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0054 BUMPS RIVER ROAD - Health
54 Bump s River Road Osterville 126 136 .ate—r+..a•a�wrr . , I , .. a F 9• p n 1 0 ✓,. i r o N 00 fiXg o i sl .{tB./DH(FND) 317- 9j45' CB/DH(FND) , ry SHED 01 o \ M to Q 0 Ln PROPOSED) h`a 9.6' E-1 LIJ ADDITION to • o � I z � FXIST� NG L 21.4' ly0�s f LO `\ C\2 20.3, v ' 13.9' CB/DH(FND) rn r\' ST ` J v N oLP 0 LP v R R sz Oq� �30 . 0 15 30 60 120 ( IN FEET ) - .ASSESSOR MAP 120 PCL 136 1 inch. = 30 ft. SITE PLAN — PROPOSED ADDITION DATE OF SURVEY 09/16/06 LOT AREA: 22,400tSF 51 RUMPS RIVER ROAD SEPTIC SYSTEM LOCATION AND CONNECTION DETAIL,FROM YOSTERVILLE, MASSACHUSETTS BOH DATA FURNISHED BY CLIENT: `�! tiq,� SCALE: 1' = 30' DATE: 11/29/06 0,a,�as`c.4 - DAVI CD 9� ' DMAD C.. THULIN, PE, PLS •� a THULIN "-i 211 MILL ROAD U NO.39403 y EAST SANDWICH, MASSACHUSETTS . 02537 SURVsqOe PREP. FOR: WOLFE DRAWN BY: PST I CHKD BY: DCT �� / JOB No: 06-045 REV. Z 2 3 (� DATE 8123104 PROPERTY ADDRESS:- 54-Bump,6 Rivet Rd.. --- -- MAP O�te2vi��e, l7a. PARGEL 02655 ' ------------------- 0 On the above date, .the septic system at the above addPA05AMED Inspected. r This system consists of the following: AUG 2 7 2004 1. 1-1500 ga-eion zept.ic tank. 2.4-D iz;bz ikut.ion Aox" TOWN OF BARNSTABLE 3-2-1000 . ga.Q.Qon -each.ing p.i.t4 HEALTH DEPT. Based on inspection, I certify the following conditions: 4. 7h.i4 .i,3 a t.ii-ie Zive zept.ic zystem., (78 code) 5. 7he ,sep:t.ic System 1,3 .in /22ope2 wo2k.iak o2dez a.t .the /22ezent time. 6. iea6h.ing /.i.t #1 .i. u12 .to' .inve2t 12.il2e to Leaching /z.it #2.- 7.-Leaching 12.it #2 . watea ievei .iz 7.2' 70 inve2;t ./z.i/ze.. SIGNATURE:Zwe-1_ Name• B2uce Maca ei iztea •------------------------- Company:__j_-l_MacomP,e,z and.meson _inc., Address: Box 66 Cent eay.ii ee,'Ma..026 32 Phone:_L50=-3338 ___ THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tanks-Cesspools-Leachfields Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775-3338 775-6412 2,0 COMMONWEALTH OF M.ASSACHUSETTS EXECUTIVE OFFICE`OF ENVIR(MM•,NTAL AFFAIRS DEPARTMENT-OF + M1i014MENTA1,?A6TVTION „ •. TITLE 5 OFFICIAL INSPECTION FORM—.NpT FOR.VOLVNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART•A CERTIFICATION Property Address: . 54 Bum�i /2.'ve2 Rd., 4 Owner's Name: ! Don-feu Owner's Address: 5.4 Bum 12,s /2122P 17 Ub.tonZ),iLpvr lyln'� Date of Inspection: 8/2 3/0 4 Name of Inspector: (please print) B2'u ce lr�.c.c�.�� hea Company Name,. M gput., Mailing.Address: a.6b..02632 �s Telephone Number: 5 0 8-�7 7 3 3 3 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 flincdon and maintenance of on.4ite sewage disposal systems.I am a DEP approved system inspector pursuant to Section.15:340.of-Title 5(31.6 Cmxa.000). The system: XX' :Passes -Conditionally Passes Needs Further Evaluation.by the Local Approving_Authority Fails . ' nanre: Inspectors Sig .. x ' of Health or The system inspector shall submit a copy of this inspection report-to the.Approvm Authority•(Bo and DEP)within 30 days of completing this inspection.If the system:is.a.shazed system or has a design flow of 10,000 gpd or greater,the inspector and the system'owher.shall`subtnit the report to the appropriate regional•offiee 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 inspectidn-pnd 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. f c„cmnnn cage 1 . Page 2 of I 1 OFFICIAL INSPE,CTION:FORM—NOT:FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM,INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 54 Buml?_6 Rivet Rd. Uat e/Lv-i iLa,, Ma.•026 5 5 Owner: Pat Dorzie(a Date of Inspection: 812 3 104 Inspection Svm`mary: Check A;B C;D or.E/ALWAYS�comp:lete=all of Section D A. System Passes: n o 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: Thp An,p.ila AgALPm in Pnnnva ),joaking fimo B. System Conditionally Passes: no 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. no: 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. ND explain: n.o 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 brokep,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health)' broken pipes)are replaced. . obstruction is removed distribution box is leveled or replaced ND explain: no The system required pumping more than 4 times a year due to broken or obstructed pipe(s):The system will pass inspection if(with approval of the Board of Health): v broken pipe(s)are replaced ' obstruction is removed ND explain: Page 3 of l 1 OFFfiCIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION<FORM PART A _ CERTIFICATION(continued) Property Address: 5 4 Buml2z R ive2 Rd. Owner:. l a t Donee R w Date of Inspection: R/?3/0 C. Further Evaluation-is Required by the Board of Health: no Conditions exist which require further.evaluation'.by.the.Board.of flealthdia order.to.deternline ifthe 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(l)(b)that the system is not funrctioning in.a manner which:will.protect public health,safety-and the%environment: no Cesspool or privy is within 50 feet of a.surface water r 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 mariner.that protects the public health,safety and environment: aD_ 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. no The system has a.s.eptic tank and SAS and the iSAS is within a Zone 1 of a--public water•supply. no The system has a septic tank and.SAS andthe SAS is within:.50 fret of a private water supply well.. no The system has a septic tank and SAS and the-SAS is less than 100 feet.but 50 feet or.more froth a private water supply well". Method used to determine distance *"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from-pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5.ppm,provided that no other failure criteria are triggered.A copy of the analysis must bey attached to this form. 3 Other; 4 Pdge 4 of 11 OFFICIAL INSPECTION FORM-NOT'FORNOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 54 l3um12,3. 1U'Ve2 Rd. 0,3t e zv-i e e, Na.026 5 5 Owner: l at [ion i Date of Inspection: 8123176%-- D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to.each of the:followingfor all inspections: Yes. No _ x Backup.of sewage.:into facility.or.system component due to overloaded or clogged SAS.or cesspool x Discharge:or-ponding of effluent to the surface:of the,ground or surface waters due to an overloaded or clogged SAS or cesspool x Static liquid level in the distribution box above outlet invert due to an.overloaded or clogged SAS or cesspool _ x Liquid depth in-cesspool is less than.6"below invert or available volume is less than'h•.day flow x Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped x Any portion of the SAS,cesspool or privy is below high ground water elevation. z Any.portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply: _ x Any portion of a cesspool or privy is within a.Zone 1,of a.public well. x Any portion of a cesspool or privy is within.50 feet of a private water supply well. _ x Any portion of a-cesspool or:privy is less than 100 feet but greater..than 50 feet from a.private water supply well with no acceptable water quality analysis..[This:system..passes if the well water.analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution;:from:.that.facility and.the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are-triggered-.A'copy of the analysis niust be attached.to this ford.] n o (Yes/No)The system fails.I have determined that one or.more,of the:above failure::criteria exist as described in 310 CMR 15.303,therefore the system-fails.The system owner.should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the:system must.serve.afacility with a design flow of 1,0100.0 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 x the system is within 400 feet of a surface drinking water supply _ x the system is within 200 feet of a tributary.to a surface drinking water supply x the system is located'in a nitrogen sensitive area(interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or.failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS �LIRSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 54 Bum12,3 12ive2 /-.: 0.3;t Zvi PPof lyln n�/55 Owner: %aL Don.PnE,� Date of Inspection: R -2?J-n� Check if the following have been done You must indicate"yes"or"no"as each.of the following: Yes No x Pumping information was provided by the owner,occupant,or Board of Health x Were any of the system components pumped out in the previous two weeks? x Has the system received normal flows in the previous two week period? x 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 tote as N/A) x Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? x Were all system components,excluding the SAS,located on site.'? x _ 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? x _ Was.the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site.has been determined based on: Yes no' _x — Existing information.For example,a plan at the Board of.Health. " _ x 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)J L — 5 Page 6 of 11 , OFFIC-.1'][N. SpE-cT GN:F-0RM'-NOT FOR V4L[Jl�'I?ARY ASSESSM-E S .SUBSURFACE-SEWAGE DISP:.OSAUSYSTEM,-INSPEE'TION FORM PART C SYSTEM INFOR'1ATION Property Address: 54 Bam/zz R ive2. Rd., Tea v.c T Te, 77 a. V 73 5 5 Owner: Pal 7ohtey _ . Date of Inspection:, 8/2V Q 4 , FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):'-< Number of.bedrooms-*tual): 4 /x.1 /0=4 4 0 rL DBSIGN flow based on'310 C 15.203 (for example:'110 gpd z#-of bedrooms): g� Number of current residents: .: Doesresidence have a garbage grinder(yes or no):. n o Is laundry on a separate sewage.system'(yes or no):. no ['if yes separate inspection 'required] Laundry system inspected(yes or no):tLe 3Qo ,Jtp Seasonal use:(yes or no):n.a Water meter readings,if available(last 2 years usage(gpd)): ®`1,�' /g).,q d Sump pum (yes or no):n Last date o� n occupancy: 2a e Ze n t COMMERCUSTRIAL Type of estate n aDesign flow `:M�gftt: • ' on 310 CMR 15.203 nu aUd, " )1. BaSis.ofdign'flow(se ,et a Grease trappresent(yes or no):L 110 Industrial waste holding tank present.(yes or no): na Non-sanitary waste discharged to the Title 5 system7(yes or no):nu Water..meter readings,if available: na . Last date of occupancy/use: , n a OTHER(describe):. ha 'GENERAL INFQgMATION Pumping Records Source of information: a• !.'Maeom&e2 and ion Was system pumped as part of the inspection(yes or no): n o If yes,volume pumped:l 5®0 gallons--How was quantity pumped determined? Me a.6 u 2 e d Reason for pumping: /?umRacd .tank 10/02 main nc- TYPE OF SYSTEM x Septic tank,distribution box,soil absorption systemn' _Single cesspool _Overflow cesspool _Privy 4 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 .w obtained from system owner) ' - - _Tight tank Attach a.copy of the DEP.approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: 1984 Were sewage odors detected when arriving at the site(yes or no):no L 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 54 BumRs R ive2 Rd.- O,steRv.i.P-ee t1a. 02655 Owner:_ l at DoneeU Date of Inspection: 8123104 BUILDING SEWER(locate on site plan) Depth below grade: 14 Materials of construction:_cast iron _40 PVC x other(explain): Distance from private water supply well or suction line: 10' t Comments(on condition of joints,venting,evidence of leakage,etc.): lo"intd apl2ea2 tight,.. No ev"idenc,e o7 .eeakage.'SyZtem vented th2ough hou.6e vent,6. SEPTIC TANK:_(locate on site plan) Depth below grade: 17 Material.of construction: x concrete_metal fiberglass__polyethylene _other(explain) If tank is metal list age: 2_0_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) -- Dimensions: 5 ' 8"h.igh 5 ' 8'wide 10' 6".bong Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 4 ' 1 0 Scum thickness: 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: 1 2" How were dimensions determined; m p X'3 u a e ad Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural inte as related to outlet invert,evidence of leakage,etc.): Zesty,liquid levels Ractuaae_Py zound. Ineet and outie"t teen a)ze e. GREASE TRAP:n a(locate on site plan) Depth below grader n a Material of construction:_concrete_metal fiberglass polyethylene_other (explain): _ Dimensions: a a Scum thickness: n a Distance from top of scum to top of outlet tee or baffle: n a Distance from bottom of scum to bottom of outlet tee or baffle: n a Date of last pumping: n a Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): tea.6e .tea 12 not Bee sent. . Title S Tnenn*,finn Tlnrm r,il aionnn 7 Page 8 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS S, &VRF;A►CE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 54 l3um��s /2�vea /2d. 2655 owner:. Pat DnnZpu Date of rwpection: R/>31 n 6 TIGHT or HOLDING TANK: na (tank must be pumped at time of inspection)(locate on site plan) Depth below.grade: na Material:of construction: na concrete na metal na fiberglass na polyethylene na other(explain): Dimensions: no - Capacity: _ n n• gallons Design Flow: na gallons/day Alarm present (yes or no): no Alarm level: na Alarm.in working order(yes or no):na Date of last pumping: na Comments(condition of alarm and float switches, etc.): Tight o2 hoidinu tank,3 nod 22e,6P-nL- DISTRIBUTION BOX: -6Lejif present must be opened)(locate on site plan) Depth of liquid level above outlet invert: no Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box, etc.): No evidence o4 .t?eakaaP .into na ou n4 Pox/3ox hai onP ,eatelLai No Py.cdenrp- _o,Z .so.P.i •s odaaw PUMP CHAMBER: nO (locate on sife.plan) Pumps in working order(yes or no): na Alarms in working order(yes or no): na Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.); l umR chag eiz not •naPAenL 8 * L Page 9 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 5 4 13um1?,6 R iven RD. e/tvzrze, a. 26 5 5 Owner:. Pat Don.E?e'q Date of Inspection: 8123104 SOIL ABSORPTION SYSTEM(SAS):yet,(locate on site plan,excavation not required) Located Zee pagz 10. If SAS not located explain why- Located See „ 2d ge 10 y Type leaching pits,number: 2 n o leaching chambers,number: n o leaching galleries,number: no leaching trenches,number,length: no leaching fields,number,dimensions: a o overflow.cesspool,number: no innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil, condition of vegetation, etc.): h d zaa-Oic �a.i gulte. .^ (7ed.ium sand to cou2ae hand. No ev.�dence o� y 0 ondin , Ve etat.ion i,3 no2ma CESSPOOLS: no (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: na Depth—top of liquid to inlet invert: HE Depth of solids layer: na Depth of scum layer: HE Dimensions of cesspool: na Materials of construction: na Indication of groundwater inflow(yes or no): na Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): CeZ.6/200-eh not fl2ezent.- PRIVY: n O (locate on site plan) Materials of construction: na Dimensions: na Depth of solids: na failure,level of ponding,condition of vegetation,etc.): Comments(note condition of soil,signs of hydraulic l 1t.jV y nOt /Me6ent.' .9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS / SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) . { 54 Bumpz Rivga Rd: Property Address: U te2v iL,.2.9�655 Owner: Pat . Donigu Date of Inspection: R/ 3/ ' — SKETCH OF SEWAGE DISPOSAL SYSTEM vide 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. ow t >o Page.11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 54 /3ump,6 Rivea Rd., 0.6 eltv-i.t e, P a.,026 5 5 Owner:_hui- [ion eeu Date of Inspection: _8/Z 3/0 4 SITE EXAM Slope Surface water Check cellar Shallow wells j Estimated depth to groundwater 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: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you establ ed the hi u d���tsr�eption: ubeC�:Gahe1tty and m� ea mo 92ound wa.te2 move sea eeve- 14cn� •?a94QiarA4 4it99a ;n 92 nnn n9 n0afo #LZrin 9992 Annuai aange16 1 +�c�h LrrurJ wa+kr 434myt l,'91-?ar Fl-04eX q'2. 9 TitlA Tnera inn Form A/1 f/)Mn 11 - �:,•>T>z TI 1-'1t iT�•,T..,FTiiRtJI,R.Cri"I.ti•.:S,T.tT:Tt-.•„-1`TR4Tl!I.rFCI,Ai,,,t:.tTi„L-.f.tORl� 'I OWN OF WARD OF HEALTH SUIISUUFACF SEWAGE DISPOSAL, SYSTEM INSPECTION FORM - PART D •- CERTIFICATION `O .+m,R�,.*r,...am.rr,r.,.n•.,-tom.-,-•,--.-,>_..11 .•••T.:'t-T':'::l�T.t 17:••.T.T;R�.WI'lt:1T1 TtT�.Z['17FSR:TTt•T!.M T.•StlTT.:7 TR1RF'1�T'� � ' —TYPE OR PRINT CLEARLY— PROPERTY INSPECTED STREET ADDRESS `5 ASSESSORS MAP , BL.QCK AND PARCEL �00 , OWNER' s NAME t PART:D - CERTIFICATION I NAME OF INSPECTOR 'Bruce Macallister COMPANY NAME Joseph P. Macomber & ''Son Inc COMPANY ADDRESS Box 66 Cen•tervill p.. MA 0263? Street Town or City State LIP COMPANY TELEPHONE ( 508 1 775 - 3338 FAX 508.E 790 - 1578 - R CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that tii.e information reported i;s true , accurate-, and omplete as of the time of ,inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my tv ainin.g and experience in the proper function and maintenance of on- site sewage disposal systems . t Check one: xl r;>system PASSED The inspection ;ghich I have conducted has not found any information which indicates that the system fails to adequately protect public health or, the environment as defined in 310 CMR. 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection which, I have con tm ed has found that the system fails to Protect the j-iublic health and the environment in accordance with Title 5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form , Inspector Signature Date One copy of this certification must be provided 'to the OWNER, the BUYER where applicable ) and the' 130ARD OF HEALTii. * If the inspection FAILED , the owner or operator shall up.grade ' the system. within o'ne year of the date of the inspection, unless allowed or required otherwise as provided in 3,10 CM.R 16 . 305 , partd .doc TOWN OF BARNSTABLE LOCATION S7 .�Utiirs LC dy`� SEWAGE # 513 VILLAGE G 5 -01cal"X ASSESSOR'S MAP & LOT/0O- AA, INSTALLER'S NAME & PHONE NO. , fa2r�yc.0`� f �►g� 4/ ` usEPTIC TANK CAPACITY lGoc� LEACHING FACILITY:(type) f�/ � (size) <o� NO. OF BEDROOMS 17, PRIVATE WELL O BLIC WAT BUILDER OR OW ER ,�Ghl�c.� r, v%IS7 'ldi� 'o�GO DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: d VARIANCE GRANTED: Yes -Noi j�'J 9K p _ 37, S� i SU e f ° s ,, SEWAGE 11V5rL�."_ . , 77— eA� LGt;AT10N dVQy RA DATE All , VP.:L.AGE ASSESSOR'S MAP & LOT ;INSPECTOR SEPTIC TANK CAPACITY O® LEACHING FACILITY: (type) L—. (size) 1®©® NO.OF BEDROOMS BVMDER OR.OWNER OWNER MAILING ADDRESS l _ RIDlli"( f J-"% PPROVED No:�l.�statar Ctst,serv�uon Departmard Fizs....�0'`J...J . ......... `� < HE COMMONWEALTH OF MASSACHUSETTS ' / Sa�/ aa-''e'B'OAR® OF HEALTH TOWN OF BARNSTABLE Appliratiou for Diripwwl Worlds Cron-Orurtiun 11amit Application is hereby made for a Permit to Construct ( ) or Repair (x) an Individual Sewage Disposal System at: Location-Addres- or Lot No =-- s-�---�rti� ,�o•� -------,sue �vrr�s � Owner A r ss W `C-l�`7�-------- nl, Ur 7uyJ .......................................... -•-•-- 1�/n�tc ........... ,.� � Installer Address d Type of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms---------------19-e----------------------Expansion Attic ( ) Garbage Grinder ( ) pa., Other—Type of Building ...................... ..... No. of persons......................------ Showers ( ) — Cafeteria ( ) 04 Other fixtures ------------------------------- - - w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity-/—MLT.galIons Length________________ Width................ Diameter................ Depth................ x Disposal Trench— No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No----- --------- Diameter........Aa..... Depth below inlet................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by....... ---•-------------------------------------------------------------- Date........................................ Test Pit No. I----------------minutes per inch Depth of Test Pit-.-_--_--__-__-_-_ Depth to ground water......................... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ---•.......................................•--•--------•----•-•---...-•-•••......•--•----•-•-.....--......................................................... 0 Description of Soil........................................................................................................................................................._.............. x v ....................................... w U Nature of Repairs or Alterations—Answer when applicable.----}--'� ----- -- /T�--.-.W ..�T__.____... .................... ........... ............ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha ee issued the board of health. Signed --------------- ......... ..... ---- ----- .. . . ............. ----- .... r� Dace Application Approved By .._—..:...W....... . _. ... ... . .. ........................................f!. ..... Application Disapproved for the following reasons. ....................................... . ............... . ...... .. . .......................................... .................. ...................................... . . ... ................................................... ................................. ...................... ........................................ Dve Permit No. .. :... .. ... .... . ...... Issued ........� '-.p� : -.. ` -- -------- Dare `��.�.i r ,V_..___r-.,,y--- :uji•`- w _ _—• wy v`v_. v 1.-r... _.. 'asti°•e.�.i`w-'wS._"'V'aa`..='V"'w`gR..�.r`�4ty�"`rµY.SY"=.t�� �� �.•..; ._ _� w.a - S � f , No.................. Fxs....�DU:- f..... J F 7 THE COMMONWEALTH OF MASSACHUSETTS M M1 1 BOARD Of/ HEALTH �" � 3�A TOWN OF BARNSTABLE Apphration .for Diripaml iVor1w Tonotrnrtion Famit Application is hereby made for a Permit to Construct ( ) or Repair 06 an Individual Sewage Disposal System at• Location-Address/ or Lot No, lit /hJQ✓�'I�(L % s rrr............................������ ��vl''r's c �-ul2 - .............. r- a i ���I-----------.--�•• ...�c.:v c.�?�......�.E. 7 r.,f,4 L Address ........................ '/�1 i c S--•-•-••--- Installer Address UType of Building Size Lot............................Sq. feet .. Dwelling— No, of Bedrooms................V/_-----------------_----Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ------------------------------- - - W Design.Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity;/-4W._galIons Length---------------- Width---------------- Diameter................ Depth................ x Disposal Trench-No. .................... Width.................... Total Length.................-_• Total leaching area....................sq. ft. 3 Seepage Pit No.---•—.--.�...------- Diameter--------/.0------ Depth below inlet......!A.......... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ") a Percolation Test Results Performed by..................... -•-•-•••--•••••••----------------••-•-----------•--• Date----------- -•--•-•---•-••-••-••-•----- ,� Test Pit No. I................minutes per inch Depth of Test Pit.......-............ Depth to ground water........................ G14 Test Pit No. 2................minutes per,inch Depth of Test Pit..................•• Depth to ground water........................ ------•---•---------------------------------------------------------•---•.•----.......-------------- --..-..-.......,...----•----......_..--------- *• ....... ODescription of Soil..........................................................................................................................-...--------•------••••--•••••--------•---_.. x U ...........................•--------•----------.......----•------------------------------------------------------------------------------------=------------------------------------------._.-....-..-••. x ----------------------------.:.... ....---------------------- --•------•- U Nature of Repairs or Alterations—Answer when applicable..... A:0_0-------- .RY.-..!!�!l��...=. ............... ........ ------ ........................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the �`.system in operation until a Certificate of Compliance has••ee issued by the board of health. / f Signed .............. : - G-�. , _.�--- -------- ----- Daw Application Approved By ......-... !"- 2� y ..- - -- _.............................. �. Dare Application Disapproved for the following reasons: -_---------------- - ..........- . . ............................ ............................................. ............. ................................................. . ................................................ .............................. Date Permit No. .. ,.. .. ... Issued -------- Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BAR((��tTNSTABLE vertt� firate of (110 pliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (b<"') p�bl-o LO� 7 L-D�1 sq-/Luc�7 u,--1 by .... .. ...... ..........................----------------------------------------------------------------------------------------------------------------------- �;� Insrnllcr ---------------------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. -..� /. ............ dated _ "'y.^.. ----: _._q THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. — DATE..._............. -...�....-...���. ... Inspector ............V... . ... ..... - V THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �a TOWN OF BAFINSTABLE No '` J FEE.-.....`-..��..... i� rosttl or�� Tonatrnrtivit Vernfit Permission is hereby granted.....................< ........................................(G -S7/ �/ r/G�./ ............ to Construct ( ) or Repair (� an Individual Sewage Disposal System Street -ram as shown on the application for Disposal Works Construction Permit No����_7Dated..... --------------- Board of Health DATE------.�-'-/.----------[-�------------•-- l FORM 3850E HOBBS&WARREN.INC.,PUBLISHERS :............... THE COMMONWEALTH OF MASSACHUSETTS y BOARD OF EAIeT ...................OF................ ...................... ................. -------------- Appliration for 43hiposal i8orkti (9jandrurtion reruttt Application is hereby made for a Permit to Construct (�r Repair ( ) an Indi idual Sewage Disposal System-at: ..................... ..!� V ............................................. ....................... ion-Address r Lot .......... .._:�_�.._... ....d. ..`g._ ................. .....r.___ ... _.... _ ....... ."-_•_.__ // - ddress = . - - _.dam._......... Installer Address Type of Building U YP g Size Lot_.._. _.!_.l__.....Sq. feet Dwelling—No. of Bedrooms__ ........................................Expansion Attic ( ) Garbage Grinder aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures .-----------•-•-----•--•----•-----•-••-•---------------•--------------•-••--•------------•---•-••--••--•-•••......------.....--•••----------------- W Design Flow.................................`.�... gallons per person per day. Total daily flow..........................................._gallons. WSeptic Tank—Liquid capacity .......gallons Length...:............ Width................ Diameter__----_----_____ Depth_..-•-_-__--... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area------------------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '-, Percolation Test Results Performed by.......................................................................... Date------------------------------------- W - .. Test Pit No. 1................minutes per inch Depth of Test Pit..................... Depth to ground water-------_-------------- Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ ------------------------------------------------------------Q', ODescription of Soil----------------------------------------------------------------------------------------------------------------------------------------------------------------------- "4 U ..................................................------------•---•---•--•--•-------------------•---------•-------••••------•-••-•-•-----••----...-------•-••-----..................................... W ---------------------------------------------------------------•--------------------•-•------------- --------------••---------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable-----•------------------------------•--_-_____------•-__-____-_..-.-_____--.---__-.-------_.--. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned fuLither agrees nrit to place the system in operation until a Certificate of Compliance has been issued by th"ardalth. �� ------- Igne ".�. t ApplicationApproved --- -• ---------------•----------------------------•--•-----......--•-•------ ---------------------- Date Application Disapproved f r tl following reasons--------------------------•--•--------------------------------------------------------------- •-------------- --------------------------------------------------- Date r, PermitNo..--..................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS 4 BOARD OFF ..;EAL-f .OF.. ��Gt l�� -r . potiration for Uhipviial Worko Tout drurtion rrrntit ,� Application is hereby made for a Permit to Construct (J') or Repair ( ) an Individual Sewage Disposal System at t /^ •.'-'' i! ,oc hon Address ,,�-,,rs7. ^�'"./ j� s or Lot,rN. Y- ----------Fs3'. _ ` _ -_f T r T f2s .-----•-•--•• f---- f l.,eri__.a a=--•._Cr_ �,d� .........� —4._--- \ r'yO��w�ne�g ,C J -, sddress W , r / r' t w ...._..----- --------�.............� �- J �/ r Le.? +i �� Installer Address QType of Building Size Lot.__:_ __ ' _.___Sq. feet U Dwelling—No. of Bedrooms._`�--------------------------------Expansion Attic ( ) Garbage Grinder PL4 Other—Type of Building ____________________________ No. of persons-______________._______..... Showers ( ) Cafeteria ( ) Q' Other fixtures ...................................................... Design Flow...................................—------gallons per person per day. Total daily flow..........__................................gallons. Ix . Septic "Tank—Liquid capacity/.9:�gallons Length................ Width-----........... Diameter---------------- Depth................ W Disposal Trench—No.____________________ Width.................... Total Length.................... Total leaching area--------------------sq. ft. x Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date---------------------------------------- ,.� Test Pit No. 1................minutes per inch Depth of Test Pit____________________ Depth to ground water___________________-_ faq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ ....................................................................................................•----------------------------------------------------------•-----....-•----•--------•-••-----•__•---......................................................... 0 Description of Soil------------------------------------------------------------------------------------------------------------------------------------------------------------------------ W U W ------------------------------------------•----------------------•--------------------•----------------------•...---------•---------•------------------------------------- ........................... U Nature of Repairs or Alterations—Answer when applicable.-________________________________________________________________-__-______-____________-_-. -----------------------------------------------------------------------------------------------•--•-•-------•---------------------------•-------------------------•---------------•-------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees n,9t to place the system in operation until a Certificate of Compliance has been issued by he and of health. . l f s Si /sly./ 1.. ..,. ... � ' 4-K- $ r ApplicationApproved _ _. -== ••--------•------•------------------------•-------•-••-----------•. ---, -���--------------------- Date Application Disapproved or t e f ollowing reasons------------------------------------------------•--------------------------------------------------•---•-•__--••- ----•---------•--------•-------•-••--------------------------••------•----------.._...-•--------•-•-•----------•------•--------•-••---------------•--•••--------------------•-----••--•---------------- Date PermitNo....................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....:.....................................OF...........................................I......................................... wrrfifirate of Tootphattrr 'IS IS T ERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) (OZ4,444 Installer has been installed in accordance with the provisions of Ai( j--X,I of The State Sanitary de ar,,�d�escribed in the application for Disposal Works Construction Permit No______ ________ _____________________ dateCLOU_.d, --_________________________ THE ISSUANC OF THIS CERTIFICATE SHALL NOT BE CONSTRI D AS A GUARANTEE THAT THE SYSTEM W,iL.F TION SATISFACTORY. DATE . �--•• Inspector == THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Ira ..........:...............................OF........... .......................................................................... .- N ---.... 1.......... FEE ................. Permission is hereby granted__..,)a'? fa.: _____________________________________ to Construe �o Rep -r ( ) an ndividual Sewage Disposal System atNo. --- •-- ` --•- -• : s =-----------------•-•------------ ------------------------------------------------------------ .......................... Street as shown on the application for Disposal Works Construction Permit- _______________ Dated_______.._____________.__.________.______. •--------------..... _..--------- •-------------- -------------- ............... Board of Health DATE.............................................. .................................. FORM 1255 HOBBS & WARREN. INC.. PUS.LISHERS Y"'►�7'+C;4 E 5 A cl.6 1:}FfCA 1' ' : : r ' f1 "u-cr rr: 1 5 j �• j is y ;_-,:f �.,,,/� � � i'f ., � �f �E; I f , ;, � '•� �, # � � � � • �,. - {.. tJ7�L ' �� f • �;{ I: i i ! f �..i,.`� A=.i" �`j•Tf e d 1p s 3 r... 5tt7�NA4L• '� p $ �S' { -<kp .z. :"C'•/� `�• HIL T• ..' t ?��f_'' � 7-0y. 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