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HomeMy WebLinkAbout0152 STEVENS STREET - Health oyannis P 30 0 1 I 0 III TOWN OF BARNSTABLE 1� LOCATION 15 Z L �� ��- SEWAGE # Pr-7100 VILLAGE / y�°� /'S ASSESSOR'S MAP & LOT 390/"' -99�,V INSTALLER'S NAME&PHONE NO. � � � SEPTIC TANK CAPACITY 13u) Cvt LEACHING FACILITY: (type),4-4/s,,a4 (size) /D'/Jef-'X; NO. OF BEDROOMS BUILDER OR OWNER PERMI DATE: I?z 4 COMPLIANCE DATE: Separation Distance Between the: _ Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 5 f 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 Jy� Feet . within 300 feet of leaching facility) Furnished by `c o SQ. �a 0 _ 'Z Alo. .�GO / L 1,1)6 `. Fee / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ' PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes pphratton for �Btgpogal 6pgtem Co ructton Vermtt Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ' ❑Complete System ❑Individual C pon is J(�� Location Address or Lot No. 5 Ff/C/�S j1 ,�� /j�Z Owner's Name,Address;and Tel.No. O Assessor's Map/Parcel •3 �� f©�� �'�'�'�"Y✓��' Installer's Name,Address,and Tel.No Designer's Name,Address and Tel.No. 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 Bo Health. Signed Date Application Approved by Date tt 5^- Application Disapproved by: Date for the following reasons Permit No. '� Date Issued a— 1 S— 0 -oy i No.�.t �G' 40 Fee /A/� Entered in computer: THE COMMONWEALTH OF MASSACHUSETTS Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Application for �Digpoal 6p.5tem Co truction Permit. r i Application for a Permit to Construct O Repair O Upgrade O Abandon( ❑ Complete System ❑Individual Co ponents T n Location Address or Lot No. ��� S -lev,S Owner's Name,Address,and Tel./Noo. 0\2 �� '1L i 1/} ;b, Assessor'sMap/Parcel ,3p OD ✓ �� '�� '� y F i Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. a III 70L elf, Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures �i Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title i Size of Septic Tank Type of S.A.S. j Description of Soil Nature of Repairs or Alterations(Answer when applicable) � 1 Date last inspected: j 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 Boa f Health. _ Signed_ Date Application Approved by 1111AIDate Application Disapproved by: Date i for the following reasons gd Permit No. O Date Issued 4 ------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS CERT+I that the -site Sewage is osal Sy em Constructed ( ) Repaired ( ) Upgraded ( ) Abandoned(�Y)by / / at j /✓f✓1 has been constructed in accordance r' with the provisions of Title 5 and the for Disposal S stem Construction Permit No. .2 00& - 64 dated Installer Designer #bedrooms /"1 Approved design flow gpd , The issuance of his e it all not be construed as a guarantee that the system w' nction as designed. Q p Date Inspector �� F No. �b� b —O Fee I THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS Digo!gal *p5tem Construction Permit _-+ Permission is hereby granted to Constru t ) Repair ( 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. i Provided: Construction must be completed within three years of the date of this it. Date — (`�� U Sy[ Approved by Barnstable Assessing Search Results Page 1 of 2 mx q Home: Departments:Assessors Division: Property Assessment Search Results New Search y`" New Interactive Maps >> Owner: 2008 Assessed Values: MORIN,JACQUES N 152 STEVENS STREET Appraised Value Assessed Value Map/Parcel/Parcel Extension Building Value: $92,000 $92,000 309 /004/ Extra Features: $5,600 $5,600 Outbuildings: $0 $0 Mailing Address Land Value: $ 113,500 $ 113,500 MORIN,JACQUES N Totals $211,100 $211,100 1597 FALMOUTH RD-SUITE 4 CENTERVILLE, MA.02632 2008 REAL ESTATE Tax Information: Tax Rates: (per$1,000 of valuation) Community Preservation Act Tax $41.67 Fire District Rates Town Barnstable FD-All Classes $2.04 $6.58 C.O.M.M. -All Classes $1.03 Commei Hyannis FD Tax(Residential) $322.98 Cotuit FD-All Classes $1.03 $5.80 Hyannis-Residential $1.53 Persona Town Tax(Residential) $ 1,389.04 Hyannis-Commercial $2.35 $5.80 Hyannis-Personal $2.35 Other R; W Barnstable-Residential $1.86 Commur W Barnstable-Commercial $1.86 W Barnstable-Personal $1.86 Total: $1,753.69 Construction Details Building PrQperPrsoperty�Skdetch & ASBUILT Building value $92,000 Interior Floors Carpet Style Ranch Interior Walls Drywall Model Residential Heat Fuel Gas Grade Below Average Heat Type Typical Stories 1 Story AC Type None I I http://www.town.bamstable.ma.us/assessing/assess/displayparcel08map.asp?mappar=3 090... 2/27/2008 Barnstable Assessing Search Results Page 2 of 2 Exterior Walls Wood on Sheath Bedrooms 2 Bedrooms Roof Structure Gable/Hip Bathrooms 2 Full Roof Cover As h/F GIs/Cm living area 906 � � G P P 9 Replacement Cost $110807 Year Built 1964 , Depreciation 17 Total Rooms 4 Rooms Land EMR8 �f •. ��t r a 3-iir`1 AW4MMMIP1140 CODE 1010 Lot Size(Acres) 0.33 ��jiai k r Appraised Value $ 113,500 AsBuilt Card N/A Assessed Value $ 113,500 t -View Interactive Maps > �,. Sales History: Owner: Sale Date Book/Page: Sale Price: MORIN,JACQUES N Feb 13 2004 12:OOAM C172108 $200,000 OSTON,WAHNA TUSA Dec 4 2003 12:OOAM C171468 $ 1 OSTON,WAHNA TUSA& Feb 15 1996 12:OOAM C139814 $ 1 OSTON,WAHNA TUSA Nov 15 1983 12:OOAM C94108 $0 Extra Building Features Code Description Units/SQ ft Appraised Value Assessed Value BRR Bsmt Rec Room 740 $3,100 $3,100 FPL1 Fireplace 1 $2,500 $2,500 Property Sketch Legend BAS First Floor, Living Area FST Utility Area (Finished Interior) UAT Attic Area(Unfinished) BMT Basement Area(Unfinished) FTS Third Story Living Area(Finished) UHS Half Story(Unfinished) CAN Canopy FUS Second Story Living Area UST Utility Area (Unfinished) (Finished) FAT Attic Area(Finished) GAR Garage UTQ Three Quarters Story (Unfinished) FCP Carport GRN Greenhouse UUA Unfinished Utility Attic FEP Enclosed Porch PTO Patio UUS Full Upper 2nd Story (Unfinished) FHS Half Story(Finished) SFB Semi Finished Living Area WDK Wood Deck FOP Open or Screened in Porch TQS Three Quarters Story(Finished) http://www.town.bamstable.ma.us/assessing/assess/displayparce108map.asp?mappar=3090... 2/27/2008 No. S Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes "plication for �Digpogaf �&pgtem Cottgtructiou Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon V) ®.Complete System ❑Individual Components Location Address or Lot No. 152 Owner's Name,Address;and Tel.No. 1 0Wnl I)r BAA QS 1A2 Assessor'sMap/Parcel R IANNIS MR L1(001 Installer's Name,Address,and Tel.No. K l l9�k u m bEK. Designer's Name,Address and Tel.No. 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) TOTAL REMtNAL.. OF SEPri C TAPlk N LEACH 114r EVV-i M Date last inspected: 9.3U•6b 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 Bo%Aof Health. , Signe 4� Date Application Approve by Date Application Disapproved by: Date for the following reasons Permit No. , Date Issued ®� THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded ( ) Abandoned(X )by H*wwM D' 1. , IoW N DF r1*21AAKMAISLE at It Z, STETS S'Ti N11 4t IS t MA b2(P01 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. �7JG� dated Installer Designer #bedrooms Approved design flow gpd The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector ———————tom———————————————————————— —— ——— --- No. / � Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Wigpool. *pment Construction Permit Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon (X ) System located at 152 S 1 EyE NS SIr JAYANN IS 0A 02- 01 and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction m st be completed within three years of the date o Date Approved No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF'BARNSTABLE, MASSACHUSETTS Yes Zipprication for ID.igo�al *pgtem Congtruction Permit a , t ; Application for a Permit to Construct O Repair O Upgrade O Abandon(-X) ®.Complete System ❑Individual Components Location Address or Lot No. 152 Owner's Name,Address;and Tel.No.I()WQ pF BAA To pc Assessor's Ma /Parcel 1 p 1-1'II�►NNIS r N1A d2to01 Installer's Name,Address,and Tel.No. E11 UN U RI Ur. Designer's Name,Address and Tel.No. II 1 Type of Building: j a Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) , Other Fixtures i Design Flow(min.required) gpd Design flow provided gpdI Plan Date Number of sheets Revision Date ' Title Size of Septic Tank Type of S.A.S. Description of Soil j 1 Nature of Repairs or Alterations(Answer when applicable) Tn,A t_ (R r_M byAL n f C rPT I C TANI'� 1.EAcm II-IG SIRE'I`� Date last inspected: 9•5n, of Agreement: x. The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in j 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 Boar f Health. Date Application ApprovI by Date Application Disapproved by: Date i for the following reasons 4` II Permit No. Date Issued c, --------------------------- --- - - ------------- THE COMMONWEALTH OF MASSACHUSETTS i r BARNSTABLE, MASSACHUSETTS Certificate of Compliance f ; THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded ( ) Abandoned(X )by kiGFlIn1A'_1 V��lrl. I01n)N OF 6ANSTAIST I at 152 STEVG._►.IS S t. I-1*44N 15..e MA bZ.(G'O1 . has been constructed in accordance i with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Designer JJ #bedrooms Approved design flow gpd The issuance of this permit shall not be construed as a guarantee that the system will function as designed. . Date Inspector ——————————— I. - Fee � JJ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS 1 wigoml �&p5tem Construction Permit Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon (X ) �I w System located at 152 _,�'iEVE NS S-i: f MANN IS .P/IA 02tool I 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 /' i � b, � Approved .rr.vw--•..__.+.•r--rr.—^`.I`^w.,r. J•1•'*••r"`l'^ai.+..•.l'H`Y` A _ TOWN OF BARNSTABLE BAR-w 4823 Ordinance or Regulation WARNING NOTICE Name of Offender/Manager M .PAr-L Ula"i ' ' a Address of Offender 1 � a n , f r MV/MB Reg.# Village/State/Zip t"i V/1 Af 1' ,--', A Business Name /e!arzmD/pm,, onrJ 20(�! Business Address / rift pert 3r'P 1 Signature.of Enforcing Officer Village/State/Zip Location of Offense ,!; - 7t 'ts.U11t. a , � l (' �/C. t�'+ICYf ,1 r r r Enforcing Dept/division Offense ' Facts � � �:; �� -t' ' tl �O 3 !) !1 ,! �/#'" �?A e06 ri �Qr 14 MIS ��'-�� :�fic-0 oV SP h�fr��- This will `seve only as a warning. At this time .no legal- action has been taken. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT. TOWN OF BARNSTABLE BAR-W Ordinance or Regulation WARNING NOTICE d i f Name of Offender/Manager ter Address of Offender 1 r . `�,rr-Ikerl�,., �, n 1 "" MV/MB Reg.# Village/State/Zip ¢S {r` ' s' ; J Iy ltl 17"QAo Business Name fam,/pm., on c.:, ; ` 20 Business Address Signature .offEnforcing Officer Village/State/Zip Location of Offense r - _ ! err;= Ff � r - ' ` Enforcing Dept/Division Offense ' ' try , +, § !�' ,. P Facts I `, } {'� ;t . r y 1. 1r { i � ! r NJ P P This, will serve only as "a warning. At this time n'o legal` action`has been taken. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT. TOWN OF BARNSTABLE BAR—w4822 Ordinance or Regulation WARNING NOTICE ��,�ff��// Address of Offender MV/MB Reg.# Village/State/Zip yIt#A MA 0(�- 601 Business Name f �am/p,ff,, on 2011 Business Address '?!"'r : , Ze .f" `r l {' •, S gnature .of"nforcing Officer Village/State/Zip } p j �/ Location of Offense l r 11 , N1 - � �7 Y" 1 i�{ J r� ke t, ''t��.. 1/92 Rr,A— f/I Enforcing Dept/Division Offense � j�r't,. 1 Facts P.) / V f!rcc .S? / 1 i .3Pr P) OA oq AM O I� j OP P)y d-I'lloa- /?( *1a)MAA1 rl�E This will serve only as a warning. At this' tim4 do legal action has been taken. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT. TOWN OF BARNSTABLE BAR-w Ordinance or Regulation WARNING NOTICE A I A Nkme of Offender/Manager -P Address of Offender MV/MB Reg.# Village/State/zip Business Name on 20 Business Address Signature f" Enforcing Offic!er Village/State/Zip Location of Offense " Enforcing Dept/Division Offense a. f US r, Facts f This will serve only as a warning. At this' time, no legal action has been taken. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT. L TOWN OF BARNSTABLE LOCATION /5 Z STe,(L�5 -sT SEWAGE # ?Llie VILLAGE /�Y/�Yi'y ASSESSOR'S MAP & LOT ✓PI' "ego�V INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY ISGu Ca LEACHING FACILITY: (type) 1,44ila-u _(size) /C".-3d r,4 1 ' NO. OF BEDROOMS BUILDER OR OWNER OSr�/J PERMIT DATE: �?' COMPLIANCE DATE: Separation Distance Between the: _ Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility r Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) ;), h Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) 1� Feet Furnished by his 00 i rw ao THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 0[pprication for Migozal *pgtem Congtruction Vermit Application for a Permit to Construct( )Repair(tr)Upgrade( )Abandon( ) ecomplete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel No. D a � Assessor's Map/Parcel Installer's Name,Address,and Tel.No. !�r Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(10�/® Other Type of Building CS No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 3350 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. — 17, 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 Certifi- cate of Compliance has been issued by is o of ealth. Signed Date `7 Application Approved b Date Application Disapproved for the following reasons Permit No. Date Issued Fee V k' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION;TOWN OF BARNSTABLE, MASSACHUSETTS 01pplication for �N!5pool *p5tem Construction Permit Application for a,Petmit to Construct( )Re gair(/)Upgrade( )Abandon( ) 1 Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: 7 Dwelling No.of Bedrooms J Lot Size sq.ft. Garbage Grinder(11t�0 Other Type of Building 415f Pyi°C� 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 /7 OD Type of S.A.S. /�f/"�' �'� Description of Soil 5 � Nature of Repairs or Alterations(Answer when applicable) 7-1;/lt- _�7-- 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 b his o �ealth _--- Signed ✓� Date Application Approved b Date Application Disapproved for the following reasons Permit No. Date Issued ----------------------------— ------ THE COMMONWEALTH OF MASSACHUSETTS 309-aay BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( - Upgraded( ) Abandoned( )by 7�L4 / CC�dY;S at f J�—Z 6 /CP 6lli' S has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. - / - dated_T ' f Installer , Designer The issuance of this porudshall no be construed as a guarantee that the 4..stem!w' 1 function as de,�igned. Date n l 4 Inspector V.fall/A t_. No.--—�—�---------------------��_-- Fee � — + THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE,, MASSACHUSETTS �Dfgpool *p6tem ongtruction Permit Permission is hereby granted to Construct( )Re air( ))Upgrade( )Abandon( ) J System located at Z �s ST 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 p,pqnit. "Ae Date: ' /° Approved P / 5 i r i p r ' NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) L D�O "� r "el-Ze�j , hereby certify that the application for disposal works construction permit signed by me dated �1yl�9 concerning the property located at meets all of the following criteria.- 4/The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch /There are no wetlands within 100 feet of the proposed septic system There are no private wells within 150 feet of the proposed septic system /There is no increase in flow and/or change in use proposed There are no variances requested or needed. Y The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: > A) Top of Ground Surface Elevation(using GIS information) Mi B) Groundwater Table Elevation 2- max, adjusted g.w. �J = Z ' Z ' DIFFERENCE Z - 4 SIGNED : DATE: [Sketch pmposed Plan of system on bads]. - DaN6 folder oeet i Y r3 �t .s•, _ _ _ -.., _t N .uc .. -......�• .__.. ... ' ' ___ --__.ems _ �`-"�w^ne. '^` - - - - COMMONWEALTH OF MASSACHUSETTS ID EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION V ' MAR PARCEL 00 'LOT TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:. f��Q/lllr A Owner's Name: RECEIVE® Own.er's Address: �/ • � 1 Date of Inspection: 3 OCT 16 2003 Name of Inspector- (please rint) {^� TOWN OF BARNSTABLE Company Name ', HEALTH DEPT. Mailing Address: Telephone Number: -7 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 pursuan7 Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs.Further Evaluation by the Local Approving Authority zF Za, s,, Inspector's Signature: % Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10.000 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: p/ Owner: Date of Inspection: Inspection Summary: Check AAC,D or E/ALWAYS complete all of Section D A. System Passes: t/ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltratton or tank failure is imminent. System will pass inspection if the existing tank is replaced with a.complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection.if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or-high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broker_pipe(s)are replaced obstruction is removed distribution box is leveled or.replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will Pass inspection if with approva l of the Board of Health):. broken pipe(s)are replaced obstruction is removed ND explain: 2 t Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of Inspection: 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 f,ui ctioning iri'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 iess 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 5 S I - Page 4 of 11 OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: q . Owner: Date of Inspection: �a�j(j D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or / cesspool 1/ Liquid depth in cesspool is less than 6"below invert or available volume is.less than '/day flow 7 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. t/ 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 nitroger_.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.] (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 contac±'the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a.large'system;the system must serve a facility with a'design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 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 ender Section D shall upgrade the system in accordance with 310 CMR 15.364.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 1.1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART R;. :. CHECKLIST Property Address: L Z Owner: Date of Inspection: 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. A/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? tl 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) _LZ" Was the facility or dwelling inspected for signs of sewage back up 1� Was the site inspected for signs of break out? 1C 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 I I OFFICIAUINSPECTION-FORM—NOT:F* OR P VOLUNTARY ASSESSMENTS PV SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: q, Owner: Date of Inspection: c FLOW CO DITI07VS RESIDENTIAL V Number of bedrooms design Number (design of bedrooms(actual): �.. DESIGN flow based on 310 CMR 13.203 (for example: 110 gpd x#of bedrooms): QDQ -Number of current residents: ta Does residence : have.a garbage grinder(yes or no Is laundry on a separate sewage system (yes or no Eyes separate inspection required] Laundry system inspected(yes�or noLA& Seasonal use: (yes or noj/�Kl ��---- Water meter readings, if available(last 2 years usage(gpd)): '�� ` �` $Sd 0/ Sump pump(yes or n ): n Last date of occupancy: _ COMMERCINUINDUSTRIAL Type of establishment:. Design flow(based on 310 CMR15.203): 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:, Was system.pumped as part of the i spection(ye or ne): 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 — ch a copy'.of the DEP_approval 4ZOther'(describe). n n �G ,Approximate.a-pre of al e ,ponent ,date installed(if known)an source infor atio i Were sewage odors-detected when arriving at the site(yes or no): 6 Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: �� 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 liner Comments(on condition of joints,venting,evidence of leakage, etc.): SEPTIC TANK: _olocate on site plan) & ///t Depth below grade: Material of construction: lzeoncrete_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: ( Sludge depth:_,/() Distance from top of sludge to bottom of outlet tee or baffle: 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 affle' How were dimensions determined: LWJ Comments(on pumping recommend tions, i let and outlet tee or baffle condition, structural integrity, liquid levels related to outlet invert,ev' ence of leakage etc.): l�+1 /I �C,PEJ GREASE TRAPbcate on.si:te plan) 6 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 f Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: ': 00 3 TIGHT or HOLDING TANK: & tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain;: Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: V Comments(condition of alarm and.float switches, etc.): DISTRIBUTION BOX 1-(if present must be opened)(locate on site.plan) Depth of liquid level above outlet invert: 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.): PUMP CHAMBER:/ locate on site plan) Pumps in working order.(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFOR-M,QATION(continued) Property Address: & MA Owner Date of Inspection: 3 SOIL ABSORPTION SYSTEM (SAS):_(locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ lz;fc-hing chambers,number: leaching galleries,number: leaching trenches,number, length: leachins 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.)* p , CESSPOOL`S:A/� cesspool must be pumped as part of inspect ion)(]ocate on site plan) Number and configuration: Depth 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.): PRI�locate on site plan) Materials of construction: Dimensions: Depth of solids: Conunents(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4 Owner: Date of Inspection: c�>C)03 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building. elo� f� 73 30 10 Page I I of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property-Address: s � Owner: J Date of4nspe!t:Lion- � � SITE EXAM. Slope Surface water Check cellar Shallow wells Estimated depth to ground water / 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: hecked with local excavators, installers-(attach documentation) Accessed USGS database=explain: You must describe how you established the high ground water elevation: 11 Permit Number: Date: Completed by: HIGH GROUND-WATER LEVEL COMPUTATION IE Site Location: s ," Lot No. Owner: Address: �y Contractor: Address: `�a /�/'G��$ - S" Notes: STEP 1 Measure depth to water table to nearest 1/10 ft. .......................... Date /G ® J �� month/day/Year 'I STEP 2 Using Water-Level Range Zone and-Index Wel1'Map locate i site and determine: J A Appropriate index well..............................���/. l Z3GJ Water-level range zone ......... .....................L--J• ` STEP 3 Using monthly report."Current II Water Resources Conditions" determine current depth to water level for index well .......::.................. v O� ' ��I month/year STEP EP 4 Using Table of.Water-level Adjustments for index well (STEP 2A), current depth to water level for index.well (STEP 3)., i and water-level zone (STEP 28) _ determine water-level adjustment............................. STEP 5 . Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from"measured'de'pth to water level at site (STEP 1) .:............ S..............................._......................... -i I • Figure 11--Reprcducible computatj01-1 Term. . ;, . ,�^: �-� ��: `�; . =�° Qi � � — . � � �� . � � a �. . � ���� . �. t ;� 4 ' , ��� 6 �.y d �ti '�i i �^^� S �` i� rio ' pp _ 3 � I -�—.�� } fs . �i 1� �� l� � � � } 1; . • �� { � qq 7 �'ei .. .�. f ` � �� 1 0 R t f � ii is �� �� i �{ ti:. � ti >> s w. � ` a �` � � � �3 _�_� ��� . 4 i � � � ,. _. j `