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Home My WebLink About0033 ASPEN WAY - Health 33 ASPEN WAY OSTERVILLE A = 120 019 J i Commonwealth.of Massachusetts Title 5 Official -Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �< 33 Aspen Way Property Address Charles H Donald Trust Owner Owner's Name information is required for every Osterville Ma 02655 11/3/2011 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:when filling out forms A. General Information on the computer, (� use only the tab 1. Inspector: I. key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. Capewide Enterprises ry Company Name 153 Commercial St. Company Address Mashpee Ma. 02649 City/Town State Zip Code 508-477-8877 SI 4522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance 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 ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 11/3/2011 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. ****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. i I l � I I � t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewn a Disposal System•Page 1 of 17 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 33 Aspen Way Property Address Charles H Donald Trust Owner Owner's Name information is required for Osterville Ma 02655 11/3/2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or 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. ❑ Y ❑ N ❑ ND (Explain below): 1 l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 33 Aspen Way Property Address Charles H Donald Trust Owner Owner's Name information is required for Osterville Ma 02655 11/3/2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ . obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 33 Aspen Way M Property Address Charles H Donald Trust Owner Owner's Name information is required for Osterville Ma 02655 11/3/2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® 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 '/day flow t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M e 33 Aspen Way Property Address Charles H Donald Trust Owner Owner's Name information is required for Osterville Ma 02655 11/3/2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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 ❑ ® Y pP Y tributary to a surface water supply. ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system'is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone 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. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 33 Aspen Way Property Address Charles H Donald Trust Owner Owner's Name information is required for Osterville Ma 02655 11/3/2011 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate yes" or no as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of 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: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 33 Aspen Way Property Address Charles H Donald Trust Owner Owner's Name information is required for Osterville Ma 02655 11/3/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: 2009 = 70,000 total = 192 gpd 2010 = 85,000 total = 233 gpd Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 33 Aspen Way Property Address Charles H Donald Trust Owner Owner's Name information is required for Osterville Ma 02655 11/3/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 33 Aspen Way Property Address Charles H Donald Trust Owner Owner's Name information is required for Osterville Ma 02655 11/3/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: hem repaired 3/16/2001 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints ok, no leakage, vented through roof Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons Sludge depth: 5" t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 33 Aspen Way Property Address Charles H Donald Trust Owner Owner's Name information is required for Osterville Ma 02655 11/3/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 3.5' Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 101, How were dimensions determined? opened covers and took measurements Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): ***CAUTION GAS LINE RUNS OVER THE SEPTIC TANK*** Tank does not need to be cleaned now but should be done soon and again every 2 years as maintenance. Water level was ok, tank was not leaking and was structurally sound. Outlet baffle was intact and in good condition. Grease Trap (locate on site plan): Depth below grade: feet 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: Date t5ins•11/10 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M a' 33 Aspen Way Property Address Charles H Donald Trust Owner Owner's Name information is required for Osterville Ma 02655 11/3/2011 every page. Cityffown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I 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 per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 33 Aspen Way Property Address Charles H Donald Trust Owner Owner's Name information is required for Osterville Ma 02655 11/3/2011 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box was functioning as intended. II Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 33 Aspen Way Property Address Charles H Donald Trust Owner Owner's Name information is required for Osterville Ma 02655 11/3/2011 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ 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.): Leaching facility was video inspected from the vent and found to have 0" of standing water with no signs of past hydraulic overloading Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 33 Aspen Way Property Address Charles H Donald Trust Owner Owner's Name information is required for Osterville Ma 02655 11/3/2011 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 33 Aspen Way Property Address Charles H Donald Trust Owner Owners Name information is required for every Osterville Ma 02655 11/3/2011 page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately C'P' o S r S Et r ,q-i - 8-! 0 - z c-3 25` t5ins•11/10 Tide 5 Official Inspection form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 33 Aspen Way Property Address Charles H Donald Trust Owner Owner's Name information is required for Osterville Ma 02655 11/3/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Groundwater elevation was established by accessing Town of Barnstable groundwater contour maps Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 33 Aspen Way Property Address Charles H Donald Trust Owner Owner's Name information is required for Osterville Ma 02655 11/3/2011 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF BARNSTABLE LOCATION 35.�/'e`7/ ' Z SEWAGE # VILLAGE OS T�/l//2� ASSESSOR'S MAP & LOT c� INSTALLER'S NAME&PHONE NO. �0�7�� / s 7! ✓ � SEPTIC TANK CAPACITY MA9 641- LEACHING FACILITY: (type) Z —5-410 V/ e'44w (size) Id X 30,,`Z NO. OF BEDROOMS BUILDER O OWNE PERMIT DATE; ;�— COMPLIANCE DATE: "0 2� Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet .. Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet 3' Furnished by u 0 3� �} 17 ` V1 /4� 0 UcAo on No.a00 i—Io? (Sll' 1.% 8 �� ^ 0.1tered Fee �`�--WECOMMONWEALYH OF MASSACHUSETTS in computer- 1/ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for Digoml *pgtem Congtruction Permit Application for a Permit to Construct( )Repair(r')Upgrade( )Abandon( ) ❑Complete System Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parc 12o d 1 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 7i � Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( Other Type of Building Re 42�'No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow �f� gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank lOOdgQ NiXl1`)` Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) T'j T`e ,��✓ Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue y t is az of Health. Signed Date Application Approved by l i► �i ZW I-to 1.1 Date Z Application Disapproved for the following reasons Permit No. 4?Cb)— low< Date Issued -S a d TOWN OF BARNSTABLE } LOCATION 3 dZ.0e fit a S/, SEWAGE # VILLAGE ASSESSOR'S MAP & LOT i r INSTALLER'S NAME&.PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) '�J4�941 �G�fiy (size) /U.-r 3G>,{'Z NO. OF BEDROOMS ?n / BUILDER O PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: I Maximum Adjusted Groundwater Table and 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 j within 300 feet of leaching facility) Feet i Furnished by., I I 3d ,j 0' 3�b C�o d, O UOrNow OO � �,1 1^f�) �^ vn Fee TIE COMMO EALT O MAS9ACH ff$ _qW ntered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLEs MASSACHUSETTS ZIppYication for Migool *p6tem Conelruction Permit , 1 Application for a P�`'t to Construct( )Repair( Vr Upgrade( )Abandon( ) ❑Complete System EP4dividual Components Location Address or Lot No. Owner's Name,Address and Tel.No. '¢s ''e�t lr�Qy Assessor's Map/Parcel ��f� )� �1 I_)o — )9 / Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 93 6 Type of Building: ^— Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder Other Type of Building O P.0IDt�'<lWTio. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow /J gallons per day. Calculated daily flow �✓.3O gallons. Plan Date Number of sheets Revision Date Title - Size of Septic Tank 1,gam G'� �X/S /f//'� Type of S.A:S.-" Y Description of Soil Nature of Repairs or Alterations(Answer=when applicable) /7-Oe, �'L�, '/�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. Signed Date _�lal /7 .. Application Approved by �� Qi? 2s� n t 'o,t� L-4 je I I Date . 2 7 Application Disapproved for the following reasons Permit No. n?Chh)— Icy Date Issued 3/a jr) ) ---------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE MASSACHUSETTS r C,c Certificate of (Compliance I� THIS IS TO CERTIFY, that the On-site,,Sewage Disposal System Constructed( )Repaired ( ✓j Upgraded( ) u� Abandoned( )by i�/'7`-dLo�i`/ G'!!J S] at /�9.r�i�l9 (�'Cr 1/ L /^�!% i� has been constructed in accordance with the provisions 4f Title 5 and the for Disposal-System Construction Permit No. dated � �01 Installer Designer The issuance of this perm�shay not be construed as a guarantee that the syst will fuunct�io�� s desig ed. Date 3/��lD� Inspecto�Z wi ---------------------------------------- No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSETTS Miopooaf *p5tem Construction Permit Permission is hereby granted to Construct( )Repair( V5"Upgrade( )Abandon( ) System located at 1 fled dk10 d , 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: 3 I Z In ) Approved by 6 a 4„ SIC ti 01 0 NOTICE: This Corm Is To Be Used For the Repair Off ailed Septictic Systems.Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED FLANS) hereby cerffy that the application for disposal works cons=ction permit signed by me dated : concerning the property located.at 3345 e w 1-4,1q�/ meets all of the following riteria:. a/ 7he failed system is conne=ed to a residendal dwe'?ing only. There are no-otn c:cizt or business ,uses associated with the dwer ;ng he soil is c s--iiied as CLASS I and me ro�oiatioa ate is itis han or =aua ;D ?:mutes oe: nc:L a Y s ace are no wetlands within l00 of 'me oroDosed s.=tic:rstem /7,here are no private weir within' .1:0 :of the ormcsed sczric ace is no inc-,se in flow and/or chang.in--use proposed here re no varancs.=uescd or nmde�+ 6/ne bottom of the pro-Dosed i chino facility will not 6c located less t - 4—: 1 P _ � than five.__.above the .zarmum ad3tuZ ,�oun(i atc able e.Ieration. (Adjust the ?Tounduater.tabie.rsin;the F rimptor ethod when applicable]. S 25 tt . of S._�S.wtil be located with�_0 feet of a,-ty ve;_ated we.lands. the;Dorton or the prooesed leaching facility will not be located less than fourteen(14)feet above the tn2.-amum adhMed groundwater table elevation, " Please complete the following: 'w e . A) Top of Ground Surface'Elevation(rising GIS information) . B) G.W.Elevation 6 5 -the MAx laugh G.W. Adjustment.3 DI•EFE ENC BETWEEN A and B SIGNED : DATE: [Sketch Proposed glace of system on back]. haft hie — best STANDARD LEGEND \ NOTE:not all symbols will appear on a map MAP 120 MAP 1 GOLF COURSE FAIRWAY c :v="Y EDGE OF DECIDUOUS TREES \\ / # 3 EDGE OF BRUSH r � ORCHARD OR NURSERY T-T-v-v EDGE OF CONIFEROUS TREES MARSH AREA MAP 120 EDGE OF WATER \ ----- DIRT ROAD DRIVEWAY PARKING LOT # 24 �--PAVED ROAD —.- — DRAINAGE DITCH PATH/TRAIL �-' -------- --- PARCEL LINE** % ap na MAP# 21 F PARCEL NUMBER #1860 HOUSE NUMBER s -_-- 2 FOOT CONTOUR LINE 10 FOOT CONTOUR LINE Elevation based on NGV029 i/4.9 SPOT ELEVATION STONE WALL -Y.—X- FENCE \� -- --- A.- RETAINING WALL 12 0 MAP 120 1_4---I-+ RAIL ROAD TRACK t� STONE JETTY 52 Croo SWIMMING POOL �r 0 # 9 PORCH/DECK MAP 120 , MAP 120 Q -��'��-- � � BUILDING/STRUCTURE � 2 0 � I � i {-�g� DOCK/PIER [✓ J ...J.# O #L1 / k J HYDRANT f/ E3 VALVE OO MANHOLE Io POST p" FLAG POLE T O W N O F B A R N S T A B L E G E O G R A P H 1 C 1 N F O R M A T 1 O- N S Y S T E M S U N 1 T p SIGN ® STORM DRAIN N PRINTED SCALE:IN FEET *NOTE: This map is on enlargement of o **NOTE:The parcel lines are only graphic representations DATA SOURCES: Planimetrics(man-made features)were interpreted from 1995 aerial photographs by The lames }4r 1"=100'scale map and may NOT meet of property boundaries.They are not true locations,and W.Sewall Company.Topography and vegetation were interpreted from 1989 aerial photographs by GEOD UTILITY POLE n TOWER w'` �'' National Map Accuracy Standards of this do not represent actual relationships to physical objects Corporation. Planimetrics,topography,and ve vegetation were mapped to meet National Mop Accuracy Standards .,�,� OLL L h,�r25 u�z1��50 P ry P P P V� I P 9 PP P V 4 LIGHT POLE O ELECTRIC BOX I IN[H=SO FEET* enlarged scale. on the map. at o scale of I"=100'. Parcel lines were digitized from 2000 Town of Barnstable Assessor's tux maps. M f ` � k"1 .- G i J f � i _ THE COMMONWEALTH OF MASSACHUSETTS TOWN OF BARNSTABLE BOARD OF HEALTH NOTICE TO ABATE A NU SANCE 3 D � jok 614aJ :2�2 As occupant of you are hereby notified to remedy the conditions named below within 24 hours of the service of this notice, according to Massachusetts General Laws,Chapter III,Section 123: C' 0," (("-,p D C�) S s4,1 S 5 (J x ca�' Z/ If at the expiration of time allowed these conditions have not been remedied, such further action will be taken as the law requires and a fine of$25.00 per day may be charged. Hazardous Waste $50.00 By Order of the Board of Health �G Inspector