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HomeMy WebLinkAbout0051 GERALDINE ROAD - Health 51 Geraldine Road °• �` COti11t` y �I -- II ! �I q 4 1 No. < �'/ �J Fee 5 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pptiCation for -Misposal *pstrm Construction Permit Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. -1 Gerc Owner's Name,Address,and Tel.No. 60 Assessor's Map/Parcel (j I vetw wey mo vi-A 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(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) fC�ye 12 6ic I&V4 1.j /Y1--0 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 Certificate of Compliance has been issued by this Board of Health. Si ed Date , Application Approved by Date Application Disapproved by Date for the following reasons Permit No. fr4o 1-2 Date Issued ki 'Y i z 9D ? Fee .75 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2ppYication for 3Disposal 6pstem Construction permit Application for a Permit to Construct( ) Repair(l) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No..S► Gtrr,l dj',j e Rd Owner's Name,Address,and Tel.No. s rr sor' f" ��GN vv e �A Assessor's Map/Parcel ®`h -v(C) N4/j Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. a 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(min.required) gpd Design.;flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type.of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Ll 4 q xL r.. r'/�,✓Y /vrm( G"'V/l/r,N Date last inspected: - Agreement: % The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disp6sal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this B�pard of Health. Signed Date. Application Approved by Date Application Disapproved by Date for the following reasons t - " Permit No. Date Issued:'= _ ---------- - - -------- — - - -- -- ----- •-- --- ------; - - --- - - - - -- -- - ------- LTHE COMMONWEALTH OF MASSACHUSETTS 0CLO TAeP Ltyl Or-A �^��.� BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( ) Abandoned( )by �ri�ir It s Ewe- at •i/ G.e/G 1e/,,,,P has been constructed in accordance With the provisions of Title 5 and the for Disposal System Construction Permit NoAya—393 dated )1 Installer -OL, b 4 4 Designei #bedrooms / Approved design flow gpd The issuance of this permit shallnot be construed as a guarantee that the system wi'1'1'funcfionnaas dr esi� ed. Date i �r Inspector�� - -;--- ---.------------ ---------.----- ------ tU - No. �� -- �teJi �rJ1�i- loi%�Y C:7n1�`I Feej THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction i3ermit Permission is hereby granted to Construct( ) Repair Upgrade( ) Abandon( ) System located at <- and as described in the above Application for Disposal System Construction Permit. The applicant recognized 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 1 l J' Approved by � -----------------�—ter.___. TOWN OF BARNSTABLE �q� LOCATION 17 i SEWAGE # 99- 7o 9 VILLAGEcaf�l�zASS/ESSOR'S MAP&LOT Oyo -d/g INSTALLER'S NAME&PHONE NO. %9 c%s4pz 94�1-1-195 SEPTIC TANK CAPACITY YS'oo LEACHING FACILITY: (type) (size) 26k /3 NO.OF BEDROOMS 3. BUILDER OR OWNER PERMTTDATE: /D-26 - 9 9 COMPLIANCE DATE: ilo 2-/-P� 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 ;�.-c,_ff,� c _ �. _. � F r • C 0 �� d� , s -� ,�� M4" .L^ ���� ,. ; T T WN OF BARNSTABLE ems• 1-'We SEWAGE # LOCATION _ VILLAGE /�/j', /y�1QSS- ASSESSOR'S MAP & LOT—:4-11�::: INSTALLER'S NAME&PHONE NO. l SEPTIC TANK CAPACITY .SG�9 01 ��SQ�I� sue LEACHING FACILITY: (type) ( ) NO. OF BEDROOMS BUILDER OR OWNER ` 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 acility(If any wetlands exist within 300 feet o eac fac' ' Feet Furnishe y - �— — -— -------- . 57[ RBI golf J Y\� , r fI '0 e 1 i Al-38 9 Ft? A 2--341 az 29 03 A3.33' 33�3�1 2 DATE. 12/5/01 ---- PROPERTY ADDRESS:51 Geraldine Road_______ Cotuit Mass 02635 V `� ------------------------ On the above date, I Inspected the septic"`system at the above address. This system consists of the following: - 1 . 1 -1500 gallon septic tank. 2 . 1 -Distribution box. 3. 2-500 gallon leaching chambers. 25 'X13 'X2 ' v Based on my inspection, I certify the following_ conditions:. 4 . _This is a title five septic system. (Installed 10/27/99 ) 5 Chambers are are-6 ' below grade. ( Not vented ) 6 . Covers not raised. 7. Pumped septic tank at time of, inspection. 8. The septic system is in proper working order at the present time: 9. This is a four bedroom house with a three bedropm designed leaching area. T S GNAURE- Name -J_P _.Macomber _jr------- ". ., Company: Josejh_P . Macomber_& Son , Inc .: CEINJED _ ,, - .• Address: Box 66 p01 DEC 2 Centerville , Ma .. 0263270066 ------------ ------- TOWN OF BARNSTABLE HEALTH DEPT. Phone:---508_775__3338__ THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY '- JOSEPH P. MACOMBER & SON, INC. . Tan ks-Cesspools-Leachflelds r Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632 00066 ` . 775-3338 775-6412 I ' , 4� COMMONWEALTH OF MASSACHUSEITTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM FORM PART A CERTIFICATION Property Address:51 Geraldine Road Cotui , Mass_ " Owner's Name: Richard Weymouth Owner's Address: .c;r3ma Date of Inspection: 1 2 5 01 Name of Inspector: (please print) J.P. Macomber Jr. Company Name:Joseph P. Macomber & Son Inc Mailing Address: P_O_ Box 66 rpntprv; 1 1 A 14a 62632 Telephone Number: 508-775-3338 ` 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- rraining 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 or Title 5(310 CMR 15,000). The system: L—_Passes' Conditionally Passes Needs Further Evaluation by the Local Approving Authoriry _ ails Inspector's Signature: Date: The system inspector shall mit 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 authoriry. , Notes and Comments ""This report only describes conditions at the time of Inspection and under the conditions of use at that - --time.4 , --utne.This inspection dots not address how the system will perform in the future under the same or different 1. conditions of use. Title 5 Inspection Form 6/152000 page I r Page 2 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 51 Geraldine Road Cotuit,Mass.' Owner: _Richard Weymouth Date of Inspection: 1 2/5/01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D . A.r System Passes: ' . have not found a�infor�mation hich indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR�5 failure criteria not evaluated are indicated below. ,Comments: _ +The septic system is in proper—w- orking order at the present Mime. The leaching is designed tor trifee bedroOM5. `fr1r5Z5 a four bedroom house. r �� 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. _ eO 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): ' • - 7 J�,a.. • ' .. - broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:51 Geraldine Road Cotuit,Mass , Owner: Richard Weymouth Date of inspection: 12.1 S.ln 1 C. Further Evaluation is Required by the Board of Health: .,416Conditions exist which require frther eva luation on by the Board of Health m order to'determine if the system is failing to protect public health, safety or the environment. s 1 System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning id a manner which will protect public health,safety and the environment: 11 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,Eif any)determines that the system is functioning in a manner that protects the public health,safety and,environment: �t) 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. .GAD The system has a septic tank'and SAS and the SAS is within a Zone I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. .� The system has a septic tank and SAS and the SAS is less than 109 feet but 50 'et'or more front a private water supply well". Method used to determine distance L •'This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform. bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:51 Geraldine Road'- o ui a . . Owner: Richard7-We—ymoufn Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No �ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ischarge or ponding of effluent to the surface of the.ground or surface waters due to an overloaded or logged SAS or cesspool Static liquid level.in.the-distribution box above outlet invert due to an overloaded or clogged SAS or cesspool 'dl C/l4 dti Wiyl f 1!�`�C/��X� j quid depth 1n xz;&peel is less than 6"below invert or available volume is less than '1/2 day flow Y Required pumping more than 4 timep in the last year NOT due to clogged or obstructed pipe(s).Number f times pumped I •ly,��f1/+y y portion of the SAS, cesspool or privy is below high groundwater elevation.. y portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface /water supply. ' arty portion of a cesspool or privy is within a Zone 1 of a public well. _ k, /arty portion of a cesspool or privy is within 50 feet of a private water supply well.. Any portion of a cesspool or privy-is less than 100.feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is.free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] (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) a yes no e system is within 400 feet of a surface drinking water supply t1�e system is within 200 feet of a tributary to a surface drinking water supply system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped' Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant"threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 4 ='s Page 5 of 1 1 t, OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B ` CHECKLIST Property Address: 51 Geraldine Road Cotuit,Mass. Owner: Richard Weymouth Date of Inspection:12/5/01 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. r 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) -21 Was the facility or dwelling inspected for signs of sewage back up Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction,dimensions, depth of liquid,depth of sludge and depth of scum ? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface Y sewage disposal systems? ' P The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no + / Existing information. For example,a plan at the Board of Health. ✓ — Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)j.. ' ,1 f 5 ` r � Page 6 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C' SYSTEM INFORMATION ; R Property Address: 51 Geraldine Road Cotuit,Mass. Owner: Richard Weymouth , Date of Inspection: 1 2 5 01 FLOW CONDITIONS. RESIDENTIAL - Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: �f Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system es or no):AV [if yes separate inspection required] - Laundry system inspected(yes or no): Seasonal use: (yes or no): VD Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no):X,70 Ip�- Last date of occupancy: COMMERCIAL(INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): /)+ Grease trap present(yes or no): ,UA Industrial waste holding tank present(yes or no): _ t Non-sanitary waste discharged to the Title 5 s stem(yes or no):d'�4 - Water meter readings, if available: Last date of occupancy/use: VA OTHER(describe): GENERAL INFORMATION t Pumping Records Source of information: 11t),*J Was system pumped as part of the inspection(yes or no): J If yes, volume pumped: /6dOgallo --How was ua titypump d determined?,P 5V //*7/ . Reason for pumping: TYP OF SYSTEM eptic tank,distribution box, soil absorption system 40 Single cesspool d 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 PVd Attach a copy of the DEP approval y . 'Other(describe); Approximate age of 11 components, date installed (if known)and source of information: - Were sewage odors detected when arriving at the site(yes or no): 41w* 6 Page 7 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) r Property Add ress51 Geraldine Road " o ui ,Mass. Owner: 12/5/01 Date of InspectionRi chard Weymouth BUILDING SEWER (locate on site plan) Depth below grade: Materials of construction:mast iron : 40 PVC. 4 other(explain): 4/,IL Distance from private water supply well or suction line: /Q`r` Comments(on condition of joints, venting, evidence of leakage, etc.): Joints appear tight No evidence of leakage. The system is vented through the house vents. SEPTIC TANK: � (locate on site plan) Depth below grade: Material of construction: a-concrete NsmetaI 6kfiberg]ass polyethylene /Uather(explain) IV " If tank is metal list age:Wei is age confirmed by'a Certificate of Compliance(yes or no): (attach a copy of certificate) ) �i 0 ,_J, i� Dimensions: �j�L3 , Sludge depth: Distance from top of sludge to bosom of outlet tee or baffle: d Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bonom of scum to bo"Amof outlet tee or baffle: �r How were dimensions determined: Comments(on pumping recommendation inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of.leakage, etc.): `"Inlet & outlet tees are in place The tank is structurally sound and shows no evidence of leakage. GREASE TRA locate on site plan) Depth below grader Material of construction:�oncrete t/&metal4RfiberglasvLIfpolyethylene4Mother (explain): Dimensions: t Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bonom of scu. 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.): Grease trap is not present- 7 Page 8 of 11 cob _ OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION'(continued) Property Address:51 Geraldine Road Cotuit,Mass. Owner: Richard Weymouth Date of Inspection: 12/5/01 TIGHT or HOLDING TANK' ' (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: 414 Material of construction: concrete, /_metal fiberglass�i polyethyleneother(explain): Dimensions: - Capacity:_ AM gallons Design Flow: A114 gallons/day Alarm present(yes or no): _ Alarm level:)4 Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): Tight or holding tanks are not present. DISTRIBUTION BOX: (if present must be opened)(locate on site plan) ' Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D—Box cover is about 5 ' " e ow a exis ing gra e. Wou s ec; that the box cover be raised. PUMP CHAMBERA- locate on site plan) Pumps in working order(yes or no): Ao Alarms in working order(yes or no): ;Vlf Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Pump chamber is not present. I ' 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:51 Geraldine Road Cc uit,Mass Owner: Richard Weymouth Date of Inspection: 12 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) , 2-500 all 1 -cover ` of the chambers should be raised. This is fd)r service access. If SAS not located'explain why: — Located; See page Type .,ilU leaching pits,number: 0 leaching chambers, number: y� leaching galleries,number: 06 leaching trenches,number, length: ,(� leaching fields,number,dimensions: _ overflow cesspool,number:of) D 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.): No si ns of Loam s hAyely- ailure or CESSPOOL(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: �l z 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.): Cess , PRIVY(locate on site plan) Materials of constr�ctin. � Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): Privy , 9 Page 10 of I 1 M OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 51 Geraldine Road Cotuit,Mass, Owner R i eha d W ytnouth ' Date of lnspectioo: 1 2/S/t11 ; 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, r-t t i AI-33 g I-t9 az 7 9 2 I I 10 . Page 1] of I 1 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 51 Geraldine Road Cotuit,Mass. ` Owner: Richard Weymouth Date of Inspection:12 5/01 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 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) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Used; Gahrety & Miller Model Grond water ahcwa '_GPa 1 E'up_.1 - Used; Ohservation wP11 data .Tuna 1A42 psPr3; ilSGS 2—0 0 Q 1 PI a e# 2 Tup of Ground Leaching Pit 11; :eet Groundwater. t-eet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method Therefore, the vertical separation distance between the botto of the leaching pit and the adjusted groundwater table is feet. 11 a•rmnrw.-n.rR-�T�am-mlnsPrlrTnrTnmm•n++11rnT.TTrna na'nt•Y rrnlneetRT .T7rT-tier-:.....r..•' TOWN OF Barnstable BOARD OF HEALTH, � SUI)SURFACE SEHAGF DISPOSAL SYSTEM INSPECTION FORM - PART D .- CERTIFICATION -TYPE OR PRINT CLEARLY PROPERTY INSPECTED STREET ADDRESS 51 Geraldine Road Cotuit,Mass. ' ASSESSORS MAP , BLOCK AND PARCEL # QgQ10I� OWNER' s NAME Richard Weymouth PART D - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber Jr. COMPANY NAME Joseph P. Macomber & $an Inc COMPANY ADDRESS P.O. Box 66 Centerville Ma 02632 Street Town or City State LIP COMPANY TELEPHONE (508 ) 775� - 3338 FAX ( 508 ) 790 - 1578 A CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and omplete as of the time of -inspection .' The inspection was performed and any recommendations regarding upgrade , maintenance , and 'repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check ne . Systevi PASSED The inspection which I have conducted has not "found.- any information which indicates that the system .fails to adequately protect public health or• .the environment as defined in 310 CMR 16 . 303 . Any failure. criteria not evaluated- are as stated in the FAILURE CRITERIA section of this form , System FAILED* The inspection which I have con Lcted has found that the system fails to protect the public health and the environment in accordance with Title • 5 , .. 310 CMR -15 , 303 , and as specifically noted on' PART C -•'FAILURE CRITERIA- of , this Lecti n form . ;: , Inspector Signatur Date 'dJ ecopy of this certification must be provided to the OWNER, the BUYER On Where applicable ) and the 130ARD OF HEALTH. If the inspection FAILED, the owner or operator shall upgrade ' the system ' within one year of the date of the inspection, unless allowed or required otherwise as provided in 3.10 CMR 16 . 305 . partd .'doc ' n.: I TOWN OF BARNSTABLE /CJ LOCATION SEWAGE # 99- 70 0 VILLAGE ASSESSOR'S MAP & LOT 040 -Dt g INSTALLERS NAME&PHONE NO. q77-C 3 /q J�s-c � y I SEPTIC TANK CAPACITY L-00 LEACHIlNG FACILITY: (type) -,S"dD �.�� drui!:,�1e (size) �. NO.OF BEDROOMS 3 „ BUILDER OR OWNER PERMITDATE: /0,2 G q 2 COMPLIANCE DATE: 70 2?- 9 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet `I 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 l within 300 feet of leaching facility) Feet Furnished by r ---------- 7 i t No. © ` Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: s PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZfppYication for Migool *pgtem Cow6tructiou Permit Application for a Permit to Construct(vYRe/pair( )Upgrade( )Abandon( ) El Complete System O Individual Components Location Address or Lot No. s� (��/''f ��I r! G /2� Owner's Name, ddress and Tel.No. c2"C�il�i'r`r� Gc%y:yiovr�i Assessor's Map/Parcel 7�0 <p Lo+f j Installer's Name,Address,and Tel.No. o:�y'f Designer's Name,Address and Tel.No. cfosepll 0,4 /.3'arees ✓osep/ !7� �<�i���s Type of Building: Dwelling No.of Bedrooms 3 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 Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) L2- .4 W ZZ /ADO t/," / S-ewr/ Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this)3oazd f Health. Signed ' Date le G - 5`9 Application Approved by Date— C2 9 Application Disapproved for tht4olloW4 reasons Permit No.& 70 Date Issued No. Q 1 Fee _ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pplication for Mi!5pooar *pMem Con.5truction/permit v Application for a Permit to Construct(6-'Repair( )Upgrade( )Abandon( ) El Complete System El Individual Components Location Address or Lot No. CaE/'/?/W 1117-G 4.1 Owner's Name,Iddress and Tel.No. 4 Assessor's Map/Parcel d Y© Installer's Name,Address,and Tel.No. G/7'7— O 3 y f Designer's Name,Address and Tel.No. � c%S epti d-t /�prs�ds ✓os cpG, d� �sQ�'�S 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 Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 2�4T/4 ZZ /�'DU ,,a/ S jbli G &W,4 j Date last inspected: Agreement: The undersigned agrees to ensure the construction and"maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been/issued by this lard 9f Health. Signed li.GtG'L Date %22--2 G - 9f Application Approved by ,ttM ,,,,,, Date�� �rr Application Disapproved for th, ollovhJg reasons r Permit No. Date Issued ------------------------------------ I I THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS r (Certificate of QCompliance a THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed("Repaired( )Upgraded( ) Abandoned( )by ,rt O S at / -e ml hS 01o'lls has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer o,5 eg-4 /� &y wa S Designer t? The issuance oft is pe t s 1 o t ba construed as a guarantee that the will f ncti, s d�i�n d. Date Inspector 0 r''�' No. � 7 — ��� Ot/0 O/q Ga73 Fee i. THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Miqu al *potem (Construction Permit Permission is hereby granted to Construct( epair( )Upgrade( )Abandon( ) W. System located at S/ Pr t�/ irw t �Iaa�stahs hv9,%/s 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. i Date: Approved by �, 1/61g9 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 PERMrr(WITHOUT DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated 2G - f/ , concerning the property located at S/ �er�y/�h� /2� C,,rv�T meets all of the following criteria: �rhe failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling: Z---The sail 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 (--There is no increase in flow and/or change in use proposed ere are no vanances requested or needed • The bottom of the proposed leaching facility will not be located less than five feet above the maximum adji=ed groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S. Sall be located with 250 feet of any vegetated wetlands, the bottom of leaching facihtY will not be located less than fourteen(14)feet above groundwater. table elevation, the maximum adRtrsoteased Please complete the following: A) Top of Ground Surface Elevation(using GIS information) 7, B) G.W. Elevation +the IMAX. High G.W. Adjustment — DIFFERE NCE BETWEEN A —`"' D and B SIGNED ; [Sketch proposed plan of DATE; �p_1 q:heeNh fold¢arc system on back]. It GGSSD �` /Sr/H� b�t 2 50o a o • PROJECT TI TLE M It -CENTRAL COO TRUCTIO.N COMPA col STREET T .820 MAI �COT --VA IPREPAREDI�..�,FOR Y L-7............z=E IU cdfi Qmoon ent tev Id,e:�D m qT Street Cohift-WA*'508-4204 20 gin 0 IATEL�V DWG`N DE81 ON DR AWN .......... PROJECT TITLE Npo ADD 1, v) bit L T- r:�, 1�f b it, _4 :r'::7`k �-ti- lu e -P' -co t otUitl. 42 `13-0 0 WG 0 C EC H' ''DRAWN" i4l,. _F a d ­7 7 A W Q a Alt .... ........ too ins, Wnqy� -a A .4" v,QQ=4` p, A 0 0 PRIM M _,77w, Niv 4., i4j".WA "T, ,. 1 7; C,t 2,':7. X. �Qyvqi ova, pilots., 14 VN Tn-4 CA -0-1 'Zn NO MAO A j-1 A ­0 t., 7=VT�� p WK W '&;;"5;�29" v" -7:4; A AS,"04 OSMAN M'. 7', v WUMS00" of jaw 4wn My, Low no,"Q A-0-410 -gymnyon p! g"�gm. 4 14- cow, full tgy 77 .4 OWNS-my, TwZYWARV known va OSMAN. a May �A�W"7_ _W1 INV! j _"W 0 Alz % RT ,r"-- '..- ,4 -agoviR.K.JS incovi�, T zl�'� ., ., , I . _W "MMXW`�" A .W. ., ." W,Q _. -_- 1 �r`� , Q W"Whii, n too _T, Oak WO A . P 01, ",4-:�Y ATWA TQMVWX"�-�� I f, -':' . ; ;-, a �tAi 3, A �W ' Ik' X; SAMOA ZQA P- "o MOAN V -wi- --a vu., con 0-4 Qj- Q; �A�y -AWA WOW- L.� PA,kycoz V, W AN, polo JI sit :;1 1 Ica Ax=As" . ..... VAT 7 5�, 3;1���,� gv, X� Q �N loss W %solo!j MOAN;.401 :,V77 "i.17­�,­�,�.j vemy em IME 1,i4. '� �,I. d. ij`,��.�i, I pqov -we Not own q-_o An" ........�, j, P, 10 loom, ;% WAS Nv iA� 4. 7­% A ........... 4. VA,� V�Wj- WWWW"W-pa" Q"Q_Qn,_ A 0=1 0 ,, '. , ':.1��, WOW t .... . ..... "TAW,wo d pr� A� _4L, ........... ir, 7".4 Y-Q Q qW,I A 1, 7*� 'o __jjjQQ A Ono,VQ,no"AR, _J� ­__c M-TA AWA Qnv�Q�Wmm kjq� "Mai isiony liagan0 L WES, "K, WE Q"_WNW "W-guy- 7 U-N-012 gow Fin to .. .. ........ _q 5� -0 AT "o .............. WAS 10 PROJECT TITLE' q. 6 44� —. 4 Am L 6 7: 1A z ii�i, 4', 5t; YA ' 'A -77 6� A� �,4(,<,�4,z,, 41, 4 pr et, ti e'&-CL)Aj 77777,,' c "k,4 t, ty it ttt- t v yto Z..V 7� 4NM 4 L3 4", 7" ti. 7�: . ... ...... . V P v j -tt�Q , .;..'1.;., �us, a t;,Z, "tt.�.�,O. it, T ",-:7 �V, M6 Kfft AKh 'd A 7777777=it-,� 'N 77 h�, 4 i 41 rl, cb I e� 'DeWin,-'Pies en "t tel. j 'Ex--W 40n$b.1' e: c m t 1, :-7, 506-420-- A, Z F' tt.1 7, 6, o (i.E-pe VUL,-� RD �MX� n- V 77 q, 77, M�zM� -7 ,7 en!�s pons0up ornai�,db ructlom ntralcapeconst �No sl 1p;. �bW % t,�, tv , . ",.';.1 L Y p tt, lot --Vtt T t DA,T DW.G"NO", lz CHECK DRAWN. c. JUH NO ------------ 777 TITLE, PROJECT 7`7 W -ATM ITS was Inv its lot kit �t,nvnvt nos f "CIA do sit A TEO 17, it,Not 00, TOM— vk 1REPA.,ED��,,:FQR In off'.. goody z wool Tom, zloty............... 7 L p idehi, Mow& .......... loan;q constru" onopq Pam ........... �7 7;F "Iwo 4 ----------low, 0 Lot post Away! G 7jk DESMW 14 CCK 'PR .......... PROJECT TITLE t7' aa�A 777777 77777=7 Z1, 777777, 7= -RE Iti: A gma com b; It e s w re CA06co t cf, SCALE� 77' . DA G�WO� D SIGN E HEC DRA W JOB �s :OF