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HomeMy WebLinkAbout0523 BUMPS RIVER ROAD - Health 523 13umps lUver `s stervi e A= 143 038 t r ..��3 _�� f, , ,. •j dam---- Commonwealth of Massachusetts `y Title 5 Official Inspection .Form` Subsurface Sewage Disposal System Form -Not for Voluntary Assessments*" wM 523 Bumps River Rd Property Address David Bowman Owner Owner's Name iT? information is ✓ MA 02655 2-18-16 required for every OSterville page. City/Town W State Zip Code Date of Inspection Q+ SAl 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. A. General Information r 1. Inspector: = Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 _ ..r _ + .. , • r r Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S 13971 Telephone Number Ucense Number B. Certification I certify that 1 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 E]I Fails, • ❑ Needs,Fu valuation by the Local Approving Authority, < - 2-18216 ' J 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. t5ins•3113 Titre 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 r � o �� Vs e Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 523 Bumps River Rd Property Address David Bowman Owner ;, Owner's Name information is,ery x required for Osterville MA 02655 2-18-16 .,e3 page. <w 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: w' ! System is in good working order with no sign of failure. 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): . t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 r • Commonwealth of Massachusetts Title 5 Official In' pection'f drn' r Subsurface Sewage Disposal System Form=Not for Voluntary Assessments SVB'a 523 Bumps River Rd , •=y M Property Address t David Bowman Owner Owner's Name information is Osterville MA 02655 2-18-16 required for every ' page. City/Town State Zip Code Date of Inspection B. Certification (cont.) f. ❑ Pump Chamber,pumps/alarms,not operational. System will pass_with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): b: '•x,"' _#` ❑ 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): u. t6 `• i n. .r* °fit X. 44 ❑ broken pipes)aye replaced ❑ Y ❑ Ni.,❑. ND (Explain below): ❑ obstruction is removed +{r r ,❑ Y j*❑ 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. A 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 , - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 523 Bumps River Rd Property Address David Bowman Owner Owner's Name information is required for every Osterville MA 02655 2-18-16 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. F ❑ 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 El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments M 523 Bumps River Rd Property Address David Bowman ,.r. _ 4. Owner Owner's Name information is Osterville MA 02655 2-18-16' required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) .7, Yes' -Not' ❑ ® 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 El ® T tributary to a surface water supply. . • ` El • ' • ® , , }Any portion of a cesspool or privyis 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 F ; ' 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- The system fails. 1.have determined that one or more of the above failure ❑ ® 'criteria exist as described in 310 CMR 15.303, therefore the system fails.The r r: system owner should contact the`Board of Health to determine what will be r: r necessary.to correct the failure:' w 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.',4,1 -A1 . .r; Yes No ❑ ❑ the system is within 400 feet of 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 at ❑ `. + ❑ '" 'Area—IWPA)or a mapped Zone II of a public water supply well •If you have answered "yes"t'o any question^in SectionrE 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 °r 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- . 523 Bumps River Rd Property Address David Bowman Owner Owner's Name information is required for every Osterville MA 02655 2-18-16 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?' ® El available 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 backup? ® ❑ Was the site inspected for signs of break out? ® r ❑' 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 i t Commonwealth of Massachusetts J. - W Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form -Not for,Voluntary Assessments M 523 Bumps River Rd ? :. Property Address David Bowman , • J' Owner Owner's Name a information is r required for every Osterville MA 02655 2-18-16 " page. City/Town 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? (Include laundry system inspection, Yes ® No information in this report.) El" 1. Laundry system inspected? T �.r, _ ❑ Yes ® No Seasonal use? .- El Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump?, _ r T,,.o-a f. ,.f fr ❑ Yes ® No Last date of occupancy: ,. 1-2016 Date Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based,on 310 CMR.15.203): Gallons per day(gpd) >.1v Basis of design flow�(seats/persons/sq.ft., etc.): � '. Grease trap`present?t ;.... ' ,1: �•., ❑ Yes ❑ No Industrial waste holding tank present? 3s !� `'"t ° ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13`' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �. 523 Bumps River Rd Property Address David Bowman Owner Owner's Name information is Osterville MA 02655 2-18-16 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) l Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: - Source of information: N/A 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official- Inspection Form r T t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments, 523 Bumps River Rd + `• Property Address David Bowman - Owner Owner's Name information is required for every Osterville MA 02655 2-18-16 page. City/Town' . r State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of,information: 1999 Were sewage odors detected when arriving at the site? Yes ® No BuildingSewer(locate on site plan): { 24"_ Depth below grade: r. a . . _ Y . „ i R «,.-feet Material of construction: .4:� ® cast iron ® 40'PV' j, ,, ❑ other(explain):, Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: feet Material of construction:, ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) s If tank is metal, list age: years Is age,confirmed by a Certificate of Compliance? (attach a copy of certificate)` ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 12" t5ins-3/13 - Title 5 Official Inspectlon Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 523 Bumps River Rd Property Address David Bowman Owner Owner's Name information is required for every Osterville MA 02655 2-18-16 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 20" Scum thickness y 1" 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 15" How were dimensions determined? Tape Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. 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 L Date of last pumping: Date t5ins•3113 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 M 523 Bumps River Rd Property Address r David Bowman Owner Owner's Name information is Osterville MA 02655 2-18-16 required for every page. City/Town State Zip Code_ Date of Inspector 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 f , . ., r .y ,rk. •r" :��:` :4.'.: ... f. ..�. 1Y i4�• �. _ .e 1... �T.1 ri - t`r, 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: f .,f ', s.ti t: '� i __." .{, gallons per day ,+ Alarm present: ' ❑: "Yes"' No „st. 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-3113 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 523 Bumps River Rd Property Address David Bowman Owner Owner's Name information is Cisterville MA 02655 2-18-16 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 Comments note if box is level and distribution to outlets equal, an evidence of solids carryover, an ( q Y rY � Y evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from field. 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.): Small pump chamber with pump servicing out building in good working order. * 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: ,. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 i - - Commonwealth of Massachusetts 7 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•=Not for Voluntary Assessments , M 523 Bumps River Rd Property Address David Bowman Owner Owner's Name information is Osterville ' ' MA 02655 2-18-16" required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number. ® leaching chambers number 4-infiltrators ❑ 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.): Infiltrator leach field in good working order with no sign of back-up into d-box or surrounding stone. 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Aft Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments 523 Bumps River Rd Property Address David Bowman Owner Owner's Name information is required for every Osterville MA 02655 2-18-16 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.): 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•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 17 , Commonwealth of Massachusetts Title 5 Official Inspection F®rrvi Y Subsurface Sewage Disposal System Form Not for Voluntary,Assessments a- 523 Bumps River Rd Property Address David Bowman Owner Owner's Name . .. information is = �� required for every Osterville MA 02655 2-18-16 •'• page. City/Town 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 g bo"Z,& -L J ID r i • _ f- , . / , ;,., ,,;,,#, � �. Nor►. .1: v- i 7% t 4_'?, t L''. b:'r' :6r. t`.. r" •bt fi, t'Z r.•::;J.,,: f,� '. t5ins•3/13 • _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Y Title 5 Official . Inspection Form. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 523 Bumps River Rd Property Address David Bowman Owner Owner's Name information is required for every Osterville MA 02655 2-18-16 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: 1 et+ 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: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 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 523 Bumps River Rd Property Address David Bowman Owner Owner's Name information is required for every Osterville MA 02655 2-18-16 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 T R.OF7�F ID3, t try 1.00p�1(ION — ' VXZ:,IaACilr -- -EK Sxp,I,I,Ialt'S NAME 8t I' IOAtE I+tO d00> Gc/ LS ACI IING'PAC S��airnt�on�r�tauQ��l�atwe�n s;tr�: ;. MAX tnum Al justc�Gzauudwate�'l ble la tlac$crttarn ai X,�;ai;htn�t?,ciUly ..—��.�,w. --•---�'c r I'lluaJ�r.V,►&ar Sunli!^�i�dc f surd Ircdc64in� ?acM y any s�Ils CRtS1 k� 9 y sin sgta'ae�v3thin;2(lp felt a�i�tictu�►�facsit�t}�) cli+cry vVt9and and lL�ac�un� actl�y�it(";au9y��ctlall ds exist i+f1911tcr.dUCS fc.e7'c►t I�tu:tia��'ari4stya, � 1'jI �e, 1l°uriitsj U by :Axe -c - 3 g 14 - 19- 1s'� `` � -� - 1 TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE ASSESSOR'S MAP & LOTI SEPTIC TANK CAPACITY U LEACHING FACILITY: (type)Ailkl wj(aIl Ly� (size) f4 x 3v',c,2 NO.OF BEDROOM 3 BUILDER O OWNE 6wolctol PERMPTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 7 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) 4? Feet Furnished byI r O �g- i /d f. 1Vo. G Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: !� Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 0(ppItcation for IBiquar *pgtem Cott!6truction Permit Application for a Permit to Construct( )Repair(/)Upgrade( )Abandon( ) ❑Complete System /Mdividual Components Location Address or Lot No.15—V /,���! Owner's Name,Address and Tel.No. Assessor's arcel vl 1�4 Q D� �� � Installer's Name,Address,and Tel No. Designer's Name,Address and Tel.No. Q®�r�l,�I�-�Coey i Z / 9 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building R No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow Ile gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title i Size of Septic Tank 1000 VW Type of S.A.S.AO &PX 2 Description of Soil 4) ' �xCi'/�J''Q�0�' Nature of Repairs or Alterations(Answer when applicable) 7-lX e 7 6e�l 71ZV 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 th' B d o Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issuedr` 4 �� y. `yam 3T .No., y� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: l/ i Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 0Lpprication for ;Diopool *pgtem Construction Permit Application for a Permit to Construct(' )Repair(✓)Upgrade( )Abandon( ) El Complete System ICJ Individual Components Location Address or Lot No.t—�j 7, � �JC %� Owner's Name,Address and Tel.No. ' Assessor$ >�PCe�.��e� is✓ 7-1- 49 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. . Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building fle'5kie146e No. of Persons Showers( ) Cafeteria( ) Other Fixtures 'Design Flow gallons per day. Calculated daily flow gallons. .W Plan Date Number of sheets Revision Date ` Title Size of Septic Tank /04:90 Type of S.A.S./D,N 3ez r Z Description of Soil Nature of Repairs or Alterations(Answer when applicable) /e a 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 y th s B and� - Signedeyl Date Application Approved b Date Application Disapproved for the following reasons Permit No. Date IssuedP°l � ————— THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that//the On-site Sewage Disposal System Constructed( )Repaired(1/)Upgraded UGQ ( ) Abandoned( )by rDd/ 7 �f'e 0�!.PZ at Z w / ✓ / r C-ell1e1611 e has been constructed in accordance with the provisions of Title and the for Disposal System Construction Permit No. -%1'—// dated Installer Designer The issuance of thidpermit s)LAI all not be construed as a guarantee that the y teT,willll function as de igned �^ Date l Inspector _ r 6Al ----- -- it re r THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS 1wiqu of *pgtem Congtruction Permit Permission is hereby granted to Construct( )Re air Upgrad ( )Abandon( ) System located at .5' �'eh •pry le-i/lef 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 It. Date: Approveci���,,�' TOWN OF BARNSTABLE LOCATIONS �� �5 /�ii^ )VI, SEWAGE # VILLAGE Cad? /'yl�l� ASSESSOR'S MAP & LOT j—e3g INSTALLER'S NAME&PHONE NO. 1'"Y7Z1�1 4111,4617- SEPTIC TANK CAPACITY 1"4 , 164 G LEACHING FACILITY ..(type) (size) i0 x 3o',_i NO. OF BEDROOM 3 BUILDER O OWNE ,XQv PERMUDATE: COMPLIANCE DATE: Separation Distance Between the: - a Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility" Feet Private Water Supply Well and Leaching.Facility (If any wells exist on site or within 200 feet of leaching factLty) Feet Edge of Wetland and Leaching Facility(If any'jwetlands exist within 300 feet of leaching facility) Feet Furnished by o; br fi �fs� 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) I, klel T �. ,&/'/*Z0///hereby certify that the application for disposal works construction permit signed by me dated ��/�l�"9 concerning the property located at meets all of the following criteria: The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. /The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within 100 feet of the proposed septic system There are no private wells within 150 feet of the proposed septic system ✓ There is no increase in flow and/or change in use proposed s' There are no variances requested or needed d✓ The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor r/method when applicable] r If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W.,Elevation . 5 ' +the MAX.High G.W. Adjustment. , = 1 1 l DIFFERENCE BETWEEN A and B 1 a SIGNED :— DATE: [Sketch proposed plan of system on back]. q:health folder cat I I/IrF,7'/' r y C' 0k L 0 �i Q� 4 Al S�a 3 f3' VAAPU 4 t MAR-14 SCALE 3 IN FEET �00 0 1 fr✓/J�f .� r53`�` '� jr\� 2 \� h j�37.9 = \` ` `t - J _.✓/ r'r f f lf X9.5 X 4 kr r } \ 119 143 H x9.5 \I / ,tt lr y}! ♦\`� `� \ tip\ yes;, '/. .. ZU \\ 9.7 '4+iC�€ 31r''f `'y ..... � 1 42 1E ZA 118 Tip ♦ "7 r 4'O".t __ `j t € , q 2 f 1 �1 US �_�.-.{�� ds13 / \ r tl sf,rf !/ ,t t�/ V � e -^ 418✓ 42 7 _is€S ilv. '/✓ X9.2 / X91 itf/f i f ,: ii ♦ tt tooins \� ♦\\ X38.2 is \ a ief(tt� �^ l rfrl :s t d,/ j�60.a \ al�'a T. J ^ - ..,r<,! >� ✓/ / f r._'FirIx p5pUr i t S.r rt \ ,: ♦ s ; \ r'+ >.^ :a .+`.. , /Y't _�60 5 ✓ " t590 i��57t r � ♦�\ n Et 7(bAf t. i t X fit 7 l :` a y . Va/10'7 ♦1` r : tl9 tit MA "Xi X58.8 11t 4 its, n ♦�6 ` X60.5 ♦f629 �6@ {€�€p; , 2�, r lMW _10�{i 1 f=I€ �/' � X59 9 � 3 r s` it ( r X 63 0 i t X= 11 ss is f 3 { \ j r i ♦ Z ; .{ \\ \ / J s = = li ♦ \� �R( ` ..I X l0 2l!f f sf..,l 1 S rMUM woM / _J t 1 } ' C r�l.Pll♦ KOO t tJ{ ' by 7 f ..LL51Jf i S,(1 1 r r t 31 s s1 i r•°a�•� ♦\ d 2 it Q] X58 Qw -N ti `�611 rs4 u SPA F I e Dd \ t i:. \/58 } }f j , 1 #91 r s\ �, Q?5 AC = ``s � i law ��/ \ r� �0 ,``1 029 AC f\: r X 61.1 i s.fx�rrllf // ''� BAI Oita; ItF tt`t ;. ( ♦ ^, 5 ♦/ r y Ross, / 09<6k551� � - 6.2 _ _ > e� 7 s `t t`51 ✓ \ y: Duce[^ ., fr� :i\ \ :r/ X56.9 OM .� � ' , `` ✓ ( }N �` // \\ *y +r /, \ 51 59 9 i. _♦ r `.\ ITO AS `,�j0: c r ` Z, f( 1ti yon ZsAc My f �S �59 \ iB�C71 MIA—: € ! ♦ ( ..N , i3^5 n<56.5 , ♦ = L I� �' / f I y; ; \ r�527 / 7 \ i 56 5. s ( ". \ i} \ } X585r \�r N383 iN `oo\ \ j/ r �\ \\l ri 'j •� j�52:� ♦\ ilr PIN . r y NOTICE: This Form Is To Be Used For the Repair Of Failed f Septic Systems Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) L kiel T J • A/j�D`olj`/hereby certify that the application for disposal works construction permit signed by me dated TAX14� concerning the property located at _ s 3 � �s�jl �"� meets all of the following criteria: v The failed system is connected to a residential dwelling only. There are no commercial or business /The uses associated with the dwelling. soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within 100 feet of the proposed septic system There are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed There are no variances requested or needed / iv The bottom of the proposed leaching facility will not be located less than five feet above the ma�dmum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor `/method when applicable] r If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, L 71 Please complete the following: f A) Top of Ground Surface Elevation(using GIS information) / B) G.W.Elevation . 5 +the MAX.High G.W. Adjustment. (� = 1 l l 9b P DIFFERENCE BETWEEN A and B l a y SIGNED : DATE: [Sketch proposed plan of system on back]. q:health folder cen L-0 C A:T ION SEWAGE PERMIT NO. Vi LLAGE o3b I N S T A LLER'S/ NAME i ADDRESS L yd 17 Ale B U I L D E R OR OWNER A Al DA T E PERMIT ISSUED /D . 1978 DAT E COMPLIANCE ISSUED �_ �� _ 7� /000. GAL . - S P_7lc" -TAVK i -,f 4 GAL.- I Y 1 - No.................::....... Fizz... .. ................. THE COMMONWEALTH OF MASSACHUSETTSSUBJECT TO APPROVAL BOA RP OF H E A LT BARNSTABLE CONSERVA'.' T01r 1n.......................OF.....Ba sable-----.-------------------------------------------C.OMMISS60N ,Apure#inn for Bhgp aa1 Wurkg Tomitrurtion amit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ..4. m .der._M.......0stes�+rille.-------------------------- ----.Map..14 _srit �1 .........- Location-Address or Lot No. ........................ohi A & Maw. --t �s.-• ..... .......... ••. -- 1QS.$QM.Ax...Qst=YU1e--&.................................... Owner Address W ..-•-- '-.. Za*A, 3ay.._�Ias-aA25.32.......... ... ... ...._..... Installer Address Type of Building Size Lot............................Sq. feet aDwelling—No. of Bedrooms...........1..............................Expansion Attic ( ) Garbage Grinder (1 ) p, Other—Type of Building ..Dwet.13 rlllg...... No. of persons-----2.................... Showers (1 ) — Cafeteria-(- ) a' Other fixtures .._DiSbkWher.......................:........ d --------------------------------------------------- -------------------------------- WDesign Flow......110.....................:.........gallons per person per day. Total daily flow--------33Q--..--------.--_--..-._---gallons. WSeptic Tank—Liquid*capacity 1000-.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...10QQ.....sq. ft. Z Other Distribution box (1 ) Dosing tank ( ) O, -pC 4�— �" Percolation Test Results Performed by._Baxter-.&-.JW0........................................... Date---5M11--9..-------..---.---,. aTest Pit No. 1.....2........minutes per inch Depth of Test Pit------12._Ft.. Depth to ground water........................ w Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -------•----------------------------------------•-•---••--•----...------------....-•----•--•-------........................................................Ned 0 Description of Soil...... A..Ft,..L9a9.....tben. Aw.. ame--- nd----------------------------------------•----•------------------------------- x W ---------------------------------------------------------------------------------------------------- ------------------------------------------------------•----------------------------.............. UNature 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 IITHE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beenissyed by the oar f he Sid----- -----------------------------------------------------------------------•----- .................. Date Application Approved By------ l ............. -'7...Zk--=.............. Date Application Disapproved for the following reasons----------------------------•--------------------------------------------------------........................... •-----...-•---•-----••-------•-----•--------------------------------------•--•--••-...--------------------- -------------------------------------------------- -- --- ----------- --- -- - Date PermitNo......................................................... ..................... Date No.--------V_------_--•• Fzcal.al ................. THE COMMONWEALTH OF MASSACHUSETTS .:� BOARD OF HEALTH ........... ..oF. Ea �v� yyyTn�,3a......°.............I...-------------•-- ................ -.yy}- Applira#iou for Bhip"al lVerkfi Cnnntrnrtiun Hari# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal b System,at: ff .A_P!?.mra.. 623 ......_... 5e�3 41=G`*x.h � 9 ..........•• u er. { .-..... gy Location-Ad d /' or Lot No. J49Y1t s . t 1`.tb.. : '' t Owner/ Address -_. :*� .'�^? ., Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms ... .._ p g (I )Expansion Attic .( ) Garbage Grinder p, Other—Type of Building :_:_ No. of persons..... .................... Showers Cafeteria ( ) w Other fixtures ..P,54hnt. !�r........................................... A... W Design Flow:..___y� ;........................ gallons per person per day. Total daily flow......... 3. ...........-.................gallons. 1:4 Septic Tank—Liquid capacify�10 .tl..gallons Length................ Width................ Diameter-____.-___--_-- Depth................ Disposal Trench=No. ................... Width..... .............. Total Length....____a......... Total leaching area....................sq. ft. Seepage Pit NO...__.c.... k. Diameter ;......... Depth below inlet., Total leaching area..'0�1n......sq. ft. Z Other Distribution box.(I ),;`.':; Dbsing tank.(.'.;.) Percolation med .............. 4 Date_.evl1.,27?_._........_........ PTesoResultsPerfor ...... P- Test . minute`s per inch Depth of Test Pit ` !-Depth td ground water....................... Test Pit No 2....: _..minutes per inch Depth;of Test Pit.................•.. Depth to ground water........................ pd ..... ....--•-••------------------•---.........._.........••-•-------•----...... ------------------------------------------------------------------------------ O Description of So>1 & ` '--- a.`.q?r, `fin .•�,, ;. F 'r= V ------------- •-----•--_- ..---- ----...-•----•-•-•----•-----------..:---..........--------------- W ........................... _____..__ --. p 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 TITLE 5 bf the SSiateiSanitary Code—The undersigned ful'-: r agrees not to place the system in operation until a Certificate of Compliance has b by o f- h. p, �� Signed-�` Date Application Approved By.....j a • - --- = ------------- Application Disapproved for the following reasons--------------•------------•-----------------------•------------------------------..._. _......----------••---- -•-•----------------...........................................................-------•------------•---------- --- ------- ---------- ------ -------------------------------------------------- Date Permit.No....................................................... IssuedL....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF. .. THIS IS,TO CERTIFY, at/the F a:vidual Sewage Disposal System constructed r Repaired ( ) byy� T f -- -------------------------------------------------------i-'---.....-------------._._...----- has been installed in accordance with the provisions of TITLE j of The Stat r - scnilied in the . application ISSUANCE for IWorks OF THISonstruction Permit No.CERTIFICATE SISAL'- --- - --BI�� IST E®�ated__..-_-_-- -=----------------------...... A GU A TEE TRAT THE SYSTEM WILL FUNCTION SATISFACTORY. Q s DATE.......... 1 .................................. Inspector......... .. 1 �^ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH :.:.... L oF................... :...........:.. FEE.....: ... t L : tst�a r ern - anti Permissionis -eby granted..............................................----•-•..............----•-------------------•------••-•---------.....•-_..... to Construct ( or. Repair ( ) atf Individual Sewage Disposal System at.No .. --- -- ----- •-- ------------: «.._. .............. PYX > d l u ' P" S as-showe apocat' � s`id s bn t on ermi No................. Dated----------------------.:�.____..:. .. 7 / .+r ow G� F - -- �y w.y .....__. DATE------ .................... t FORT? 1265,.,,HOSBS &.WARREiV4 ql(�C., PUB0§4ERS, r t 13 iz t3�z Uff t 3 Nrl) ! =101 D¢TM� l,¢_U xt -,lj/'l y \ r�•',,�,rr, '�L. �'a r r fi SG �LC i 4 rat _ ..�.y.�r �..... __-- � �►ay. = 33.E Lo►�u r--- �.�y� Ibov �►.W� r J ,fit rIST ruv C�tAL 19'L7 ��. TAtiJ � INSVVITO � t��,rj � � WeS��rss.• ( 11.1D�y��JvAI. V�.L -L EL- �� 1 I•lo 1�(�G�r` p t �J L 1�o►�. ITS ; d k".: �. Nv C—AV6 S,e (:;QUDEL_ DAB . 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