HomeMy WebLinkAbout0105 BAY STREET - Health 105 BAY STREET, OSTERVILLE
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 105 BAY STREET
Property Address
MARY TARDANICO
Owner Owner's Name
information is OSTERVILLE MA 02655 11/2.1/2014
required for every
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 A. General Information
filling out forms
on the computer, I
use only the tab 1. Inspector:
key to move your
cursor-do not JOHN P GRACI SR
use the return Name of Inspector
key.
GRACI SEPTIC INSPECTIONS LLC
rab Company Name
PO BOX 2119 f
Company Address
TEATICKET MA 02536
City/Town } State Zip Code
508-641-6694 S 1468
Telephone Number - License Number
B. Certification
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 aluation by the Local Approving Authorityf ,
Jj4, 11/21/2014
Inspector's Signature Date
The system inspect shall submit a copy of this inspection report to the Approving Authority (Board
� of Health or DEP) in 30 days of completing this inspection. If the system is a shared system or
has a.design flow o 1 0,000 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 of 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
t the same or different conditions of use.
t5ins-3113. Title 5 Official ln4 cti Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 105 BAY STREET
Property Address
MARY TARDANICO
Owner Owner's Name
information is required for every OSTERVILLE MA 02655 11/21/2014
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:
® 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:
SYSTEM PASSES TITLE V INSPECTION
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):
NA
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 105 BAY STREET
Property Address
MARY TARDANICO
Owner Owner's Name
information is required for every OSTERVILLE MA 02655 11/21/2014
page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced '❑ Y ❑ N ❑ ND (Explain below):
NA
❑ 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):
NA
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-3/13 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
105 BAY STREET
Property Address
MARY TARDANICO
Owner Owner's Name
information is required for every OSTERVILLE MA 02655 11/21/2014
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:
t
❑ 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 Vof 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: NA r '
**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:
NA
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
O ® 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 r
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/z day flow
t5ins•3113 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
105 BAY STREET
Property Address
MARY TARDANICO
Owner Owner's Name
information is required for every OSTERVILLE MA 02655 11/21/2014
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
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
El ❑ 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 105 BAY STREET
Property Address
MARY TARDANICO
Owner Owner's Name
information is required for every OSTERVILLE . MA 02655 11/21/2014
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): 4. Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
t5ins-3/13 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
105 BAY STREET
Property Address
MARY TARDANICO
Owner Owner's Name h
information is OSTERVILLE MA 02655 11/21/2014
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
1500 GALLON SEPTIC TANK DISTRIBUTION BOX AND 6 INFILTRATORS 461 X 11'W X 2'D
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ®' Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d TOWN
9 ( Y 9 (gp ))�
Detail: '
2012 106,000 2013 149,000 2014 1/2 OF THE YEAR READING 18,000
Sump pump? ❑ Yes ® No
Last date of occupancy: Date ED
I
Commercial/industrial Flow Conditions:
NA
Type of Establishment:
. A
Design flow(based on 310 CMR 15.203): N Nations per day(gpd)
'Basis of design flow(seats/persons/sq.ft., etc.):; -X NA
Grease trap present? ' ❑ Yes ❑ No
Industrial waste holding tank present? El Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available: NA
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 BAY STREET
Property Address
MARY TARDANICO
Owner Owner's Name
information is required for every OSTERVILLE MA 02655 11/21/2014
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
33"
Scum thickness ZERO
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
How were dimensions determined? MEASURED
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
SYSTEM APPEARS TO BE STRUCTUARLLY SOUND AND FUNCTIONING PROPERLY AT TIME
OF INSPECTION.
Grease Trap (locate on site plan):
NA
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
NA
Dimensions: NA
Scum thickness NA
Distance from top of scum to top of outlet tee or baffle
NA
Distance from bottom of scum to bottom of outlet tee or baffle NA
Date of last pumping: NA
Date
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 105 BAY STREET
Property Address
MARY TARDANICO
Owner Owner's Name
information is required for every OSTERVILLE MA 02655 11/21/2014
page. City/Town 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.):
NA
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: NA
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
NA
'Dimensions: NA
Capacity: NAgallons
Design Flow: NA
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: NA Alarm in working order: ❑ Yes ❑ No
Date of last pumping: NA
Date
Comments(condition of alarm and float switches, etc.):
NA
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 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 105 BAY STREET
Property Address
MARY TARDANICO
Owner Owner's Name
information is OSTERVILLE MA 02655 11/21/2014
required for every
page. City/town 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 BOTTOM OF PIPE
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.):
DISTRIBUTION BOX APPEARS TO BE STRUCTUARLLY SOUND AND FUNCTIONING
PROPERLY AT TIME OF INSPECTION.
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.):
NA
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
NA
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
105 BAY STREET
Property Address
MARY TARDANICO
Owner Owner's Name
information is required for every OSTERVILLE MA 02655 11/21/2014
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 6
❑ 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.):
LEACH FIELD CONSISTS OF 6 INFILTRATORS 461 X 1VW X 2'D (1) ONE INCH OF LIQUID IN
FIELD AT TIME OF INSPECTION. LEACH FIELD WAS VIDEO INSPECTED.
Cesspools (cesspool must be pumped as part of inspection) (locate on site.plan):
Number and configuration NA
Depth—top of liquid to inlet invert NA
Depth of solids layer NA
Depth of scum layer NA
Dimensions of cesspool NA ,
Materials of construction NA
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
u W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M0 105 BAY STREET
Property Address
MARY TARDANICO
Owner Owner's Name
information is required for every OSTERVILLE MA 02655 11/21/2014
page. City/Town 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.):
NA
Privy (locate on site plan):
Materials of construction: NA
Dimensions NA
Depth of solids NA
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
I
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
a
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,M 105 BAY STREET
Property Address
MARY TARDANICO
Owner Owner's Name
information.is OSTERVILLE MA 02655 11/21/2014
required for every
page. CityrFown 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
A B
SUN Roots AA 50
A 13 4-7 4
suoer�. AC M
N C.
s� �� BA N
o IfiW GAUN CA Dq
o 1 Ce 12,
CC 38
61 M I LtlzMU S 4&L X I I'w x V D
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 105 BAY STREET
Property Address
MARY TARDANICO
Owner Owner's Name
information is required for every OSTERVILLE MA 02655 11/21/2014
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: 12+ FEET
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:
HAND AUGER
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
105 BAY STREET
Property Address
MARY TARDANICO
Owner Owner's Name
information is required for every OSTERVILLE MA 02655 11/21/2014
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
t -
x
9
k
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
o e 7 J3/91 TOWN OF BARNSTABLE
LOCF: JN L\ � S 1 e'e. SEWAGE #
VILLAGE E?-. 1�,AA ASSESSORS MAP& LOT
INSTALLER'S NAME&PHONE NO. C . Are r
I� C��,i z/2�._ �C,��-1 1.
SEPTIC TANK CAPACITY I SCXf ry a c.
LEACHING FACILITY: (type) A (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMTf DATE: '1—2-4- rl�, COMPLIANCE DATE:
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
Furnished by
n!
'ea a
., IND
4C
TOWN OF BARNSTABLE
LOCt'lI'IO.N �_US� 1� SEWAGE #
VIIILAGE y � ASSESSOR'S & LOT 7 d
s
Per—TORS NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACII,IIY: (type) (size)
NO.OF BEDROOMS
BUILDER O OWNER
PERMIIDATE: COMPLIANCE DATE:
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
Furnished by
F.
�1
. o
G
�,
.,
�; ., _> .
No. - ► jb Fee�10
i THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
ZippYfcation for Digpogal *pgtem Conotruction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System O Individual Components
V
Location Address or Lot No. IC?5- /jp s f Owner's Name,Address and Tel.No.
Assessor's Map/Parcel l C Ci f/✓!� YGfA v1 z C v
Installer's N e,Address and�TT L No. Designer's Name,Address and Tel.No.
3-039 /Ti JOG,h
21 -5 s 9 9 3-95
Type of Building:
Dwelling No.of Bedrooms Lot SizeSzsq.ft. Garbage Grinder( )
Other Type of Building /Yes : o.of Persons Showers( ) Cafeteria( )
Other Fixtures d
Design Flow gallons per day. Calculated daily flow �l�1 d gallons.
Plan Date I-97 Number of sheets / Revision Date
Title
Size of Septic Tank /S'00 Type of S.A.S.
Description of Soil
Nature of Repairs or A lteratipn (Answer hen applicable) Pie--I ov-c _o.X i s /I k 5 C t S S a oU
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
Signed (/( Date 7-2 3—19
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued
;�pp{pf"�lrr .)'F'�-Il•' r �..Fi, r � ���+.. , -« � 4(�R'�p -rrY-. -. . .. .. .. .
o. u 7 � �. r. �. Fee
NO.
THE COMMONWEALTH OF MASSACHUSETTS- Entered in computer: ✓
Yes
PUBLIC HEALTH DIVISION;TOWN OF BARNSTABLE., MASSACHUSETTS
Zipprication for Migpool *pgtem Congtruction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( -) ❑Complete System ❑Individual Components
Location Address or Loot--No. /0 f f7jQ s f Owner's Name,Address and Tel.No.
Assessor's Map/Parcel r C�-7 G//�S °7,� 1-I v
7—
Installer's Na/me,Address anddTT 1.No. Designer's/Name,Address and Tel.No.
3 U�'7 h lG1//a JO�7`�7
i z -S s'9 3- 41.1 `9s
Type of Building:
Dwelling No.of Bedrooms 41 Lot Size .2 ys7 sq.ft. Garbage Grinder( )
Other Type of Building r'es J,'o o. 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 Seprac Tank /Sd Type of S.A.S. r
1 Description of Soil
Nature of Repairs or A Iteration (Answer hen applicable) /�+Uv-e 4 Y F s /F y c S S ✓J v(��
a H xy st� S , IZ
Date last inspected: y
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
Signed Ci'/ Date _7
Application Approved by Date
Application Disapproved 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(I.—)
Abandoned( )by X4"
at —� has been constructed in accordance'
with the provisions of Title 5 and the for Disposal System Construction Permit No. - ,: dated 2/ t_t!kx
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the system-will function as designed.
Date 1 ' :J 1 6/3 c,_', Inspectorc�t7
r ,
No. �� _ L� ./S''' --------------------------Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Migpogar *pgtem Congtruction Permit
Permission is hereby granted to Construct( )Repair( )Upgrade(y)Abandon( )
System located at�/ $�, Q.4 ez�;a 2,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:Construction must be completed within three years of the date of this permit.
Date: '7 Approved by �_
10/9/97
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
ENGINEERED PLANS)
I, JO� L2 ;hereby certify that the application for disposal works
construction permit signed by me dated 3 — p , concerning the
property located at /O 5- 15a S Itl vJ 1149 meets all of the
following criteria:
• There are no wetlands located within 100 feet of the proposed leaching facility
• 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.
• If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the
proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation.
Dlease complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S.map)
B)Observed Groundwater Table Elevation(according to Health Division well map)
SIGNED : DATE: Z—Z 3
LICENSE 4PTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
q:health folder:cert
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LOCATION
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VILLAGE ASSESSOR'S MAP &LOT
t INSTALLER'S NAME&PHONE NO. J.��^ C A �.l r• 1-40
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SEPTIC TANK CAPACITY
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LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS t"{
BUILDER OR OWNER hr 1 1 a G' r1 L C
IPERMITDATE: 'l- 7-%4- 34�;. COMPLIANCE DATE:
Separation Distance Between the:
j Feet
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility
Private Water Supply Well and Leaching Facility (If any wells exist
Feet
on site or within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility(If any wetlands exist Feet
within 300 feet of leaching facility)
Furnished by
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t,765 WAKEDY ROAD,MARSTONS MILL:, MA G48 -
508-771-9399 508428-8926 FAX: 5014428-�+3I9
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SUBSURFACE SEWAGE DISPOSAL SYSTEM IM5PirCTION FORM
PART A :.
CERTIFICATION
Property Address: ! (�
Date of Inspection: 8' Inspector's Nanse:
Opyner's Name d Address:
zz
CERTIFICATION STATEMENT:
I certify,that I have personally inspected the sewage disposal system zit this and that the informa-
tion reported below is true,accurate and complete as of the time of inspectir n.The inspection was per-
formed'based on mytraining and experience in the proper function and rums 11(mance of on-site sewage
disposal systems. The System: `
Passes : ,a• j : _ 4 . ,:. .. P
Conditionally Passes .
4 Needs Further Eval i By`t L al AN`roving Author s i i ,
i Fails .. ._....< .F , . .•._.A M "
Inspector's Signature: Date:--_-.._ `'' 91
The System Inspector shall.submit a co/y of this inspection report to the A pvoving authority within thin- .
ty(30),days of completing this inspection.=If the system is a shared ar has,a-jesign flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report:i�,the appropriate regional
office of the Department of Enviromt►ental Protection. The original shwulr.be sent to the system owner
and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARYa
A)SYSTEM PASSES:
I have not found any information svhich is.dicates that the si.vstvnn violates any of the failure
criteria as defined in 310 CMR 15.303. Any failure cr tei:i, .!!i)st evaluated are indicated
below.
B)SYSTEM CONDITIONALLY PASSES;
One or more system components need to be replaced of paivid. The system,upon comple-
tion of.the replacement or repair, passes inspection.
Indicate yes,nor,or not determined.(Y,N,OR ND). Describe basis of deteraYlination in all instances. If
"not determined_",.explain why not.
°The septictank is'meta,cracked,structurally unsound,a rievs!ikiistantial infiltration or
exfiltration,:or tank failure is immninent. The system w i]l lea:s inspection if the c .fisting rep-:
tic tank is replaced with a conforming septic tank as apyc)-;ed by The Board of Health.
Sewage backkup or breakout or high static water level olssarvealita the distribution box is due
to broken or obstructed pipe(s)or due to a broken,settli-xl or 41 wven distribution box. The
system will pass inspection if(with approval of The Bua a 1 ol, I Ir alth):
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".SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC 110N FORM
PA RT A y
CERTIFICATION (continued)
Broken pipe(s)replaced
Obstruction is removed
Distribution Box is levelled or replaced
The System required pumping more than four times a year due to broken or obstructed pipe(s).
The system will pass inspection if(with approval of The Board of 1•Icalth):
i Broken pipe(s)are replaced
Obstruction is removed.
C)FURTHER EVALUATION IS REQUIRED BY TILE 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 die public health,safety and the environment.
1)SYSTEM WH.L,PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE
SYSTEM IS NOT FUNCTIONING IN A MANNERWHICH WILL PROTECT THE
PUBLIC HEALTH AND SAFETY AND THE ENVIR6NMENT:
Cesspool or privy is within 50 Feet of a surface water
Cesspool or,privy is within 50 Feet of a Wrdering vegetated wedand or a salt marsh.
2)SYSTEM WILL FAIL UNLESS THE BOARD.OF HEALTH (AND PPUBLIC WATER
SUPPLIEK,IF.APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION-
ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONIVMENit
The sysletpi.has a septic lank and soil absorption system and ic_w.4Wn 100 Feet to a surface
waters4ply or tributary to a surface water supply.
The system has a septic lank and soil absorption system and is with a Zone I of a public
water supply well.
The system has a septic tank and soil absorption system and is within 50 Feet of a private
water supply well. },
The system has a septic tank and soil absorption system and is loss than 100 Feet but 50
Feet or more from a private water supply well,unless a well water analysis for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from
the1acili1y and the presence of ninmonia nitrogen and nitirato:rltrogen Is equal to or less
than 5 ppm.
D) STEM FAILS:
I have determined that the system violates one or more of the followingafaflure criteria as defined
in 31 . MR 15.303. The basis for this determination is identified below. The Board of Health
sho d be contacted to determine what will be necessary to correct the failure.'
Backup of sewage into facility or systen►component due to ari overloaded or clogged SAS
or cesspool
Discharge or podding of efluent to the surface of the grouud.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 clog-
gedSAS'or cesspool;F�
Liquid.depth in ces spool-is rless than 6"below invert or availablebvolttme is less than 1/2
day flow. -
Required pumping more than.4 times in the last year N c➢ue:to`clogged or obstructed
pipe(s): Number of times pumped
2- v l;:
"#SUBSURFACE SEWAGE'UISPOSAI SYS'fEM`IIVSPECTIOhI FORM
PART A
CERTIFICATION (continued)
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater
elevation.
Any portion of a 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 I of a public well.
Any portion of a cesspool or privy is within 50:F.eet of.a privatewater 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. If the well has been analyzed
to Wacceptable,attach copy of well water analysis for coliform bacteria,volatile organic
compounds,ammonia nitrogen and nitrate nitrogen.
E)LARGE SYSTEM FAILS:
The following criteria apply to a large system in addition to the criteria above:
The design flow of a system is 10,000 gpd or greater(Large System).and the system is a significant
threat to public,Health and safety and the environment because one or more of the following '
conditions exist-',
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The system is within 400 Feet of a surface drinking water siipply,
system is within 200 Peet a�GibutaryAo a.surface.drinking water"supply
The system is located in a nitrogen sensitive area Interim.Wellhead Protection Area
or'ainapped Zone 11 of a public water supply well..
The owner or operator of aqy,such system shall bring the system and facility into full compliance with the
groundwater treatment program requirements of 314 CMR 5.0(1 and G.i)0, .PIa4e consult the locals
regional office of the Department for further information.
a> SUBSURFACE SEWAGE UISI'USAL SVS'l'EM INSPECTION FORM
PART B
CHECKLIST
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Check if the following have been done:
✓Pumping information was requested of the owner,occupant,and Board of Health.
_�1Qone of the system components have been pumped for atleast two weeks and the system'has`
been receiving normal flow rates during that period. Large volumes of water`have not been
introduced into the system recently or as part of this inspection.
✓As built plans have been obtained and examined. Note if they are not available with NIA.
e facility or dwelling was inspected for signs of sewage back-up.
e system does not receive non-sanitary or industrial waste slow.
The site was'inspected for signs of breakout.': -
" ZAll`system components,'excluding the Soil Absorption Syslem,;have been located on site.
"A l'he septic tank manholes were uncovered,opened;-and the interior .r the septic'tank'was'in-
.1 spected',for condition of ba Mesor tees,material of construction,fymensions,depth of liquid,
/depth of sludge,depth of scum. ned based on
✓Thesiii:'and location of the Soil Absorption System on the site hat,been determi
existing information or approximated by non-intrusive nrAhods.
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-"'PSUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST(continued)
li The facilityowner(and occupants,if different from owner)were provided with information on
pa
the proper maintenance of Subsurface Disposal System
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPIECTION FORM
PART C
SYSTEM INFORMATION
FGatbage
I/ FLOW CONDITIONS
low: lions Number of Bedrooms: Num r of Current Residents:
Grinder: Laundry Connectcd To Systenc4 Sensonai Use:
Water Meter Readings,if ail able. v
Last Date of Occupan .
COMM.ERCIAI JlNDUSTRIAL/Jo
Type of Establishment:
Design Flow: #All'ons/day .Grease Trap Present: (yes or no)
Industrial Waste Holding.Tank'Present:
Non-Sanitary Waste.Discharged To The Title V System:
Water Meter.Readings,If Available: Lash Date of Occupancy:
OTHER: Describe)
Last Date of Occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of informati n.
System Pmnped as part of inspection:_ If yes,4olume puniped:j gallons
Reason for..pumping'
TYPE.OF SYSTEM:,
Septic Tank/Distribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool
Privy
Shared System.(If.yes,attach previous inspection records, if any)
Other(explain),
qPROXIMATE GE of al c mponents,daleins ailed(if known)and=sourm.of;inlbrmation:
eilidge odors detected°when arriving°atilic e: �)r)
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SUBSURFACE SEWAGE,UISPOSA•i SYSTFAIIINS}PECTION FORM
PART C
GENERAL INFORMATION (continued)
SEPTIC TANK: d
Depth below grade: Material of Construction: concrete metal FRP_Other
(explain)
Dimisions: Sludge Depth: Scum Thickness:
Distance from top of sludge to bottom of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments:(recommendation forpumping,condition of inlet and outlet tees or baffles,depth of_liquid
level in relation to outlet invert,structural integrity,evidence of leakage,etc.)
GREASE TRAP: Q_
Depth Below Grade: Material of Construction:_concrete_metal_FRP_Other
(explain) -- -"--
Dimensions: Scum Thickness:__,_
Distance from top of scum to top of outlet tee or baffle: �' a
- Comments: (recomtnendation.for,.pumping,condition of inlet an_d outlet tees or 4pgbs;depth of liquid
_ - level in relation-to outlet invert,structural integrity,evidence of leakage,epee) y
TIGHT OR HOLDING TANK:
Depth Below.Grade: Material of Construction:_concrete__mcrai-.. FRP_Other(explain)
Dimensions: Capacity: gallons Design Flow: _� gallons/day
Alarm Level:
Comments:(condition of inlet.tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX:
Depth of liquid level above outlet invert: _
Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into
or out of box,etc.)
.. " PUIiP-CHAIi}tBER: ' .. ;�44 77+`•.,r�.4K .va ,y
.. `.4.� ~�..' � �'aw.T l~�Y,,.+fin �.. ~ u. •,,, ';•
- Pump is-in working order: {-
- -- Comments:(note condition.of pump chamber;conditions of pumps a»ci R ptlde'nances,etc.)-`,
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~ SUBSURFACE SEWAGE DISPOSAL-SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (conlinucd)
SOIL ABSORPTION SYSTEM(SAS):,(
UAmte on site plan,if possible;excavation not required,but may be approximated byanon-intrusive
methods) If not determined to be present,explain:
Type
Leaching pits,number: Leaching chambers, number: Leaching galleries,number:
Leaching trenches,number, length:
Leaching fields,number,dimensions:
Overflow cesspool,number:
Comments: (note condition of soil,signs of hydraulic failure level of ponding,condition of vegetation,
etc.)
CESSPOOLS: /
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 groundivatcr:
Inflow(cesspool must be pumped as part of inspection)
Comments: (note co tion of soilk, signs of hyd ulic failure, level of on on o vegetation,
etc.
Ile
PRIVY:
Materials of construction: Dimensions:
Depth of Solids:
Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
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SUBSURFACE SEWAGE DISPOSAL-SYSTEM INSPECTION FORM
PART C
ar. , SYSTEM INFORMATION (continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permaneiit.refereaccs, laodmaiks or bcnchmarks.
Locate all wells within 100 Feet.
DEPTH TO GROUNDWATER,
Depth to groundwater: $ Feet
blethoo ofDetermination�or Ap roximation:
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