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HomeMy WebLinkAbout0111 POPONESSETT ROAD - Health 111 Poponett Road Cotuit P A = 019 076 . gar 06 1411:54p p.1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Popponesset t Rd. -- Property Address _ Stephen O'Connor - owner Owner's Name information is Cotuit page MA 02635 3-5-14 reqtACityrrown d for every State Zip Code Date of Inspec ion Page. 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~When A. General Information filling out forms H OF on the computer, use only the tab 1• Inspector: .y k to move our cursor-do not ��: •JAMES P use the retum James D. Sears _ key. Name of Inspector *` CapewideEnterises,LLC Company Name `RTIF� 153 Commercial St �����•••••• ••,+�,a��` Company Address Mashpee MA 02649 Cityrrown State Zip Code 50B-477-8877 S1623 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 oLon site sewage disposal systems. I am a DEP approved system inspector pursuan�to Sect(a 15.;1 40 of Title 5(310 CMR 15.000).The system: F °� r Q ® Passes ❑ Conditionally Passes [3 Fails .'+t ❑ Needs Further Evaluation by the Local Approving Authority 3-5-14 '� s�, spector's 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 qpd 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(i.onditions at the time of inspection and under the conditions of use at that time.This Inspectfon does not address how the system will perform in the future under the same or different condflons of use. � Lt5irns 3113 Tine 5 Olbdal Un form:Subsurfeoe sewage stem•Page 1 of 17 Mar06 1411:54p p.2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Popponesset t Rd Property Address Stephen O'Connor Owner. Owner's Name information is Cotuit MA 02635 3-5-14 required for every page. Cityffown State Zip Code Date of Inspection B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E I 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: 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 exfiltratlon 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): tsins•3013 Tdfe 6 Official inspection ram:SubeLifacs Sewage crmosel system-Pape 2 0117 Mar 06 1411:55p p.3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 911 Popponesset t Rd Property Address Stephen O'Connor Owner Owners Name Information is Cotuit MA 02635 3-5-14 required for every page CityrTown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumpsfalarms not operational. System will pass with Board of Health approval if pumpslalarms,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 L7 Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 15ins•3113 We 5 01WEl bapectkon Farm.Subsurface Sewage DiapoeA SY918m•Page 3 d 17 Mar 061411:55p p.4 k Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 111 Popponesset t Rd Property Address Stephen O'Connor Owner Owner's Name information is Cotuit MA 02635 3-5-14 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) 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 clogged SAS or cesspool ❑ N 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 is less than 6°below invert or available volume is less T than 'r4 day flow 7A C'9!-vc t5ins-3113 Title 5 OlficW tnspec5on Form Subsurface Sewage Disposal System•Page 4 of 17 Mar 06 1411:55p p.5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for voluntary Assessments p y 111 Popponesset t Rd Property Address Stephen O'Connor Owner Owner's Name Information is Cotuit MA 02635 3-5-14 required for every page. Ckrrmn state Zip Code Date of Inspection B. Certification (cunt.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to dogged or obstructed pipe(s). Number 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. ❑ 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 Il 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 c5ins•X13 Tiille 5 Official h3pedon Fwm 80murfaee Sewage Disposal Syslem•Page 5 of 17 Mar 06 1411:56p p.6 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Popponessett Rd. Property Address Stephen O'Connor Owner Owner's Name Information is required for every Cotuit MA 02635 3-5-14 Paa9e. CitylTown State Zip Code Date of Irepedion 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 ❑ 0 this inspection? ® El available as built plans of the system obtained and examined?(If they were not available note as NIA) ® ❑ 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? ® 0 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 approArnation of distance is unacceptable)1310 CMR 15.302(5)) D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 15ms•3113 Tale 5 Official Inspection Fowm:SLbcurfeoe Sewage Disposal System•Pepe 6 of 17 f Mar 061411:56p p.7 Commonwealth of Massachusetts, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Popponesset t Rd. Property Address Stephen O'Connor Owner owner's Name information is required for every Cotuit MA 02635 3-5-14 page, c4frovm state Zip Code Date of lnspedion D. System Information Description: The system is a 1000 Gal. tank D Box and three 500 Gal. dry well chambers. 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 Seasonaluse? ❑ Yes No Water meter readings, if available last 2 ears usage d 2012-93,000Gals g ( y g (gP �)' 2013-176,000Gars Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date Commercialllndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15,203): Gallons per day(gpd) Basis of design flow(seatstpersonslscI t., 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: t5ins�W13 Tile 5 Offidal Inspection Fam:Subsurface Sewage Dispoul System-Page 7 W 17 Mar 061411:56p p.8 Commonwealth of Massachusetts Title 5 official Inspection Form i• Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Popponesset t Rd Property Address Stephen O'Connor Owner Owner's Name information is Cotuit MA 02635 3-5-14 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cant.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA 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) ❑ InnovativelAlternative 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;3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 8of 17 Mar 06 1411:57p p.9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 111 Popponessett Rd. Property Address Stephen O'Connor Owner Owners Name information is Cotuit MA 02635 3-5-14 required for every state Zip Code Date of inspection page Cityrrown D. System Information (cont.) Approximate age of all components,date installed (if known)and source of information: 2000 Permit * 00-669 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 34" 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.): Pi ein is 4" PVC SCH 40. Septic Tank(locate on site plan): 2• Depth below grade: 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: 1000 Gal. Precast Sludge depth: urns,-3113 TWO 5 Official Inspection Farm:Suburface Sewage Disposal System-Page 9 of 17 Mar 061411:57p p.10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 111 Popponesset t Rd. Properly Address Stephen O'Connor Owner Owner's Name information required for every Cotuit MA 02635 3-5-14 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 29u Scum thickness 01 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 18- How were dimensions determined? Asbuilt-Tape Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank at 2' below grade w/cover's at 1% outlet tee. No sign of leakage or over loading. Grease Trap(locate on site plan): Depth below grade: feet w 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: Dace t5inns-&13 Title 5 otfidal I nspedion Form:SutsLaraoe Selrege Disposal System-Pape 10 of 17 Mar 06 1411:57p p.11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 111 Popponesset t Rd Property Address Stephen O'Connor Owner owners Name information is Cotuit MA 02635 3-5-14 required for every page. Cityrrown 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: gagons 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 15irs 3113 Title 5 Qfrxial UnpedlanForm:Subsurface Sewage Disposal System•Page 11 of 17 Mar 061411:58p p.12 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Popponesset t Rd. Property Address Stephen O'Connor Owner owner's Narne information is required Eor every Cotuit MA 02635 3-5-14 page CitylTown State Zip Code Dale 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.): D Box is 16"x16"-2' below grade. Box is clean and solid wltwo line's out. No sign of over loading or solid carry over. t 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: t5cis•aft Title 5 of6c ar inspsaon Fornt Subsnlece Sewage Uisposw System•Page 12 of 17 t Mar 061411:58p p.13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Popponesset t Rd. Property Address Stephen O'Connor Owner Owners Name Infbffrequired is Cotuit MA 02635 3-5-14 required for every page. City/town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ leaching galleries number: ❑ leaching trenches number, length: '= ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Typetname of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is three 600 Gal, dry well chamber's (33'x13'). Chambers are 3'below grade. Chambers are clean and_dry,wail's are clean like new. No sign of over loading or solid carry over, 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 t5ir�s•'3/13 Tits 5 Mal Inspedion Fom Subsurface Sewage Disposal Syclem•Pepe 13 of 17 Mar 06 1411:58p p,14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 111 Popponesset t Rd. Property Address Stephen O'Connor Owner Owner's Name information is required for every Cotuit MA 02635 3-5-14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) 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.): l5ins•g1l3 This 5 01kial Inspection Fomt SubsuAace Sewage Disposal System•Pepe 14 of 17 Mar 061411:59p p.15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 111 Popponessett Rd Property Address Stephen O'Connor Owner' owner's Name information is Cotui MA 02635 3-6-14 t required for every C otui wn State Zip Code Date of Inspection page- 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 BACK �-3 o � 02 0 3 t5im r 3l13 TUte 5 OfSdat Inspection Fam SLbowtwe Sewage Disposal System-Pape 15 of 17 Mar 06 14 11:59p p.16 <L,\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 Popponessett Rd Property Address Stephen O'Connor Owner Owner's Name information is Cotuit MA 02635 3-5-14 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells JV41 Estimated depth to high ground water. 10' feet Please indicate all methods used to determine the high ground water elevation: Cl 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: Hand Auger T H 10'no G W T H at 4' below bottom of chambers. Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ine•�3113 Tine 6 Official Inspection Form:Subsurface Sawage Disposal System•Page 16 o117 Mar06 1411:59p p.17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 111 Popponesset t Rd. Property Address Stephen O'Connor Owner Owner's Name require for is Cotuit MA 02635 3-5-14 required for every page, Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, 6, 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 t5ns•3n 3 TRW 5 Olriaal Inspedlon Fomr&A ulew Sewage uWpmel System•Peas 17 or 17 COMMONWEALTH OF MASSACHUSETTS F EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS v d DEPARTMENT OF ENVIRONMENTAL PROTECTIONCZ-iV 1ED tia s °�M 5�•� DEC 2 2003 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION MAP Property Address: #111 Poponesset Road Cotuit,MA PARCEL 01 Owner's Name: Paul&Tracie Grover LOT Owner's Address: 6 Allen Street = " Marion,MA 02638 Date of Inspection: 10/31/03 Name of Inspector: (please print) Mr.Carmen E.Shay Company Name: Shay Environmental Services,Inc. Mailing Address: 34 Thatchers Lane East Falmouth,MA 02536 Telephone Number: (508)-548-0796 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: XX Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority �n �'!t4 Fails " tAOF ,9 Inspector's Signature: Date: 10/31/03 E fE The system inspector shall submit a copy of this inspection report to the Approving Authority(Boar , f or p y DEP)within 30 days of completing this inspection.If the system is a shared system or has a design fl �oP gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional oP'" ,- DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the app o— authority. Notes and Comments Excavated cover of SAS. No evidence of hydraulic failure noted. 1" liquid noted in SAS. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: #111 Poponessett Road Cotuit,MA Owner: Paul&Tracie Grover Date of Inspection: 10/31/03 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: XX 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: 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: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: #111 Poponessett Road Cotuit,MA Owner: Paul&Tracie Grover Date of Inspection: 10/31/03 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 "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: #111 Poaonessett Road Cotuit,MA Owner: Paul&Tracie Grover Date of Inspection: 10/31/03 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No XX Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool XX Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool XX Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool XX Liquid depth in cesspool is less than 6"below invert or available volume is less than'/2 day flow XX Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped XX Any portion of the SAS,cesspool or privy is below high ground water elevation. XX Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. XX Any portion of a cesspool or privy is within a Zone 1 of a public well. XX Any portion of a cesspool or privy is within 50 feet of a private water supply well. XX 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.] NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: #111 Poaonessett Road Cotuit,MA Owner: Paul&Tracie Grover Date of Inspection: 10/31/03 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No XX Pumping information was provided by the owner,occupant,or Board of Health XX Were any of the system components pumped out in the previous two weeks? XX _ Has the system received normal flows in the previous two week period? XX Have large volumes of water been introduced to the system recently or as part of this inspection? XX Were as built plans of the system obtain n examined? I p y obtained and e am ed. ( f they were not available note as N/A) XX _ Was the facility or dwelling inspected for signs of sewage back up XX _ Was the site inspected for signs of break out? XX _ Were all system components,excluding the SAS, located on site? XX _ 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 XX _ 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 XX _ Existing information.For example,a plan at the Board of Health. XX _ 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)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM j PART C SYSTEM INFORMATION Property Address: #111 Poponessett Road Cotuit,MA Owner: Paul&Tracie Grover Date of Inspection: 10/31/03 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: Unknown 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):_ Seasonal use:(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): 2002— 100,000 gallons Sump pump(yes or no): No 2001 —93,000 gallons Last date of occupancy: Currently Unoccupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unknown Was system pumped as part of the inspection(yes or no):_ If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM XX Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: November 21,2000-per Board of Health&Owner Records Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #111 Poponessett Road Cotuit,MA Owner: Paul&Tracie Grover Date of Inspection: 10/31/03 BUILDING SEWER(locate on site plan) Depth below grade: 16" Materials of construction:__cast iron XX 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): No evidence of leaks or damaged piping. Venting noted on roof. No odors noted. SEPTIC TANK: XX (locate on site plan) Depth below grade: 12" Material of construction: XX concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 5' deep x 5'wide by 10' long (1500 gallon) Sludge depth: 4. 75' Distance from top of sludge to bottom of outlet tee or baffle: 3.00' Scum thickness: 2" 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: 14" 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.): Structural integrity of tank was ok. No evidence of cracks, leaks,or water infiltration/exfiltration. 4" PVC Tee present and in good condition. Outlet tee also in good condition. Liquid level equal with outlet invert. GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8of11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #111 Poaonessett Road Cotuit,MA Owner: Paul&Tracie Grover Date of Inspection: 10/31/03 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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: Present (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: equal 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.): two outlets to leaching chambers. D-Box in good condition. No evidence of solids carry over. PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.)- Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #111 Poponessett Road Cotuit,MA Owner: Paul&Tracie Grover Date of Inspection: 10/31/03 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: XX leaching trenches,number,length: 1 Trench—13'wide by 33 feet long,2'deep. (3)Chamber Trench leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments (note condition of soil, sips of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No evidence of hydraulic failure, ponding damp soil or stressed vegetation. Probed stone with no evidence of hydraulic failure. Excavated cover of chamber and noted 1" liquid. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, sigr_s 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.): f Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #111 Poaonessett Road Cotuit,MA Owner: Paul&Tracie Grover Date of Inspection: 10/31/03 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. e� sue* ep f.. '> ,rIN-4b; 4 b' �r a 6 4 5 I �x k = � ✓ 7, m F f °PA�.each amber—44' Leach Chamber—42' Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #111 Poponessett Road Cotuit,MA Owner: Paul&Tracie Grover Date of Inspection: 10/31/03 SITE EXAM Slope Surface water -None Check cellar -Yes Shallow wells—None Estimated depth to ground water 26' feet below grade. 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: XX 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) XX Accessed USGS database-explain: _ You must describe how you established the high ground water elevation: checked with Ouadranyle of USGS Map&Engineered Plan. Performed hand auger to 16 feet below grade at leach trench. Per Hand Boring by Auger: Elev.of Ground=26 Elev.Of Groundwater=4(assumed GIS Groundwater Maps) Elev.Of Bottom of Leach Trench=20 Therefore: 20—4= 16+ 16 feet separation between Bottom of Leach Trench and Groundwater(assumed). Groundwater Adjustment using Index Well MIW 29 : 1.9 feet Adjusted Groundwater Separation= 16'— 1.9=13.9 feet or Elev. 5.9 (Refer to attached work sheet) Grade=Elev.26 feet Leach Trench D-Box Septic Tank Bottom of Leach Trench=Elev.20 feet Adj.Groundwater=Elev. 5.9 Permit Number. Date: i Completed by: HIGH GROUNDWATER LEVEL COMPUTATION Site Location: Lot No. Owner: Address: r Contractor: Address: Ec>A_mwsy ,' IM;A Notes: �— c STEP 1 Measure depth to water table to nearest 1/10 ft. ................. 41 ............................................................. .Date Mont day ear STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: OAppropriate index well...................................I................ Mt i OWater-level range zone ..................................................... fl" i STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well (0 Month/-year F STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth 1 to water level for index well (STEP 3), and water-level zone (STEP 2B) CT determine water level adjustment ............................... �1 STEP 5 Estimate depth to high water by subtracting the water• level adjustment (STEP 4) from measured depth to water levelat site (STEP 1) ................................................................................................. h f i Figure 13.--Reproducible computation form. e I i . 15 i { i i l 1 1 �• Permit Number: Date: Completed by: HIGH GROUND-WATER LEVEL COMPUTATION Site Location: _i 1. �OQ©n e 5 , �,� Lot No. Owner: (�,� ��Q�� Address: Contractor: J Address: Notes: STEP 1 Measure depth to water table ! tonearest 1/10 ft. ........................................... ............................... .Date rrfonthTdayheiar STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: O Appropriate index well.................................................... I CXCk 1 OWater level range zone ..................................................... STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well ........................... moot /year STEP 4 Using Table of Water level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) determine water-level adjustment ........................................................................................... i STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water level at site (STEP 1) .............. ................................... J 1 I, Figure 13.--Reproducible computation form. 15 TOWN OF BARNSTABLE c LOCATION 1// POAON g.SSc n- RD Q SEWAGE # 00 L 84 VILLAGE (foTv/T ASSESSOR'S MAP & LOT ol4 076 INSTALLER'S NAME&PHONE NO. e-121-671,2117 Jos c604 a- , /3�y►s�as SEPTIC TANK CAPACITY /600 LEACHING FACILITY: (type) 3 4/i£/1s (size) 33x 13 NO. OF BEDROOMS BUILDER OR OWNER . PERMIT DATE:_U 2/•00 COMPLIANCE DATE:4� 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 leachin facie ) Feet Furnished by -o'� •Qh ` 1 r -0 7& No. OD Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: te PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pp[ication for ;Digpozar bpgtem Con.5truction Permit Application for a Permit to Construct(vrRepair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. /// Po1o0©kq e s5-2I7 g Owner's Name,Address and Tel.No. Assessor's Map/Parcel C_ ' /;?,-f 607217 Installer's Name,Address,and Tel.No. �17yf_03 el Designer's Name,Address and Tel.No. Jos,ei`�ti Type of Building: Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank / Type of S.A.S. Description of Soil 5j,e;,, Nature of Repairs or Alterations(Answer when applicable) _72�-/5t1,01r e4 - S�Oo (mow d pw a_/ GUiTLi G/'STDl�P /,51 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 Boazd f Health. Signed - Date Application Approved by Date 1124 1240 Application Disapproved for the following reasons Permit No, _t_�00_ Date Issued Z tj 20d_� Na. 00 68� 0 1570 7& - Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer- Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Z[ppYication for Migozaf *p!5tem Cow5truction Permit Application for a Permit to Construct,( Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. /// fol,,904,e S5•2 rT 12cOwner's Name,Address and Tei.No. oTUi �I/ici-= �✓/gr�3 Assessor's Map/Parcel t ' i / /2� CdTv� Installer's Name,Address,and Tel.No. J� Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms i 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 sheet$` ] a Revision Date Title i Size of Septic Tank + Type of S.A.S. Description of Soil Sloa���y f 1 Nature of Repairs or Alterations(Answer when applicable) --e ` Date last inspected: ! Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this)3oard of Health. t` k: Signed t Date Application Approved by _ Date 2f 2de", Application Disapproved for the following reasons J Permit No. Date Issued 2 / 2OvJ ---------------------------- — -------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed(e--)-Repaired( )Upgraded( ) Abandoned( )by ✓6544?X U, at //,/ has been construct d in ccordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated // 400 Installer 0-e Designer The issuance of this permit hall lot be c nstrued as a guarantee that the sysstte-ylw�ill function as td�esi�Ed. Date /� Inspector d � 1`> /'I��t� --- y,h� Ii v -------�—G------------------------------- No. >(200 C IJr$ � O/ 0 f 4 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS wfi6pool *potem Cougtruction Permit Permission is hereby granted to Construct(pair( )Upgrade( )Abandon( ) System located at /// i, i�Pon . ryir 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:Con ct' n must be completed within three years of the date of this e:. 't. Date: / 2e Approved by 3w U669 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH .k`yD .-PPLICATION FORA DISPOSAL WORKS CONSTRUCTION PER-NUT C'ITHOUT DESIg D PLA-NS) I, -J -�-e,0(24 9i91—w I hereby cl-uy that the application for disposal worts con=ctlon permit signed by me dated °,�/—pp concerninv the property located at J[j �,� py� �s S�Zj' �oI �D TUi 7T meets all of the following criteria: ! The failed system is conner ed to a residential dwelling orilv. There are no cotnmerc:al or business " uses associated with the dwelling. Rh`' The soil is classined as CUSS I and the eercolarion rate is less than or equal to minutes oe: inch. Y—lizere are no we lands within 100 fe`t of the proposed septic s+sern G� There are no private wets within i-50 fee;of the oroposed seodc srse n T'ne:e is no incase in flow and/or change in use proposed �nere are no varianc= recuesed or needed t ne bottom.of the proposed leacaing facility will not be located less rl= Live tee;above the tna.,amum adjusted grouncwater table elevation. (Adjust the groundwater table awing the Frimptor me;hcd when apolicable] the S._�.5. xill be located sviCh '_ 0 �;of anv vegetated wetlands, the boaom of the oroposed leap ung facility will net be located less than fourteen (14) fee; above the ma.-cimum adjusted goundwater table e!�riatiort, Please complete the following: A) Top of Ground Surface =:(rYation (us-MI,, G-S information) B) G.'V, E?gyration 5r =the NLa C. ;igh G.bV. Adjusrneat ell,,2' D rC -.-_RE`;CE B ET7,V EEN a,and '3 � SiGtiED D a.i c: (Si:-,c i proposed Dian of sg: em on bacl-1. q::,c=ilh ioidcr..crt i Cs O 4 � v Y J � y d C\ � �V $ TOWN OF BARNSTABLE LOCATION 1/� PoAoH e SSc 7T SEWAGE # _ Od VILLAGE earvrr ASSESSOR'S MAP & ioT 2L4 d�G , INSTALLER'S NAME&PHONE NO. '-/h'1-03 5'9 Jos cl�� d /3�Nrms ' SEPTIC TANK CAPACITY /400 LEACHING FACILITY: (type).3 wI_/ls 33x 13 (size) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE:_L l 1/•d 0 COMPLIANCE DATE: Separation Distance Between the: I . 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 leachin facili . Feet. Furnished,by. co�sr 1 t 4 s t N ya