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HomeMy WebLinkAbout0111 RUSHY MARSH ROAD - Health 1"11 Rushy Marsh Road,COtUIt A 019 182 - / No. V V Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 4plication for MispDSal 6pstrut Construction Pf mit Application for a Permit to Construct( ) Repair(X Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. t I 054Y NA&S4 Rc7 Owner's Name,Address,and Tel.No. M%C"AGc... + TA-9-4 Assessor's Map/Parcel I q ( (I k05"Y %-IA� Installer's Name,Address,and el.No. SD 91y^Y7 7 S ` -7 Designer's Name,Address,and Tel.No. G4PC—W(-0E K/A 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(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Heal Signe Date �1— Application Approved by Date Application Disapproved by Date for the following reasons Permit No. �3 L1 Date Issued S No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer PUBLIC HEALTH DIVISION , TOWN OF BARNSTABLE, MASSACHUSETTS Yes . 2pplication for Misposal *- pstrm Construction Permit Application for a Permit to Construct( ) Repair(X Upgrade( ) Abandon( } ❑Complete System Individual Components Location Address or Lot No. I I ( P,v54Y M. &24 R t7 Owner's Name,Address,and Tel.No. C`©Ti�rT M i GF•(AG c.. -�. T�itA �'k/�c.Tj Assessor's Map/Parcel a"-;k- CO-r�l"i"' Installer's Name,Address,and 1el.No. :50$-47'1-8 S11 Designer's Name,Address,and Tel.No. Type of Building: i Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) j Other Fixtures Design Flow(min.required) gpd Design flow provided gpd i Plan Date Number of sheets Revision Date Title -`Size of Septic Tank Type of S.A.S. Description of Soil (F i Nature of Repairs or Alterations(Answer when applicable) �' (� j° ,1"z"(„ 'm'f^' _r Date last inspected: Agreement: . .< The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in � gr g P Y accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of , Compliance has been issued by this Board of Health.", Signed A Datern- :1!..:/P 7.►'"' p f Application Approved by Date «tr••''' ` Application Disapproved by Date for the following reasons y Permit No. f I Q ''� Date Issued - -- ------------ - - - ,- =------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance i' THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired O Upgraded( ) Abandoned(' )by at 1/if P•V k4 lu Pm IL'SST kJ 1-r has been constructed in accordance / r with the provisions of Title 5 and the for Disposal System Construction Permit Nog�Xy ' dated Installer f1AC4,J1b,G 0— 1?X 1<&-f Designer . #bedrooms Approved design flow .. gpd The issuance of this permit shall not be construed as a guarantee that the system will function as d se gnedd F Date c�J/ �/ / � Inspector �'---_ �`•�.I r i -------------------------------------- ------------ No. .- - - =- - - - - - -- - � / 3 / - -T - Fee 1 THE COMMONWEALTH OF MASSACHUSETTS l PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction Permit Permission is hereby granted to �Construct( ) `. Repair(X) Upgrade( ) Abandon( ) System located at and,as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be Winpletee"d witthhi-n•three years of the date of this permit. Date r-) / ! C�_/ Approved C) by uommonweann or massacnusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 111 RUSHY MARSH ROAD A GILLMORE, GEORGE R JR Owner Owner's Name Q7 information is required for every Cotuit MA 02635 1/10/16 a page. City/Town State Zip Code Date of Inspection E•• tl CA Incnar+inn racidtc•MI1et ha ciihmittart nn thie fnrm Inenartinn fnrmc may not ha altarari in anu way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information ! # on the computer, c: !/ IN 03 use only the tab 1. Inspector: key to move your cursor-do not Robert Paolini use the return key. Name of Inspector Company Name 17 Playground Lane Company Address Yarmouthport MA 02675 ufryf i own Mate [ap uoae 508 362-3555 S 14454 Telephone Number License Number B. Certification i i:ci tiiy u idt t i iiivc l.ici aul iciiiy ii iJl.icUMU U is Suwdiy.C ulbpUbdi SyaLtui i i at u llb duui vab di iu u idt U id 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: n PaccPc n rnnrfitinnally PaccPc n Failc ❑ Needs F er EVRIuati a Local Approving Authority N 1/10/16 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 Title 5 Officiai Inspection Form:Subsurface Sewage uisposai System•Page 1 of 17 AO VS uommonweann oT massacnusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 111 RUSHY MARSH ROAD V ivvj icy FiUl U. GILLMORE, GEORGE R JR Owner Owner's Name information is required for every Cotuit MA 02635 1/10/16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ltl,,Pt;:;uUll JUilmidly. tiiluL;K h,D,U,U Ul C 1 dMa-ya,kUllljJlClV clil Ui QUL;UUil U 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 inriinnfcri KgMln%Ar Comments: ®% 5y;bmll 1,rv1[lulLlU111 iily rd5btrs: ❑ 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 u�iei i ni i�u, Lnoaa�cnNiau . 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. r►i i iuLdi tiupui;tdl iK Will Pabb ii ibpt;G;tivi i it it lb sti Utaui ciiiy --iUul 1U, i lU[ivam ly df iU it d tiVl tii it:citV VI Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Vommonwealtn of Massacnusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments e 111 RUSHY MARSH ROAD ;FN l Ly.%Uui.. GILLMORE, GEORGE R JR Owner Owner's Name information is required for every Cotuit MA 02635 1/10/16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) u Frump unamoer pumps/alarms not operational. System will pass wan hoard of Heaitn approval it pumps/alarms are repaired. B) System Conditionally Passes(cunt.): ❑ 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 pdbs ii iQPWULlUl i ii kWlu i dNpl uvdi vi DUdi u U! rediu 1). ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): n e io+rihi i+inn Knv ie IovainA nr renloneri n v n AI r-I till /Cvnloin helnu\• u I ne system required pumping more than 4 times a year due to broken or obstructed pipe(s). i ne 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: u i;esspooi or privy is witnin ou teet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 uommonweann or massacnuseas Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 111 RUSHY MARSH ROAD wv; i ky��ui c� GILLMORE, GEORGE R JR Owner Owner's Name information is required for every Cotuit MA 02635 1/10/16 page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) c. Qy3LC.iii Will idii uli11WOb tilt UUMU Ul FlUd ui taiiu ruuiiV VVdRU 0i.111NNiiirr, ii ally) 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: ijlia ayaieiii paaaea ii ulu weii viiaiei aiiaiyaia, fieiiviiiieu al.a LjF-r Geliiil(dU iaiiuiaiUiy, ii.ii MUcii 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: U) 3ySiciii rdiiuiu viiLutid i4ppiit;dviv to Fiii 5ysi.taiits; You must indicate"Yes"or"No"to each of the following for all inspections: Yes No n n Backup of sewage into facility or system component due to overloaded or cioggea -3A,) or cesspool ❑ R Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ 0 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less ❑ ❑X ♦L.....1/ .d...,il..... t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 uommonweann of massacnusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 111 RUSHY MARSH ROAD GILLMORE, GEORGE R JR Owner Owner's Name information is required for every Cotuit MA 02635 1/10/16 page. CiWrown State Zip Code Date of Inspection B. Certification (cont.) I va 114U ❑ 0 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ❑x Any portion of the SAS, cesspool or privy is below high ground water elevation. n n Any portion of cesspool or privy is within 100 feet of a surface water supply or iriuutary to a suriac;e 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. ❑ Z Any portion of a cesspool or privy is less than 100 feet but qreater 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.] a i r ie Syb=Il rS d UUZi6.ii.iv1 OUI vii ly a iaii:iiity wits r a UW.-Avi t liUw ui ZUUUYf.U- 10,000gpd. ❑ FZ 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. L) LditW OySiCiIM' 1 V Vt;WiibiUVO WU ca 141gu tiy3LC1i1 Liiv-.S-ybwfli iliuSL sti VU a lal.11lLy vvnui sa 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 Li Li to a syster►i is witnlint 4uu Teel of a sunac a arming water supply ❑ ❑ the system is within 200 feet of a tributary.to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 I Vommonweann of massacnusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 111 RUSHY MARSH ROAD GILLMORE, GEORGE R JR Owner Owner's Name information is required for every Cotuit MA 02635 1/10/16 page. City/Town State Zip Code Date of Inspection C. Checklist lVl1GV1X II ll IG IVIIVVVII ly I IC7VC iJf:C11 UUI IG. i iii.i(IItA°J'St I11UIl.GItG yU3 vl i IU ci.3- li!Call l i7i ii 11; ItiIIl7Vv ii i-tJ.-. Yes . No ❑x ❑ Pumping information was provided by the owner, occupant, or Board of Health n n Minrc env of 4hc evefcm nmmnnnenfe ni emncr7 ni 4 in 4hc nrcvino ie fi,vn%AuanL e'> ❑ X Has the system received normal flows in the previous two week period? ❑ 0 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 ❑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? Li LJ vvere the septic tanK mannoies uncovered, openeca, ant?trig 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 vUU11 Uvivi i 110 iWU i.7i ovu U1.1. ❑ 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)] C. 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): uommonweann or massacnusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,•'" 111 RUSHY MARSH ROAD GILLMORE GEORGE R JR Owner Owner's Name information is required for every Cotuit MA 02635 1/10/16 page. City/Town State Zip Code Date of Inspection D. System Information Number of current residents: ` Does residence have a garbage grinder? ❑ Yes ❑x No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑x No information in this report.) Launa y system inspected L^J Yes U NO Seasonal use? ❑ Yes No Water meter readings, if available last 2 ears usage d na- g ( Y 9 (gP ))� Detail Sump pump? ❑ Yes ❑X No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: LJGSiyi 1 i1lJYV iAJ81jG1.7 VI I J I V ViTfll\ I.J.L\!J/. - Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Inch ie+rinl%eincto hnlr+inn+nnlr nrccen+7 F-1 vee F1 kin Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 commonweann or massacnuseas Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 111 RUSHY MARSH ROAD .viovi iy nUvl ,x GILLMORE GEORGE R JR. Owner Owners Name information is required for every Cotuit MA 02635 1/10/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) LCial Uc2LC Vi Vt;UUFjc21 luyluaC. Date Other(describe below): i9�Iii`.i Gil 1911 Uiliii�ui911 Pumping Records: Source of information: 1A/mc cvcfem ni imnorl -me nnrf of fhe incnerfinn') n Vec iY Aln If yes, volume pumped:. gallons How was quantity pumped determined? Reason for pumping: li YNU v, Qy;bL!UM: 0 Septic tank, distribution box, soil absorption system ❑ Single cesspool r-I (1vorFlni necennnl. ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ , Other(describe): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Vommonweann or massacnuseas Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 111 RUSHY MARSH ROAD ric;N�i.y RuuiZa3 GILLMORE, GEORGE R JR Owner Owner's Name information is required for every Cotuit MA 02635 1/10/16 page. City)Town State Zip Code Date of Inspection D. System Information (cont.) iAPPi Uiiii i IdLt✓dyc Ui dill L:Ui i IPUI IUI iLS, Udild it iSidlIVU ;il KI IUWi l) di iU SUui Ge ill ii 11U I i ICUIUi i. Were sewage odors detected when arriving at the site? ❑ Yes ❑x No Rnilrlinn CO%Arar/Inro+c nn ci+c nlnn1- Depth below grade: 1' feet Material of construction: ❑ cast iron R 40 PVC ❑ other(explain): Distance from private water supply well or suction line: I U feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the building vents. Orr:IRIG 1 diliK klUL:die UI I SiLU Pidii 1). Depth below grade: 1.5' feet Material of construction: MY r•nnnrc+c n mc+ol n fihcrnlocc /cvnlnin\ it LdI iK is I Iifrldi, ii9l alJ.--�. years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gl. Ch irinc ricn+h• 3" t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 commonweann of massacinusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 111 RUSHY MARSH ROAD i-.ly r,uujVo-. GILLMORE, GEORGE R JR Owner owner's Name information is required for every Cotuit MA 02635 1/10/16 page. Cityj town State Zip Code Date of Inspection D. System Information (cont.) Distance from top of sludge to bottom of outlet tee or baffle 36" Scum thickness 0" Elie+onne from+nn of cr•i im +n+nn of ni i+Ie+too nr hoffle 7" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, G....:.J L.....In .. i.l..✓•.-..1 i.. ..,,il..i ...i .:.J..r..... ..F L...L...... ..J•..\. Pump tank every 2 years.Inlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. Depth below grade: feet Material of construction: n rnnnnre+e F--1 M M I-I n+her/evnloinl Dimensions: Scum thickness U!bLdiILAC fitiiii LUP Ui aWlli Lv LUP vi Lii.i11e1 Lee vi iidilie Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 commonweann of massacnusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 111 RUSHY MARSH ROAD 1-i Upra Ly F-,Uui GILLMORE, GEORGE R JR Owner Owner's Name information is required for every Cotuit MA 02635 1/10/16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) kaU11111 ICI Lb "U1 I 1JUMPH 19 IUL;UIIIII lul iUd-LiUi ib, H HUL d!IU UULIWIL L-t;;U UI Udlilid UJI iURIU1-1, bil ULAU!di it Ruyi Ry, liquid levels as related to outlet invert, evidence of leakage, etc.): I#-!-d-i!L U! FtUliU1i-1U-- i Wilk kad-i Ir%MU61 UW pUillpvu aL LHHU U! 11-1bPUL;LiUI 11 klUud-LU U1 I Z10e Plat l/. Depth below grade: Material of construction: F-1 ennrra#.n F1 mmfol F-1 filharninee nnitimf1hi-Anno r-1 Minor Invir%loinli- Dimensions: Capacity: Design Flow: gallons per day Alarm present: El Yes El No Alarm level: Alarm in working order. 1:1 Yes El No Uc2mi Ul id51.PUi i ipil ly. Date Comments (condition of alarm and float switches, etc.): Attacn copy of current pumping contract(requirea). is copy attactileare L-j Yes .L-i No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 commonweann of massacnosens - Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 111 RUSHY MARSH ROAD 11 vii�.i Ly -%uui czo GILLMORE, GEORGE R JR Owner Owner's Name information is required for every Cotuit MA 02635 1/10/16 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) U15 AJULIVII QUA kn pi irsiri ii i i 1w i uu upui ivu) tiui,;aiu ui i 5iiu plai i). Depth of liquid level above outlet invert No Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box is Ievel.Box has one outlet Iaterals.No evidence of Ieakagge.No evidence of solids carryover. ruoiiip%AH-0-iilEildi tlUUdLU Ui1 bRU pidii). Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* (`nmmenfc tnnfe rrr%nriifinn of ni imn nhmmher rrnnAifinn of ni imno nnA onni irfernnnnee efrr V ii pui i 1Ns Ui tilai i i is di u i iiii-I-I i vvui KH iy ui UUi, sysiei i i is a i.;ui i i iai Mass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Gom►nonweann or massaenuseus - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 111 RUSHY MARSH ROAD GILLMORE, GEORGE R JR Owner Owner's Name information is required for every Cotuit MA 02635 1/10/16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) ❑x leaching pits number: 6'x6' H2O with 3.5 stone ❑ leaching chambers number: I—I Ic�rhinn n�llcrice ni imhor• ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: Li If fff tlVCiliVCi 91kCf l iiCtiiVfr SySICIit S Type/name of technology- Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy soil.No signs of hydraulic failure. Leaching pit was dry at time of inspection.Stain line observed di Jcivn i-d i-1i Lc a i i ry r ii is—iiv iid ii-- J. vcaaNvvFs ti.cssNi;vi liiiiSi UV,Puiiilllail dS tieiii vi ii isFlUi,ifviiI Si iaii). Number and configuration Depth—top of liquid to inlet invert fleni•h of enliric lover Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 • Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 corn monweann of massamuserts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 111 RUSHY MARSH ROAD GILLMORE, GEORGE R JR Owner Owner's Name information is required for every Cotuit MA 02635 1/10/16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) ---- -- - - - -- - -u - �Vii{FiF�CI ItS (4{ViG i,,Vi{Ullfiii F VF SV{I, Slit.F i3 i.vf I IyUf aui�ir iclltf.tl G, I \!Ct iJt I.lUi iuGi ty, Gtii iUfiiUi F Ui VCysr€aiiiJi{, etc.): i _.. Fi6tly kitiLdi.`c vi o iaiij. Materials of construction: Dimensions r)onfh of enliele Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t�ommonweaitn of rviaSSacnuseutts Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 111 RUSHY MARSH ROAD GILLMORE, GEORGE R JR Owner Owner's Name -----__�.--- --__.--- — information is Cotuit MA 02635 1/10/16 required for every _ _—_.— page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 � I � t t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 I ( oti monweann otf 1!tilassacnusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °p 111 RUSHY MARSH ROAD GILLMORE, GEORGE R JR Owner Owner's Name information is required for every Cotuit MA 02635 1/10/16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Siic iGRGiii. ❑X Check Slope Surface water n (`hcnL rcll�r ❑ Shallow wells Estimated depth to high ground water: Bottom of leaching 7' feet Please indicate all methods used to determine the high ground water elevation: LJ umaineu from syiwrn aesign piai-i80 till recora If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) As-Built ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS observation well data.USED:Technical bulletin 92-0001 annual ranges of groundwater elevations.Hand auqered 5' below Ieachinq.No groundwater observed. — ---- ------- - --- ----- ---- — - - �iciviG iiiiii� sills iii:7�3�iV8iiiii �i;�itiii.� �ii:�st�Si�C t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 uommonweann or massacnuseas Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °- 111 RUSHY MARSH ROAD GILLMORE, GEORGE R JR Owner Owner's Name information is required for every Cotuit MA 02635 1/10/16 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist u- inspection z5ummary: A, ts, (;, u, or t cnecKea ❑x Inspection Summary D (System Failure Criteria Applicable to All Systems) completed System Information—Estimated depth to high groundwater fvini._,_.. ,.c c+........... n:__......i n....a...... ..:ai.._....i,........ ,.... .......... �c ......aa....�_.+ :_ ,.,..__-..a..c:i,. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 f9 ' CGi les "P LOCATION SEWAGE ER IT N0. VILLAGE f ST A LLE 'S NIA-ME R a ADDRESS 0 U I l D E R OR OWN-ER ,�0 e, r22 ,e ' DA T E PERMIT ISSU E-D DA-T"E COMPLIANCE ISSUED . 1 . i� y� V • s No. -0 s:� �.. Fus.... Z THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ...............o ► ..%_uc.......................... Apptiratiou for Dispati al Works Tnnilrn.rtion ramit Application is hereby made for a Permit to Construct ( or Repair ( ) 'an Individual Sewage Disposal \� System at: -,.Aga_ k...0Q .................................................................................................. .... Location:Addres or Lot No. ..A -1---••-j.......................... ........-•--...................................................................................... w r Address a .....................�^'- _..... .:a .............-.......... ------------=-------------------------•---• Installer Address r UType of Building Size Lot_ 3)7O__1.....Sq. feet Dwelling—No. of Bedrooms.___ __________________________________Expansion Attic { (� Garbage Grinder Other—T e of Building ............................ No. of persons___________________________ Showers — Cafeteria a Other fixtures --••-•--•-•-•••-•-••--•---•- -•- - e. Desi Flow....... allons er erso @r da . Total dailyow_-____._ gallons. W -------------------- --g P P _ aYe } C ,r WSeptic Tank—Liquid capacity_)CM_gallons Length :7 __. Width_..!..tO__ Diameter----------------- Depth__- _... x Disposal Trench—No_ .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-___.__-____ � � .._._,_.. Diameter.___._..__.___ Depttii below inlet______!........ Total leaching area_.20.0...sq. ft. Z Other Distribution box (Ya5 Dosin tank ( '-' Percolation Test Results Performed by. A2 � I_l, ll+>1 � Test Pit No. 1._/. _____minutes per inch Depth of Test Pit... ...... Depth to ground water_rjd GL, Test Pit No. 2................minutes per inch Depth of Test Pit...._______.____.__. Depth to ground water_---___________________- a ............... -•-- �j /�j ' Description of Soil--- '��s_ .. M 5.114 =� 1"Z, =a --� G • --------- x U --- ---- -------------------- •---------- •-------------------- ______----•---------------------•----------------•---------•-•-----•-------------•--_____-_---------•---_-•-------------•-------- x --•------------------------------------------------------------------------------------•---•-------------------------------------------•----•---------=---------------------------------•--••---•-••••-- 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 TITLL 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. Ad...................... .......................................... ............ -- -..._....--•-a. ....._..... c' /.vhs Date Application Approved By..... -._..._.�..�..� - •f Date Application Disapproved for the following reasons:-----••••••-----•-••.._._._..•-•----••-••-•---•--•------•--•••-•••-•--•----•--•---•--••.._..•---••••--•-......._ .................•--•--....--•---•-••-------_-•---••---•-••-•-=-•---------•-----...••----------......-•••.................................-............................................................. �Z: - ssed--•----------•-•--•-••----•-•••-•--- ------------- -^--• —Date Permit No............. Issued _..... Date THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH Appliration for Disposal Warkii Tonstrurtinn Frrutit Application is hereby made for a Permit to Construct ( Kor Repair ( ) an Individual Sewage Disposal System at: 7-1-� _ -----.4.. kcZS f—..... i i . .'._�...... .......................................... Location-Ad ess f or Lot No. ---•----------.•--- CCSr ... d�-. ®r ................ ..............•-•---...-•-•-•------••----............--•---._...--------------....-------•----.... 1....,,(bwner Address W •--• •••a .............................................. - _..........__....------••••-•----------- Installer Address Type of Building , J Size Lot.. r.7 -�---_- q. ft Dwelling—No. of Bedrooms------ Attic Garbage Grinder (.4d c)i aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures .---------••-••--•------•.............•••-•-•••-...--•-•-----•-•-••-------••--•--•--•-- -•--------•-•-•-•••-••••....-•-•••-••-•-•-•••-......--••--••. W Design Flow________ -2e ....................gallons per person t day. Total daily f1pw----- �2_ ...................... lonj. W Septic Tank—Liquid capacity_.).V allons Length.....`. Width._'!.w'#0-- Diameter......°°'n"...... --- ---------- Depth--- --- x Disposal Trench—No..................... Width.................... Total Length....__......•••••• Total leaching area____---•-•..__--_---sq. ft. Seepage Pit No_______________ _ Diameter.._.._? _.... De tl below inlet.....6............ Total leachin area. ?.r� ----- --- - P --•- g -- '-,��__sq. ft. z Other Distribution box (Yon Dosin tank O �... _ Percolation Test Results Performed by_.& �_ 4 ►.�&• i i Date_ �".Z'S-0�J-.-... Test Pit No. 1____________....minutes per Inch Depth of Test Pit---- :.__....... Depth to ground water...__. ................ LX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water____••___-_...---_--___- Wr- ....I_.._,a__------1G.______________ ___ _c:__.._._..._____.....____ .___........._.....__.------------ - ----••_. ODescription of Soil - ...................................$ ...........-�(<-...................................1 , - 1- � x w x --••-•---------------------•------••••-----------••----••••----••--•---•-------•-------•...••-••--••---••---••••-----•--••••--------•-•••-•-••-•--•-•••---•-••••-•••••••---•-•-......--•••-•-•.......... 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 T IT I:- 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. Date Application Approved BY.................................... ....--_. ••••'......•••••-•-•• -•-.=�'......------•-•------. .... Date Application Disapproved for the following reasons----------------------------•--------------------------------•-------.....------------------------------......... ---------------------•-----•------------••---•-----•-----•--•---.................-•--------....-----........--•--•-----------------•---------------•-•----------------------------------------•--••----•--- Date Permit No................. T +G Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r ............A' . .............OF.......... �.��`1�:............................. Trrtifirtttr of Tompliaurr THIS IS TO CEIjT;FyY ha��t, .the Individual Sewage Disposal System constructed ( or Repaired ( ) by------------------- ----------__-_ " .---- ------------•---•-------. ..................................................... Installer �. at ""�-----..._...�..... -l?�,:. .` ---------- ---±--':�---..lze. has been installed in accordance with the preions of TIT f The State Sanitary Code as described in the application for Disposal Works Construction Permit No-------------- `__--*..d.Y dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM MILL FUNCTIONSATISFACTORY. DATE........... . //Y f--- .............................. Inspector Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD .. OF HE L ZH OF......B .!r`............ct...... .�.............................. .............•••••.•..... FEE.................... Disposal IVo o wo tr rit rrutit Permission is hereby granted......., f'! ;-----------------•-•--------•----•-••-•-----••---............-----•--•--- to Construct ( )��epair (roan Ind'vi_dual w ge Di�posal�S3�stem ------•- Street as shown on the application for Disposal Works Construction Permit Now` _..._:2_cyD ed......... .......q ......... . ,� 3 Q 6 Board of Health v DATE ...............................................•-••-••-•••..-••--• 4 FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS 1 . oo. J /Z i �Pti ss PATER 92, O y SULII AN 11 /Z/ U 1Z0 No.24133 e :a, 9•q. sG . -ti. .�.�: Low � ��o.�•a� RICHARU 1;,;i; A. BAXTET- ?'T No.24048 ft SUM \jArM ; �4 itsCl L cam-S 4 f 2v� Ylog- ��L.�►`J� 1�1�V' �lC� / = SITE ZB.�. �a2 QC-�l 9 • q • $� �. �_� A G � Ci.CZ.fit' !-ov 0 3 s ' ITA�tiK:,1. t l 02rR Y tE :3 G. B n o 1 jLt I Irk +. ;f5"O JE t ;I- 3 I I I A . (.� �_ 5U IVY ,�. e t l l -�i fiIO. �7 V 18N:TEA i J-4 11 j 11 I VJ �r � i I - ��M(8 L 8 ' f j. f -:x- -1 ��.1 ... ? r 1 "i I ! F►G. •►? `1 t lopo. 108 O I � -i.� .: - � ; C,E'- rc' _�. _ L..t-y-1,OZF(� S•E'Pr�C I OZ �j+ •. .. IlK • :r wt D r f 7 .2T ST I /F/EO 'PG OT p4:44/ eft4 _ OWN . +• -,tom- . 1 I r I i-.,. •eT : p2 T`alsit `+ �-r4 ,eE• ci,�' a ?,�y I ; ' i,cc. :'J. � W/ y�y�-ma`s Al '00V a� A:'&Z3 e•J317U]71 - I. i I .STt�L/ 1GT•1.-//YES T USE <<, DES iCN DATA 'S 1 NG-LE FAM►�-�. _ - 3- NO GA1Z13AC--E G9-1N DER- DAILY F•UDW 110 x 3 = 33o G.P. D. SEPTIC TA N 14- = 3 3 o y lT07.. • 49 S G.►'• r-,�. USE 1000 GAL. TAKE YK Z '1"�..�. �t✓v DISPOSAL PtT --- QSE (I) l000 GAL. 2 sI DGWALL AR-EA f, Z 3 7-5- Cr-.P. O. l••', �. Serrom A9-EA = So 5.F, { So S.F. x l, o Sc� G P, D. TOTAL OESl& J _ 4ZT G, P. 0, T TA L 'CA ILA F:Low/ 3 3 o G-. P D. P- t A-ricN3 2A-M : I"lN .Z M��7 ,02 LESS P�ty� OF rc' RICHARD SULLIVAN IVAN A. No. 29733 " BA);TER s k Na 2;C.4; f' T•Es9rq, o -z,< Ae7c,4 eeetacz ., T1 - WiTU, J . C.o► 1-o 0 25.8 5 CG RI 5 m.Z TO►� N t ^l2'o rCx'3 `~ � G = t 2 0 -- G 110. 5 u35o/L �yt• Oisr, O O O /.f/s/.L. /W. ( goX 11VII /000 10-7.1. 07•F) .. y CEAcN lbZrp S.EPrrG • P,7- 107•Z 1 bT q �.E.2T/F/EO PG oT pL.4�✓ • WRsHC-D „ ,t S7oAJE fb 14-164-, tJo SCALE 5>2 Atio B,4xT�,e .f�7'l�r�G�. .eEQv/�EHI��vrS d� Tiy4 I.uc. Gocdr�.o L✓/r-.s��iV T.�.E .C�aovPt�4.iti . . �l-�s.� T/�lr o09"lfl /s iS/oT le714SE0 mil/,4 iY/X-/57-7- .yE.e�arV.5.4/ovGllp 1107- L USE 92 P,T. ? P;:+ /Ac I -To.6 F- ICHARD V. K,2A j d a 9s•7 95� � t � i O eq 9 •q • $66 is.4 t�� Eo2GL G i �M62Ezo. B � �---.� 1 I �n� r . _, ,..,,,, I� No. InJ��1l1_ ___ �1 Fee--� --------- - BOARD OF HEALTH TOWN OF BARNSTABLE Application,for Ver[ Construct ion permit Application is hereby made for a permit to Construct Alter �( )_, or Repair ( )an individual Well at: z /Location — Address Assessors Map and Parcel Getl" Ge Co t'! •tti��l -- 11L_1�� _� nnoiC 9--R'j , — --_ Owner -- — Address — Installer — Driller —-- Address Type of Building Dwelling --- -- - ------ Other - Type of Building------------- No. of Persons----------------------- Type of Well �( --- Capacity------------------ Purpose of Well Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate of Cqmpliance has been issued by the Board of Health. \ ate Application Approved By `f ---—-— -- -- date Application Disapproved for the following reasons: — ------- ------- - - — — ------------- date — Permit No. W 20o2 y0 — Issued-- �'_ --___ __-- ----------- date BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate ®f Compliance THIS IS TO CERTIFY, That the rLidual Well onstructed ('I, Altered ( ) or Repairedw..r / Installer at /1 1 t 14 S ( /u w S /Z ------- -----_----- has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Prot ction Regulation as described in the application for Well Construction Permit No.W21/O�=- �Dated- 2--- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE— Inspector--------------------- ----------- Fee---1---------------- BOARD OF HEALTH TOWN OF BARNSTABLE Applicat ion-*r V efr Con.5truct ion Permit Application is hereby made for a permit to Construct (f), Alter ( ),'orr,Repair (. )an individual Well at: Location — Address / ( Assessors Map and Parcel __G�C�/ �� COI �vil -- r;' •—r ��°�n.�0i_� ►�� -------- Owner Address s _0- SC/urvc # 0,12ax-�6U- -M�'��tt IAA c0G C�-L - Installer — Driller T— Address Type of Building Dwelling --- -- ----------—_ Other - Type of Building-- ------- No. of Persons-------_--_�—______ n Type of Well Y --- -- Ca acit ---- Purpose of Well Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation The undersigned further agrees not to place the well in operation until a Certificates of C mpliance has been issued by the Board of Health. Signed n J _--- date Application Approved By . -- -------- U --- date I!I Application Disapproved for the following reasons: -- ------- ------ - — — — ------- date _ Permit No. Issued-- hrh;')-- -- ----- date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the Innd** 'dual Well Constructed (- ), Altered ( ), or Repaired ( ) // Installer has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No.�=`�a�!U�" ��—Dated --- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE------ - Inspector----------_—___- ------___-- BOARD OF HEALTH TOWN OF BARNSTABLE Ietl Con5truct ion Permit r No. IN )()Ud �U Fee Permission is herebyranted / g ----- to Construct ( L,,), Alter ( ), or Repair ( ) an Individual Well at: No. -------------------------------- Street ---- as shown on the application for a Well Construction Permit No.- 062- b Dated-- 02 - �' �- ------------------- ------ Board of Health DATE —