� Permissi hereby granted........... -••---••--•••.--------•••• .................•. •----•----•--•......;:.---•.........--•....._.. to Construf t or�jr..( ) d'vl el& i p sal tem at No.------^---------------- .-- --/c /.Y --•••� -. �.. 1---'�-- 1Street / i � as shown on the application for.Disposal Works Construction Permit N ............ .... Dated_.... _./� ..�. ......... Board of Health DATE............................................................................... -- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS 1. S/6/V ,124 �� GL:.,C. f�4M/L Y 3f3 E0.20o - i�._Y �W 3 330..6.P.a f3301( 1 b-U =q9 6.PIS USE 1000 64L. � oSgG Pi' --lJ E .. -�Gl x d� 1 EaGt �►:�G�-' �c,t, ��! ' S T�N i� O N C 5 ,�/oe ks/,q LL ,4�2�',4 - 14�� �..�' Z � o►.a �ti,fl g � �2'k<o 3cr77- l.d,eE,4 XT -4L r PE,Sle-5 V ,.P,o. c� -4L '!).a•;L)'�'Go{�t/= 336- G.P..t7•, • x:. DETER D ' BAXTER ti 24I33 9 No.24048 ��o s,,rca� a ��',!• AE GIs TEREo Zak- I-c 00 _. 1,4 .1. d : 000 ell � q 2•grc4 /,�i1! .BOX A/V ,S .• 77.0 CE,2T/�/EO G,LDT per,: Al G'E.2T/.cy 7-.1•%1`T Tf4/,1 �r o u►.�pA'R at`t .L oC G T/o t/ CbT�..� C7 i SHOWS yE,eEO.(/CO�s'1pL YS W/22V Egli/.eE�s-!�'.Vrs of THE a .. tiz tit)T+�Z�C .4.vo./s. t-1 o T /S.'A,4XX1/S XA02-BASE4 d�v A�f/ .AEG/STE.2Ep .C.A�c/!� SU.eJiEyb ) . �,�•�S,E'TS Syv1J�/y S�v[o �t/p7- 8�,. ' F ` J � I A k.,.ZZ:L6Ta? 1 TU 2.t-0 N o \30-OO 10 I Ilk t tx yet ..a 1 Peo,•t t oE.b 30.'off. VV '. ' SN OF M' ... , ,PETER � SULLIVAN No:29733 " WA� IS 1 NAL E„ t. AsBuilt Page 1 of 1 TON.OB BARNST,'iBLE LOCATION _� / 7 ga/Ilo q p/ Y SEWAGE # VILLAGE CQ i ASSESSOR'S MAP 6 LOT INSTALLER'S NAME G PHONE NO. riC'K.41Cn LI,{y_f� SEPTIC TANK CAPACITY Gma Z LEACHING FACILITY:(type) 2GpI�EyS (size)--6 NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WAT BUILDER OR OWNER DATE PERMIT ISSUED: DATE COIIPLIA14CE ISSUED: VARIANCE GRANTED: Yes No 29 g�2z' http://issgl2/intranet/propdata/prebuilt.aspx?mappar=022087&seq=1 7/28/2011