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HomeMy WebLinkAbout0181 SCHOOL STREET - Health '81 SCHOOL STREET j COTUIT ti. i c� V j l� i_ TOWN OF BARNSTABLE LO 'r TiON ` L d a 3 �C�idr9� 'f • SEWAGE # cl LOS-3�q m'; LAGE C®f cJ -f ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 3 5,M011 A- `3 OJ 2lc,- SEPTIC TANK CAPACITY 14, Z® LEACHING FACILITY: (type) (size) NO.OF BEDROOMS ! BUILDER OR OWNER PERMITDATE: ���C� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 et of leaching facility) Feet Furnished by Z a Bel Par U`o > too,= 1• qV, S x . I Ck Ile COMMONWEALTH OF MASSACHU-SETTS t �a EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION Di vislo TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A - CERTIFICATION S -3 Property Address: 181 School Street Cotuit, MA 02635 Owner's Name: Paul Grover Owner's.Address: Date,of Inspection: June 10, 2005 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Ostetville,MA 02655-0049 Telephone Number: (508)862-9400 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: Passes ✓ Conditionally Passes Need rther Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: June 19. 2005 The system inspector shall subracopy 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. Notes and Cotmnents ****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 con'ditions'of use. Title 5 Inspection Form 6/15/2000 page 1 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 181 School Street Cotuit, MA Owner: Paul Grover Date of Inspection: June 10, 2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron 40 PVC other(explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) - Depth below grade: 10" Material of construction: ✓ 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: 1000 gal. (H-10) Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 6" 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: 10" How were dimensions determined: Measuring stick Comments(on pumping recotmnendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees werepresent. The liquid level was even with the outlet invert There did not appear to be any suns ofleakaze Note The tank is H-10 and under a gravel driveway. It needs to be made H-20(heavy duty) loading GREASE TRAP: None (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 orbaffle: Distance from bottom of scum.to bottom of outlet tee or baffle: Date of last pumping: Continents(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 10 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 181 School Street Cotuit, MA Owner: Paul-Grover Date of Inspection: June 10, 2005 - 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. . � Q �fon� C 3 �. as . a3 3q Tr 1 S ae 10 /Ck COMMONWEALTH OF MASSACHUSETTS '(j)�3 a!-4141f FT EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS 11]05 JuN 28 . A�3 g DEPARTMENT OF ENVIRONMENTAL PROTECTION 'V1S10 TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION S Property Address: 181 School Street Cotuit, MA 02635 Owner's Name: Paul Grover Owner's.Address: Date of Inspection: June 10, 2005 Name of Inspector: (Please Print) Jmnes M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508)862-9400 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: Passes ✓ Conditionally Passes Zeierther Evaluation by the Local Approving Authority Inspector's Signature: Date: June 19, 2005 The system inspector shall sub 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 buyerjf applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that 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 r Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 181 School Street Cotuit, MA Owner: Paul Grover Date of Inspection: _June 10. 2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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. Yes 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. The septic tank(H-10 loading)is under a gravel driveway. It needs to be made H-20(heavy duty)loading.- ND explain: No Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: No The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 I Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 181 School Street Cotuit, MA Owner: Paul Grover Date of Inspection: June 10, 2005 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: 3 r Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 181 School Street Cotuit, MA Owner: Paul Grover Date of Inspection: June 10, 2005 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility.or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ 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 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. S Large stem: Y 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 II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a,significant threat,,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 181 School Street Cotuit, MA Owner: Paul Grover Date of Inspection: June 10 2005 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 this inspection? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ _ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS,located on site? ✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of-the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ _ 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(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 181 School Street Cotuit, MA Owner: Paul Grover Date of Inspection: June 10, 2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4(per as built card) 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: I Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes.or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied 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: t: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: A leach field was installed on 1216100-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 a I Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 181 School Street Cotuit, MA Owner: Paul Grover Date of Inspection: June 10, 2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron 40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 10" Material of construction: ✓ 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: 1000 gal. (H-10) Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 6" 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: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert There did not appear to be anv signs of leakage Note The tank is H-10 and under a gravel driveway, It needs to be made H-20(heavy duty)loading GREASE TRAP: None (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: Continents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 I Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 181 School Street Cotuit, MA Owner: Paul Grover Date of Inspection: June 10, 2005 TIGHT or HOLDING TANK: None (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: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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.): The D-box was level. No solids were present. The D-box was H-201oadinz PUMP CHAMBER: None (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.): P/ 8 r Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 181 School Street Cotuit, MA Owner: Paul Grover Date of Inspection: June 10, 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: 3 drywells leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil, condition of vegetation, etc.): The drywells were clean. There did not appear to be any signs of failure. CESSPOOLS: None (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,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 r Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 181 School Street Cotuit, MA Owner: Paul Grover Date of Inspection: June 10, 2005 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. � a y a - a3 -39 10 ' Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 181 School Street Cotuit, MA Owner: Paul Grover Date of Inspection: June 10, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25+/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: Topographic and water contours snaps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Usinje Barnstable topographic and water contours mans the maps were showing approximately 25'+/ to ground water at this site. This report has been prepared and the system inspected and conditionally passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 e ,y COMMONWEALTH OF MASSACHUSETTS ' ` EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM , PART A CERTIFICATION Property.'Address: 181 School Street _ Cotuit. MA 02635 Owner's Name: Paul Grover Owner's,Address: Date of Inspection: _June 10. 2005 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508)862-9400 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: Passes ✓ Conditionally Passes Need rther Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: June 19, 2005 The system inspector shall sutaco�pyy 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. Notes and Comments ****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 I Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 181 School Street Cotuit, MA Owner: Paul Grover Date of Inspection: June 10, 2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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. Yes 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. The septic tank(H-10 loading)is under a gravel driveway. It needs to be made H-20(heavy duty)loading. ND explain: No Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: No The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): 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: 181 School Street Cotuit, MA Owner: Paul Grover Date of Inspection: June 10, 2005 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: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 181 School Street Cotuit, MA Owner: Paul Grover Date of Inspection: June 10, 2005 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/Z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ 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 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 System: 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 II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 181 School Street Cotuit, MA Owner: Paul Grover Date of Inspection: June 10, 2005 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 this inspection? ✓ — Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ _ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS,located on site? ✓ _ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ _ 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) [31.0 CMR 15.302(3)(b)J. 5 i Page 6 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 181 School Street - Cotuit. MA Owner: Paul Grover Date of Inspection: June 10, 2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4(per as built card) 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: I Does residence have a garbage grinder(yes or no): n1a Is laundry on a separate sewage system(yes or no): n1a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied 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: Unavailable Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: A leach field was installed on 1216100-per as built card 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: 181 School Street Cotuit, MA Owner: Paul Grover Date of Inspection: June 10, 2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron 40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 10" Material of construction: ✓ 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: 1000 gal. (H-10) Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 6" 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: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage Note: The tank is H-10 and under a Pravel driveway, It needs to be made H-20(heavy duty)loading GREASE TRAP: None (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 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 181 School Street Cotuit, MA Owner: Paul Grover Date of Inspection: June 10, 2005 TIGHT or HOLDING TANK: None tank must be pumped at time i( p of inspection) locate on site plan) P P )( P ) 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: ✓ (if present must be opened)(locate on site.plan) Depth of liquid level above outlet invert: Even 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.): The D-box was level. No solids were present. The D-box was H-20 loading PUMP CHAMBER: None (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.): 8 r Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 181 School Street Cotuit, MA Owner: Paul Grover Date of Inspection: June 10, 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: 3 drywells leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): The drvwells were clean. There did not appear to be any si ng s offailure CESSPOOLS: None (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,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 Page 10 of 11 0o 5 act Co- OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 181 School Street Cotuit, MA Owner: Paul Grover Date of Inspection: June 10, 2005 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, 1 , Q C 3 . a3 3q 10 i Page 11 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 181 School Street Cotuit, MA Owner: Paul Grover Date of Inspection: June 10, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25+/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: Topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours mans the maps were showing approximately 25'+/ to Around water at this site. This report has been prepared and the system inspected and conditionally passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied,relating to the system, the inspection and/or this report. 11 TOWN OF BARNSTABLE LOCATION A �C cn� SEWAGE # VILLAGE— y- ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. Lu Z +-- SEPTIC TANK CAPACITY I ,5co 14 7 c LEACHING FACILITY: (type) (size) NO.OF BEDROOMS. BUILDER OR OWNER � �� PERMITDATE: C) _COMPLIANCE DATE:. Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility: Feet . Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist I within 300 et of leaching facility) Feet Furnished 2-A W-S `1t-C. A E too. 0 r . c G O OF'BAMSTABLE .' LOCATION ' 0 I SG�d0 SEWAGE VILLAGE CO TU ASSI SOR'S.MAP & LOT U-)-O " O9 0 i INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 3• SW �( 33x ITY LEACHING FACILITY: (type) (sine) I NO. OF BEDROOMS 0 BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Betw e: 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 1 Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching�facility) J Feet Furnished by T-4MLGtlU� C C 0/C. i i A 0 j as � 3 as a3 3q OW OF BARNSTABLE ~~ r ¢1 S , LOCi1TION I v do SEWAGE # % n1 5s1s VILLAGE CO Tlz ASSESSOR'S MAP & LOT d,0 01 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 3' Sw e1. 1) (size) 33� NO. OF BEDROOMS (0` BUILDER OR OWNER PERMITDATE: 42 _COMPLIANCE DATE: Separation Distance Betw e Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching ffacihty) Feet Furnished by , T-/1sO�Gtl�n .� . F0/("J ��onT C ' r as i� > y a3 39 TOWN OF BARNSTABLE E e" S'T- SEWAGE # O D G 1i'5' VILLAGE L0 TvI% ASSESSOR'S MAP & LOT o 2 0 -090 INSTALLER'S NAME&PHONE NO. 03y y Josi Al !�-e, SEPTIC TANK CAPACITY /000 LEACHING FACILITY: (type) 3-,5-,00 LliLlsi'ze) NO.OF BEDROOMS BUILDER OR OWNER /Pu�G� is9 C�rot/1�' PERMITDATE: b 30- O 0 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Tablet he 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 faac�cili��ty) Feet Furnished by ' li �— G lull LFL s - , i 0 sekool �T I __Box olvl� ` No. 9 Fee THE COMMONWEALTH OF MASS ACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01pplication for Vigo a' *pztem Cone;truction Permit Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. l S 0 er's Name,Address and Tel.No. Assessor's Map/Parcel Gv-tu- vet 67-0VC4Y,*? Installer's Name,Address,and Tel.No. "7-7 L/—?3 (o-57! Designer's Name,Address and Tel.No. aaSo) /- • Sou Za, Jig 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 16ZZType of S.A.S.Ff'e-lcQ `A) 3 Cl1c w, b �r_C Description of Soil Nature of Repairs or Alterations(Answer when applicable) A CX " ' k iz se�d c- - A,-, Cc— +,A-2 cnew 41-0 t S� G1�4ytclr 7' I r. / 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 b n issued by thiFBoard of Health. Sign' ® Date Application Approved by Date Application Disapproved for the following real n Permit No. ' Date Issued --------------------------- y .::._ -_.- ,. _, .�-__✓'_-..-,,1 ..mac.-., -AOX CALY No Fee -< O. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS } gfpprication for 30igoogal *pgtem Cottgtruction Permit- . Application for a Permit to Construct( . )Repair Xpgrade( )Abandon( ) ❑Complete System 0 Individual Components E Location Address or Lot No.1 Se_ho l -_I S-4. O//��ner's Name,Address and Tel.No. i Assessor's Map/Parcel Go fiU i G� YQv1 6,_ + Installer's Name,Address,and Tel.No. - -7 C—F 3 (o-5??L/ Designer's Name,Address and Tel.No. �aSuryl Suu z a. ee 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`.-1 rZt) 14 Z.,) Type of S.A.S.F e-1�PIT3 C14 r.gq C Description of Soil {lY4 Nature of Repairs or Alterations(Answer when applicable) , itg �!A sc 4 ,. /c S is+Xj c j ",7 r) 1 ri 4t l lr Ta IL_ �` ` - Date last inspected: c9 5 `.:. 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 en issued by this Board of Health. F `. Signe1< 124 A � 190am_ Date' , Application Approved by /i!/A �)A \> Date Application Disapproved for the following reasons/ �� a Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS . f BARNSTABLE, MASSACHUSETTS { Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( )Repaired( )Upgraded( ) Abandoned( )by `� ✓ at I � .I.o.n RCN . C_���d°— ,r���has been constructed'in accordance with the provisions of Title 5 and the for Disposal System Construction Permit NoQ�_3 dated / >� Installer •sue.. Designer The issuance of this permit shall'not ,e construed as a guarantee that the system will functionr-as- designed. Date 6>1 Inspector ------��------------------------- No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS d ig ogar kim Cong1ruction Permit ermtssion is hereby gra ted to Construct( )Repair( U rade( )Abandon ) System located at 1 ��A06� W 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: Co stru tion must be completed within three years of the date of th' p it. / Date: a Approved by 7�JP\ No. �•d2/t7' 7 r Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: a� Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZipphCation for 30iqual *pgtem Con5truction Permit Application for a Permit to Construct(4-)-Repair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. /•$/ ,��`j fj p l Owner's Name,Address and Tel.No. Assessor's Map/Parcel C U/ Selma/ .fir grab Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. S- Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank / Type of S.A.S. Description of Soil Nature of Repairs or Alteratio s(Answer when applicable) f'OSI-4/l Y- H-2 0 194y 4l/i-I/,� y ' Stop-r_ 14ra11h 2 " /oFw sTah Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. 6 Date Issued /0-1°P�� No. Fee ' b THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ` Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS v Otporication for Migogal *pgtem Con6truction Permit `* Application for a Permit to Construct(4,)Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. /$/ ,SCl9 001 .577' Owner's Name,Address and Tel.No. Assessor's Map/Parcel r Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Jbs 1-104 1]� �3�r•--v S �✓O,s � �� /�f41� (�S Type of Building: Dwelling No.of Bedrooms�_ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Y. Design Flow gallons per day. Calculated daily flow k` gallons. 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) {�rtaf� ?- H-�/I ` Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore,described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. r Signed A Date Application Approved by Date /©-?0 -Zap Application Disapproved for the following reasons ` t Permit No. -� Date Issued /c►-.3 0--Zwv ----------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed(L.)-Repaired( )Upgraded( ) Abandoned( )by Q s­-4o,4 t-e /9,Wt­la f 2"/ /�,,tip -; f ��'cl�ti a �i�,✓/� at /a/ S 0 5 r. e�"2 j;.+4 r has been constructed in accordance — - with the provisions of Title 5 and the for Disposal System Construction Permit No?-A v-(9r/S--' dated Installer ��.�� �� /� �v�o� Designer_,/hs,-sod (7���,/-..��- nj r�, T� p The issuance of this permit shall,n t be con trued as a guarantee that the system will function ap designed. 1 L Date tF f � Inspector --��r 1 / -A A—/V " V - -—0 f- ct--p--------- No. 74 'o .6 4S� �4 0 0/ 4 Fee __1 y, •�"— THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS 4 ligoml *psstem (fon5truction Permit Permission is hereby granted to Construct( r..-)pair( )Upgrade( )Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Date: /0 -3 0 Approved by 1i6i99 NOTICE: This Form Is f6 Be Used For 'the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH .kYD APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERNN, 11T (-W=OUT DESIGYED PLANS) Gk 9,os-kds` _ hereby ceru'ythat the aoolication for disposal works construcaon permit signed by me dated _lv_.3a_ ao concerning the property located at . meets all of the following criteria: /-,—The failed system is tonne✓ed to a residential dwelling only. There are no commercial or business // !uses associated with the dwellinz. Cs/The soil is classified as CLASS I and the percolation race is less than or equal cc 5 minutes Der inca. 6--l'-7here are no wetlands within 100 fee;of the proposed septic system mere are no private wets within 1.40 fee;of the proposed se?dc system there is no increase in flow and/or change in use proposed § There are no variances requested or needed ; • i ne bottom of the proposed leacain;facility will not'be located less than five Feet above the ' maximum adjusted groundwater cable elevation. (Adjust the zoundwacer table using the Frimpcor metod when applicable) • If the S.A.S. will be located with ?50 fee;of an-i ve;enced wetlands. Che boctom of the proposed leac:ting facility will net be located less than ouree t(14) fee;above the ma::cimum adjured Q*oundwater table elevation, Pleo_se complete the following: g ` A) Too of Ground Surface S:zrauan(usin; GIS informauon) D, B) G.W. cle iacion _9 -the:NL� (. E l:. G.W. Adjussneni . _ R . DEFERENCE B E-FtVEEN• A and B r v (Sketch proposed plan of on baCkl. q:::uth[oider.:`-t Sri 0 ! 11.10 SEWAGE PERMIT N0 PILLAGE INSTA LLER'S NAME i ADDRESS uILD R� OWNER DATE PERMIT ISSUED DATE COMPLIANCE ' ISSUED ' l 39 ©q V THE COMMONWEALTH-OF MASSACHUSETTS �� BOAR® OF HEALTH D � ..........TW.n........OF.....6arn.6-larb) ............................ ApplirFation for Bispvii al Works Toutdrnrtinn thrutit Application is hereby made for a Permit to Construct ( ) or Repair (k-� an Individual Sewage Disposal System at: .......�fSL.._._ .&b _J0 ._... x e l................... .................... ........... ............. Location-Address. or Lot No. ---.......yu h..._ eY....................................... .......... .. . 774,j:. ....:------...---........................................ � Own Ad r s Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) `4 Other—T e of Building No. of persons____________________________ Showers — Cafeteria 04 Other fixtures .......................••---•-:......-•••••••- ••--------------------------•--------___...._-••--••-•••----•------•----•-- W Design Flow....................................._------gallons per person per day. Total daily flow___.____.___._______...______...__.________•gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No..................... Width.................... Total Length.....................Total leaching area....................sq. ft. 3 Seepage Pit No_____________________ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date............•-••-•--•••••••••--•-•-•--- ,� Test Pit No. ]................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (i, Test Pit No. 2________________minutes per inch Depth of Test Pit.................... Depth to ground water........................ _.c?.),c c).----•----------------------------------------------------------------------------••---•-------- O Description of Soil... V --------------------------------------------------=-----------------•-----------------------------------------------------------------�, ii U Nature of Repairs or Alterations—Answer when applicable._._1.:1Q_Q� LO-__-� 1,7.��____________________________________ ------------------------------------------------------------------------------------------------•.-••-• l..-••Jet`I......................................----------------------------...------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has Xcil, issued by the board of health. ,Da Application Approved By... r../1'�_..- ra�. �� �%-A1--------- Date - Application Disapproved for the following reasons_______________________________________________________________ ••••••--•-••••-••-•--•--•----• ••--••---•---- ........-•...................•-------•-•-•-----------------...---------......----------•---•-•---•------..__....__....--••-•-----•----------------------------------------------------------------...._._ Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH.OF MASSACHUSETTS BOARD,.OE HEALTH ............[OUIV)........OF.... ` %:, _ -------------------•--...----- Applirtttion for Disposal Works Tonstrudion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair (k-) an Individual Sewage Disposal System at 3 J' C C1 ......... ._.. - --------•------------------- ------------.-----•--------------------_ � ...._. r", ocation-Address or Lot No. ...................... �.�..... ���.>..��:' ........---•--------•---••-----•--•---. . �t�.�. .--•......................••--...................... w' i Owne' �-�-;� Address _.. Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................:............Expansion Attic ( ) Garbage Grinder ( ) 14 Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures .................................. d •---•.................---------------------•------------ -----------••------•---- W Design Flow............................................gallons per person per day. Total daily flow..............._..._................._._....gallons. WSeptic Tank—Liquid*capacity............gallons Length................ Width............... Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.....:.............. Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by------------------------•--------•---•--•-----.---•----............ ••----• Date......................................... . aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �Tq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ...........- .... a -•_ l'•-•-•-.....•-•--------•......_..-••--•-•---•-•-•-----•.._......•--••...---------••.........•--••_.-- Descriptionof Soil...............„- ... -----------•------•-------------------------------•----•----- x UNature of Repairs or Alterations—Answer when applicable _ ...............I%.. ..---•------------------------------------------•---•----...---•--------------------..............-•••••---•••• ....t f�+ . ` ' -................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT E 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. !. Application Approved By---- '. '':... _ .111.1.......................... G � Application Disapproved for the following reasons:.............:.................................................................................................. -•-•-----•-------•...............•----•-•---.._.....-•-•----••------------•------•----....................------------------•-----:..-------------------------------------•--••-•-----------•-----•------ Date PermitNo........................................................- Issued..................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......... ................................... ' � �ler#ifirtt�e oaf f�uut�littnrr � . THIS IS TO hCER T�FY That the Individual Sewage Dispo al System constructed ( ) or Repaired ( ) by .:�..�r �. r = 7i,f�' 'a � (y � �2�� . -4.'���-=----------------------------------- ......... r _ �. _ ...: ,,,�t ) at ........................................... 1 ..............•- - ------------------------------••...........----•----•--• . ........................ has been installed.in accordance,with the provisions of TIT F: 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No. ------ ..:.....:.:... dated................................................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.................................................--••--.......--•-••------_..... Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH a ... . ............OF.... � .�. ` �lf Nca F,. .......[{g�.. FEE.-- ....... �t�� ttl ,�rk� Cann #rnr#tla�t rrt�.t� E f. Permission is hereby granted...--------f------')_ �,��.ao�._-��---'�-.....�._�._�=�.-•--•�..................•--...--•---._.... to Construct ( or Repair an IndividuaI-Sewage Disposal System �, atNo....1-��`J �Lj. .........................� ' l�.._._ �_'_ d --------------------------------------•----_---_- -�-��'-�?� ------ Street as shown on the application for Disposal Works Construction ermitt No................... Dated.......................................... "-•- li'�....1/-. . -......•....................••---•--•--..............._ �f Health DATE. FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS t TOWN OF BARNSTA.BLE LOCATION %8/ SEWAGE AGE #mod- GyS� - :VILLAGE 7611% r ASSESSOR'S MAP & LOT o 2 d -090 . INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY fD00 LEACHING FACILITY: (type) -,Sdo � f�i`,J i — NO.OF'BEDROOMS—:.S� ' ti�—f�ie) 3 X / // x . BUILDER OR OWNER_ iPUTy� Ia,,jh' w�lJ1�T PERMIT DATE: CplvtpLr e rvr-E „A�. Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility feet Private Water Supply Well and Leaching Facility r • g ty (If any wells:exist on-site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of le achin facibt - Feet. Y t y 7 !t yM A, IN&r IQ y L F > " d LV AN xc r THE COMMONWEALTH OF MASS ACHUSETTS BOARD OF HEA TH w Apphrarwn for Dispasai '.Harks aunsimOwn 11irmi# Application is hereby made for a Permit to Construct (. .) or Repair (1-1 an Individual Sewage Disposal System at: oz Lot NaAW- ' Installer eaa=e , Type of Building Size Lot_- Sq.'feet 1 Dwelling—No. of Bedrooms R-pausion Attic ( ) Garbage Grinder Other—Type of Building -No. of persons_— Showers (. ) —Cafeteria ( ) Other fixtures ----_ _ — — — Design Flow. _gallons per person per,day. Total.daily flow ...-_ Septic Tank—Liquid*capacity-_—gallons Length--_Width___Diameter____._.. _Depth_ 1 Disposal Trench—No.___._—Width----Total Length Total leaching area----sq.fL Seepage Pit : Diameter_.._—..Depth below inlet— Total leaching area.__ sq.ft Other Distribution box ( ) Dosing tank Percolation Test Results Performed by- -----_--_-- jTest Pit No. 1_.—____minutes per inch Depth of Test Pit____ Depth to ground water____-- _- Test Pit No.2 _minutes per inch Depth*of Test"Pit—_._ Depth to ground water-_—_.—�__.. . Description of Soil-•__—.. 4 L.!LI C _� l l)� ----- ---.... — ------ --- — --- j Nature of Repairs or Alterations—Answer when applicable Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in . operation until a Certificate of Compliance has issued by the board of health D Application Approved By__ _ D t; Application Disapproved for the following reasons:__—___�___•__ - Date Permit No. _ Issile� ._ .Datc THE COMMONWEALTH OF,MASSACHUSETTS " BOARD OF HEALTH ........OF... 1t1r-tt-L� :.=-- Ta if CtttP of &nt}tltam THIS IS TO CERVY That the Indi dual Sew e Disposal System constructed( ) or.Repaired (s—) by .iCCf J at has been installed in accordance with the provisions of TI F �of The State Sanitary.Code as described in the application for Disposal Works Construction Permit No: �) ✓� --- dated......._._ _—•-_- ------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. , Inspectoi•—� s _ THE COMMONWEALTH OF MASSACHUSETrS BOARD OF HEALTH E — F8s____' • Djo pact urko trut erz# Permission is her grantedto ConstXu�ct ( o{Repair (1� an India ewage Dis sal System. t at No._1_lE_�— c � � street _ as shown on the application for Disposal Works Construction ermit No:__� .-:_t Da ll oard of Health- DATE----------G�•��>�•- FORM 1255 H086S 8 WARREN. INC.. PUBLISHERS �� • • • .. 6