HomeMy WebLinkAbout0045 OLD KINGS ROAD - Health 45 Old Kings Road
Cotu it P
022 067
F,
'I
SEWAGE INSPECTIONS
LOCATION DATE fl
VILLAGE—C4Q,I r ASSESSOR'S MAP & LOT D—
-INSPECTOR �, wa c n a1rD�i�_
SEPTIC TANK CAPACTIY
LEACHING FACILITY: (type)Lp cl lib ize)
t
NO. OF BEDROOM.-..-2' ,
B JILDER OR OWNER ► Qro '�
OWNER MAILING ADDRESS /
J
i
`3q%
d �
DECEIVED
OCT 0 6 2004
TOWN OF BARNSTABLE
HEALTH DEPT.
DATE_9/17/04—__
PROPERTY ADDRESS- 5 O ed K�.n_cA_1?�a6L-- �22
BAR ,.._. -
;,. C o t u i t ''ARCKb,
Mazz 02635
�0T
On the above date, the-septic system at the above address was
,
Inspected.
This system consists of the following:
1-1500 gae.eon .sen.ti c �laak.
1-Dista.igut.ion Sox.
2-500 ya.e.eon ieach.infc�hrtai�� �e' foilowIng conditions:
Based on inspection, y
7h.i,6 .i.6 a t-it.ee dive 6e/2t.ic
ao ea woak.iag. oadea at the /zae�ent
the •3el2t.ic. Z y',tem
time.- at time o� inh/zectz. .
.eeach.ing cham9e2-3 we to day
SIGNATURE: _ --------
3
/ZO eat l aoi'�ni __--
N a m e:-------�---- ------
l. Macomaea and,- .son, Inc. —;
Company.•-a.-------
Address:_ ------ ;
0_• Box-6 6 ----------- M i
Cen.teavii,ee, Ma.:02632
00 m
I
Phone:_15 0 8,1-7 7� �3$_-----------
T CONSTITUTE A GUARANTY OR
THIS CE
RTIFICATION DOES NO
WARRANTY
rjOSEPH p. MACOMBR & SON, INC.Tanks�Cesspoots-Leachfields
Pumped & InstalledTown Sewer Connectionsox 66 Centerville, MA 02632-0066
775.3318 775.6412 /;
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF EN vIROrNMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTMION
a
r TITLE 5
OFFICIAL INSPECTION FORM—.NOTE FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PARTA
CERTIFICATION
Property Address: 4 5 O-ed Urz g,3 Road
Co.tuit Na 02635
Owner's Name: Che2uP Ni4-P 'amn
Owner's Address: .6 am e
Date of Inspection: 9/13 0 4
Name of Inspector: (please print)42 o A e z t. /?a o i a. '-
Company Name: „ , P.:1lacom4 e2 & .Son Inc.
Mailing Address: Pox 66
- Cen ezv.c e, a.�b.•02632 .
Telephone Number: 5 0 8—7 7 5_3 3 3 8
CERTIFICATION STATEMENT
d at the.information reported
em at this address an that dis disposal s st P
I certify that I have personally inspected the sewage p y .
as of the time of the inspection.The inspection was performed based on my
below is true;accurate and completeP
stems.I am a DEP
training and experience in the proper function and maintenance of on site sewage disposal systems.
approved system inspector pursuant to-Section.15340.of Title 5(31-6 CMR 15:000). The system:
xzxPasses
-Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
VFai
P
Ins ector's Signature: Dater P
The system inspector shall submit a copy of this inspection reporrto the.Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system;is.a.shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner.shall submit the report to the appropriate regional office of the
DEP.The original should be sent to-the system owner and copies sent to the buyer,if applicable,and the approving.
authority.
Notes and Comments "
****This•report only describes conditions at the time of inspection'and under the conditions of use at that
M '~ time.This inspection does not address how the system will perform in the future under the.same or different
conditions of use.
Titlo 5 In-me tin / / 000 page I
.c� n Form 6 15 2 P g ,. . .
Page 2 of 11
OFFICIAL INSPECTION:FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM,INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:4 5 0 ed Kin.Q.3 Road
Cotui.t Na
Owner:Che2ui Wi e eiam,3
Date of Inspection: 9/13/0 4
Inspection S.ummary: Cheek A;B C;D or.E/ALWAY&comglete>all of Section,D
A. System Passes:
NO I have not found any information which indieates'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:
SP1011r A14A1om iA in T nnr on ),)nnkina nnr/on ni fhv +p7__APRi i.t_my.
B. System Conditionally Passes:
NO One or more system components as described in the"Conditional Pass":section need to be replaced:o.r
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.
NO. • 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 bytheZoard 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:
NO. 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):
N A broken.pipe(s)are replaced. .
N A obstruction is removed
N,4 distribution box is leveled or replaced
ND explain:
NO 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):
NA broken pipe(s)are replaced
N R obstruction is removed
i
ND explain:
Page 3 of 11
OFFICIAL INSrPECTION FORM-NOT TOR VOLUNTARY ASSESSMENTS
SUBStWACE SEWAGE DISPOSALSYSTEM INSPtCTION FORM
PART A
CERTITICATION'(ooritinued) :
Property Address: 4 5 O ed Una Roa.d
CotuTt Na
Owner:. Che2y.2 ViV.7ainz
Date of Inspection: 9/13/04
C. Further Evaluation-is Required by the Board of Health:
NO Conditions.exist which require further.eyaluation.by.the,Board o€-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 mariner which will.protect public health,safety and the.-environment:
N,4 Cesspool or privy is within 50 feet of asurface water
NA 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 mariner that protects the public health,safety and environment:
NO 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 asurface water supply.
NO The system has a.sepiic tank and SAS and the!SAS is within a Zone I of a public water-supply.
NO The system has a septic tank and.SAS and-the SAS is withint.50 feet of a private water supply well.
N 0 The system has a septic tank and SAS and the-SAS is less than 100 feet..but 50 feet or:more front a
private water supply well". Method used to determine distance
**This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from-pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5.ppm,provided that no other
failure.criteria are triggered.A copy of the analysis must be.attached to-this form.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR:VOLUNTARY ASSESSMENTS'
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:4 5 Oid Ki n g.a Road
Loturt 17a
Owner:Cheayi .c iam1s
Date of Inspection:
D. System Failure Criteria applicable to all systems:.
You must indicate"yes"or"no"to.each.of the.following:for all inspections:
Yes No
_ X Backup of sewage:into fheility..or system component due.to overloaded or.clogged SAS..or cesspool
T Discharge:or ponding of effluent to the surface of the ground or..surfacematers 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 thank"below invert or available volume is less than%..day flow
T_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
X of times pumped ,
_ 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.
_ X Any portion:of a cesspool or.privy is within a Zone 1,of a:.public.well..
_ 7- Any portion of a cesspool or privy is within.50 feet of a private water supply well.
7 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..]
N0 (Yes/No)The system fails.I have determined that:one or:more:of,the:above failure:::criteria exist as
described in 310 CMR 15.303,therefore the system.fails.The system owner.should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the:system must.serve.a facility,with a design flow of 1.01000 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 �o
_ the system is within 400 feet of a surface drinking water supply
_ X the syste m.is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area Qnterim 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.
.4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
9ifUSURFACE SEWAGE DISPOSAL`SYSTEM INSPECTION FORM
PART B
CHECI{LIST
Property Address: 45 Oed Urtgz Road
o ai
0wner:Che2y C GI C 2 irim.3
Date of Inspection: - A 9 1 31/0 4
Check.if the following have been done You must indicate"yes"'or"no"as.4o 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?
V — 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 depthof scum?
X _ Was.the facility owner(and occupants if diff6rent 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.
— Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance .
is unacceptable) [310 CNM 15.302(3)(b))
li:.
5
Page 6 of 11
OFFICIAL I;NSPECTION::FOR -NOT FOR VOLUNTARY ASSESSMNTS
SUBSURFACE SEWAGE BISP.-.OSALSYSrTEM,%INSPEC"TIOL.�IFORM
PART.0
SYSTEM INFORMATION
Property Address:4 5 Qipp -K.in g.s 1?o aN
Co.tu.it
Owner: Che2u e V Lei iam.6
Date of Inspection:-9//-3./01
FLOW CONDITIONS
RESIDENTIAL
Number of bedroorits(design: , °Number of.bedrooms.(ictual):3
DESIGN flow based on*310 C&M 15.203'(I'or example:-110 gpd z#U bedroo'a X/ �0-3 3 0 G%1D
Number of current residents: .:
Does•residence have a garbage gr'der(yes br no °
Is laundry on a separate sewage.system(yes or.no):? Eif yes separate inspection required]
Laundry system inspected(yes or no):no
Seasonal use:(yes or no)h•o
V�ater meter readings, if available(last 2 years usage(gpd));?- Z R 6, Q 0=2 3 5., 6 yl2d
Sumppum (yes orno):no 2003_87, '000=238., 3yl2d
Last date o occupancy: 121t e Z e n t
COMMERCIA•hMUSTRIAL
Type of estal A-1141
fit: NR
Design flow. �on 310 CMR 15.203):. NA gpd
Basis.of doipii'flow(seats/persons/sgft,etc.):, NA
Grease trap#esent(yes or no):U
Industrial waste holding tank present(yes or no):/y.4_
Non-sanitary waste discharged to the Title 5 system•(yes or no):NR
Water.meter readings,if available:NA.
Last•date of occupancy/use: . N4
OT4ER(describe):. NA .
GENERAL INFORMATION
Pumping Recprds
Source of information. not ava i.2ag.2e
Was system pumped as part of the inspection(yes or no):4p-h
If yes,volume pumpedl 55 0_gallons--How was quantity pumped determined? m e a a ua ed
Reason for.p..umping: M(z inta:infz.nce
TYPE OF SYSTEM
14L.Septic tank,distribution box,soil absorption system - .
n _Single cesspool
no_Overflow cesspool
n o Privy
Shared system.(yes or no)(if yes,attach previous inspection records,if any)
rLa Innovative/Alternative.technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
no Tight tank. _Attach a.copy.of the DEP.approval
no Other(describe):
Approximate age of all components,date installed(if known)and source of information:
6 yea2.6 Insta2ied 3119.198 A,69ai.O.i
Were sewage odors detected when arriving at the site(yes or no)h_Q__
6 _
Page 7 of I l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 4 5 O.Qd k in n.s Road
o u.c
Owner:Che,tyX 777-, X-iama
Date of Inspection: 9/13
A A •
BUILDING SEWER(locate on site plan) `
Depth below grade: 12
Materials of construction:_cast iron X 40 PVC_other(explain):
Distance from private water supply wed or suction line: N,4
Comments(on condition of joints,venting,evidence of leakage,etc.):
Xeakage., n� o
SEPTIC TANK:—qxf$ocate on site plant'5 00 ya-teo n tank.
Depth below grade: 14"
Material of construction: X concrete metal fiberglass_polyethylene
_other(explain) —If tank is-metal list age:NA Is age confirmed by a Certificate of Compliance(yes or no):_(attach a co of
certificate) PY
Dimensions: 10' 6" L X 5' 8"X 5/7"K
Sludge depth: 2 a c e
Distance from top of sludge to bottom of outlet tee or baffle: t a a c e
Scum thickness: t 2 a c e
Distance fiom top of scum to top of outlet tee or baffle: 0
Distance from bottom of scum to bottom of outlet tee or baffie 0
How were dimensions determined; me a.6 u a e d
Comments on( pumping recommendations,inlet and outlet tee or baffle condition,structural irate
as related to outlet invert,evidence of leakage,etc.): Britt',liquid levels
Pump tank eve2y 2 to 3 yeaaz �,P-o�z ma.iataance.•
tees aze .in 12.lace. tank 2uc u2a Irz het out het
y �soun
GREASE TRAP:d(locate on site plan)
Depth below grade: NA
Material of construction: concrete_metal '
(explain): NA — _fiberglass__polyethylene—other
Dimensions: ti q
Scum thickness: NA
Distance from top of scum of um to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or-baffle:NA_
Date of last pumping:AA
Comments(on pumping recommendations,inlet and outlet tee or baffle l integrity,condition,struc
as related to outlet invert,evidence of leakage,etc.): liquid levels
rat °
Titles C TnorAr.tinn Fnrm!./1 C/7(1!1/1
7
Page 8 of I I
OF'vICIAE IN.S•PECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
�& URF ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continues})
Property Address:4oO-ed__L'� Road
Owner:Che)zui 6J.iiiiam�3
Date of Inspection: 9/ 3/•0 4
�A \
K.
TIGHT or HOLDING TANK: N0 (tank must be pumped at time of inspeetion)(locate on site plan)
Depth below grade:NA
Material of construction: concrete metal fiberglass___polyethylene other(explain).
NA
Dimensions: N
Capacity: NR -gallons
Design Flow: NA gallons/day
Alarm present (yes or no): NA
Alarm level: NA Alarm. working.order(yes or no):
Date of last pumping: NA
Comments(condition of alarm and float-switches,etc.):
7igh.t oa ho.Pd.ing. .tanks a p a.04 PAAAAni
DISTRIBUTION BOXye.s (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invertno
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,):
Diis.taigut.ion Pox ha.s I .E?a.teza.e No, .6iaa,6 o-1 zoe..id.6 ca22u
�ouvn Nn.v o»ir�o_nro n� l�on.ka�o in nn nul n, ke)4.
PUMP CHAMBER: Zo (locate on sife.plan)
Pumps in working order(yes or.no): NA
Alarms in working order(yes or no)Nd_
Comments(note condition of pump chamber,condition of pumps and appurtenances,etb,);
Piim rhnmOpo iA nnf �nno4onf
8
Page 9 of 11
OFFICIAL INSPECTION FORM—'NOT FOR VOLUNTARY ASSESSMENTS
---. SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART:C
SYSTEM INFORMATION(continued).
Property Address: 45 0 ed K.ia gz rd v_..
Co.tu.it. Na
Owner:.Che2u.e WILLiam
Date of Inspection: 9/1 3 0 4
SOIL ABSORPTION SYSTEM(SAS):_-(locate on site plan,excavation not required)
/nratpd .sPa aaav 90
If SAS not located explain why:
Type
n o leaching pits,number:_
y e L leaching chambers,number:. 2 `
rz o leaching galleries,number:
leaching trenches,number,length:
n,)_leaching fields,number,dimensions:
n o overflow cesspool,number:
an 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.):
.-�. Mtn!j/) modium .rand an is aa/i n4 ydnau2ic �a iivae oa Rond.iag.
1/n nnfnf in i t hampvn.S >>ono dnU_
CESSPOOLS: no (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n�
Depth—top of liquid to inlet invert: na
Depth of solids layer: na
Depth of scum layer: na
Dimensions of cesspool: na
Materials of construction: n a
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
Ce'jzs ooiA not aeeen;t.
PRIVY: no (locate on site plan)
Materials of construction: na
Dimensions: na
Depth of solids:. na
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
l a.[.vy not /?aeben.t.
j
;9
Page 10 of 11
OFFICIAL INSP:E�3ION �( RM=. OF FOR
NOLUNTARYASSESSMENTS
SP ECTIDNFQRV
SU89 ACE'SEWAGEOSAL SYSTEMlNSP
,--�
PAR`F C`-
SYS'FEM I WORNIp1TIDN(contihured)`
Address: 5 find KinU-s
Property •
Na .
h
Date of Inspecti : o"_? /n C
SKETCH OF S WAGE-DISPOSAL SYSTEM
Provide a sketch if the sewage disposal system including ties to at least o permanent reference landmarks or
benchmarks.Lo00.eet.Locate where public wate supply enters.the building.
c a all wells within 10
r
10
' Y -
Page 11 of 11 °
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 4 5 O.Pd K in.gz rd,=
Gotu.i.t. l'la.'
Owner: Ch o n y_P /d.;.PZI rz.m.6
Date of Inspection: 9/1 3/0 J
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 6 Q r feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within.150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
...Accessed USGS database:explain: h f} t p wn. a s/t n
You must describe how you established the high ground water elevation:
—,,,6g =nhonf1j nnrl m,;_Lee2 mode.2 12/16/94 gzound watea above yea
�, z � gig In 92 000 01 ?,Paste#2 annua.P aangez o
"eet
Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpte�r Method 3
Therefore,the vertical separation distance between the bottom
of the leaching pit and the adjusted groundwater table is
feet. '��
11 �
r
' srTarsrsner+rar'n-+-rr'rrrrrr�:,.�z�i.`r—..�:
•,�r,r~,.-R,.,-�,.,_,_.,,r-.,,r...,r..,s-„rr>t.,,r�r�,-.•,rr„o..,,,�r,rm.,�r,�.,•.�-.,�,,.t. WARD OF IiEJ1LTI1
','OWN OF
SUBSU11FACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM - PART D .- CEwr1F1CATI0N
inRFtTTr:ITRrt:Tr`TT'T•,t_••j
•••rt•r-r•:•::r--.ra-•.r.-•r+:nr.m•nrs,r+snr�rs+rrir�+rrrs�r.rrt+r.t astrmrT�!� .
—TYPE OR PRINT CLEARLY—
PROPERTY INSPECTED
STREET ADDRESS 45 Oid King-3 Road
ASSESSORS MAP , DI4,OgK AND PARCEL # 022-067. `
OWNER' s . NAME Chg,Aui IdiiilaNh
PART' D CERTIFICATION
a
NAME OF INSPECTOR R A - . .
Joseph P.' Macomber & 'bon
COMPANY NAPiE -
COMPANY ADDRESS Box 66 Cent
Street Town or City .$tat• LIP
COMPANY TELEPHONE ( 508 775 33388 FAX ( 508 ) 790 T 1578 „
CERTIFICATION STATEMENT
I certify that I have personally
inspected
isthe
truesewage
accuratesaandsystem' at
this address and that the information reported
omplete as of the time of �inspection . The inspection was perfo:r.med and any
recommer�clatiorrs regarding upgrade , maintenance , and repair are consistent
with my 't'raining and experience in the proper function and maintenance of on
site sewage disposal systems ,
Check one:
XXX Systeui PASSED
Tile inspection iihich I have conducted has not found any information
which indicates that. the system fails to adequately protect public
health or, the enviro:i:iment as defined in 310 CMR. 16 . 303 , Any failure
eriteria ,not evaluated are as stated in the FAILURE CRITERIA section of
this. form .
System FAILED*
The inspection which I have con Lrcted has found that the system fails t(
protect the i-jublic health and the environment in accordance with Title
5 , 310 CMR 15 . 3031 and as specifically noted on PAR,,C. -JAILURE
CRITERIA of this ins ection form,
. -
r ► � O
Date
Inspector Signature'
ne copy of this certification must -be provided 'to the OWNER, the BUYER
O
where applies-able ) and the DOARD OF HEALTIt, .
* If the inspection FAILED, thy+ owner or operator shall up.grade ' the system.
within o'ne year of the date of the inspection., unless allowed Qr requi..red
otherwise as provided in 3;10 CMR 16 , 3-06 ,
gartd .do,
TOWN OF BARNSTABLE , C,
ATI of# .t 9 ot®I/e/A1 "N /?,Q. SEWAGE # �0 q 9
VILLAGE C4/U,'f -/_;Zr4Sh,A/e-A/9ASSESSOR'S MAP &LOT d'Aa-�
INSTALLER'S NAME&PHONE NO. : TOE H A R Vet 7
S®SEPTIC TANK CAPACITY Io
LEACHING FACILITY: (type) �0 z®® Uty v (size)
i
NO:OF BEDROOMS
BUILDER OR OWNER
PERMIT DATE: -2.g'--COMPLIANCE DATE: _r If /
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
,
03 =38
s9s:ys f
0
B3s 33 B �.
y® ISO
No. Fee
THE COMMONWEALTH O ASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF B RNSTABLE., MASSACHUSETTS
0[ppYication for Diopaal *pgtem Construction Permit
Application for a Permit to Construct(X )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 45 Old Kin 's Road Owner's Name,Address and Tel.No.
g Cheryl Williams
Assessor's Map/Parcel Cotuit School Street, Cotui
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Joe Harvey Cape & Islands Engineering
48-1920 257 Palmer Ave., Falmou h Shellback Place, Mashnee
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size 23,H3F sq.ft. Garbage Grinder(no)
Other Type of Building No. of Persons R Showers( ) Cafeteria( )
Other Fixtures
Design Flow 55 gallons per day. Calculated daily flow 330 gallons.
Plan Date 12-10-97 Number of sheets 1 Revision Date 1-21-98
Title single resid. & prop. sewage disp. system
Size of Septic Tank 1500 gallon Type of S.A.S. drywells
Description of Soil 0111- 2" loam, 2"-24" sandy loam, 24"-144" med. sand
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected: 11-19-97 p-9054
Agreement:
The undersigned agrees to re the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisio s of itle 5 of thp E vironmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been is ed y t ' ft
f e th.
Signed Date 1-20-93
Application Approved by _ Date
Application Disapproved for the following reasons
Permit No. - Date Issued
TOWN OF BARNSTABLE
:LOCATION �f 74tI C 040 MAer I-S RO- SEWAGE #' 7 y
`:;VILLAGE Go AU, -/.�nSta6IC-Ijl4ASSESSOR'S MAP & LOT
.'INSTALLER'S NAME&PHONE NO. . TOE H A R V Y
:-::SEPTIC TANK CAPACITY I Soo
` LEACHING FACILITY: (type) ,SOO A^ Ott W (size)
.:: .NO.OF BEDROOMS
BUILDER OR OWNER ORE�� LMI�0/'n
I K S
`,::`;PERMrrDATE: �� O •�� 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
.:. .... .. ...Ob
..,
r
d ,
T , � 1,9
h:
s
No. 7
Fee
THE COMMONWEALTH 0 . ASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF B RNSTABLE., MASSACHUSETTS
01pplication for �Dioogat *pg em Congtruction Permit
Application for a Permit to Construct(X )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 45 Old Kin 's Road Owner's Name,Address and Tel.No.
g - - Cheryl Williams
Assessor'sMap/Parcel Cotuit. - _ �,. School Street, Cotul
map 22 parcel 67 l e
Installer's Name,Address,-and Tel.No. Designer's Name,Address and Tel.No.
Joe Harvey Cape & Islands Engineering
48-1920 257.Palmer Ave.,. .Falmou h Y'Shelback Place, Mashppe
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size 23,636 sq. ft. Garbage Grinder(no)
Other 'Type of Building No.of Persons 8 Showers( ) Cafeteria( )
Other Fixtures
Design Flow r` i 55 gallons per day. Calculated daily flow 330 gallons.
Plan Date 12-10-97 Number of sheets 1 . - Revision Date 1-21-98
Title single resid. & prop. sewage disp..system,.
Size of Septic Tank 1500 gallon °Type°of{S:A:S- .drywells
Description of Soil
0f"- 2" loam, 2"-24" sandy ,,Ioam.,.1241.'-144"!,med. . sand, .
Nature.of Repairs or Alterations(Answer when applicable)
p-9054
Date last inspected: 11-19-97 . • . � ,.._. "`' "` '
Agreement: ;
The unde-signed agrees t re the construction and maintenance of the afore describedror-site sewage disposal system
in accordance with the provisio s of itle 5 A the Environmental Code and not to place the system in operation until a.Certifi-
cate of Compliance has been is ued y ' /d of He th
Signed d i Date 1-20-98
t
Application Approved by r Date
Application Disapproved for the following reasons
Permit No. t' Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed(41'5 Repaired ( )Upgraded( )
Abandoned( )by
at d r has been constructed in accordance
with the provisions of Title,,5 and f r Disposal System Construction Pert o. dated
Installer V—-r,.A.9h Designer /9 �-
The issuance of this permit not be construed as a guarantee that the system ill unction as designed.
Date _3 9- Inspector
r — -
————
No. / ---------------------------Fe�— / —fJ
THE COMMONWEALTH OF MASSACHUSETTS _
PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS
wfi6pogat *p!5tem (fon5truction Permit
Permission is hereby granted to Construct(' )Re air( )Upgrade ) andon ) L
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: Approved by
S YS TEM PROFILE
NOT 747 SCALE
4
TOP FNDN. FINISH GRADE OVER FINISH GRADE
EL . 78.ev FINISH GRADE FINISH GRADE OVER OVER TRENCHES 7 ••
r p.,p;•d DIET. BOX 75 7
SEPTIC TANK
:oQ.ao 12" MAX. T
114
CaQ•b r .• • •Q.•a••Dye,4 •:Q,e'D•'a,y•.i•O,'da�j..d '« y' �
p 3„ OUTLET PIPE LEVEL
TO TA L ENGTH OF TRENCH 2
a..p:o.; '�• . FOR 2 FT. hllN4.
60
.
D d a.qq
'D •�qo. 7J,8[' • 1'•b `.o: :+'. a Op y� .j Q b 00
db C.'I. OR PVC TEES �.Z7 7z
TZ
d" Q
.o•o,�D � cd _y �
BSMT FL a''o p ''
.1500 GALL ON DISTRIBUTION BOX
EL . 7e), S Ir
q a a.o o� INSTALL ON LEVEL BASE ��Jt—O0 GAL L ON DR YWEL L S "
PAECA S T CONCRETE
'Qv 4'oe o.d:p'.•:pt• :1 CO
ab H-- 0 REINFORCED ;
•
C• b0 _
G •e :ab.d:o,b •d eo. Q e p :c'a 5•e + o
a:�w.•o.v',bu. d ,veb;:b'�•:�. :: :4ht0,iq.� a ,q.a•.C�7?4.
SE'P TI C T,4 Nil
TRENCH SECTION
INSTALL ON LEVEL BASE NOTE.• EXCA VA TE TO EL EV. ^'�W OR
LONER TO REMOVE ALL IMPERVIOUS
MATERIAL BENEATH THE LEACHING AREA s2' MIN.
4 DIAM.
REPLACE EXCA VA TED MA TERIAL N1 TH
- CLEAN, CLAY FREE SAND a ''' a ' �'0. •d ''�;b�e;• '�r�}! •3 M OF .l�B"-1/2"
HASHED PEA STONE
DA 3/4" 1-1/2" WASHED
/ CRUSHED STONE oN
••`� •p' � 70. SD
r GENEPAL. NOTES TRENCH WIDTH
Z� 40 ��
gB p
1 ALL ELEVATION.' SHOWN ARE BASED ON ASSUMED
. NUMBER OF TRENCHES ?
P. ALL PIPES IN ,VE SYSTEM MUST BE CAST .IRON NUMBER OF DRYI�ELLS 2 G.
OR SCHEDULE 4t, PVC, r'!t��" ,�. «�••. e
3. THE BOARD OF i .SAL TH MUST BE NOTIFIED
WHEN CONSTRUCTION IS COMPLETE PRIOR 7' -
; TO BA CKFIL L ING PERGOLA TION RATE.•
N Z ` 4. ANY CHANGES rA THIS PLAN MUST BE APPROVED MIN./IN. 2ro y,, r ,.,, s,,, Z
B Y THE BOARD GF HEAL TH AND CAPE 6 ISLANDS WITNESSED B Y:
z /o 3 o i
o 0 0 o SURVEYING CO., INC. GERRY DUNNING
22,00 's.
0 `� 5. MA TERIALS AND INSTALLA TION SHALL BE IN ti �� COMPL IANCE w'17H THE STA TE SA NI TARP BARNS. BAD. DESIGN DA TA
OF HEALTH
n DA TE.` NOY. 19_J997
m CODE TITLE ' — AND LOCAL APPLICABLE
5Eo RULES AND REGt LA TIONS o >y / r'2 -.•� I 3 f
oPo Cie, NUMBER OF BEDROOMS
o ha n gpaM NouNr g cn 6. NORTH ARROW I� FROM RECORD PLANS AND z A
3 sASF" �' o S L PU,q p GA RBA GE DISPOSAL NO i f IS NOT TO BE GS •D FCR(N�NA�AZAR�I SES s�. �ry �.oa,.� for e s/8
'o.00 , o��K /8, 7. FLOOD HAZARD :'ONE Zv N DA IL Y FLOW 330 GAL .
,�z� ,,_ , — B. jWA TER SUPPL Y�
SEP TIC TANK RE D. 1500 GAL .
SEPTIC TANK PROVIDED 1500 GAL .
LEA CHING REQUIRED 330 GPD.
tioo -- Z_ 0 7- 2 ioy�? 6�G SIDENALL AREA 152 S.F. C
152S.F. X 0. 74G/S.F. = 1.t2 GPO. i
BOTTOM AREA = 329 S.F.
LEGEND 1 329 S.F X 0. 74 G/S. F. a 243 GPO I
LEACHING PROVIDED = 5 GPD
5 Nu lj r H c w:71
62 h yo, PA OPOSED ELEVATION w- �a�; z)
4 2•
4h -- y --- EAISTING CONTOUR
SINGLE FA Y RESIDEN
o �p4 OB 5'ERVA TION PIT /-0 7- 9 6 CE chi
s g3'ems's a DI 3 TRIBUTION BOX :.r
PROPOSED SERA GE DISPOSAL S YS TEM
I. V .�r•'r! G f! /1'/.,r.,/ t� .. — .� _.. . /y' / VIA! ` ': PR
EPARED FOR
SE�'TIC TANK `
•f
DREAM DE VEL OPES
REgERVE AREA _=- 4
LOT 29 OLD KINGS ROA D
for ; .
CO TUI T BARNS TA E --' MASS. '
� 3 s PI, E .INVER7' ELEVA TION DAVID
CHARLES
PLOT PLAN CAPE 6 ISLANDS ENGINEERING
sg
SCALE.• 1 7 9 y5- .,•: u fci�i�P�� z ' SCALE AS NOTED
133 FALMOUTH ROAD — SUITE RE
PL AN s / l MA SHP r ,
f rz- •* n,r*t t ,• ^s- , r - - ," ,F......,a% NO, z o 9 > EE, MASS. ,.