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HomeMy WebLinkAbout0154 MOORING DRIVE - Health 154 Mooring Drive Cotuit P ' A = 024 110 y Commonwealth of Massachusetts �N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 154 Mooring Dr Property Address Bank Owned Owner's Name Cotuit MA 02635 11/5/10 City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General 'Information 1: Inspector: Frank Nunes III Name of Inspector saa Company Name 25 Deer Ridge Rd Company Address Mashpee MA 02649 City/Town State Zip Code 508.272.6433 Telephone 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. I 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 by the Local Approving Authority 11/5/10 Inspe is Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. ****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. - /I b 154 Mooring Dr.doc•03/08 _ Title 5 Official Inspection Form:Subsurface SewaYsp.�.l System•Page 1 of 15 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments jA< ,M 154 Mooring Dr . Property Address Bank Owned Owner's Name Cotuit MA 02635 11/5/10 City/Town 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: Pumping suggested every 3 yrs to prolong the life of the system B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass.. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: 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 uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 154 Mooring Dr.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 154 Mooring Dr Property Address Bank Owned .. Owner's Name Cotuit MA 02635 11/5/10 City/Town State Zip Code Date of Inspection B. Certification (cont.) B System Conditional) Passes (cont.): Y Y ( ) ❑ distribution box is leveled or replaced ND Explain: n/a ❑ 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: , n/a C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 154 Mooring Dr.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 1 'Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 154 Mooring Dr Property Address Bank Owned Owner's Name Cotuit MA 02635 11/5/10 City/Town State Zip Code _ Date of Inspection r B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has aseptic tank and SAS and the SAS'is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis,.performed at a DEP certified laboratory, for coliform bacteria 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: n/a 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 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 El or clogged SAS or 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: El ® 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. 154 Mooring Dr.doc-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 154 Mooring Dr Property Address Bank Owned Owner's Name Cotuit MA 02635 11/5/10, City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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 than analysis. his P PP Y P q Y Y LT 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 fleet 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. 154 Mooring Dr.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 r Commonwealth of Massachusetts W Title 5 Official Inspection Form 141 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 154 Mooring Dr Property Address Bank Owned Owner's Name. 1 Cotuit MA 02635 11/5/10 City/Town 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? El ® 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? ® ElWere 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)] 154 Mooring Dr.doc-03/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts W Title .5 Official. Inspection Form Subsurface Sewage.Disposal System Form -Not for Voluntary Assessments 154 Mooring Dr Property Address Bank Owned Owner's Name Cotuit MA 02635 11/5/10 City/Town State Zip Code . Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): unknown DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330per permit Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑- Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Sump pumps ❑ Yes ® No Last date of occu 9/10 per realtorpancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: n/a Design flow (based on 310 CMR 15.203): Gauons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the-Title 5 system?, ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other (describe): n/a 154 Mooring Dr.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 154 Mooring Dr Property Address Bank Owned Owner's Name Cotuit MA 02635 11/5/10 City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: no known pumping 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): Approximate age of all components, date installed (if known) and source of information: Septic Tank from 1980. New D-Box and Leach Chambers 1999 per BOH file Were sewage odors detected when arriving at the site? ❑ Yes ® No 154 Mooring Dr.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 1 � • k Commonwealth of Massachusetts. W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 154 Mooring Dr Property Address Bank Owned Owner's Name Cotuit MA 02635 11/5/10 City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 1 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain):. >10' 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: 6" at inlet end 2' at outlet end 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 ---------------------------------------------------------------------------------------------------------1000g .----------------- Dimensions: - 211 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle >12 Scum thickness 1/2 >211 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle >2 How were dimensions determined? measured 154 Mooring Dr.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 154 Mooring Dr 1M Property Address Bank Owned Owner's Name Cotuit MA 02635 11/5/10 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.):. Pumping suggested every 3 yrs to prolong the life of the system Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ` ,❑ metal El fiberglass ❑ polyethylene ❑ other(explain): n/a 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): n/a 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): n/a 154 Mooring Dr.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 't u Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System form -Not for Voluntary Assessments ;c 154 Mooring Dr Property Address Bank Owned Owner's Name Cotuit MA 02635 11/5/10 City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: 0 Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): n/a *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Level w/the bottom of the pipes 4 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-Box 3' below grade and in excellent condition. No signs of backup Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order:, ❑ Yes ❑ No 154 Mooring Dr.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 154 Mooring Dr Property Address Bank Owned Owner's Name Cotuit MA 02635 11/5/10 City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): n/a Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: leaching chambers number: 2 ❑ leaching galleries number: ❑ Leaching trenches number, length: ❑ leaching fields. number, dimensions: ❑ overflow cesspool number: El 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.): Top of Chambers are 4' below grade. The chambers were video inspected and are dry at this time. No signs of backup 154 Mooring Dr.doc•03/08 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I 154 Mooring Dr Property Address Bank Owned Owner's Name Cotuit MA 02635 11/5/10 City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 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.): n/a 154 Mooring Dr.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 154 Mooring Dr Property Address Bank Owned Owner's Name Cotuit MA 02635 11/5/10 City/Town State Zip Code Date of Inspection D. System Information cont.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. --------------- • y 'I . �NfIL. C- Lj(0 L3 t D '�3 P) S cKL-z 154 Mooring Dr.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 w: e Commonwealth of Massachusetts w Title 5 Official lnspection Form Subsurface Sewage Disposal System form -Not for Voluntary Assessments yc°�M 154 Mooring Dr Property Address Bank Owned Owner's Name Cotuit MA 02635 11/5/10 City/Town ' State Zip Code Date of Inspection D: System.Information (cont.) Site Exam: I ❑ Check Slope Surface water ❑ Check cellar ❑ Shallow wells _Estimated-depth to high ground water: >144"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: 1980 NGW 144" Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: Checked with local excavators, inst II Ela ers (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: see above ti • 154 Mooring Dr.doc•03/08 ' - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 �, 11I5 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIR' z j DEPARTMENT OF ENVIRONMENTAL PROTECTI OPY � ' C e k TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART..A CERTIFICATION IVED Property Address: 154 MOORING DR COTUIT 02635 M024 PI 10 Owner's Name: MELISSA. ROODl( "; Owner's Address:—, 154 MOORING DR COTUIT 02635 3LE Date of Inspection: 2/25/03 Name of Inspector: (please print) JOHN GRACI, INC. Company Name: SEPTIC INSPECTIONS MAR c Mailing Address: P.O.BOX 2119 TEATICKET, MA. 02536 PARCEL Telephone Number: 508-564-6813 FAX 508-564-7270 LOT CERTIFICATION STATEMENT I certify that 1 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: X Passes Conditiona Passes _ Needs Fur er Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 2/25/03 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 shall submit the report to the appropriate regional office of the DEP. The original should be sent to the.6ystem owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments THE SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. SYSTEM IS IN GOOD WORKING ORDER. ****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. "(iO" 5 Incw-r•lion I-nrn, (/IS/7(1(1(1 ) .. .. y 7 Page 2 of 1l i OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 154 MOORING DR COTUIT 02635 M024 P110 Owner: MELISSA ROOD Date of Inspection: 2/25/03 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 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: THE SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. SYSTEM IS IN GOOD WORKING ORDER. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: 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 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: n/a n/a 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: n/a Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 154 MOORING DR COTUIT 02635 M024 P110 Owner: MELISSA ROOD - Date of Inspection: 2/25/03 C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and-environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance 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: n/a Page 4 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 154 MOORING DR COTUIT 02635 M024 P110 Owner: MELISSA ROOD Date of Inspection: 2/25/03 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than'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 NOT IN THE LAST YEAR.. X Any portion of the SAS,cesspool or privy is below high ground water elevation. _ X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for 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.] _ MYes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ X the system is within 400 feet of 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 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. a Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 154 MOORING DR COTUIT 02635 M024 P110 Owner: MELISSA ROOD Date of Inspection: 2/25/03 Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health _ X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out ? X _ Were all system components,excluding the SAS, located on site.? X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing information.For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] S Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 154 MOORING DR COTUIT 02635 MO24 P110 Owner: MELISSA ROOD Date of Inspection: 2/25/03 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Q� - Water meter readings, if available(last 2 years usage(gpd)): ioT 6�e 1 v00 Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(s eats/person s/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): 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 Source of information: NOT IN THE LAST YEAR. 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 Approximate age of all components,date installed(if known)and source of information: 1999 FROM ASBUILT 99-71 Were sewage odors detected when arriving at the site(yes or no): NO Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 154 MOORING DR COTUIT 02635 M024 P110 Owner: MELISSA ROOD Date of Inspection: 2/25/03 BUILDING SEWER(locate on site plan) Depth below grade: 22" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN 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 Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: L 8' 6" H 5' 7" W 4' 10" Sludge depth: 0" Distance from top of sludge to bottom of outlet tee or baffle: 34" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 17" How were dimensions 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 SEPTIC TANK COMPONENTS ARE STRCTURALLY 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.): n/a 7 Page 8 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 154 MOORING DR COTUIT 02635 M024 P110 Owner: MELISSA ROOD Date of Inspection: 2/25/03 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box,etc.): D-BOX WAS VIDEO INSPECTED AND APPEARS TO BE STRUCTURALLY SOUND AND SYSTEM SHOWS NO SIGNS OF FAILURE. 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 R • f Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 154 MOORING DR COTUIT 02635 M024 P110 Owner: MELISSA ROOD Date of Inspection: 2/25/03 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type n/a leaching pits, number: n/a 500 GALLON CHAMBERS leaching chambers, number: 2 n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): THE LEACH FIELD CONSISTS OF TWO 500 GALLON DRY WELL CHAMBERS-RECOMMEND RAISING COVER TO FIELD FOR MAINTENANCE AND INSPECTION. BOTTOM IS AT 7' -THE LEACH FIELD SHOWS NO SIGNS OF FAILURE. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): n/a 9 R . Page 10 of OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 154 MOORING DR CO'I'UIT 02635 M024 P110 Owner: MELISSA ROOD Date of Inspection: 2/25/03 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmirks. Locate all wells within 100 feet. Locate where public water supply enters the building. _J AA AP AC t�� A t� J, in Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 154 MOORING DR COTUIT 02635 M024 P110 Owner: MELISSA ROOD Date of Inspection: 2/25/03 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) YES Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: GROUNDWATER DETERMINED BY HAND AUGER AND USGS MAPS AND CHARTS-NO WATER AT 12'- BOTTOM OF FIELD IS AT 7' tt No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for Mi!6pozaf 6potem Construction Permit Application for a Permit to Construct( Repair(�I�pgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. IYV 6'l-C� 0iii .6 Owner's Name,Address/arnd Tel.No. Assessor's Map/Parcel convir // �o ty 6{e ,q�y y , a2 `! �r � CG U Installer's Name,Address,and Tel.No. t/7yJ—O Y Designer's Name,Address and Tel.No. jojel Jo ! % s Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank / Type of S.A.S. Description of Soilr���/ Nature of Repairs or Alterations(Answer hen applicable) 3r/ lf_� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system. in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed Date Application Approved by Date Application Disapproved for the following reason_s6L_L�_� Permit No. Date Issued r } J No. Fee J THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppfication for Mioomf *pztem- Construction Vermit - Application for a Permit to Construct( Repair V,.4-flpgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. f S/ ©O/'/f'J Q ��,I V` t Owner's Name,Address and Tel.No. Assessor'sMap/Parcel GOrvJr Installer's Name,Address,and Tel.No. !,/�J�f—D �/9 Designer's Name,Address and Tel.No. S�v r Type of Building:t Dwelling ' No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( ) Other[ Type of Building No. of Persons Showers( ) Cafeteria( ) Othev'Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank / Type of S.A.S. Description of Soil S1*eeJ Nature of Repairs or Alterations(Ans hen applicable) Z,�rl4�Z 2 g00 �a0/ Jro4� eWM0Wwer " Pao srodla. ' Date last inspected: . t Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordan"e with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Boar of Health. Signed a. Date Application Approved by' i Date Application Disapproved for the following reasons V v Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS • i Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constr6c-tedi'( r.+Repaired,( )Upgraded( ) Abandoned( )by � 1, 1�� / �s�.•roS ''` �° at rl ✓ir a een constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated" n I Installer Jos—e-A &VA405 Designer e_ 4 4e a 5 The issuance of this permit shall not!b�e construed as a guarantee that the system will function as designed. Date - t Inspector r Or No. ------- — — — --- Fee ...--- THE COMMONWEALTH OF MASSACHUSETTS �'�y k PUBLIC HEALTH DIVISION -:BARNSTABLEs MASSACHUSETTS Disposal 6pelem Construction Verm t) ' J Permission is hereby granted to Construct( s}Repair O Upgrade( )Abandon( ) System located at /5'y �rrotpr lsac� 1'ri yi= and as described in the above Application for Disposal System Construction Permit.The applicant recognizes 's/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Con st b cont eted within three years of the date of permit. Date: /f �li`l Approved r b `. l i =/ J . 1 n 1/6199 NOTICE: This Form Is To Be Used For the Repak- Of Failed Septic Systems Only. CER=CATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS hereby certify that the application for disposal works construction permit signed by me dated y—S—9q concc:rung the property located at _ /,5'Y (A 1�'I� ��, meets all of the followin ,criteria: The failed system is connected to a residential dwelling only. There are no conw ercial or business s associated with the dwelling. soil is classified as CLASS I and the percolation rate is less than or equal to `.+ minutes per inch. ere are no wetlands within 100 feet of the proposed septic system Them no private wells within 150 feet of the proposed septic system ere is no increase in flow and/or charge in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than five feet above the ma.,dmum adjusted groundwater table elevation. ,Adjust the groundwater table u:;;ng the Frimptor method when applicable] • If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom cf the proposed leaching facility will not be located less than fourteen(14) feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) _ v /19 B) G.W. EIevation +the MAX.High G.W. Adjustmentz—,L=_ to (P,�, DIFFERENCE BETWEEN A and B p SIGNED DATE: (Sketch proposed plan of system on back]. q:health folder.cent a, p0�1 ,bras-vx- Y 7 l� ' ��� 0001 r < <s No......_..:. ez .. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H EA T N..............O F.........�c,.�.. Appiiration for Uiipniia1 lVorbi Tnnitrurtinn Prrutit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at• 4 4 ......... ... .. ......... ... ......... ....... ... o)/ Owner o / ess Installer Address / Type of Building Size Lot .....Sq. feet Dwelling—No. of Bedrooms........jci4...........................Expansion At is ( ) Garbage Grinder a Other—Type of Building _ No. of persons ..........1""... Showers ( ) — Cafeteria ( ) d Other fixtu -------- Design ------. Flow......... �• gallons per person d Total it flow.._........ lL,E'................ Ions. W g P P �' y WSeptic Tank—Liquid capacity ..gallons Length__ .. Width ®__ Diameter________-___-• Depth................ x Disposal Trench—No..................... Widt ---------- Total Length..................F Total leaching area--------------------sq. ft. Seepage Pit No....../--------- Diameter... ----------- Depth below inlet..7- 3i. .... Total leaching area.d q. ft. Z Other Distribution box Dosing tan ) `-' Percolation Test Results Performed by--- o.,m V-------- 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........................ a •-•-•---•---..... - . ................................ O Description of Soil W -- ,/ ----------------------•--------------------•----------------------••-------------------------•••... ---------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alteratioris—Answer when applicable_______________________________________________________________________________________________ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with -the provisions of TITIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' sued by the rd of ht?alth. Signed_... ...................... Date ApplicationApproved By.................................................................................................. Date Application Disapproved for the following reasons:.............................................................................................................. ••--•-••-•••••••-••••••-•••--•--•-•••---...••••••--•-•••••--••------•----•-•---•--•--.......-•••-••-•----•••--••---••••--•-........................................................-•--------•---•--- ` Date Permit No......................................................... Issued...C;K f Date No...._...... :.. F .............................. i J THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH, /............oF.......... '. -fl ApplirFatiun for UiupuuFal Works Tonutratiun Vrrmit Application is hereby made for a Permit to Construct O or Repair ( ) an Individual Sewage Disposal System at,, �r:�. Z .... - -•--•�. ... .. ,11� Loc on"'Address / �/ or'I:ottNo. /�� --•�' /Owner/• y Address .....Gf r.(.d /'i .;�:l�. e4........l .. .......................... Installer Address Type of Building Size Lot_u �-._--Sq. feet U Dwelling—No. of Bedrooms........ ____________________________Expansion Attic ( ) Garbage Grinder ( ) '_l Other—Type of Building !11-,!e'Z%jte� No. of persons.....__...� ------------ Showers — Cafeteria d Othertes ...61 ; Design Flow............................................gallons per person p >t day. Total daily flow.._........._2::Vn................gallons. WSeptic Tank—Liquid capacityZ��M.gallons Length___.._e Width..... !`_. Diameter................ Depth................ Disposal Trench—No,. .................... Width.................... Total Length......... ._._... Total leaching area------ ---___._sq. ft. Seepage Pit No._...../.....__.. Diameter ............ Depth below inlet._ _..__ _..._. Total leaching area.._ �4.�4 ft. Z Other Distribution box ( ) Dosing tank ( ) '-' Percolation Test Results Performed by..........��' .A&glvr-t __.._ Date... ...... . •--.-•-_.. _... = a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground fs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �+ --••-•---- r� ........................... O Description of Soil..................... .. 1 ...j..' .. ?".................... =. •? , t s W ---------------------------------------------------------------------------------------------------------------------------------------•---------------------------------------•---•-••---------•------- 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 TITIE 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 board of health. Signed - Date Application Approved BY.......�<4L.................................... ---•--••--•-------------................. Date . Application Disapproved for the following reasons:-------•--------------------------------------------------------------------------------------•----......._..-- ------•----------•------.._...•-•---'-------'---•--...••-•-••--•------••-------•-•------------------------------------•-•-------------------------•----•---•-••-•--•-•--••-------•----•-•••-•--•---..--- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH "7"> ,, 4 /Kr'/ /.........OF....... ................ l/17. ................................ w Trrtifiratr of Tuntlitt anrr THIS IS TO.CERTIFY/ That the.Individual Sewage Disposal System constructed (,X) or Repaired ( ) 1�.�.>/. ../_ .!r'�/ z t 1. by ..;.......... .. -----------------------------------•---•--•--'---._.....--•••••'•..................---......--------_.._--'-----._.'•-----•-- Installer ---------------------------------------------------------------------------------------------- has been installed in accordance with-the provisions of TIT F of The State Sanitary Code as described in the application for Disposal Works Construction Permit No....... _!' __ _Pt_ ..... dated------- "' ....... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTI N SATISFACTORY. DATE.......... D ----'...-•---- inspector,.G_ ------.....THE COMMONWEALTH OF MASSACHUSETTS / ► BOARD OF. � HEAL�/T'H / ........fff�..IC.. OF..............?../r...' .r i�f�st'..l.c'�.-----..................... No...... ....... .... FEE. ....` ...... �iu�ruuttl,Turku �unufrnr#iun rrutit Permissio is hereby ranted...... --�� . . r . Systgm at No.sty(-"C);r�.�R,epai�(�r�)�-� rivid�... r�-�'� Disposal ,./ -•--..._.... �//`` Street as shown on the application for Disposal-7orks Construction Perini o___ Dated....., �7'.. • Board of Health DATE........ _... ---�...._...��....................•------•-------- FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS - .. . u 1 Pw TOWN OF BARNSTABLEe,,_�c—�j►� 9� ,LOC,kTION f i '0 I .[J h1la SEWAGE # VILLAGE� // ASSESSOR'S MAP& LOT 0� '//J INSTALLER'S NAME&PHONE NO. f�11-0:74Ya SEPTIC TANK CAPACITY , loon LEACHING FACILITY: (type) 2 6ofil aw w011S (size) 5-X /i NO.OF BEDROOMS 3 BUILDER OR OWNER PERMITDATE: 4/ — !, 9`�i' COMPLIANCE'DATE: el — Separation Distance Between the: Maximum Adjusted Groundwater Table and 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)f Feet Furnished by "� �`� a � i b �, Q n s3 , _ �� :e ,�. _ � -� _ � � • � � c ash .. ; . 03nSsl 3 :) Nvlidwo3 31va a3ASSI 11MV3d 31y0 —/Md � N3 NMO vo v 3 0 l l n N SS3VOOv I 3wvN' 4311 v1SNI 19v111A 'ON liwV 3d 3 9 V M 3 S NOl 1 v13 u I O Cti L r `f kv- 1. b I a r 1 r: ELEC. E PNL. E CO2 S 0 H.W.H. UP 'I MECHANICAL o s T C m GAS ui y 'O BOILER a a '> a cn p i p n� �~ 1 FAMILY ROOM 12'-9"x22'-8" N S 0 BEDROOM = _ 11 0"x1T_0" to s civ-r c�i 2"x4"STUD PARTITION W/32'R-13 0 x< BATT. INSUL.COMPLYING WITH 3'-0" LAUNDRY 2009 IECC: CHAPT.4 TABLE 402.1.1 F.T.RCD MCI-% Fir ;L`7 Ella V El J � 0)W C ° NEW EMERGENCY ESCAPE WINDOW '� W 36"A.F.F.,COMPLYING WITH 2O09 IRC R310 0 " MIN.OPENING HEIGHT 24", W 0 � o MIN OPENING WIDTH 20" Lu m � LoO 2 LOWER LEVEL PLAN 0 SCALE: 4" = 1'-0" a z Z :3 i r f•!�tY+ I-X'IV4SH OrAV-4• _ r✓r/V(SM GtA'pE R,*,4w 415-IT,4 veer - - - -�__-.� _�_� �` i D✓�rQ Tip N K � �� �✓�� /m;T = .�rsJ_..:2.. r TOP oiF-eVNO. 1 ; �'�:•u:�,�,,�ii�y.`�Y'`�"�J/,(sJu!�'.�/,d''i y,��J,C �iC•�li(�JS��T%. - - - _ _.. . Ae Vf C-.f"w 9 F j l/,� 6AL I � / o o �� A 11 . Ecty + t D 1ST box o'► �1, L it{1 t eel ..-� \4it �- J 1 y erorre�► o f Sys �► ort&C . �+n• � .S�c a *--- _ ___ -- -- �'-=Q- —-. =`�._.,._�,,; `, .. r LEr9GN1fK� P,rT � � DES r G/tif C,p� r'E�EA � ,No a F ",3 � �. -•- �� ; � . �'� '�� '. GAG. PE•¢ t.��yrY - -- -•• � � -�.._..__----. ._�__....... •. ICA om 7c / Air llwvlolly ,1r5I•r� U T �-CJ 0. i I r: or !" 4,-�w'���!NCB INSOC3G7"�D �: 1�t='::/L /�1[/,�E�.�.•;*j/ t�'✓.?.r='.�/ .c�'1'7 /iai'G'.•!'r�,% . Pam!TL .tc•AfrE 2�,�w/,rd S[i!t-E•- J` �3�r �9rE• s r � G�w rj Cis cIe e 44 r>, 7-4,isr rk �, � %-, �,,�'°��,.. ,,;� ��LE-✓- cy .�S L . D,4>u,�'9 �.C-��i9 T Po�vt7 �Qi v� ;1�-441 z:'Al P1.,9f� 5• yA�MG t.JTI�, �q 5 3. "o Oe M A Av �^I7� P i1rE IL• OO GA11� 4 L