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HomeMy WebLinkAbout0303 MAIN STREET (COTUIT) - Health 3)3.Main Street (Cotuit) — — -- Cotuit P t 1 A = 022 034 I' I YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is . recuired by law. DATE: If Fill in please: ' t APPLICANT'S YOUR NAME/S: ki�xr BUSINESS YOUR HOME ADDRESS: '303 1 In�ry S1 . " TELEPHONE # Home Telephone Number © T 3-t17 a� NAME OF CORPORATION: NAME OF NEW BUSINESS TYPE OF BUSINESS IS THIS A HOME OCCUPATION? V YES NO ADDRESS OF BUSINESS .36 3 Ma k V MAP/PARCEL NUMBER (Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - [corner of Yarmouth Rd. &Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature COMMENTS: 2. BOARD OF HEALTH This individual h n inform 4df&erm!t u!re Es Mat pertain to this type of business. 7i Authorized Sig turUUST e; MPLY Wl . ALL COMMENTS: ,, 1LATION!(� 3. CONSUMER AFFAIRS (LI NSIN UTHORITY) This individual nfor d t licensing requirements that pertain to this type of business. Autho i " d S(g�jature* COMMENTS: 0 a) I j e s S i„ -\ COMMONWEALTH OF NlASSACHUSETTS X EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS. rEPARTIYIE2*TT OF ENVIRONIYTENTAL PROTECTION a TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Pro perty Address: �A-L,I Owner's Name: v(�o� — 6.3 Owner's Address: Date of Inspection: Name of Inspector: (please print) Company Name: o , C. ' • )x-ry Mailing Address:. _0 C3 _ Telephone Number: 90 1 . k 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(3.10 CMR 15.000). The system: JPasses Conditionally Passes eds Further Evaluation by the Local Approving-Authority ils / /' a 7 Inspector's Signature: : i 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. i ; Notes and Comments4 _7. G� C ::. x** !( * This report only describes conditions at the time of inspection and under.the conditions of use-at tha•t,j time:;This inspection does not address how the system will perform in the future under the same or different conditions of use: r Title.5 Inspection Form 67157.2000 page 1 Page 2 of 11 , OFFICIAL INSPECTION FOR1V1-NOT FOR YQI UNI'ARYSSESSItiIENTS. SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM..' PART A. CERTIFICATION (continued) � /( Property Address-. 303 Ql n S . Owner:a. . U Date of Inspection: w� Inspection Summary: .C'heck'A,B',C,D or E FALWAYS complete all of Section.D A. System Passes: I have not found any information which.indicates that any of the failure criteria described in 310:CMR 1.5.303 Orin 310 CIv1R 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.iND)in the for.the following statements. 1f"not determined"please explain. The septic tank is metal!and;over.2.0 years..old* or the septic tank(whether metal or not):is structurally unsound, exhibits substantial.infiltration or exfiltratiori or.iank failure is immiiie.nt.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: Page of 11 OFFICIAL INSPECTION FORM-. NOT FOR V L O UNTARY-ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'FORM PART A CERTIFICATfiON(continued) Property Address: Owner: Date of Inspection: 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 w ilI pass unless Board of health determines in accordance with 310 cmk 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 sunless 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 SASS is.within 100 feet of a, surface water supply:or tributary to a surface water:supply: The systemhas 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 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,perfdrmed 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 thatno other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3. Page 4 of. 11 OFFICIAL,INSPECTION FORhI-.,NOT FOR VOLUNTARY:ASSESSMENTS SUBSURFACE SEWAGE'DISPOSAL'.S:YSTEM INSPECTION FORM PART A CERTIFICATION(continued) t I Property.Address: 0 Owner: no I Date of Inspection:. D. System Fail.ure'.Criteria applicable to all systems: You must indicate"yes" or"no"to each.of the following forall inspections: Yes No _ Backup of.sewage.into:facility:or system component due to.overloaded or clogged SAS or cesspool Discharge or pondmg of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static.liquid Ievel':.in the distribution box above.outlet invert due to an overloaded or.clogged SAS or / cesspool V Liquid depth in cesspool is less.than 6"below invert or available volume is.less than %day flow Required pumping more than 4 times in.the last year NOT due to clogged or obstructed pipe(s).Number of times pumped yV Any portion of the SAS,cesspool or privy is.below high ground water elevation. Any portion.of cesspool:or privy. is within .100-feet of a surface.water supply or tributary to.a.surface / water supply: Any portion of a cesspool or,privy.is within:a Zone 1 of a,public well. _ Any portion of:a cesspool,or privy is within.50166t of'a.private water,supply'well: Any portion of a cesspool orprivyis:less than 100 feet but.greaterahan.50 feet.from a private water supply well with no acceptable water quality-analysis..[this system passes-if.the well water analysis, perform ed,at..a DEP certified.laboratory,for coliform ba.cteriaand:volatile organic compounds indicates that the.well is free from pollution from that.facility and the.presence of ammonia nitrogen andinitrate nitrogen is equai.to or less t13an ppm, provided that no other failure criteria are triggered..A.co.pyof the analysR 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,thereforethe 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 largesystem the system must serve.a.facility with a design flow of 10,000.gpd to 1.5,000 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 Il of a public.water supply well. If.you i have,answered"yes"to any question in Section.E the system is considered a sign ificant.threat,.or answered yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threatunder 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. i 1. Page 5 of 1.1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE*SEWAGE DISPOSAL"SYSTEM INSPECTION FORM PART B `CHECKLIST Property Address:3 1 4-1A Owner: t Date of Inspection: oalo� 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.. jWere any of the system components pumped out in the previous two weeks _ Has the system received normal flows in the previous two week period? /Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not'available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? ` Was the site inspected for signs of break out? Were all system components, excluding the SAS,,located on site _ Were the septic tanl:.manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees; material of construction, dimensions, depth of liquid,.depth of sludge and.depth of scum? . _ Was the facility owner(and occupants if different from owner)provided with information.on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System(SAS) on the site has been'determined'based on: 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 . _ I 5 Page 6 of l l OFFICIAL INSPECTION:FORM NOT TORVOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE:DISP,OSA:L.SYSTEM INSPECTION FORM, :PART.C SYSTEM_INF.ORMATION Property Address: j0 - = Owner: Date,of Inspection: o FLOW CONDITIONS RESIDENTIAL Number of bedrooms.(design):-. 13 Number of bedrooms(actual)-. DESIGN flow;based on:310.CMR 15.203 (for example- 1`1.0 apd x#of bedrooms): 330 Number of current residents:. O Does residence have a garbage grinder(yes or no):fL() Is laundry on a:separate sewage system(yes or no):DD fif yes separate inspection required] Laundry system inspected( es.or no):_ Seasonal use: (yes or no): S Water meter readings, if available(last 2 years usage:(gpd)): Sump.pump (yes or no):_ y Last date of occupancy:; COMMERCIALIINDUSTRIAL Type of establishment:. Design flow(based on J1-0 CMR 15.203): gpd 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 Sourceofinformation: (1, ?'fin Was system pumped as part of the inspection , es or no): IV If yes, volume pumped: gallons--How was quantity pumped determined? Reason.for pumping: T ,E OF SYSTEM Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool ; _Privy _ Shared system (yes;or no)(if yes, attach previous inspection records, if any)' Innovative/Alternative technology.Attach a copy of the.current operation and maintenance contract(to be .obtained from system owner) —Tight tank —Attach a copy.of the.DEP approval _.Other(describe): Approximate age of all components, date installed(if known)and source of information: Were sewage odors:detected when.arriving at the site(.yes or no):,ft 6 . Page 7 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL`SYSTEM INSPECTION FORM PART:C SYSTEM INFORMATION(continued) Property Address: 0 Owner: (4�4o ATij n A ir Date of Inspection: -�-�Q r� 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:: .. r Comments (on'condition`ofjoints,.venting, evidence of leakage, etc.): SEPTIC TANK: -""(locate'on site plan) Depth below grade: � Material of construction:. s!concrete_metal_fiberglass . Polyethylene —other(explain) If tank is metal list age:— .Is age'.confu-med by a Certificate of Compliance(yes"or no)`,_(attach..a copy of certificate) Q F Dimensions: 0.'S 1C Sludge depth: ° f/ Distance from top of sludge to bottom of outlet tee or.baffle: c � . Scum thickness: Distance from top of scum to fop:of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: iI How were dimensions.determined: soq."0(1 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels a5 related to outlet ert, evidenc of leakage, etc'.): - OLU' , 000 J GREASE TRAP:_(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, structufal integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7 l T Page 8 of I .'OFFICIAL INSPECTION FORM NOT FOR:: OLUNTARY'ASSESSMENTS SUBSURFACE-SEWAGE DISPOSAL SYSTEM-INSPECTION.FORM PART C. SYSTEM INFORMATION(continued) Property Address: VQ Owner: R %-. Date of Inspection: D OF TIGHT or HOLDING TANK: 00—t--(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: k. 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�)u�of ox; ete.): PUMP CHAMBER::VD(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.): 3 Pase 9 of 11 OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE ;SEVIAGE DISPOSAL SYSTEM INSPECTION FORNI PART'C " SYSTEM INFORMATION(continued) Property Address:slM Owner: Date of Inspection: I;a,1®177 SOIL ABSORPTION SYSTEM (SAS)::700cate on site plan,excavation not required)' If SAS not located explain why- ' TYPe n leaching pits,number:L ; leaching chambers,number: leaching.galleries, number: leaching trenches, nuinber,'length: leaching fields,number, dimensions: overflow cesspool;number: innovative/alternative system T e/name of technology: �y Comments (note condition of soil, signs or hydraulic failure,level of pondtn�a, damp soil,:'condition of vegetation. Ja-f? s � V. a zv .. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth'.—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: . Dimensions of cesspool: Materials of construction: Indication of.groundwater inflow(yes or.no): . Comments (note condition-of soil, signs of hydraulic failure,:level of ponding, condition of vegetation, etc'.): PRIVY:0(lonte.on site plan) " Materials of constriction: Dimensions: Depth of solids: Comments (note condition'of soil, signs of hydraulic failure, level of ponding', condition of vegetation, etc.): 9 - Pace 10 of 1.1 OFFICIAL:INSPECTION FORiMI=.i�IO I FOR-VOLUINTARY ASSESSMENT. S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORiMI. PART,C. SYSTEM INFORMATION(continued) Property Address: %3/'l-tiri_ Owner: Date of Inspectio G2.d✓� SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the;sewage disposal system includin-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`D • �1 t 4 F,% 10 Paae 11 of 11 OFFICIAL INSPEC3'ION FORIM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM;INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: J0 3 Main S� Owner: no r Date of Inspection: I X;L16n SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 1tJ feet Please indicate(check):all methods used to determine the high groundwater elevation: Obtained fromsystem 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 groundwater elevation: ? 11 # Permit Number: Date: Completed by: ._��� HIGH GROUND-WATER LEVEL COMPUTATION Site Location: Jv �`�S �� G' Lot No. Owner: ,? /- Address: Contractor: R-CZ7 Address: ' �" ��✓ 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: OA Appropriate index well............................ ....... © Water-level range zone ................................................. STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to j 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 2B)determine water-level adjustment ...._..................................................................................... V, 419 STEP 5 Estimate depth to high water by subtracting the water level adjustment (STEP 4) from measured depth to water level at site (STEP 1) ......................................................... Figure 13.--Reproducible computation form. 15 TO, / ®� Ll is ray K IF L 1 i t ' I ;.t • ;y COMMONWEALTH OF MASSACHUSETTS ExECUTIVE OFFICE OF ENVIF.ONME�p{NTAL AFFAIRS n y Y KA Y DEPARTMENT OF ENVIRO l t A `CTION - ?905 MAR 14 PM 3: 16 TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM_ FORM PART A' CERTIFICATION Property Address: Owner's Nam Owner's Address: ` Date of Inspecti: ' r Name of Inspec • (please pr'nt) - )(' Company Nam r , a i PL Mailing Address: ( " Telephone Number: 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: _L/Passes Conditionally Passes Needs Further Evaluation by t-e Local Approving Authority Fai s Inspector's Signature: Date: / U" The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within�0 days of completing this inspection.If the system is a sha_-ed system or has a design flow of 10.000 gpd or greater,the inspector and the system owner shall submit the repor_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 ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of.l I OFFICIAL INSPECTIO>N•FORM—NOT FOR-VOLUNTARY ASSESSMENTS SUBSURFACE SEW"AGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address' 3 10., �u, " Owner: Date of Inspection / G Inspection.Summary: Check A,B,C,D or E./ALWAYS complete all of Section D A. S stem Passes: I have not found an. information which indicates that an of the failure criteria described in 310 CMR ' Y Y 15:303 or in 310 CMR 15.304 exist. Ar_y failure criteria not evaluated are indicated below. Comments: B: System Conditionally Passes:. One or more system component3 as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion*"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_O years old*.or the septic tank.(whether metal or not)is.structurally unsound, exhibits substantial infiltratioo.orexfiltration or.tank failure is imminent. System wall pass inspection if the existing tank is replaced with a.complying septic tank as.approved by the Board of Health. *A metal se tic tank will ass ins ectior,if it is structural) sound,not leaking and if a Certificate of Compliance P P P Y � P indicating that the tank.is less than 2.0 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,setaed 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 tr_are.than'4 times a year due to broken or.obstructed pipe(s).The system will. pass inspection if(with approval of the Board of Health):. broken pipe(s)are replaced obstruction is removed ND explain: 2 �I Page 3 of 1'l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner Date o nspection: /a C. Further Evaluation is Require 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 Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 0 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 cr 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 i Page 4 of I l OFFICTAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM' PART A CERTIFICATION(continued) r i Property A dress: Owner: Date of Inspection: 70l c;)C D. System Failure C.r eria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes N9 _ V 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 V cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped (� Any portion of the SAS,cesspool or privy is below high groundwater elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water.supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is.less than 1.00 feet but greater than50 feet from a private water supply well-with no acceptatle 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 nitrcgen.is equal to or less than 5 ppm, provided that no other failure criteria. are triggered. A copy of t=ne analysis must be'attached.to this form.] )The Yes/No system fails. I have determined that one or.more of the above failure criteria exist as ( Y described in 310 CMR 15.303,therefore the system fails. The system owner should contact,the Board of Health to determine what wi_I 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"tc 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 questian in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat.under Section E or failed under Section D shall upgrade the system.in accordance..with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ;. PART B . CHECKLIST Property Address: Owner• / . Date of Inspection: Check if the following have been done. You must indicate"yes"or."no"as to each of the following: Yes /N° . 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) V _ Was the facility.or dwelling inspected for signs of sewage back up? . L' Was the site inspected for signs of breakout Were all system components, excluding the SAS, located on site Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction, dimensions, depth of liquid: depth of sludge and depth of scum? Was.the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System (SAS)on_he site has been determined based on: Yes no Existing information. For example, a plan.at the Board of-Heal- h. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIALINSPECTION-FOR M—NOT FOR'VOLUNTARY ASS - 'ESSMENTS SUBSURFACE SEWAGEDISPOSAL SYSTEM INSPECTION.FORM 'PART C SYSTEM INFORMATION Property Address: fa. " Owner: Date of Inspection: / LOW CONDITIONS RESIDENTIAL VK Number of bedrooms(design):�. plumber of bedrooms(actual): DESIGN flow based on 310 Cv1R 15.203 (for example: 11:0 gpd x#of bedrooms): Number of current residents: Does residence.*have.a garbage grinder(yes or no):Z/o Is laundry on a separate sewage system fAes or no)1 .[if yes separate inspection required] Laundry system inspected y s or no'yt U Seasonal use: (yes or no): Water meter readings; if a i able(last 2 years usage(gpd)): 05-37 OVf�/Mo Sump pump(yes or no): Last date of occupancy:COMMERCIAL/INDUSTRIALI/"`— Type of establishment: Design flow.(based on 310 CMR.15.203): gpd Basis of design flow('seats/persons/sgft,zte,): Grease trap present(yes or no):_ Industrial waste holding tank present Eyes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use:. OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the in �eztion_(yes orn If yes, volume pumped: gallons—How was qua��iity pumped determined? Reason"for pumping: TYP�OOF SYSTEM !�Septic tank, distribution box,soil absorption system _Single cesspool Overflow cesspool Privy vY _Shared system. (yes or no)(if es attach previous ins ecti on re cords, if any)' _Innovative/Alternative technolog-.Attach a copy of the.current operation.and maintenance contract to be obtained from system owner) _Tight tank _Attach a copy'of tie DER approval Other-(describe): A pr xi mate age of all components, date installed(if known)and source of information: Were s . age odors detected when arr:ving.at the site(yes or no):7L/ U) i Paee 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(ccritinued) Property Address: Owner- �` Date of nspection: BUILDING SEWER(locate on site plan)/n Depth below grade: Materials of construction:_cast iron _40 PVC_other(explain):- Distance from private water supply well or suction line: Comments(on condition of joints, venting, evidence of leakage;etc.): ` Z(IocateSEPTIC TANK: on site plan) Depth below erade: �g' �r Material of construction: i/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: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: -- Distance from bottomof scum to bottom 9f outlet tee or baffle'. How were dimensions determined: / Comments (on pumping recommen tions, i et and outlet tee or baffle condition, structural integrity, liquid levels related to outlet m=rt,e ence of leakage, etc.): o r — ? _ O �1 1/6 GREASE TRAP locate on site plan) .Depth below grade:_ Material of construction:_concrete - metal_fiberglass_polyeth;Iene_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 ccndition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7 Page 8 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2b &P Owner. Date of°nspection: /0; �US— TIGHT or HOLDING TANK (:a_A 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: gallor_s 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.); DISTRIBUTION BOX: Z(ifesent must be opened)(locate on site plan) Depth of liquid level.above outlet invert: �outlet Comments(note if box is level and distributiqual, any evidence of solids carryover,any evidence of kage into a out of box,et ): ,. �r PUMP CHAMBE (locate on site plan) Pumps in worki , on�. rder(yes or no):. Alanns in working order(yes:or no': s ti• 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:.• Owner Date Inspection: Q SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why: T Type eaching pits,pumber/ leaching chambers,number: leaching galleries, number: leaching trenches,number, length:. leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of po:ding; damp soil; condition of vegetation, C. /1 10YLC.x'L�YG' 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: 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;°conditiori.of vegetation,etc.) PRI locate on site 1 ;J % (. pan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): 9 Page 10 of 11 L. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .PART C SYSTEM INFORMATION(continued) ; Property Ad.dress:. 1 Owner: y Date:of nspection: r 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 i - r 1000 a l�c�n j j ' an iJOY � 10 Page 1 I of 1 I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property A dress: rJ Owner: )_I Date of nspection: SITE EXAM Slope Surface water Check.cellar Shallow wells Estimated depth to ground water Z&1 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) �ccessed USGS database-explain: You must describe how you established the high ground water elevation: � rill .d 11 Permit''Jumber: Date: Completed by: HIGH GROUND-WATER LEVEL COMPUTATION Site Location: ��d� s ��CIG�� Lot No. Owner: / C �® Address: Contractor: l�f /� / //cS�' Address: Notes: STEP 1 Measure depth to water tole tonearest 1/10 ft. ................................................................................ .Date month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: ?� l O ..Appropriate index we I.................................................... i OWater-level range zone ..................................................... STEP 3 Using monthly report "Current Water Resources Conditicns" determine current depth ,o �Z Zo water level for index well ........................... f� month/year .STEP 4 Using Table of Water-levEA Adjustments for index well (STEP 2A), current depth to water level.for index well (STEP 3.), and water-level zone (STEP 213) determine water-level adjustment ...................................................................................:...... Lo'� STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water levelat site (STEP 1) ............................................................. ............................................... �r Figure 13.--Reproducible computation fon. 15 I ,-Tu • �.......,._�...._,., _._.__,<! �fit ' s' ..._.�®C..f-... _ i I ASSESSOR AWNO FR> ........0 0 ............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiou for Divi-pwial Workii Tvastrurtion Errant Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: Q .. -----•-------------- �.-1 t... •. -•---- ....------•-------------------------------- `�-�,�/,, / cation-Address or Lot No. �p ------•• ............ X W� /'f��,( res ..........-•-.... veil..0 .... Installer Address Type of Building Size Lot............................Sq. feet V 13 Dwelling— No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) dOther fixtures -------------------------------------------------------------------- - --------------- W Design Flow--------------------------------------------gallons per person per day. Total daily flow-.------------------------------------------gallons. WSeptic Tank—Liquid capacity........_._gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench— No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.. 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed bY.......................................................................... Date........................................ ,�. Test Pit No. 1................minutes per Inch Depth of Test Pit-------------------- Depth to ground water------------------------ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 -------------------------------------------------------------•------------•----------•......--------......................................................... 0 Description of Soil........................................................................................................................................................................ x ------------------------------------------ y------......••------------- ----- U Na�u�e ofePa� or Alterations—Answer en a pl'icable;�__ ...j_. ... _ ._.._ • �.........__. ......--•-------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Comp ed b �olard o�he h. 0 - vSigned ... ----------- % Dare Application.Approved BY - .. .. .. -- -............- 3 l3 ----9.S re Application Disapproved for the fo lowing reason.. ....... - .. ......:.......................... . .. - ...... . ........................ .... ................................ - .. - - ......... ... -- --....- _........-............................................ ........................................ Date Permit No. --- ..3.. ---------- -------------- Issued .......... b .............. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiuu for DiaVn.!3ttl lVor1w Towitrurtiuu Famit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: .._. .. ...................... ........... ._. ..... •...................................................... d.o ation-t\ddress • or Lot No. .. ... =-� ---f--------------------------- ---------- ---- ---------------...- ---•--.•...... ... 00 f O� �er� dress _r� Installer 'Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.-.•_____-----------------------------------Expansion Attic ( ) Garbage Grinder ( ) 04 Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures _______________________________ _ _ w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length---------------- Width---------------- Diameter---.------------ Depth................ x Disposal Trench—No. .................... Width-------------------- Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit No.......... .......... Diameter............-------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water....................... Gi, Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water._----____-.-_--.-_-_--. R+ ---------------------------------------------- •-------------------------------------------------- •-.------ -------------------- •--------------- •-•----------- ... 0 Description of Soil.--------•------------------•--•----....------------------------------------------••---------••---------...-------------------------------------------•-•-- •--.... Vx '! --••••---•-•- w ------------- � _._. - - ..------� -- - ---- ----- ---------•-----•••...-- --------------- ------------ s ............... Alterations—Answer when appic __. _-_._._____Naturr ofReU ............ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with j' the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by"the-board of.health. Signed --------------- .� ------------- -----.._. 3. 3.©... f ,— Dve Application.Approved BY -------------- � ��-s �--� - _:..'1..��_-.. rJ' v `Da[e� Application Disapproved for the following reasons: ...._......:.._...._------..._---------------- ---------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------ ----------- ------------------------- C� Da[e Permit No. ......1... -- �` .................. Issued ......__... ....-.: �5...-..yam,. ................. Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE (fErttfirate of CamplianCE THIS IS TO/ CERTIFY.That nd_ii'vidual Sewage Disposal System constructed ( ) or RepatreC��(-�' ) bv--------- �� ' ..:..........._.. .... R `'`� -- _ - - has`been installed in accordance with the provisions of TI fI.E 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ...... ------------------ --------------- dated .....__.__--------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. 5%, DATE-------- --- -- -------- Inspect ---- --- ....... ------- -----_---„--•----------------------- -----_-_---__,--__ --�,-------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH C9� QQ� TOWN OF BARNSTABLE c.°e N0? FEE ............. Permission is hereby grantedO'AnAZ _.. ----------•---------------------------•--•-- to Construct ( ) or Repair ( vidual Sewage Disposes$System , ' -:- - '� �_ at No.------ -•- -------------------- ; •----•---•-- . ----- �' f � f ''' S'frfet p as shown on the application for Disposal Works Construction Dated-_ .......... - ------- "' Board of Health DATE........ -- - -- ---- .................. FORM 36508 HOBBS a!WARREN.INC..PUBLISHERS