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HomeMy WebLinkAbout0059 MARINER CIRCLE - Health 59 Mariner Circle cotuit P A _. 023 045 J ' t Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 59 Mariner Circle Property Address I D Carvill Owner Owner's Name ' information is required for Cotuit MA 10-1-17 every page. City/Town State Zip Code Date of Inspection rya Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important` A. General Information When filling out S forms on the computer,use 1. Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. D.A.BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE MA 02632 2 Citylrown State Zip Code 508-420-4534 S14297 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems..)am a DEP approved system inspector pursuant to Section,15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails Needs Further Evaluation b the Local Approving Authority ❑ y pp g 7141t xcha G 10-1-17 Inspector' ignature 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. ****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. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 /0)04 VS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 59 Mariner Circle Property Address Carvill Owner Owner's Name information is required for Cotuit MA 10-1-17 every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: At time of inspection system met all minimum passing requirements. This report can not predict the future performance under the same or increased usage. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section-need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or 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. ❑ Y ❑ N ❑ ND(Explain below): t5ins•3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 59 Mariner Circle Property Address Carvill Owner Owner's Name information is required for Cotuit MA 10-1-17 every page. CityrT'own State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ 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 t5ins•3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts w r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 59 Mariner Circle Property Address Carvill Owner Owner's Name information is required for Cotuit MA 10-1-17 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *"This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or El ® 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 Y2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 59 Mariner Circle Property Address Carvill Owner Owner's Name information is required for Cotuit MA 10-1-17 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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 ground water elevation. An portion of cesspool or privy is within 100 fee?of a surface water supply or ❑ ® YP P P Y PPY tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 59 Mariner Circle Property Address Carvill Owner Owners Name information is required for Cotuit MA 10-1-17 every page. Citylrown State Zip Code Date of Inspection C. Checklist 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 ❑ ® 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 th is Is inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with 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: ® ❑ 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(5)) D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 59 Mariner Circle Property Address Carvell Owner Owner's Name information is required for Cotuit MA 10-1-17 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: According to the as-built cARD THIS SYSTEM CONSISTS OF A 1000 GALLON SEPTIC TANK D- BOX AND A 60X4X2 FT LEACH TRENCH.ALSO THE ORIGINAL PIT APPEARS TO BE IN PLACE AS WELL. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d HOUSE 9 , ( Y 9 (gP )) VACANT Detail: HOUSE VACANT. SYSTEM NOT DESIGNED FOR USE WITH A GARBAGE DISPOSAL. Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No i Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 59 Mariner Circle Property Address Carvill Owner Owner's Name information is required for Cotuit MA 10-1-17 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type 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)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 59 Mariner Circle Property Address Carvill Owner Owner's Name information is required for Cotuit MA 10-1-17 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: TRENCH WAS INSTALLED IN 1998PER ATTACHED PERMIT. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1.5 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: APPEARS TO BE 1000 GALLON Sludge depth: MODERATE t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 59 Mariner Circle Property Address Carvill Owner Owner's Name information is required for Cotuit MA 10-1-17 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness TRACE Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I RECOMMEND PUMPING AT TIME OF TRANSFER AND AT LEAST EVERY 2-3 YRS THERE AFTER FOR MAINTENANCE. THE HOUSE WAS UNDER REMOVATIONS AT TIME OF INSPECTION AND IT APPEARS THAT THE PAINTERS HAD RINSED THERE BRUSHES DOWN THE SINK. THIS IS NOT A GOOD IDEA AS IT CAN CAUSE THE SYSTEM TO CLOG AND OF FAIL. Grease Trap(locate on site plan): Depth below grade: feet 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: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 59 Mariner Circle Property Address Carvill Owner Owners Name information is required for Cotuit MA 10-1-17 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 59 Mariner Circle Property Address Carvill Owner Owner's Name information is required for Cotuit MA 10-1-17 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): BOX WAS FUNCTIONING PROPERLY AT TIME OF INSPECTION. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: NO OBSERVATION PORTS ON TRENCH OR MEASUREMENTS TO LOCATE ON AS-BUILT. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 5 59 Mariner Circle Property Address Carvill Owner Owner's Name information is required for Cotuit MA 10-1-17 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 1 60X4X2FT ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): THERE WERE NO OBSERVATION PPORTS OR MEASUREMENTS TO LOCATE THE TRENCH SO WE WERE UNABLE TO LOCATE. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts a d Title 5 Official Inspection Fora o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 'r 59 Mariner Circle Property Address Carvill Owner Owner's Name information is required for Cotuit MA 10-1-17 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 59 Mariner Circle Property Address Carvill Owner Owner's Name information is required for Cotuit MA 10-1-17 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 59 Mariner Circle Property Address Carvili Owner Owner's Name information is required for Cotuit MA 10-1-17 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ 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: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G ' 59 Mariner Circle Property Address Carvill Owner Owner's Name information is required for Cotuit MA 10-1-17 every page. CitylFown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 No. Fee (_4jo 1 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: V Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Zfpprication for 3i!gpoal *p.5tem Construction Permit Application for a Permit to Construct( Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Z17 / Owner's Name,Address and Tel.No. Assessor's Map/ParceI Installer's Name Address,and Tel.No. Designer's Name,Address and Tel.No. 02 114 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 000 Type of S.A.S. Description of Soil 0 .oaf ajj 1 40 0� e el L Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of T199 of th ' onrVntal Code and not to place the system in operation until a Certifi- cate of Compliance has been issuedAt#iis B d H Signed Date Qg Application Approved by Date Application Disapproved for We following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed Repaired ( ) Upgraded( ) Abandoned( )by Ott?,- at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. _ dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system yr'll function as designed. Date Inspector > 1 No. �Tf 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 59 MARINER CIRCLE COTUIT,MA 02635 Owner: GEORGE PAPADEMETRIOU Date of Inspection: 9/4/02 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent.reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. ET- A 15 ZTP ac 0A D &I DD L03 y p o C t�i •,t COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PRO In. f NED a • � d SEP 3 0 2002 TOWN OF BARIJSTABLE yK= " ' F• . HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUB SURFACE!SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 59 MARINER CIRCLE COTUIT, MA 02635 02 3 O(l S Owner's Name: GEORGE PAPADEMETRIOU Owner's Address: 20 LANTERN LANE NEEDHAM MA 02492 Date of Inspection: 9/4/02 Name of Inspector: (please print),,,, ;•,JOHN GRACI Company Name: SEPTIC INSPECTIONSi�1.'i,� Mailing Address: P.O BOX 2119 TEATICItET, MA.02536 i Telephone Number: 508-564-6813,FAX 508-564-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as")f the time of the.inspection.The inspection was performed based on my training and experience in the proper functiomand maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes l',5, ' h _ Conditiojases _ Needs Fualuation by the Local Approving Authority Fails Date: 9/4/02 Inspectors Signature: �r� The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspect on. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shalli Anit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ****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. V 4}} S .Page 2 of 1 I '4 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 59 MARINER CIRCLE COTUIT,MA 02635 Owner: GEORGE PAPADEMETRIOU Date of Inspection: 9/4/02 Inspection Summary: Check A,B,C,D,or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information`wliich indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. B. System Conditionally Passes: _ One or more system components as-described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacerq nt or,repair„as approved by the Board of Health,will pass. .Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and''ovef`20;years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfrltrat'.ion 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 oidlls available. ND explain: n/a n/a Observation of sewage backup or break oUt or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or.uneve:distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumomglmoiet 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 _ob'struction is removed ND explain: n/a t , �. Al Page 3 of 1 I OFFICIAL INSPECTIN FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) 4c,• Property Address: 59 MARINER CIRCLE COTUIT,MA 02635 Owner: GEORGE PAPADEMETRIOU; Date of Inspection: 9/4/02 C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or.the"environment:, 1. System will pass unless Board of,Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is withirr 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 tat&and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. t•.r' _ 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 an'8 SAS and the SAS is within 50 feet of a private water supply well. _ The system has aseptic tank and SASand the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used"to determine distance n/a. "This system passes if the.well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is.equal to-or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be'attached to this form. 3. Other: '3 n/a t, a � s Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A `, CERTIFICATION(continued) Property Address: 59 MARINER CIRCLE',COTUIT,MA 02635 Owner: GEORGE PAPADEMET;RIOU Date of Inspection: 9/4/02 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for alLinspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than ''h day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped 1999 BY OWNER. X Any portion of the SAS,cesspool or privy is below high ground water elevation. _ X Any portion of cesspool or privy`is!Iwithin 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or,privy`i�,within a Zone 1 of a public well. _ X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis,performed at a DEP certified laboratory, or coliform bacteria and volatile organic compounds indicates that the well is free 1 :,€ It. , from pollution from`hat 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. Irhave.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 sy'steins in addition to the criteria above) yes no 4! _ X the system is within 400 feet off-a surface drinking water supply X the system is within'200 feet of a tributary to a surface drinking water supply X the system is located in nitrogen'sensitive area(Interim Wellhead Protection Area IWPA)or a mapped Zone 11 of a public water supply'well If you have answered"y'.es't to.:any question in Section E the system is considered a significant threat,or answered It in Section D above the luebe syslcnn has failed.The owner rn operator of any large system considered a signifcant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner 9 'M,, should contact the appropriate regional office of the Department. i.i.: d -Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 59 MARINER CIRCLE COTUIT,MA 02635 Owner: GEORGE PAPADEMETRIOU Date of Inspection: 9/4/02 Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks f X _ Has the system received 'normalflows in the previous two week period _ X Have large volumes of water been introduced to the system recently or as part of this inspection'? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwell''ing'in"spectea for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components;excluding the SAS, located on site '? E X _ Were the septic tank manholes'uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems'? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing information.For'"example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] a �1 r, i ro .3r S 'Page 6 of l I OFFICI AL INSP ECTION N FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 59 MARINER CIRCLE COTUIT, MA 02635 Owner: GEORGE PAPADEMETRIOU Date of Inspection: 9/4/02 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):3,?'Number of bedrooms(actual): 3 DESIGN flow based on 310 CM'R B.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents:2 Does residence have a garbage grinder(yes.or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO 1 Water meter readings, if available(last 2,years usage(gpd)): nfa-0 . 5q,000 Sump pump(yes or no): NO 00 .3 q,0 0v Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 151203): n/a:gpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank;present(yes or no)t: NO Non-sanitary waste discharged to'the Title 5 system(yes or no): NO Water meter readings, if available:n/a, Last date of occupancy/use: n/a ' OTHER(describe): n/a ! GENERAL INFORMATION Pumping Records e 1z,µE;z}�,h t' Source of information: 1999 BY OWNER Was system pumped as part of the inspection(yes or no): NO If yes, volume pumped: n/agallons--',How was,quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) Innovative/Alternative technology, Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a !k t. Approximate age of all components,date installed(if known)and source of information: APPROX 1980 BY OWNER Were sewage odors detected when arriving at the site(yes or no): NO '',- a Page 7 of i I !' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 59 MARINER CIRCLE COTUIT,MA 02635 Owner: GEORGE PAPADEMETRIOU Date of Inspection: 9/4/02 BUILDING SEWER(locate on site plan)' Depth below grade: 22" ; Materials of construction:_cast iron _40 PVC Xother(explain): 20 PVC Distance from private water Supply well or suction line: n/a Comments(on condition of joints,'benting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan)' Depth below grade: 16" Material of construction: Xconcrete metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Isiage:confir`med by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: IOOOG L 8' 6 H Vk.TV,W14"10,','; Sludge depth: 1" Distance from top of sludge to bottom of:outlettee or baffle:33" Scum thickness: 0" Distance from top of scum to tops of outlet tee or baffle: 6" Distance from bottom of scum to bottom:of outlet tee or baffle: 18" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a .. Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc..):.,; t_ t. n/a fh l ,. h.. " k Page 8 of 1 I OFFICIAL INSPECTIONv FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 59 MARINER CIRCLE'.,COTUIT,MA 02635 Owner: GEORGE PAPADEMETRI'OU Date of Inspection: 9/4/02 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) 4 Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons , Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a ass , DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert.: LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distributio 11 n to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): , , 1 4 D-BOX IS STRUCTURALLY SOUND.' PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no):"NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a ( I �F .. d t ' Q Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 59 MARINER'CIRCLE COTUIT,MA 02635 Owner: GEORGE PAPADEMETRIOU Date of Inspection: 9/4/02 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required) If SAS not located explain why: + n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a I leaching trenches, number, length: 60 n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a "t ;_< innovative/alternative system I ( Type/name of technology: n/a Comments(note condition of soil,'sigds`of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): LEACH PIT AND TRENCH ARE'ST IUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE:'BGTTOM OF TRENCH IS AT 5 FT. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or n4'N0 Comments(note condition of soil,signs of hydraulic failure, level of pending,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a s ?: .. : . t 4 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 59 MARINER CIRCLE,COTUIT, MA 02635 Owner: GEORGE PAPADEh.IETRIOU Date of Inspection: 9/4/02 ; SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. A 8 A 6 Z-1`P N3 �l(� ac 17 AD 3'1 'e �0 l03 u t TF 5 2R in Page 1 1 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 59 MARINER CIRCLE COTUIT,MA 02635 Owner: GEORGE PAPADEMETRIOU Date of Inspection: 9/4/02 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 10+feet Please indicate(check)all methods used to determine the high ground water elevatiun: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of;-lealth-explain: n/a NO Checked with local excavators;installers-(attach documentation) NO Accessed USGS database-explain: n/a i You must describe how you establishedkthe high ground water elevation: HAND AUGER- 10+ FT. r i — ---- TOWN Of BAMSTABLE. LOCATION �� '—��/� CIA SEWAGE # VILLAGE ASSESSOR'S MAP & LOT ft 3 O Y w INSTALLER'S NAME&PHONE NO. MIA# hi?arT_ 420—YS1t.9 SEPTIC TANK CAPACITY A100 F LEACHING FACILITY: (type) 1E (size) NO. OF BEDROOMS /�� ,gyp BUII.DER OR OWNER -F1��k CCU.4J PERMPI DATE: —COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of-leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by +dam TMK a 4� r 4 i . p 0; TOWN Or'BAMSTABLE LOCAI-ON SEWAGE # VILLAGE C l.1' ASSESSOR'S MAP & LOT ft!-3- on 4 S INSTALLER'S NAME&PHONE NO. bRt6)q Ar� � J SEPTIC TANK CAPACITY /000 LEACHING FACILITY: (type) J,J� (size) NO.OF BEDROOMS BUILDER OR OWNER Lfk CXOZZ:16 PERMITDATE: COMPLIANCE DATE: .r � Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 6 Udf (770 hv yy, ` No. t } 1 Fee + THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: t/ Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZIpprication for Migposar 6pztem Con6tructton Permit Application for a Permit to Construct( Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Z17 //�/)/)r�,/Q Owner's Name,Address and Tel.No. Assessor's Map/Parcel �"°�aT•LI'u` Installer's Name Address,and Tel.No. Designer's Name,Address and Tel.No. <CL 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 000`/ ----Type��o/ff S.A.S. /� it p � �"� Description of Soil IV/.2 ® L Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Ti of th ron ntal Code and not to place the system in operation until a Certifi- cate of Compliance has been issued is B Signed Date Application Approved by Date Application Disapproved for We follo ing reasons Permit No. Date Issued 4 V No. Fee C� ` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZIpPfication for M gpogal *paem Congtruction Permit Application for a Permit to Construct( Repair( )Upgrade( )Abandon ) ❑Complete System ❑Individual Components Location Address or Lot No. / Owner's Name,Address and Tel.No. Assessor's Map/Parcel eqAa 60- 700 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. .6laW 1qI6Tk1_- f d rLL 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 1 2210 gallons per day. Calculated daily flow r gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 00`© Type of S.A.S. C91 X Description of Soil ��Q C_ZA9, ro Q's, i,%Ole L Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: i The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Ti of the n iron ntal Code and not to place the system in operation until a Certifi- cate of Compliance has been issued is B d f H Signed Date 15 Application Approved by Date ,Application Disapproved for We foll ing reasons " F Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( ) Repaired( ) Upgraded( ) Abandoned( )by at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. _A dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system 'll function as designed. Date l_ - �l } Inspector NO. ILI Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS lwigogal *pgtem Congtruction Permit 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 recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date: 1{�. f� - Approved by 1019/97 _ r NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) hereby certify that the application for disposal works construction permit signed by me dated concerning the property located at _ � �"(2CCE meets all of the following criteria: There are no wetlands located within 100 feet of the proposed leaching facility • There are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed • There are no variances requested or needed. If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will W be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) B)Observed Groundwater Table Elevation(according to Health Division well map) SIGNED: DATE: LICENSED SEPTIC Sy NSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q.health folder:cert r ' i _ C^N X� X9 h � D � fN x x� o e LO`d- TION SEWAGE PERMIT NO. a - . VILLAG INSTALLER'S NAME i ADDRESS 8U LDEIII OR OWNER DATE PERMIT ISSUED_ DATE , COMPLIANCE ISSUED �� t a r ' �.� - �,� i �3 7 S � . y � 3 � No........ t-1 (f Fss.. .v...- THE COMMONWEALTH.OF MASSACHUSETTS BOAR® OF HEALTH .fit .............OF...... ................�:...:.: Appliration for Disposal Marks Toustrurtion ramit Application is hereby made for a Permit to Construct or Repair ( )- an Individual Sewage Disposal Syst at: Ct��'�fC Locatio 'Addy=ss or Lot 'd ..a c e : le-:...... ........ . .............. - ... Owner . . ........ a �Z ..................................... ..... -•...................... �................................................... Installer � Address UType of Building ,� Size Lot__s� _..Sq. feet Dwelling—No. of Bedrooms........ ____________________________Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ...... No. of persons.......4a................. Showers ( ) — Cafeteria ( ) dOther fixtures -------------------------------•----------------------------------------------------------......--------------------.......... ...................... Design Flow................ ...........---..gallons per person per day. Total dai� flow------_3__�.-!Q--_..-.----•-------__gallons. WSeptic Tank—Liquid capacity/2A .gallons Length:.% Width..,5......... Diameter................ Depth................ x Disposal Trench—No..................... Width_. ............... Total Length....... ;..F`.....Total leaching area... sq. ft. �r Seepage Pit No............I...... Diameter......X./........ Depth below inlet..Z.17........ Total leaching area..................sq. ft. Z Other Distribution box (I ) Dosing to ) Percolation Test Results Performed by._...... ! a=�; f �'�..... Date....�1�_. ... ..__.....__.. a ..- Test Pit No. 1................minutes per inch Depth of Test Pit..........._........ Depth to ground water.._._ " �l r' 44 Test Pit No. 2................minutes per inch Depth of Test%P�---•-•----._------. Depth to ground water._ � �. a --------- ------- ---•-•------•-••-----•----....--•------......._._...--------------•--•....------------••----•••-••----•••-•--...----•...----•-•. O Description of Soil.... - _- ..._____._ �. .. /----------------------------------------- --•-•--•--•-------•-•--..•. .. U Nature of Repairs or Alterations—Answer when applicable............................................................................................... --------------------•--•----•-----...---•-•-----------------------------•--......------.....----....----•-------------------------------------......................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIli LE 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 the.,/b, 6ard 9f health. Sie •-• ...............................................� ........... .......... Application Approved By--- ----------•-----• -•-• .....••.--.... -------------------- --I.e. -----.---&d Date Application Disapproved for the'f ollowing reasons----------------•---......._..------•------------------------••-----------------•---------------..........-•••-•. --•-•-••--•---------•-•--•---•--•----•----....----•--------------•---•--•--•-------•-------•----.........._..........-----•-----------------------••-----------......--------------------------....._.._. Date PermitNo............................•. Issued....................................................... Date No................�� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -._,/QcU 1t ..............OF.....� 2.....................(J ..__....... Appliration for Disposal Works Tuntrurtion Frrutit Application is hereby made for a Permit to Construct (x) or Repair ( ) an Individual Sewage Disposal . . Loio Address fj� or Lot No . ........ -•----...--------�---._...------•---•-----•----........ Installer Address U Type of Building Size Lot._J P�...Sq. feet �-, Dwelling—No. of Bedrooms----- - ...............Expansion Attic ( ) Garbage Grinder ( ) yp g ��-_-_- .. No. of persons------- ................. Showers ( ) — Cafeteria ( ) Other—T e of Building ___--..=_ dOther fixtures -----•------------------------------•--•------------._.....-----------------------------------------------•-----------•......._...........--•--.'---'- Design Flow..............=................gallons per person per day. Total daip flow.......3.Z3--_a..._....._..__..._....gallons. W Disposal Trench No......:.......... Width....._.............. Total Length........-....... Total leachin area _.P.e•=n_s . ft. Septic Tank—Liquid"ca ac>t /sad.gallons Len th../C_�s_... Width. ,,�.".._. Diameter.._g Detl�_..__..q..._. Seepage Pit No............I...... Diameter.._......_..._. Depth below inlet.7.3........ Total leaching area......-_-...sq. ft. Z Other Distribution box (� ) Dosing to ( ) _ ' Percolation Test Results Performed by }:. -.!�: _a�CGfrs L Date.... 1 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-___ fz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a _ ------ -----------------------------=----------------------------------- .................................................................... O Description of Soil....�� v G 3U... . - _ ............................... /�%` y ------'-•---•--------------------------------------------------"'-•'•--•----••-••---•'-"'----•---••-•'--•---'-'- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... --------•------------------------•-••---------------------- --------------- -----------------------------------•------------•------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 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 the 'oard gf health., Sipp _4 4 �t Application Approved BY ......................... = Lvl�1 a" 1'� -f✓ ` Date Application Disapproved for the following reasons:................................................................................................................ ........................"-•••'------'•-'-'-•-'•--....---'-'......•...........-'-•-•-•-'--'--•'-------'-••"-"'---'--"---'------•-------•--- ......................................................... Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH'""_.< `; r .".t / t��t'E�S7�/D/� C1C,rJ� ............oF......._ )........................................................... Tntifiratr of font li nr�e TH S IS TO CBWIFY That..th�e�Individual Sewage Disposal System constructed (V) or Repaired ( ) � ' \bY------ -•-�t�--•- ----------•-• ---•`-----••-- Install '--• --- ------•----•....................... at...... Q G� tr C�t� L t r=tc l✓1 �� ------------ Y.. has been installed in accordance with the provisions of 5 of The State Sanitary Cod as desc//r}iibed in lie application'for Disposal Works Construction Permit Now. ............. da.ted.._ ''.........v-................. THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SAT�FACTORY. b .' DATE..........................................---------• -�-----•--•--•------ Inspector,.............._�:��.. l�-:l..................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL 0T lo/ oF..........- . ..h1fi&S....._................:......._................. --�' FEE. ................ t Disposal lVork.5o o#r Ilan , rani Permission is herebygranted .... ! �"!f C__________________ .... "C gI .......................................... to Construct ( or Repair ) an'Individ a1 Se�y�age Di o S s em at No.,J,, /.----� 4 � 1�?,I.rl,�2 L�,t P �'/� 7 r ' - ..........-"•...... st as shown on the application for Disposal Works Construction Pei No. _.. f" Dated../4............................... /D �� . ..... Board of Health DATE. ....---- '"r ................. FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS r .�s- ---- - - - - -- BArSEiJ o�.l V.'S.C: � G-S . [?�r'�s►� a..�`►..2� . 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